April 30, 2011

Mark Foster, DO
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Bob–

I have found that many patients, and even many physicians, don’t appreciate the basic differences between psychology and psychiatry. For most of your readers, I suspect they grasp the sometimes profound divides between these disciplines. But for many patients, including highly educated people, they don’t understand that there is any real difference. To most outsiders looking in, to those who are suffering and seeking help, they assume that it’s all one cohesive system of mental health care, and they trust that whoever happens to care for them will provide the latest and greatest diagnoses and therapies. If they need counseling, then that’s what will be recommended. If they need medications, then they will receive a prescription. They have faith that the system will provide them with the “one best solution” for their problems.

In the past, I’ve explained this difference–foolishly–to my patients as “Well, a psychologist will provide talk therapy to help you work through your feelings, where a psychiatrist can prescribe you medications.” When presented this way, most patients choose to see a psychiatrist first, because they want to see the “medical doctor,” the provider with the highest level of education and the prescribing authority. I’m sure this response is in part due to the promise of a quick drug fix for challenging emotional and social problems.

It’s similar to how you might feel if you had chest pain and presented to an Emergency Room: you would be frightened, confused, in pain, and therefore vulnerable. You would be forced to put your trust in the medical authority of the hospital’s ER doctors to make the right decisions. In your vulnerable state, you would surrender some of your autonomy to the doctors who have the knowledge and experience to help you. “Whatever you say, doc. I trust you.” You submit to their expertise and hope for the best outcome.

In the case of emergency cardiac care, most emergency physicians prove worthy of that trust. They remain healthily detached from the patient’s fears, perform rapid diagnostic testing, and then provide immediate access to high-tech interventions like cardiac catheterization that can save lives.

But although the psychiatry-pharmaceutical collusion has successfully, seductively medicalized mental illness in the minds of the public and providers, the truth is that mental health care is an entirely different scenario, one that is poorly addressed by the prevailing paradigm of medical detachment, snap judgments, and drug therapies.

Quite frankly, I think too few medical professionals even understand the difference between psychology and psychiatry. Other specialists, ER doctors, and many primary care doctors prefer to “turf out” mental illness referrals. It’s confusing, even threatening, for a doctor to encounter a patient who is suffering from mental distress and to feel powerless to help them. The promise that there is some “specialist” out there who is an expert in diagnosing and treating these problems in enticing to overwhelmed primary care docs. If this specialist has a framework for dealing with these difficult patients, then does it matter if it’s psychology or psychiatry? They can do whatever they want, just take them off my hands.

Primary care doctors almost always follow the lead of the specialist organizations here, and when it takes three to six months to get an appointment with a psychiatrist, and when the family doctor over time becomes convinced that all the psychiatrist would do anyways is start a medication, then the primary care doctors slowly begin to feel confident that they can provide an equal level of care as the specialists. This is empowering to a primary care doctor, and financially rewarding, too, bringing in a vast new cohort of potential patients for treatment and follow-ups. Also, drug reps are bringing them lunch daily telling them how underdiagnosed these “diseases” are and how amazingly effectual the medicines are. By reducing symptoms of illness into easily quantifiable and wholly unscientific diagnostic categories, the DSM-IV and the drug companies have done all they can to grease the skids so that psychotropic prescribing by primary care doctors is quick and mindless,

Thus over 70% of mental health visits and prescriptions in this country come through primary care offices. But most primary care doctors are poorly equipped to handle difficult cases of mental distress and thought disturbances. In medical school, we get cursory, typically ineffectual training in mental health, barely even scratching the surface of basic human psychology and development. Then we are thrust into our medical residencies, where the focus is so heavily placed on severe medical disorders and drug therapies. It is through this prism that we are taught to gaze at mental health issues: quick cookie-cutter diagnoses, standard protocols for treatment, and drugs drugs drugs as the first line gold standard of care. At every mental health conference or lunch training that I can remember–all sponsored by drug companies, of course– the material was presented like this: “Here are the drugs that treat these vastly underdiagnosed diseases as described in the DSM-IV.” I remember hearing the half-hearted joke told many times that, “SSRIs are so safe and effective, we should put them in the water supply like fluoride. We all might be better off. (Sly chuckle).” Perhaps one bulleted item on the final power point slide at the harried end of a depression talk would suggest adjunctive therapies like exercise or referral to a psychologist.

I’m mentioning this because I think the reason that patients often don’t comprehend the difference between psychology and psychiatry, or alternatives to drug therapies, is because physicians don’t understand them. Ironically, the perceived blending of disciplines is increasingly accurate, as many psychologists have become beholden to the psychiatric paradigm, sometimes because they are persuaded that ultimate authority now resides with the doctors, sometimes because they fear the repercussions of not going along with medical authority. Often, psychologists depend on referrals from psychiatrists and thus are financially constrained from advocating a non-medical approach. They don’t want to lose patients, and they don’t want to be responsible if a patient doesn’t do well off of meds. Regardless of the reason, it is increasing rare to see a psychologist reject or even question the tenets of biopsychiatry.

This is unfortunate, because humanistic psychological approaches to mental distress have so much to offer patients. Perhaps not the quick, sexy, short-sighted fixes advertised in magazines and on TV, but rather long-term, fundamental changes in perspectives and paradigms. To make up for my own inadequate training, I have been delving deeply into psychology texts, explorations of consciousness, psychoanalysis, cognitive and emotional development, and empathic strategies for assisting suffering people. I can’t believe how rich these texts are! These are great thinkers who have explored the human mind, how we construct our reality, how we break down emotionally, and how we can rebuild again. How could I have even pretended, for my whole career, to be able to adequately diagnosis and treat mental illness in a fifteen minute visit when I couldn’t even articulate to you the difference between adjustment reaction and a defense mechanism? To my indoctrinated mind, all of that mumbo-jumbo was part of a non-medical discipline, one that I frankly viewed as unscientific and inferior.

How wrong I was.

Next week, I’d like to delve deeper into this subject, into how I’ve found that a basic understanding of psychology can assist medical providers in helping patients suffering from mental and emotional distress, not because I believe that there is “one best solution” to deal with patients psychologically. Actually, I believe that for many people in mental distress, they don’t require any intervention at all, but rather need a paradigm shift, permission to authentically experience their feelings, empathic human connections, and the healing powers of time. I believe this humanistic, holistic view of the psyche can place into context so many things about human emotional and mental states that otherwise appear frightening and out of control. This all may seem like back to the basics for most psychologists, but for a lot of medical providers and patients, this will be a much needed refresher course, maybe even an introduction.

Until next week,

Mark