Apr 5, 2013

The 33 losses of modern psychiatry

What a portrait of modern psychiatry in today’s New York Times. Psychiatrists are abandoning 45-minute therapy practice for 40 brief encounters a day. Mechanized medicine. No therapy, because the system won’t pay. The featured doctor’s wife,  a licensed social worker, gave up her own therapy practice to become the full-time office manager and copay enforcer in her husband’s practice.

Here’s a list of what modern psychiatry has given up, and what a sad thing it has become, as described in the course of the article.

1. No therapy. “Hold it. I’m not your therapist.”
2. No long appointments.
3. Less intimacy
4. Less familiarity
5. Can't know patients by name
6. Lowered goals of treatment. It used to be patients leaving “happy and fulfilled”
7. Less effective treatment. Now he tries to “keep them functional.”
8. Forced disinterest in patients. He “resists helping patients to manage their lives better.”
9. Surrender of natural capacity to care. “I had to train myself not to get too interested in their problems.”
10. Therapeutic traditions abandoned.
11. Loss of practice identity
12. Industrialized practices. “very reminiscent of primary care.”
13. Loss of mystery and intrigue
14. Loss of sense of mastery
15. Hospitals now “discharge them within days with only pills”
16. Psychologists and social workers are now economic competitors.
17. Loss of “quality of treatment” edge compared to other therapists.
18. Discovery that the “craft was no longer economically viable.”
19. Economic coercion “Nobody wants to go backwards, moneywise, in their career.”
20. Loss of competitive edge for psychiatry compared to other medical specialties.
21. Providing less potent care. He dispenses pills but “it’s the relationship that gets people better.”
22. Forced to assume a more mercenary attitude, with add-on fees and charges.
23. Less opportunity to display kindness and sympathy.
24. Less adaptability
25. Living in a culture of scarcity
26. Less access for new patients.
27. Long waiting lists.
28. Interview techniques that do not follow professional training
29. Patients “frequently ignore” advice to seek therapy
30. Forced to disclaim capacity to help people with problems.
31. Recognition that he is delivering poorer care now.
32. Feelings of shame.
33. Fear for son’s future in the family profession.

After all of these losses, what is left of what people used to call the profession of psychiatry?

I was also struck by the disconnection between office-based psychiatry and the front door of the psychiatric hospital. There is no evidence of continuity whatsoever. The hospital is an isolated, separate team. Is there a minute for a phone call if the person shows up at the hospital for help? Is that phone call in anybody’s protocols?

When police become involved with people with mental health problems, they often say they are not trained therapists, but in today's economy are there therapists anywhere? Is the economy for psychologists really so poor that there is better money to be made as an office manager for the family’s designated breadwinner than as a licensed therapist?

Given that psychiatry as we used to know it is a dead thing, a zombie profession, I am more convinced than ever that the traditional power imbalances in treatment are doomed.

Psychiatrics are mechanics now, so patients already have the power. Visit the pill dispenser of your choice. Offer your $50 buck copay, let the provider roll the dice on whether insurance will kick in anything more, see what pills are on offer. If you can get an appointment.

Meanwhile, I suspect the real market for peer specialists is as mentors, unregulated people to talk to for money. Imagine: Be a life coach, charge $50 an hour, hang out, have a relationship. It's the cost of a copay. Try to be ethical in the unregulated economy. It’s better than the $12 an hour, part-time job with a mean boss at the low end of the treatment system food chain. Plus,  since it’s the talk that’s effective, you’ll be doing your client some good, without shame.

The psychiatrists in your neighborhood will envy you.

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