Sunday, May 12, 2013

Psychiatry Today

By now, it shouldn’t be news.

Today’s psychiatry is mostly about writing prescriptions. Psychiatrists conduct short interviews, make diagnoses and prescribe medication.

Insurance companies might not be entirely to blame, but since they pay psychiatrists more for conducting short sessions and medicating their patients than for having extended conversations they are certainly part of the problem.

When it comes to hospitalized psychiatric patients, insurance companies apparently dictate the length of patient stay. The quicker the patient is discharged, the better it is for the insurance company. The best way to effect this result is through medication.

But, it is also fair to note that in the old days psychiatric patients used to be hospitalized for very long periods of time. Extended hospital stays entail their own risks. 

If it’s all old news, why did The Atlantic just run an article bemoaning the state of modern psychiatry?

Your guess is as good as mine.

Be that as it may, here is how Sarah Mourra defines the state of modern psychiatry:

In many places psychiatry has become a biological enterprise, with some psychiatrists even introducing themselves as "psychopharmacologists." In no other specialty does a physician define themselves by the medication that they use. As one of my psychiatry professors once commented, "I have never met an oncologist who says "I'm an onco-pharmacologist." Increasingly, we are convinced that medications are what make patients better -- and that if only they would stay on them, if only they would take them as we have prescribed them, if only they were on the right one or the right dose -- they would get better.

The new methods reduce the patient to brain chemistry, thereby occluding his or her humanity.

Psychiatrists know well enough, for example, that getting a job can be therapeutic, even for a schizophrenic. They also know that a human connection between patient and psychiatrist is highly beneficial.

In Mourra’s words:

In reality the process of getting better is much more complicated. Medications can play a large role, but other factors are enormously important -- environment, sense of purpose and meaning, the person's perception of their illness, and their relationship with the people who treat them. Studies have shown that patients taking placebo who have a good relationship with their psychiatrist have better outcomes than patients taking the active drug who do not have that strong personal connection. In the outpatient setting, a well-trained psychiatrist will follow what's called the biopsychosocial treatment model -- which values the biological, psychological, and social aspects of a person in considering their treatment -- and consider these other parts of the patient's healing process, in addition to medication.

Mourra does not suggest returning to the good old days, because the old days were not all that good. When psychoanalysis ruled the day its practitioners were offering the “talking cure.” Yet, the “talking cure” did not involve conversation.

With the patient lying on a couch, looking away from his analyst, babbling at the walls… conversation was not happening. Strictly Freudian psychoanalysis forbade a human connection.

Psychiatrists who were not psychoanalysts did as today’s psychiatrists do. They conducted intake interviews. These interviews might have lasted longer than they do today but they tended to be limited to a series of questions off of a checklist.

It is true that insurance companies influence the way psychiatry is practiced, how many psychiatrists know how to conduct a conversation and to make a connection with a human patient?

If the reign of the insurance companies ended tomorrow more than a few psychiatrists would still keep doing what they are doing. It’s what they know how to do; it’s what they were trained to do. They simply do not know how to converse with their patients.

Mourra and the psychiatrists she cites are also correct to say that the profession needs to take more account of each patient’s social being. But again, how many of them have the requisite skills and experience to do so?

The relational frame of reference for most psychotherapy either involves the autonomous human mind or else the patient’s immediate family. How many psychiatrists can guide a patient through a difficult moral dilemma involving friends and colleagues? How many of them can do so without mistaking the problem for another version of a family romance or reducing it to a developmental glitch?

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