Carlat on mindless psychiatrists

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.

14 comments to Carlat on mindless psychiatrists

  • I agree with much of what you say. I should say that when psychiatrists claim they do therapy in their 15 minute medchecks, it’s B.S. Call it what you will – denial, willful distortion, I don’t know what, but that is a false claim. This is a fallen profession. Can it be resurrected?
    Only if employed psychiatrists everywhere will be doing therapy and will be valued for more than their ability to sign scripts and other paperwork. I doubt this will happen. Since psychotherapy is only doable, if at all, by psychiatrists in private practice in wealthy areas – this is not a profession.

    • Pac: If you have ever done psychotherapy, you know you are getting trivial bs for 45 minutes. Come the last 5 minutes, then you get the zingers and shockers of the week, often, standing up to leave, “Oh by the way, I met someone at work, and we slept together. My wife does not know she exists.” So, truncating the session to 15 minutes should result in more meat, no filler.

  • Ironic. Dr. Carlat wants to return to the psychiatry that failed to prevent the suicide of his mother.

  • TK

    Dr. Behar, even Carlat acknowledges at the end of his piece that the psychiatry of the era might not have saved his mother, but that patients at least deserve a shot at it.

    What I took away from Carlat’s NYT piece was this:

    a. How in the world did he miss the ADHD thing the first time around?

    b. Maybe psychiatrists, as a rule (as long as it’s not a life and death sitch) need to do the kind of long, detailed, overall psychiatric health questionnaire/assessment done by psychologists-doing-assessments before even thinking about prescribing drugs. The patient has been suffering for months and maybe years. A few weeks won’t make a difference, most of the time.

    c. Why does the prescribing of pharmaceuticals and talk therapy seem to have reasonably equivalent success rates, in Carlat’s opinion? It’s simple. Someone cares about the patient’s problem. Actual or placebo, caring goes a long way.

    d. Dr. Reidbord’s point about a deeper psychodynamic approach is well-taken. But I imagine Carlat wrote about the effectiveness of adding even a bit of supportive talk therapy because in his experience, it’s working. See “c” above. Someone cares.

    e. Until the psych profession is willing to take advantage and employ advances in technology like Skype to “see” patients, this is largely a moot discussion for more than half the American population, anyway. Psychiatrists tend to cluster in major metropolitan areas. If you live in Waterville, ME, Lee Vining, CA, or Paris, TN, the issue is not finding a psychiatrist who can and will do talk therapy. The issue is finding a psychiatrist, period.

    Thoughtful piece by Dr. Carlat. Thoughtful response by Dr. Reidbord.

  • tracy

    This article makes me even more grateful for the Psychiatrist i have who does psychotherapy. He does not accept insurance, however, because of very little overhead, his rates are very reasonable.
    Hopefully, someday “the tide will turn” and somehow more Psychiatrists will decide to do therapy again.
    Thank you for a great article, Dr. Reidbord

  • For over 100 years, psychiatrists have served the most severely disturbed mental patients. Psychologists have served moderately distressed patients. And, friends, neighbors and pastors have helped mildly distressed people, including people who lost loved ones. That explains the higher fees of psychiatrists than psychologists, than counselors. They have to do more for people who are more dangerous and disabled. Psychiatrists are not better nor superior, just different.

    It is easier to get into medical school than into a clinical psychology program. Psychology students may take just 4 pre-med courses and qualify to apply.Those psychologists who want to prescribe are invited to do so. I also strongly support making most psychiatric medications of today available over the counter in low doses. They are safer in use, and in overdose than all presently available OTC medications.

    I support the obverse. If a psychiatrist wants to focus on psychotherapy, don’t stay an untrained amateur dabbler. Apply to graduate psychology program and do it full time after graduation.

    It is certain that orthopedic surgeons are fully capable of devising rehabilitation programs for their back patients. If they do not do it full time for many years, they will get inferior results compared to those who do.

    Dr. Carlat is a left wing ideologue. Left wingers like to use government force to impose their ideas on others. Having psychiatrists do psychotherapy will raise costs, prolong waiting lists, and reduce overall access. He did not disclose that he works in an area of oversupply of psychiatrists, and that his proposal is a solution to his low income (I know it because he has mentioned his income in public before, and I know average incomes around the nation. His is that of some of my residents moonlighting, years ago.)

    • “For over 100 years, psychiatrists have served the most severely disturbed mental patients.” Longer than that: “Psychiatry” was coined in 1808 to describe medical treatment of the insane. But in the first half of the 20th century most psychiatrists were psychoanalysts. As such, they mainly treated neurotics who functioned in society and could pay for this treatment. Fees have never been related to the severity of the condition being treated. If they were, oncologists would make far more than allergists, and they don’t. Psychiatrists’ fees are higher than those of psychologists and counselors due to cultural biases favoring MDs, and due to scarcity of psychiatrists compared to other mental health practitioners.

      “It is easier to get into medical school than into a clinical psychology program.” Not true. Training in psychology is competitive; I found one online reference that claimed “acceptance rates around 20-80% for master’s programs and 5-40% for doctoral programs, depending on the competitiveness of the program.” Acceptance rates into US medical schools are far lower, see here.

      There are libertarian arguments in favor of making all drugs prescription-free. Short of this, there are good reasons to maintain medical oversight of most psychiatric medications. Unlike OTC aspirin and antihistamines, which immediately remedy well-circumscribed symptoms, antidepressants can take weeks to work, and should be continued long after symptoms relent. As with antibiotics, these time-course considerations are not obvious to the layperson, often overlooked, and potentially hazardous. Moreover, major depression has multiple signs and symptoms that are nontrivial to assess. Other psychiatric medications, such as mood stabilizers and neuroleptics, are too dangerous to take without medical supervision. In addition, the judgment of the afflicted person is apt to be impaired at the time.

      “If a psychiatrist wants to focus on psychotherapy, don’t stay an untrained amateur dabbler.” I agree. Formerly, all psychiatrists were trained in psychotherapy. Fewer programs emphasize this now, which in my view is a serious problem. A psychiatrist untrained in therapy should pursue additional coursework and supervised clinical experience if he or she wants to expand into this area. A graduate degree in clinical psychology would more than suffice, but I’m not convinced it’s necessary.

      Please refrain from name-calling and personal attacks here. Dr. Carlat’s politics are irrelevant. In fact, your charge is illogical: He would make less money adding therapy to his psychopharmacology practice (and anyway he makes much of his income writing, or so he says… no wonder his income is low). While I will approve relevant commentary on the topic at hand — even nutty statements like “psychotherapy is trivial bs for 45 minutes” — I will edit or delete ad hominem attacks. Thanks for understanding.

      • Dr. Behar sent a reply, which I will not be posting as it is laced with inflammatory language and personal attacks. However, I will paraphrase his substantive points. He claimed that psychoanalysis was a bicoastal phenomenon in the US. “Around the world, and in the Midwest, psychiatrists were always biological, always treating the most severe of the insane.” This comment seems to overlook the European roots of psychoanalysis, its popularity in other places such as South America, as well as at least one Midwestern counterexample: The Menninger Clinic. Perhaps Menninger is the exception that proves the rule.

        Dr. Behar noted that acceptance into US medical schools is about 40%, since applicants apply to several, not one at a time. This is true. I am unable to confirm or refute his claim that this is “less than the rate for decent clinical psychology programs.” He also noted that “[w]hat psychologists do is as hard, as individualized, as complex as what psychiatrists do.”

        He reiterated that most psychiatric medications are “idiot proof” and have safety profiles “which are much better than all OTC now available.”

        Dr. Behar labeled me a hypocrite for “calling people who disagree nasty names,” apparently a reference to my use of the term “nutty” to describe his therapy comment above. My characterization referred to the comment and not Dr. Behar himself — an important distinction in civil discourse. Nonetheless, it was unnecessarily harsh and I apologize. (I would edit it out now but that could be construed as covering my tracks.)

  • tracy

    [Personal comments deleted — SR]

    On a completely different note, i beleive there are Psychiatric Residency programs that do a very good job of training their residents in the art of therapy, having been fortunate enough to be a patient of one such resident here in Richmond. Either he was a naturally gifted therapist, which is very possible and/or his program was a large part of his sucess.

    Thank you,

  • dinah

    One of our readers sent me to you.
    I just posted a review of Dr. Carlat’s about-to-be-published book on Shrink Rap.
    Nice to have found you, I didn’t know you were floating out here in the blogosphere.

  • […] 2000 book Of Two Minds, and has been explored ad nauseum in the psychiatric literature, countless blogs (including this one), and previously in the New York Times […]

  • NYNM, Ph.D.

    A little late, but those online psychology degrees, and their acceptance rates, are subpar. I would also suspect that acceptance to a respected PhD clinical psychology program is as competitive, if not more so, that MD program. And, while a PhD has moderate training in physiological bases of behavior, and some general training in psychopharmacology, it requires much more training in research methods, statistics, psychological testing, social psychology, and of course psychotherapy. Nevertheless I appreciate your comments in general and am pleased to see your interest in the whole person rather than the “diagnostic entity.”

    • Thanks for writing. Both top-notch medical schools and clinical psychology PhD programs are highly competitive. I’m not sure what value lies in making it a horse race. Of course, getting into ANY medical school or psych program isn’t terribly competitive. I don’t understand your reference to “online psychology degrees.”

      I agree that a PhD in clinical psychology includes significant training in the areas you list, far more than an MD’s psychiatry residency. It should be mentioned that a PsyD, which also is a doctoral degree in clinical psychology that is much more popular here in the San Francisco Bay Area, has a good deal less focus on research methodology. I myself was a post-doctoral fellow in psychotherapy process research for 3 years, and have been teaching and supervising dynamic psychotherapy for the past 20 years or so. The residents I teach consistently receive top national standing in an annual standardized exam of dynamic psychotherapy administered by Columbia University (not that I should take major credit for this… the residency in general is geared toward psychotherapy). Anyway, my point is that psychiatrists who wish to practice dynamic psychotherapy well need further and ongoing training and experience beyond residency. But this is true for most everything in psychiatry, and medicine in general — and I suspect it may be true in clinical psychology as well.

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