Recently, I have had the unusual experience of finding myself more in agreement with psychiatry’s establishment leadership (in the guise of Jeffrey Lieberman’s articles in Psychiatric News) than with some of my favorite psychiatry bloggers. This occurred in the context of discussions of a new buzzword within medical reform circles – Collaborative Care. It encompasses a number of topics and goals. One is to insure that people who are diagnosed with psychiatric disorders receive good medical care. The reported average life expectancy for people who are diagnosed with serious mental illness is 15-25 years shorter than that of the general population. Collaborative care is one means to address this. In this model, community mental health centers would provide primary medical care along side the other services typically offered.
I have been in favor of this for some time and our clinic has already moved in this direction. We collaborate with a Federally Qualified Health Center. They have opened a mini-office within our clinic so that people who come to us can meet with a family practice physician one afternoon a week. Many of my patients do not readily seek out general medical care. This clinic makes it much easier for them to do so.
But most of the attention among my psychiatric colleagues is based on the reverse situation – the co-location of psychiatry and so-called behavioral health services in primary care settings. My colleagues are concerned that this will end up constituting a further erosion of psychiatric care with psychiatrists functioning as consultants with limited direct care responsibilities. They worry it will continue the distillation of psychiatry into applied psychopharmacology. I think there is some truth to this but it does not concern me.
As people who have read my blogs know, I have a conservative view of psychopharmacology. In a general sense, the drugs’ effects have been overblown, they are often prescribed at doses higher than is needed and in combinations that are risky and untested. They are often continued for too long. But that is a problem that can occur in a private practice with a psychiatrist who is also offering psychotherapy as easily as it can in a clinic with a psychiatrist who only consults to other physicians. In our setting where we frequently consult with other physicians, we often recommend ways to reduce the use of psychoactive drugs. There is nothing inherent to collaborative care that promotes excessive prescribing practices. At the same time, this model does not ignore other forms of help. Where I work, psychologists and social workers are an important part of the collaborative team.
Some of my colleagues are concerned because in these new models psychiatrists are not the ones offering psychotherapy. I guess that bothers them more than it does me. And it is not that I am opposed to psychotherapy. I just do not think you need a medical degree to be a good therapist. These models are, among other things, seeking cost effectiveness and almost everyone else in this business costs less than a physician. I also understand that psychotherapy – being labor intensive no matter the practitioner – will always have to fight for time. But this is a problem now and it will be a problem in any system we have.
But my thoughts on this relate to another idea I have had recently – psychiatry in its current iteration could be subsumed by neurology. I do not think care would suffer and, in many ways, it would be much clearer to patients.
I have recently been reading Richard Noll’s excellent book, “American Madness“. It traces the emergence of modern psychiatry in the U.S. from the late nineteenth to the early twentieth century. This was a time of remarkable growth and development for medicine. Psychiatrists, first in Europe and then in the US, tried to emulate the practices employed successfully in the rest of medicine. It was predicated on an assumption that the problems we treat are fundamentally medical. Psychiatrists applied the methods of understanding disease processes to understanding the problems of people who inhabited the asylums of the time. This distinguishes psychiatry from other disciplines. We developed in a place – the asylums; other disciplines developed out of a study of organ systems in the body. Since those early days, psychiatry has taken a few detours – most notably the psychoanalytic one that was developing simultaneously and took hold in the US after World War II. This muddied our professional identity. But to be modern in a medical sense, psychiatry – as embodied by Dr. Lieberman’s APA and Dr. Thomas Insel’s National Institute of Mental Health – wants to take its place as the discipline that studies the nervous system. But we already have that discipline – neurology. I guess where I part ways with some colleagues is that I do not see this as fundamentally bad. But there is a critical caveat – I see all of this as peripheral to the needs of most people in emotional distress.
I continue to think that physicians have a roll to play in evaluating people who experience depression or hear voices or suffer from debilitating anxiety. Although many of these problems will turn out to be well handled in non-medical ways, not all of them will. There are endocrine disturbances, inflammations, vitamin deficiencies, even tumors that could be causing the problem. I once read a paper that was 100 pages long and listed all of the medical causes of psychosis. Someone needs the training to be able to assess for them. To be honest, most of them are rare, but still.
I also think that psychoactive drugs are here to stay. People have sought them out for a long time – well before the advent of modern psychiatry – and that seems unlikely to change. It is imperative that some branch of medicine specializes in understanding these drugs. I wish that branch would be cautious. It’s not that I more faith in neurology than I do in psychiatry to be judicious but that is a problem of modern medicine that is no better or worse in one discipline or another.
In the unlikely event, my little thought experiment were ever adopted, I imagine there would be a specialization within neurology that would approximate what psychiatry is today. But there would be no pretense about what this specialty was and the training could be focused on the medical causes of emotional distress. There is much that psychiatry residents can not learn these days because they are pulled in so many directions. Training in psychotherapy is arduous and time consuming. As it is, most residents just get a basic introduction. Perhaps without needing to put time into that area, these neurology residents specializing in this new sub-specialty would be able to acquire a depth of understanding of psychoactive drugs that is not always in evidence these days. Perhaps they could learn about those hundred other causes of psychosis. Perhaps they would gain an in depth understanding of the movement disorders the drugs we prescribe so often cause.
When I have discussed this with colleagues, there are several responses, none of them good. The primary objection is that I am dismissing humanism and promoting a largely neuroscience based understanding of human suffering. To be clear – I am not suggesting that all problems currently falling under the label of extreme distress or mental illness be solely treated by these neurologists. Far from it. I would have a whole battalion of people offering services. I like the model in Tornio, Finland. I think of the network meetings as the hub. People can get referred out for other help as the need arises. This could include peer services, cognitive behavioral therapy, psychodynamic therapy, employment support. These problems are varied and heterogeneous and the forms of support should be equally varied. In Norway, where they do similar kinds of work, the primary care physician plays an important role in the team. A neurologist could be pulled in when needed.
Another criticism is that psychiatrists are more prepared that other physicians to see the person in his or her context and grasp the complexity of human behavior. In this scenario, psychiatrists are the physicians who talk to people and understand their concerns. I will leave aside the many criticisms of psychiatrists I read on this site and just point out that these attributes should be intrinsic to all of medical practice. It does medicine as a profession a disservice to have a single discipline that is considered the holder of a humanistic approach to human suffering.
People are very confused about what psychiatry is. Psychiatry is a bit confused. I think my system would be clearer. If you want an evaluation to understand possible medical causes of your problem go to the nerve doctor. If you want to know if there is a pill for you, go to the nerve doctor. If you want to understand your experience as a human and the nature of your suffering, leave medicine out of it. Furthermore, I am suggesting that with regard to the kinds of human distress that has historically fallen under the purview of psychiatry, let medicine – under the umbrella of neurology – stand in the background, quietly in the corner, available for limited evaluations and consultations. I would have the rest of you take center stage.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Interestingly, I think I agree “partially” with Sandra here :).
The place where I part ways is with this notion that medical doctors -psychiatrists or neurologists- should have any role whatsoever in dealing with human suffering.
“Human suffering” is a very subjective term. What a good “brain” or a good “nervous system” is can be defined objectively in the same way a good “kidney” can be also defined objectively.
What a “happy” or “good” human experience is very subjective and there should be no role by the medical profession to define it. No role as in “none whatsoever”.
A few months back I listened to this enlightening talk by Robert Burton about “the mind” https://www.youtube.com/watch?v=bnu0vE2E4-M . For a self described atheist like him realizing that the difference between “the mind” and “the brain” can be ascertained through empirical evidence might be a great “aha” moment, but that’s what religious and spiritual people have been saying for millennia. That’s pretty much old news for like 95% of humanity. It’s only when this distinction between mind (soul or however you want to call it) and brain was questioned by atheists and secular people that a lot of the suffering brought about by the practice of psychiatry took place.
Many religions have, and continue to, condone what psychiatry calls “psychotic episodes” and “hallucinations” as “mystic experiences” of great religious value.
My bottom line is that people with medical training should go back to what they have been trained to deal with: the physical body -and that includes both the brain and the nervous system.
For “problems of living” or “human suffering”, people should rely on what people have traditionally relied on: friends, family, counselors, religious guides, etc.
For those who are atheists and who truly believe that life is meaningless in an absolute sense (meaning, that the universe has no purpose and that we humans are just animated pieces of meat), too bad. No amount of “drugging” or fMRI imaging is going to give them the overall meaning to life that they deny. In fact, the real travesty is that these people want to impose their secular, “chemical imbalance” view of humanity through the DSM on the rest of society :).
Sandra I think the problem for those of us with an altered mind state or psychosis is that we can’t choose whether or not to have psychiatric interventions (or at least not in Scotland anyway). It is still drugs or nothing. Especially if we have psychiatric labels in our notes that say we are schizo something or have a disorder. And they have to label us with a disorder to forcibly treat us with drugs.
I think it would be useful to have the choice of psychology/psychotherapy or psychiatry for a mind problem but where I live psychology is secondary to medical and there can be long waiting lists to have a talking therapy. Therefore why can’t psychiatrists have other strings to their bow like psychotherapy or psychodynamic counselling skills, built into their training?
The issues with links between big pharma and drug prescribing has to mean that psychiatry must separate itself completely from pharma influence. The psychiatric drugs are problematic in the short term, disabling in the longer term, and many people find it impossible to get off them no matter how hard they try. I was one of the lucky ones, getting off them within the year. For some reason I knew that for me a year was enough on an antipsychotic and tapered it myself, on 3 occasions. Same with the antidepressant, that wasn’t anti-anything, and the lithium that was no mood stabiliser. What’s in a name?
Psychiatry has to be more than drug prescribing and forced treatment. Which has been my experience and that of my family. However I’m not keen on the neuroscience taking over, more NMD and brain surgery for mental illness. We’ve got some of that going on in Scotland, to the people for whom the drugs didn’t work and the ECT didn’t work. People with depression and OCD, who are desperate for relief.
I agree that the Open Dialogue approach seems to offer another way of working with people in psychosis, and I’ve been attending seminars on OD in London, another weekend one at the beginning of May. What I like about the method is the level playing field and the inclusion, the efforts not to be hierarchical and prescriptive. The facilitators Mia Kurtti and Markku Sutela, Tornio, Finland, did not come over as “experts” and revealed their failings as well as what they have learned and still are learning.
That’s what I’m looking for in a psychiatrist. Someone just like me. Who admits that mental health difficulties are common to all. We’re all in the same boat. The mental illness label only exists because the psychiatric treatment hasn’t worked. The drugs haven’t worked, they don’t cure, and big pharma’s main aim is to create customers. Drugs may relieve symptoms for a while but they soon become the issue if there’s nothing else on offer.
Hi Sandy-great post-thanks. I went to a grand rounds where Brian Miller lectured. He found that 35% of those persons with relapsing schizophrenia were positive for UTIs. Treat the infection, the voices go away.
From what I’m hearing mental health will become part of primary care with the masters degree people being the providers. I’m not a big fan of drugs or psychotherapy. But I do believe in support groups, diet, exercise, and yoga. In line with this Tracey Shor, a neuroscientist at Rutgers who looks at the impact of exercise and learning on BDNF levels in the hippocampus, is now working with addicts. Her treatment is teaching them to dance. Works great for preventing relapse and curing depression. Hopefully that is what the new world will look like.
Thanks, Jill. Yes, I agree there are many other non-medical interventions that could be helpful.
“Music calms the savage beast.” Music and dance was my body’s natural response to “cure,” after I’d been weaned off drugs, then suffering drug withdrawal induced super sensitivity manic psychosis.
I also agree regular moderate exercise, healthy dietary choices, and working with people who have dealt with similar problems (in my case, cover ups of sexual abuse by a religion and malpractice by doctors) is helpful and important.
I have yet to try yoga, but have been thinking about it. Meditation (NOT medication), too, I think can be helpful for some. But declaring all human problems “chemical imbalances” in people’s brains is ridiculous and insane.
Dr. Littrel: please explain: what is UTI.
Urinary Tract Infection
I am not sure I am far from what either of you are saying but perhaps I was not clear. I am not only suggesting that psychiatry become subsumed by neurology. Implicit in this model is that medicine, in general,relinquishes its role as the “leader’ in this field.
But having psychiatrists trained as psychotherapists will not improve the “supply” problem for psychotherapy. Physicians are expensive for public systems. There are others who can provide this service. I am suggesting that physicians do the things that ONLY they can do.
Yes but what can doctors do without having drugs to hand? Sorry if this sounds cheeky Sandra but my experience of psychiatric treatment over 40+ years has been of drugs first and last.
GPs in the UK are also about drug prescribing or sending a person to a consultant if it requires special expertise. In general medical hospital settings I have found consultants to be person-centred and they’ve treated me as a person with capacity. Showing me the X-rays or results of tests, asking what I think, involving me in discussions. Not in psychiatry where it’s been a top-down affair for much of the time.
I am not sure I understand where we disagree. As I said, I think there is a place for someone who has an expertise in the use of psychoactive drugs. I just do not think that needs to be center stage. That person could be pulled in as a consultant. I do not understand the advantage of training physicians to provide psychotherapy.
I’m not sure either that we disagree however I do think that psychiatrists who have an understanding of psychotherapy and/or other trauma informed therapeutic interventions will be the better physicians for it. It could help them in their relationships with patients.
My son’s psychiatrist is a qualified psychotherapist and it could be why he was more in tune with our wishes when my son wanted to taper the psych drug haloperidol, which he came off in 5 months, with my support. Previous psychiatrists we both had seemed to think mental illness was lifelong and required therefore lifelong psychiatric drugs to manage it.
I think I agree with both of you. It strikes me that psychiatrists want nothing to do with psychotherapy anyway, since they set themselves up to only do “med check” visits, and have been shipping patients who want to talk to therapists. The lack of logic in that system however, is that it’s overly specialized leaving too much room for communication errors, plus the patient ends up going to too many different specialists, none of whom can see the big picture (the patient’s real problem). Plus with this type of system, the psychiatrist only listens to what the other professionals say, rather than listening to the patient, and so in my case, and seemingly many others, ends up committing malpractice.
It is a system that creates lots of doctor’s visits. It’s always about the money. But too much specialization in medicine leaves us with a medical industry that can’t put the pieces together well enough to actually help patients. We need more “renaissance men” (and women), people who are multi-talented, in the medical field.
And Chrys, in the US it’s all about drugging people, too. After I’d been weaned off all the psych drugs, I went in for a regular physical. Before I even spoke to that physician, he handed me a prescription. I asked what it was for. He told me it was for heartburn. I handed it back, telling him I didn’t have heartburn. We talked for several minutes. I told him I was still trying to quit smoking. He handed me another prescription, this time for Chanix. I told him I’d research the drug and take it if I thought it’d work well for me, since my “bipolar” was caused by withdrawal symptoms of another “safe smoking cessation med.” He told me not to research the drug. It staggers my mind how egregiously most doctor underestimate the intelligence of their patients. And how deplorably unethical the field of medicine has become. It’s all about the money. Medicine for profit does not benefit the people as a whole.
And the entire medical field seems to be set up as a caste system, which intelligent people should know is unwise. And even the caste system in India is wise enough to known doctors do NOT belong at the top. The god complex problem of doctors strikes me as a huge problem, as well as their “wall of silence” problem. Now that I’ve become fairly proficient at medical research, and since I know the doctors’ motives seemingly revolve primarily around increasing their own profits, and I know the medical journals are filled with pharmaceutical industry publication bias, plus I now know the “dirty little secret” of the medical profession, it’s hard to have a lot of respect for the medical community.
But once doctors realize you’re a “die hard” woman (not easy to kill), and are fully capable of researching medicine, they do seem to learn to have a little more respect. But what ever happened that “do not harm” promise and “treat others as you’d like to be treated? I’d like to go back to that world … but we do have more evidence that doctors should NOT be at the top of any caste system.
I think independent pharmacists should study and learn how to use psychoactive drugs. They might have enough respect for the chemistry not to throw six or seven at someone at once.
My neurologist gave me two different combinations of six drugs, and all these drugs now have major drug interaction warnings on the drugs.com drug interaction checker, particularly warning they cause anticholinergic intoxication. But I’d been told the neurologist was “the fifth best neurologist in the country” and “knew everything about the drugs.” So was he stupid, or was it attempted murder? What do you think? I think Lutheran pastors, and their Lutheran therapist friends, worked very hard to cover up their child molestation hobbies, and the religion should relearn the concept of repentance.
Churches have a problem with sexual abuse, no doubt. There’s a connection between authoritarian institutions and sexual abuse. People who feel like they can do anything they want to children shouldn’t have access to them, but there’s nothing easier to feign that piety and people think their children are safe with their church leaders and fellow members of the congregation.
It’s sad that there are people who would betray our every trust. It makes it hard to trust anyone else. Sandusky had parents thanking him for “spending time” with their troubled children. This is the kind of thing, I think, that some top psychiatrists should be working on— teaching people how to protect themselves from predators.
And they should be protecting children from predators by reporting child abuse to the authorities, rather than keeping the child molesters on the streets, by misdiagnosing and drugging up mommies with medical evidence of child abuse. But, I do understand doing such brings a lot more distressed children into the therapists’ offices. And my ex-therapist had the highest suicide rate in her local high school in the nation, by the time my son was in high school. And my ex-pastor worked with the group that was pointing out “at-risk” families, and directing them to mental “health” authorities. Plus, I’ve read about 95% of children with a psychiatric label have been abused. Gosh, and psychiatry still thinks all people’s real life problems are “life long, incurable, genetic” “chemical imbalances” in people’s brains? Some within psychiatry work to cover up societal problems for those working for the corporate “elites.”
Oh, psychiatry and the courts combined are doing a great job of joining together to disarm women and children who are at the mercy of predators and to label the women with “Münchhausen by Proxy” or “Parental Alienation Syndrome”. It’s not that those behaviors never happen, they’re just very rare and it’s very easy for sociopaths to convince others that women are guilty of this and that the predator is an innocent victim who should be given custody of children.
Sexism, racism, and classism is built into our institutions so that all it takes is a failure to challenge it in order for those with little political power to be abused by our justice system and our mental health system and the places where they meet.
What I find most disturbing about psychiatry is the misogyny that is too often evident when looking into the face of a psychiatrist. The failure of a woman to submit can be reason enough to proclaim her mentally ill. In my experience, it’s been as plain as the nose on their faces that a couple of psychiatrists I’ve been subject to are frightened of women who won’t submit to the degree of groveling before them and surrendering their agency in order to receive their “help”. The relief on their faces when they see you in the drug induced stupor they think makes you “better” is rather obvious. How is that getting better? Disagree with their assessment, and ipso facto, you are sick in the head.
Resisting can be absolutely necessary to protect one’s self and life. Letting them have the upper hand is detrimental for women who have made the mistake or had the misfortune of making themselves vulnerable to a psychiatrist’s assessment about their ability to handle themselves without intervention.
Perhaps I dealt with misogyny, but I know from reading medical records that my female PCP was paranoid of a malpractice suit because her husband had been the “attending physician” at the “bad fix” on a broken bone of mine. She put me on a bad drug cocktail, then denied the ADRs and withdrawal symptoms were from her drugs. So I went outside my insurance to get a second opinion, but ended up dealing with a therapist (also female) who, unbeknownst to me at the time, was getting business from the people who harmed my child, and wanted to cover up their child molestation hobby. In my case, I think it was primarily greed.
But there is a misogyny problem society-wide. The male police officers don’t look into cover ups of child abuse. DCFS doesn’t look into cover ups of child abuse. The heads of religions actively cover up child abuse. The States Attorneys don’t look into cover ups of child abuse. The FBI doesn’t look into such things. It’s like male chauvinistic pig-ism has run amok in this country. There is a hatred of women who act like women, instead of men. There is a hatred of mothers who believe it’s important to properly raise their children. Kill all the moms who volunteer 40 hours a week to help the children, instead of worshipping the almighty dollar! Guess we’re back to greed.
I’ve often thought some sort of computerized vending machine could do a better job than most psychiatrists.
Or even fortune cookies.
As far as I can see, current practice and formation makes psychiatrists more qualified to be absorbed by anesthesiology than by neurology. The worry that modern psychiatry will become merely applied psychopharmacology is moot – as a branch of medicine it has never been anything else. Current psychiatry – as is overwhelming practiced either in the hospital setting or in private practice – is to ask a few questions and then to prescribe a tranquilizer – major or minor -, a mood stabilizer, an anti-depressant. Whatever is needed to achieve a desirable type/level of numbness. It is undeniable that calming extreme or even moderate agitation can be beneficial. As is the administration of analgesics in the case of physical pain. However the fundamental fact is that the chemicals that psychiatrists prescribe do not cure; just like morphine doesn’t cure anything. At the very least, an honest scientific assessment can’t prove the contrary. That, in fact, is what the core of psychopharmacology and of anesthesiology have in common. I don’t see any real contribution of psychopharmacology to the scientific basis of neurology – the reverse seems to be true for the use of anti-convulsants. If anybody can enlighten me on the subject, please do.
Sandy, I disagree with your description of psychoanalysis as a detour in the history psychiatry. The disagreement probably stems from different definitions of psychiatry. If psychiatry is to denote the study of the physiological causes of disorders, as classified by the DSM, then you’re right, psychoanalysis contributes nothing to psychiatry. But if psychiatry is the discipline of understanding the phenomena so thoroughly enumerated in the DSM, then Freud was, with Kraepelin, one of the founding fathers. In my opinion, though Freud and Kraepelin had extremely primitive conceptualizations, they laid down the two basic ways of understanding variations of the psyche. Psychosis can be caused equally by syphilis or by trauma. Same symptom, radically different causes. Freud was the first to promote the insight that extreme mental states can be the result of a normally functioning mind. The validity – or lack – of his explanatory theories is secondary, it is the psychological approach which matters.
What I consider a “detour” in psychiatry is the evolution of the current ideology espoused by the American Psychiatric Association, NAMI, the pharmaceutical industry, or even the NIMH; what is called bio-psychiatry. Even though science has made enormous progress in understanding some basic biochemical processes of the nervous system, the relation to DSM phenomena continues to be pure speculation. How much longer should we sustain faith and commit so many resources to a project that has so little to show. A project which has been the ideological basis for such disastrous and massive harm to society?
I think the psychiatrists have spent 60 years working with patients who are on their “antipsychotics,” “antidepressants,” “mood stabilizers,” and the likes. And have accurately written a DSM “bible” describing the adverse effects their psychotropic drugs cause. But I do realize such a reality is a hard pill for the psychiatric practitioners to swallow. So is the “bitterest of pills.”
But that comes from a lady whose read thousands of medical journal articles and patient concerns, whose supposed to be a “judge,” according to 40 hours of unbiased psychological career testing (just prior to being drugged). But personally experienced the drugs due to the “dirty little secret of the two original educated professions.”
We should no longer sustain faith or commit resources to an ideology that is the “basis for such disastrous and massive harm to society.”
What I am suggesting is that psychiatry occupy this narrow area of looking for identifiable causes of psychosis and depression (see Jill Littrell’s comment above about untreated urinary tract infections) and that others work in the many other ways that are helpful to people in distress. I do not see why medicine needs to be central in this enterprise. Look at the work of Carina Hakinsson and the Family Care Foundation. They do very good work. I do not think any medical person is involved, at least not in a central way.
It seemed like an accident that psychoanalysis began within medicine. It has never been clear to me that one needs to be a physician to be a psychoanalyst.
I guess this arises from my own ruminations on what psychiatry is.
Fair enough, you reserve the word psychiatry for the study of the physiological causes of DSM phenomena. A branch of medicine. But if the goal is to understand the causes of DSM phenomena broadly – and it certainly is – then we all agree that medicine is sorely inadequate. We agree that medicine is a very narrow portion of what mental “health” services should be about. For every case of urinary tract infection there are ten, or fifty, cases of childhood sexual abuse. That is why the HVN is spreading like wildfire. And it explains the success of Open Dialogue, if you wish.
If not psychiatry, what word should we use to designate the study of DSM behaviors?
I don’t think it was a coincidence at all that Freud started out as a neurologist. Kraepelin’s idea – to systematically classify and to search for medical cures to psychic conditions – was foundational and fit perfectly well with the mission of medicine. At that time I don’t think there existed a distinction between psychiatry and neurology. And psychology didn’t exist as a “therapeutic” discipline. Freud was neurologist who set out and pursued the goal of his profession: to cure “nervous disorders” which were thought to be physiological in nature. That’s where he diverged from medicine.
BTW, I hate the word “therapy” or “therapeutic”, because it presumes the existence of a disease. I think “conflict resolution” is a lot closer to reality. Just like from a social perspective, war is not considered an “illness” for all its destruction and misery, but, on the contrary, natural to the human condition, so it is with the mind when it is at war with itself.
I like your your idea in theory – psychiatry remains (within neurology) as a very small, highly specialist service offering expert advice to screen out the minority of mental health problems caused by physical issues. This would leave the vast majority of distress caused by trauma/life events to be dealt with by much cheaper staff properly trained in various talking approaches. But that would involve a massive shrinkage of the psychiatric profession and an acknowledgement that the last fifty years of pharmaceutical psychiatry have been a damaging theory foisted on society by a profession that has no more idea of causation and genuine treatment than it did 100 years ago.
Psychiatry needs to keep pushing the brain chemistry/genetics/drug necessity angle in order to maintain its power in the system, justify its salaries and retain its identity/kudos as a branch of medicine. As far as I can see psychiatry is not interested in being shrunk to a tiny rump of its current size, only called in for consultation in a small number of intractable cases that don’t respond to other approaches. It wants to keep its pre-eminent position in mainstream mental health services and all the perks that go with that.
The big question for me is how do we move our services to a much more trauma-aware, social-focused talking approach whilst the great big psychiatric monolith is blocking the way and determined not to step aside?
I see a great benefit in having primary care physicians in a community mental health clinic as from what I have read the medical care of those with mental illness diagnoses is very poorly delivered. However, I am having trouble believing that a few mental health personnel scattered in a primary care clinic would have the same effect. The reason for this is when I read the stories of those labeled with mentally illness going for care, their physicians see their diagnosis and either want nothing to do with them, but refer them to behavioral health or they think the patient’s symptoms are all due to their mental illness.
I know a psychologist that was working in behavioral health within a pain clinic who is now in private practice. He was uncomfortable with the way patients were being treated as he did not believe the majority of them were displaying psychosomatic symptoms. If he wasn’t working in private practice, but for a clinic that employed him, would he have told me he found I exhibited no psychological issues, but thought my fatigue was due to a physical illness? I really don’t know.
Please explain why you think this would not happen in an integrated primary care setting.
I wonder how many psychiatrists are left who do both psychotherapy and psychopharmacology? Is it even possible to have both in one visit covered by insurance?
I think Sandra is offering something great. I think it is right on that physicians should not only not be in the lead of what we call mental health care, but should pretty much get out of the way. I agree both that physicians (neurologists) should understand known pathophysiology of of nervous system (and other organ systems) that could lead to psychiatric distress and should make treatment recommendations based on known pathophysiology. I also believe that some doctors (maybe the same neurologists) should know about what we now call psychopharmocology as you say, drug use (psychiatric or otherwise) isn’t going anywhere anytime soon.
The problems I see with this model is it doesn’t make more distinct that that psychiatric drugs are not curative of brain pathology or psychiatric distress. I would fear that combining psychopharmacology and with people who study/treat the physical pathology of what we call mental health issues, we would get the same problems in psychiatry we do now. (Eg. The nerve doctor says there might be something wrong with the chemicals in my brain and gave me drugs that fix them so that I will be better). This model would have to make it known your belief that psychiatric drugs are treatments at best that produce broad effects that probably have little to do with any brain pathology and if they feel good they feel good in the way all “drugs” might feel good. Basically, it was the mix of physician prestige, patient trust, and the “biological” focus of physicians that led to chemical imbalance craziness to begin with. I don’t know how your new psychoneurologists will manage this better than psychiatrists do. It really depends on the big cultural shift that physicians shouldn’t lead mental healthcare and wouldn’t have the prestige effect tainting care.
I agree that what I am suggesting would not address the question of whether or not drugs are effective. And I agree that is a big problem that needs to be addressed. I also agree that this is a cultural problem (and in this sense I mean the general culture as well as the culture within medicine). But at least people would understand what this physician was all about and if a person had no interest in taking a medical approach to his problems, he could go elsewhere for help.
I guess the other concern then is what Chrys has alluded to. This model is predicated on a fully voluntary approach to seeking care when in distress. How would these psychoneurologiss interface with law, commitment, forensic evaluation, etc? Psychiatrists currently have a big role in these areas, precisely because they are physicians and are considered the leaders of mental health care. What would reducing psychiatry to a limited branch of neurology that are not considered the end all of mental health expertise do to the coercive powers/”responsibilities” psychiatrists are currently structured to use? Would a move to such a model you present also require a dismantling of this interface of psychiatric evaluation/diagnosis/assessment with the various legal aspects of psychiatry?
I’m really not trying to knock what you envisioned. I think it is a much better alternative to what we have now. It just requires a lot of structural changes, as you say, generally and within medicine. I’m afraid, however, it is the bigger issues that still make the most difference in this shift of models. Otherwise what we get are consultant neuropsychiatrists that might end up behaving similarly to current psychiatrists.
I only read the concluding paragraph, sorry, it’s a busy time. However I completely agree with the basic premise, as long as neurologists would not have the power to involuntarily or coercively treat people.
I could live with your proposal.
However, I can’t imagine in my wildest imagination that the psychiatrists where I work would even begin to think about embracing such a shift in practice and treatment. Watching the way that they “practice” makes me believe that they would never embrace the idea of decreasing their power and influence over those in their power.
I also believe that we will accomplish little in changing the roles of psychiatrists until we remove the power that insurance companies have over payment for treatment. After all, this was one of the influences that changed psychiatry towards only using the drugs, along with the influx of numerous other specialties in the 1980’s that could practice talk therapy, and the advent of the drugs themselves. It came to the point, from what I understand, that insurance companies would pay for drug maintenance visits but wouldn’t pay for talk therapy visits. It forced psychiatrists who once did therapy into writing scripts for the drugs. I remember reading interviews with older psychiatrists who lamented no longer being able to do therapy because they couldn’t get paid for it. So, they succumbed and began prescribing the drugs. I know one such psychiatrist who refused to succumb to this twisting of arms and closed his practice, period. I never had him as a therapist but those people who used him said that he was one of the most understanding and amazing persons they’d ever met in their lives.
So, it’s not just the drug companies that are culprits in the changing of psychiatry; insurance companies have a great hand to play in all of this too.
What exactly do people expect from psychiatrists when they go and ask for their help? I expected them to be experts not only in easing the symptoms of psychosis – in my son’s case – but also in the underlying causes of that psychosis, be it physical or emotional. I also expected them to know how their meds worked, why they had those horrible side-effects and how to get off them safely. They didn’t know any of it. They pretended that there was no such thing as side-effects and refused to discus ways of getting off them. When I mentioned that my son had been emotionally bullied by his father since he was a toddler, the psychiatrist asked me why I was telling him this- he thought it was irrelevant. I think we need psychiatrists but their training should be changed.
Most psychiatrists have very little interest in trauma and its effects. If they did pay attention to trauma then they couldn’t go around cliaming that our emotional and psychological distress is a product of chemical imbalance or broken brains.
So, they shy away from it and won’t touch it with a ten foot pole. Valid research points to the fact that 80-90 percent of people in the system are trauma survivors but the revolving door in the Admissions departments of “hospitals” continues to revolve and people continue to be brought back because the drugs do nothing to help people deal with their trauma, except to smother it down. When people get off the drugs the pain from the trauma is always there to deal with. It takes a damned great therapist to help people transcend the effects of trauma and since most psychiatrists in psych institutions don’t know the first thing about how to do any kind of therapy people get little or no help for their real issues. This is not about broken brains but about broken spirits. Psychiatrists are of little value or help with any of this. I’d rather have a skilled and compassionate chaplain anytime than I would a psychiatrist.
I do not agree with this statement. I think there is ample evidence that there is intense interest in trauma within the psychiatric community. The concept of post traumatic stress disorder is misleading in that it seems to imply that that particular syndrome is the only antecedent to trauma. I also thin there is a general discounting of the role of trauma on some disorders (schizophrenia) in comparison to others.
Well here goes… I would have to disagree..
I was heartened to think that psychiatry would die, because of the carnage it has created in millions of peoples lives… and yes… I know there are many caring psychiatrists who try their best to help people…
But prescribing psychiatric medications to people does not help them but in fact makes them much worse, in the long run….and when I say much worse it destroys them mentally…
At this point there is no idea of what causes mental illness, or emotional problems by the psychiatric profession, or anyone for that matter.
So therefore treatment is only a shot in the dark. Above all else medical training itself has become abysmal with medical mistakes being the third leading cause of death in this country.
So, is a medical degree better equipped to deal with mental illness… I think not. When hospitals routinely fail to screen for UTI’s, because they know a positive test for a UTI, can jeopardize an admit for Dementia, if one is found.
I am not going to make any excuses for psychiatry. My experience encompasses many tens of thousands of case reviews…Its been my experience that the only way people really get better is to treat themselves, or find someone who rejects the medical model of psychiatric care.
The usual progression of care is something like this, mild causes of depression, getting worse through the years as doses of anti depressants are increased, and stronger and stronger medicines are introduced. When finally medicines fail, ECT is introduced, and sessions are increased over the years until so called “Weekly maintenance” ECT sessions are arrived at.
Whats left at the end is no person, and nothing that will help.
Until there is an understanding of what causes mental illness, if it can even be called that. Then treating it is just a guess, and a dangerous one at that.. One that often results in death, and disfigurement, and little consequences, to the person, who really didn’t know what they were doing..
Regarding my previous post, I guess I should learn from this to never comment before reading the entire article.
Psychiatric drugs are tools of suppression, not liberation. Their use in any context should be understood as at very most a toxic crutch from which one must wean oneself at the earliest possible point. If life weren’t so traumatic, as is guaranteed under capitalism, we wouldn’t be so quick to suppress our feelings and memories, be it with drugs or via other means.
So no, neurologists handing out Ritalin is no better than shrinks doing the same.
PS When I said ‘at very most a toxic crutch” I meant “at very best.” (Wish we had an edit feature here.)
I do not think I have been clear and perhaps this is a silly conceit anyway but here goes again:
This particular blog was not focused on the pros and cons of drugs. I have articulated that elsewhere and my views have not changed. This is not promoting them; it is conceding that they are not likely to go away. I am clear that drugs should play a small role.
It is a thought experiment on how we might make it clearer to everyone, what one gets when one consults a psychiatrist. It is also addresses how we utilize the expensive resources – and consequent expensive time – of those who choose to consult to people who experience altered states.
It also offers a suggestion on where medicine should stand – and what influence it might have – in this arena of human experience.
So my thought is that drugs should be limited but people will seek them out and someone in medicine should try to understand them.
It proposes that medicine should remain peripheral to the entire enterprise of helping people in emotional distress.
I have this notion that if it clear how little medicine has to offer, this would result in limiting the power and authority that medicine (in the guise of psychiatry) has been given in our society.
I would have to disagree, again. I think that psychiatric drugs will go away…
The public is becoming more aware of just how dangerous they are and how much damage they cause….and have caused.
I also think that if there is to be a profession of psychiatry in the future the sooner that psychiatrists begin to realize this the more likely they will have profession in the future.
Thanks for stating this again. What kinds of responses do you get from your fellow psychiatrists when you propose this plan? I agree that medicine should remain peripheral to the entire enterprise of helping people in emotional distress. How do we get the public to see this so that we can begin limiting the power and authority of medicine in all of this?
Re: my colleagues: I do not think they pay too much attention to me.
Re: changing public opinion, I do not know. I think people seemed temperamentally predisposed to like or dislike medical models. The the people who have direct experience, make up their minds based on their experience. There is so much discord in the field, it is hard to gain traction for any one perspective.
What do you think of people that have been through it, taking care of their own?
Sometimes I think that is the only way. After people see it working, then they will believe there is an alternative.
I think highly of this.
Excuse me, but I am of the opinion that people are dying 10 -25 years earlier than the rest of the population in the mental health system because of the drugs they are being prescribed, not despite those drugs. We have psychiatrists comparing neuroleptic drugs for psychosis to insulin for diabetes as a measure to insure compliance. Problem is, neuroleptic drugs cause diabetes. What comes of this badgering? People with alleged “seriouse mental illness” labels and diabetes who are taking both insulin and neuroleptic drugs. Insult has been added to injury. “Collaborative care” is just one more insult. Now psychiatrists are going to collaborate with other physicians in treating the damage that they have done to their patients. Were we to stop the damage, the need wouldn’t exist. If you want healthy patients, you will only get them through prevention, and if you are effective at preventing further injury, the idea of “collaborative care” becomes redundant.
Sandy, Thank you for your comments.
I am trying to synthesize your train of thought in this post. Here’s what I come up with:
1. Some of the behaviors/mental states modern psychiatry addresses sometimes have physiological causes.
2. In many circumstances physiology fails both as an explanatory theory of, and as a therapeutic approach to, such behaviors/mental states.
There is no controversy on the first point, it is a fact that psychiatrists and anti-psychiatrists can agree on. Should persons displaying DSM behaviors be routinely screened for infections and endocrine disturbances? Sure. Should there be a separate medical branch that specializes in analyzing lab tests for possible mental ramifications and then refer patients to other pertinent specialists to address root causes? Why not? That branch might be appropriately called psychiatry. I don’t know of any UTI deniers and if there are, they’re really fringe (I find Jill’s 35% very hard to believe though).
Regarding the second point I don’t think any commenter on MIA will argue that you are wrong. However, I sense many of the comments have a disapproving undertone – including my own – even if we agree with you on the fact. Szasz defined the medical model paradigm as a construct whose ultimate goal is not to improve the human condition but rather to serve as an amoral instrument of social control. To the many readers of MIA who have been profoundly abused by the psychiatric system, there is an extermination campaign going on out there. A statement like “People are very confused about what psychiatry is” can easily taken as not only condescending but offensive. Sandy, I know it is not your intention to offend and I truly respect your honesty and don’t doubt for a second your value as a practitioner. But what you describe in this post is a highly utopian image of psychiatry which is beyond reproach, and like all utopians, you seem oblivious to the reality of the ideological war in our midst.
Re: “People are very confused about what psychiatry is”; “People” in this sentence is the general public.
I do not think this essay glorifies psychiatry as it currently is. This is a suggestion of how to place the role psychiatry has come to have within the larger framework of medicine and then where to place medicine within the larger framework of offering help to those who suffer in the myriad ways we have come to label “mental illness”.
While I think there is a huge role for service users/ experiencers to play in offering their compatriots, I also think there is a role for those with professional training. Perhaps we disagree about this.
However, I just do not think the vast majority of those trained professionals need to have gone to medical school. I think it is a waste of time and I think it ends up being very confusing on many levels
In addition, psychiatry as currently conceptualized by leaders of our field seems like a subspeciality of neurology and I think it might be clearer for people to think of it that way. It might alter (and lower) expectations when one walks into our offices.
It isn’t going to happen in my lifetime, but I like the idea of just ending psychiatry. We don’t need psychiatrists to evaluate for physical causes of mental status change as this can be done by internists, neurologists and other medical specialists. Fundamentally, psychiatry is an assembly line for giving people drugs willy nilly, with no meaningful guidelines or informed consent. The world is a complex place, and one cannot say that some people’s lives are not actually improved because of their prescribed drugs. Still, looking at the big picture, the world would be a better place if psychiatry as it is practiced today did not exist at all.
Old article indeed.
“When I have discussed this with colleagues, there are several responses, none of them good. The primary objection is that I am dismissing humanism and promoting a largely neuroscience based understanding of human suffering. To be clear – I am not suggesting that all problems currently falling under the label of extreme distress or mental illness be solely treated by these neurologists. Far from it.”
I see where you are going with this, but I think that we are proposing that physicians and neurologists can diagnose “mental illness” and so they do, quite regularly. As it stands now, 60% of psych drugs get funneled through MD’s. And to put “IT” the symptoms on neurology is obviously not going anywhere, since that is pretending that neurology is more than rudimentary science, as we speak now, and look back in 100 years. Any good scientist should know that we have very limited knowledge.
So what neurology does in the case of not “seeing anything”, the subjects get sent to a shrink. Absence of seeing and knowing is “mental illness”.
Physicians do the same thing. In fact, physicians now treat absence of knowing with AD’s.
Can a 2 year old spot depression? Of course. Does this mean it needs to have collaborative care? What is that collaborative care?
Really and truly, ALL suffering that is not seen and known could be handled by “social workers”.
It is just time, plain and simple to just say “WE DON’T KNOW” and follow with, “We refuse to partake in abuse and worsening QOL”
That is the truth.
Obviously if neurology just stood in the corner, quitely, it could be good, but they don’t. They send their patients to psychiatry. And the public continues to believe that science is real. Neurology and psychiatry both know equally much about “the brain”. Nothing. Nothing that affects behaviours and symptoms, or unhappiness.