Once upon a time, psychiatrists spent uncountable hours during their training learning how to do psychotherapy. They studied the vagaries of the unconscious, had intensive training presenting cases to highly trained supervisors, read volumes on how the psychiatric greats treated their patients, and helped train psychologists, social workers, MFTs and other therapists to do therapy.
Then Insurance companies sold the concept of managed care. The mantra was simple. Treat symptoms not people. Don’t take time to understand someone, just take the depression and anxiety away. Time is money. A good psychiatrist is one who doesn’t use time, but fixes things quickly. Medication is the cure. Psychotherapy? Leave it to the other therapists.
Well, the insurance companies did what they set out to do. All the money they were paying psychiatrists ( and I can assure you that those fees were no where near what surgeons or other specialists made) now went to the middle managers who were paid to limit care. Big business defined what was good psychiatry and what was bad psychiatry.
So what does it all mean? Should psychiatrists be happy prescribing medication and just let other therapists do psychotherapy?
To me, psychiatry is a specialty that is a combination of medicine, psychology and poetry. Only psychiatrists go to medical school and have the opportunity to understand the complete person. The mind and the body always work together. One can’t exist without the other. To just prescribe meds is the equivalent of removing only the top of the iceberg. What about the main part of the person, the part that was formed back in childhood, the part that psychotherapy reaches.
In Brave New World, the dubious answer to human pain was the drug”soma”. We can’t let that happen in our society. Just using drugs because they are a cheaper way to calm the masses and save money is short-sighted and hurtful.
Psychiatrists used to be masters of the mind. They used their unique skills to help all psychological professionals understand what people were all about and how to help them combat the psychological torture that was ruining their lives.
Limiting a psychiatrist’s skills to prescribing medication starts at the top. If training programs let this happen, they are short-changing all of us. If psychiatrists just want to make more money and not learn how to be masters of psychotherapy they are no longer masters of their profession. Master carpenters, master electricians, master cardiologists and masters of anything are an important part of creating a society based on excellence. Excellence is what we should strive for.
Is psychiatry dying?
Not in my office…
Inside The Mind of a Psychiatrist 
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Your post is both thoughtful and provocative; I appreciate it.
What do you think Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) as engines of reflective self-improvement, promoted by the ABMS and the FSMB? Will they help us be better psychiatrists? This approach has reached into the ACGME and is called the Milestone Project. Residents adopt the system as the norm. Credentialing and reimbursement are now tied to participation in MOC programs.
If you think this needs to change, how should we lead it?
Jim Amos, MD
The Practical Psychosomaticist
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I think recertification always sounds good, but the stress of having to learn details that you may never need is daunting. I’m happy that my certification is “forever” and the things I read and study pertain to what I actually need and want to learn.
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I appreciate your sentiments and agree with you about what has happened to psychiatry. This change to the field I fear is not reversible, and I already see the result of whole generations of trainees who are not interested in psychotherapy or other modalties that seek to understand humanity rather than illness in isolation. The recent attention to the DSM further solidifies that our field has serious flaws and is stuck in a paradigm that does just what you say it does, pushes psychiatrists into the role of prescribers or mental health technicians. Further eroding this is the development of other psychopharmacology providers such as nurse practitioners and psychologists who have successfully lobbied for this ability.
I practice psychotherapy, group psychotherapy, have studied cognitive neuroscience and psychodynamic, and rogerian approaches such as motivational interviewing as I treat mostly addiction, an area that psychiatrically has historically been constantly behind in its approach except among a few specialists with vision. I am not hopeful about the field as a whole, and have given up on our larger organizations to pursue any real or effective change to the tide of manged care. My approach is to say basically, screw that, I am going to do what i think is best and try to make it work econimcally as best I can.
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If enough of us do what we’re doing, that’s a good beginning.
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As I will be entering a psychiatry residency come July 1, I appreciate your piece. It is encouraging, as I know I will be swimming against the tide. Thank you.
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Swim hard and never give up! I’m doing the same.
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Okay, will do! Thx. 😉
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As a fantastic psychiatrist who is a friend of mine says: psychiatry is the domain in medicine with the least knowledge, the good part is that the medication is always the same: a few choices and that is all…psychiatry does not cure, helps treat and but if clinical psychologists must study at least for six years to understand more about mind and emotions, it is truly impossible that even the best psychiatrist would have a similar knowledge – therefore let psychiatrists and psychologists work together – the results will be much more significant.
Excellent blog.
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I loved this blog.
Sent from my iPad Jann Feldman💌 310 995-3070
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Good for you! We need good psychiatrists dearly!!
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They are doing it to the internists, trying to have pharmacists treat diabetes, etc I guess us surgeons are immune, since no one else can do the surgery, so instead they just lower our fees in the guise of reducing costs!!
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You’re right. But how many procedures are denied that should really be done?
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