My fellow psychiatrist and blogger Dr. Daniel Carlat has an article in this weekend’s New York Times Magazine. “Mind Over Meds” is a memoir of Dr. Carlat’s growing realization that psychiatry can’t be done well in 15-20 minute medication visits, that talking to patients as people is important too.
I’m generally a fan of Dr. Carlat. His blog is one of the few listed on my blogroll (the short list of links over there on the right of this page). He writes well, and I share his skeptical attitude toward overzealous promotion of psychiatric drugs to our profession and the public. “Mind Over Meds” is a good article: Carlat reviews the swing from the “brainless” psychiatry of early 20th-century psychoanalysts, to the “mindless” psychiatry of today, where symptoms are treated with medications and the patient may be lost in the process.
This is all on target, and I appreciate how Dr. Carlat is willing repeatedly to make it personal and write about revisions in his own thinking — as he did in this prior NY Times Magazine article, also well worth reading. The gist is that psychiatry has painted itself into a corner by limiting itself largely to psychopharmacology, i.e., medications, and ceding psychotherapy — understanding the patient as a person — to other mental health professionals.
Unfortunately, “Mind Over Meds” goes off the rails in two ways. The less important is a passage that I have to believe is just badly worded, as it seems to denigrate psychologists and other non-psychiatric therapists:
Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.
A couple of early commenters have already chided Dr. Carlat for this “mental health hierarchy” language. Discussing whether mental health professionals constitute a hierarchy is beyond my scope here, but I believe Dr. Carlat is well aware that the expertise of many psychologists (for example) to do psychotherapy surpasses his own. In fact, he has recently taken a contrarian position in favor of granting psychologists prescribing privileges. I doubt he meant this talk of hierarchy as a putdown, but he should have been more clear.
The bigger gaffe is that the article ultimately calls for psychiatrists to do “some sort of psychotherapy… when our patients need more from us than just medication.” Dr. Carlat seems to be satisfied with a little support here, a few extra minutes of listening there. However, that isn’t psychotherapy except in the most meaningless, hand-waving sense. That is just listening to one’s patients, something every doctor should do, from dermatologists to orthopedic surgeons. I hate to say it, but it’s no wonder health plans won’t pay for that. It used to be part of the job, not something extra.
Psychiatrists have a lot more going on than mere doctor-patient rapport — or at least we used to. Even psychiatrists who choose not to conduct psychodynamic therapy still learned, or should have learned, about psychodynamics, an intellectual and historical cornerstone of our field. A psychiatrist’s work needs to be psychodynamically informed even if he or she only prescribes medication. As the most obvious example, a dynamic understanding may shed light on a patient’s medication non-compliance and help to address it. Even better, a dynamic understanding of the patient may obviate the need for medications at all. (To those who argue that psychodynamics has been supplanted by cognitive-behavioral therapies, I note that Dr. Aaron Beck, the founder of cognitive therapy, was a psychoanalyst first. Even cognitive therapy works better if it is conducted by a psychodynamically informed therapist.)
Dr. Carlat should have gone farther. Psychiatry needs to retake the position that we strive to understand and heal the mind from the molecule on up (a position taken by Freud, among many others). It is true that this encompasses a dauntingly wide spectrum, from psychopharmacology to psychological treatment, and beyond that to social and cultural influences. As physicians we are the only mental health discipline with the training to appreciate the whole span; other professions, like clinical psychology, may have more in-depth knowledge and treatment skills regarding a particular part of this spectrum. Of course, any given psychiatrist may choose not to practice at all of these levels — probably cannot, given the sweeping range. But it is the essence of psychiatry to know about the full spectrum, and either offer whatever treatment is needed at any level, or refer the patient to a professional who can provide it.
It is necessary but not sufficient to see a patient behind the symptoms, to listen. It is also incumbent on psychiatrists to conduct real psychotherapy, dynamic or otherwise, when sitting with a patient for 50 minutes and charging for it. Ceding “real” therapy to others has diminished our field and has turned most psychiatrists into technicians. “Mind Over Meds” is the right title for a much deeper topic.