Since publishing this post last October, and living through the tragedy of Robin Williams suicide, my thoughts seem even more immediate and important. We can’t just watch our wonderful profession sink into mediocrity. Too many people need our expertise…
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 nowhere 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…
Art Smukler is an award-winning psychiatrist and author of Chasing Backwards, a psychological murder mystery, Skin Dance, a mystery, and The Man with a Microphone in his Ear. All are available as paperbacks and eBooks.
Inside The Mind of a Psychiatrist 
What’s more, most psychiatrists who do pharmacotherapy exclusively (in my experience) aren’t even willing to spend time to consult with non-MD therapists with whom they share patients/clients.
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I am a psychiatrist in The Nethelands and I should say that the same thing is happing here in the Nehterlands: psychiatrist have little time for their patients, are more involving in managements and policy issues, and insurance companies gaining more power and determines what might psychiatrists allowed to doe. Time for psychiatry spring!
Best regards
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Great thoughts, and I understand your anguish. I’ve been a psychiatrist for over 30 years, and saw the writing on the wall in the early 1990’s. I used to train young psychiatrists in psychotherapy, and in psychopharmacology too. Really it was mind-body medicine before it was “cool” to say that. At least that’s what I intended when becoming a Consultation-Liaison psychiatrist. More recently I’ve expanded into classical homeopathy since that allows me to understand the whole person the way Psychiatry used to. Also it allows gradual healing without inducing the kinds of side effects we give people with our pharmaceuticals. I think Medicine in general is in severe disarray, with mental health/Psychiatry even worse. I am not on insurance panels, and work with those who want to work with me (including through psychotherapy). It isn’t a perfect solution for everyone, yet offers some well-founded hope. Best wishes, and I enjoy your writing.
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Thanks for your kind thoughts. Your solution to this difficult problem seems like a good one. Best Wishes
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Art,
I am so glad that I was recommended to see you. The first psychiatrist I was recommended to for anxiety was just a pill pusher and got me into trouble with massive doses of Xanax and an antidepressant I can’t remember the name of. When that put me to sleep at work, he prescribed Adderal and an antistimulant which all fought each other,
When you were recommended, I believe it took 2 or 3 sessions before you began to prescribe medication. In the interim and until today, you make your patients work hard to uncover underlying causes for the condition. In addition to medication, which is very mild, you recommend life style changes which make a tremendous effect on the condition. I am happy to report that between the several lifestyle changes I’ve made and limited medications I only need to see you about every 6 months…..and that is mainly for a prescription refill.
You epitomize what a great psychiatrist does and you apply all of your training to helping people.
That should never die.
Mike
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Thank you! What a nice thing to say.
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Thanks for posting, Dr. Smukler. As a PGY-1 psychiatry resident, I am a bit nervous about the present medical environment, but I do have every intention of becoming a psychiatrist in the classical sense, as Kernberg, Yalom, Masterson, Kohut, and you, as well as many others have done before me. Because as much as the medical environment has changed recently, humanity is the same as it’s ever been, and what psychiatry has to offer in it’s fullest sense, is timeless in it’s value.
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Thank you!
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I totally agree and thanks for sharing your thoughts. I just left my managed care HMO (non-profit) to return to my roots of doing therapy and meds, if needed. I no longer have to squeeze in 20 minutes of therapy into a med check! I’ve returned to where I started and I couldn’t be happier. We need to reclaim this territory as ours as well as it belonging to our non-physician colleagues.
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Obviously, I fully agree. Thanks.
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Just remember, it isn’t enough to leave the HMO that you work for. You need to be able to charge reasonable affordable fees, so that people outside the HMO network can see you! The systems that are in place for mental health for the poor or low income are inadequate, and will only prescribe meds. Oh, they might set you up with a social worker, but in my experience, a social worker can not provide the kind of therapy that a person with a major mental illness needs. There MUST be something we can do to bring this whole disaster to the attention of someone who has the authority to mandate the changes we need! There just must be!
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I could not agree more with Dr. Smukler. If psychiatrists continue to go on in this way, they do not only stand to lose their skills, their holistic approach, their claim to be the director of the orchestra we call ‘psychiatric help’, but will also lose their right to practice psychotherapy even if they want to do that. In the Netherlands sometime ago the Dutch Society for Psychotherapy declared that psychiatrists would be denied the license to practice psychotherapy since they did not have as much training and experience in the practice of psychotherapy as the (non-medical)psychotherapists (read psychologists). Fortunately it did not come so far and prompted the psychiatric training institutes to include more psychotherapy training in the curriculum for the training of psychiatrists. If we do not heed and wake up in time, the same threat will come in other countries as well. Psychiatry is a sublime specialty only because its message is to look at the man in all his/her aspects, be it physical, psychological, social or spiritual. If psychiatry gives up that sublime goal it immediately becomes no better or even worse than any other specialty.
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What can we do, as citizens and people in need of psychiatrists, to be proactive in facilitating the change that is needed to correct this serious problem? I would join any group, write letters, whatever it takes, to get something done about this, but it’s going to take more than one person. I think clients and doctors need to form a movement together, grass roots, and demand the change that is needed. What can be done to start a movement like this?
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It’s an excellent question. My solution has been to write about the problem and encourage the few psychiatric leaders that I know to enhance the psychotherapy training for psychiatrists. So far, it hasn’t’t done much, but there’s no reason to ever stop trying.
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I went to Penn State 72-76. I then worked in retail there 77-81. I do miss it and people like you. My daughter is a senior at Penn State now. If it’s suitable to meet you on one of my visits it would be my pleasure. Just to meet. I don’t need free advice. I get that from your articles. Maybe coffee at the Corner Room. Richard Goldberg.
Sent from my iPad
>
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I don’t foresee a trip back for a long time, but thanks for the thought.
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Thanks for your comments. I’m sorry life is so tough for you. It sounds like you’re a fighter and won’t ever give up!
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yes, i am a fighter! i have been told that i am a survivor. one of these days i will have proper medical coverage and i will be able to get the help that i really need. i have learned how to handle the bad days. sometimes i just sleep. other times i get a book and read all day. sometimes i call my friends and they take me out. i have started a blog,
( http://mysticheartblog.wordpress.com ) and i write about my grand daughter. she is a real gift. she is only 3, but just after her 3rd birthday, she came to me and told me that she is here to help me! can you imagine that? I know better than to lean on her, but when i am down, if i can just be in the same room with her, watching her be herself and hearing her voice, i feel better. she is my angel. writing helps me keep my thoughts straight, even if i am just writing about her, or anything else. i know i will get through this. I USED to be bi-polar, but I made up my mind to change that and I did. years later I learned what the actual process was that took place in my brain, but i didn’t know all that at the time, i just made up my mind to do the opposite of whatever bi-polar led impulse i was feeling and in a few months, my then therapist ( he specializes in diagnosis) told me that I was no longer bi-polar and he wanted to know how i did it! So, if i can do that, i can get through this too. one day at a time. thank you for responding, it means a lot to me that you did. i am following your blog so i can learn more, and I like that I can know you will respond to me. Have a blessed weekend Doctor! Susan Hudson
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I totally get what you are saying. I have suffered major depression since I was 17, and I am now 55. I live in Texas, so even though I can’t get insurance through the Affordable Care Act, I can’t get medicaid either. So I have to go through the county hospital system for all my care. They are so overwhelmed, that I can see my psychiatrist only once every 90 days! And only to talk for about 10 minutes! And, my medication isn’t working well enough, but they have limits on how much they can give and how often, so it’s like putting a bandaid on a broken leg! And, they have NO therapists in their system! Some days, I am just hanging on.
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