Not Boring At All

Today I want to urge again that if you have an interest in what has happened in mental health and psychiatry, please read 1boringoldman because no one that I am aware of is digging into the research reports and critiquing them as he has and continues to do so. And he is not the least bit boring.

Most recently he wrote about the continuing protests from psychotherapist groups over the proposed DSM V. Psychologists in both the US and Britain along with the American Counseling Association have circulated petitions and sent letters of concern to the American Psychiatric Association. That diverse professional groups agree is in itself remarkable but the APA seems to be hoping to brush aside this concern by tagging them as coming from those who are "anti-psychiatry." And I suppose if being anti-psychiatry means I am opposed to excessive medication, proliferating diagnoses, and control of research by drug companies, that would describe me at least.

He ends today's post with this:

 ...it’s unclear to me why there’s so little psychiatric noise about the DSM-5. Are we simply settling for our lot and waiting to retire? My guess is that it’s a bit more complex than that. The everyday psychiatrist has been hammered for decades having to readjust to the role of medication manager for others – out of the role of primary care-giver. Hospital psychiatrists have only a few days to adjust medications before the "days" run out. My guess is that the general gist of attitudes might be in the range of "demoralized." Who cares about the DSM-anything? It’s just a number for the form. Office psychiatry has become more bureaucratic and administrative than medical. And the bruhaha about the DSM-5? Just some more anti-psychiatry. Create a specialty that is only allowed to medicate, then complain about medication. A specialty only reimbursed for short visits, then complain about short visits. I expect that’s how things must feel to many who have adapted to the modern world of medicine. It’s a shame…


I think one reason so few psychiatrists have chimed in is the issue of turf and professional identity.  Each of the two, psychology and psychiatry, needs some claim to uniqueness, some specialness of knowledge in order to claim space in the arena. Add to that the largely unconscious issues of esteem about whether or not either is a "real" science or "real" medicine and the ground is well prepared for what has happened. 

In psychology, subjectivity has long been suspect among behaviorists. I can remember one telling me in graduate school -- and this was over 35 years ago -- that self-report was unreliable and not worth gathering. And American psychiatry has never been especially hospitable to psychology -- it wasn't until 1988 that psychologists were admitted to psychoanalytic training in the US, and that only after a lawsuit forced the issue. My former husband, who is also a clinical psychologist, used to hear regularly from his grandfather that he should go to medical school so he could become a "real doctor" not just a psychologist. 

In a curious way, the interests of modern psychiatry and clinical psychology have found common ground in their mutual desire to push subjectivity and the knowledge gained from years of research in psychodynamics out of consideration in treatment today. Each has embraced the so-called evidence-based model, concentrated research on outcome reports and on medication and short-term therapy to the exclusion of anything else. Add to this the push on the part of a significant segment of clinical psychologists to become prescribers and the two become ever more similar, though not, I believe, in the best interests of their patients.

A while back, Daniel Carlat proposed blending psychiatry and clinical psychology. Carlat favors psychologists gaining prescribing privileges but as a part of what he would propose as a rather sweeping change to the training of both psychiatrists and psychologists.nHe would have them train together with psychiatry leaving behind those aspects of medical education that he sees as not relevant to psychiatry -

I suggest that the process begin with a work group created jointly by the American Psychiatric Association and the American Psychological Association. Yes, let’s get psychiatrists and psychologists in the same room, and reverse engineer an ideal curriculum for integrative psychiatric practitioners. Let’s face it, going to 5 to 7 years of psychology graduate school, then capping is with 2 years of psychopharmacology is not an efficient use of training resources. It’s almost as ridiculous as going to four years of medical school, one year of medical internship, then three years of psych residency.


There must be a middle path—perhaps a five year program that would interweave coursework in physiology, pharmacology, and psychology from day one. The specifics would require much thought and discussion, and would best be done by reverse engineering. Start with the ideal psychiatric practitioner, list the core competencies such a person requires, and then figure out the very best way to teach those competencies.


As I wrote then, certainly that is an intriguing possibility. But how would not the market forces continue to work in this new blended profession in the same way that it has in psychiatry? I recall a study in which it was shown that a psychiatrist doing a medication only practice, seeing 3 or 4 patients per hour could easily earn 57% more than one who spends a significant amount of hours seeing therapy patients. Why believe that members of this blended profession would be immune to this kind of economic incentive? And, given that third party payers are already biased away from therapy to medication, why would they change their position?

I think what we see here is the confluence of a couple of issues underlying the old turf battle. For psychologists to gain prescribing privileges, they become more like "real" doctors, which as everyone knows can and do prescribe medicines. So it addresses an old inferiority contained within the profession. 

Psychiatrists have pretty much abandoned psychotherapy -- many residency programs provide very weak training in therapy these days -- in favor of a model rooted more firmly in the medical model. As non-medical professionals gained the right to practice psychotherapy, doing so began to carry less prestige for physicians already in a specialty often derided by their more "medical" colleagues. Abandoning psychotherapy for psychopharmacology and a brain illness model has allowed psychiatrists to be "real" doctors.

But now the psychopharmacological enterprise has fallen under a cloud with the problems of compromised researchers and the emergence of data suggesting that the medications perform much more poorly than thought. Which begins to make psychotherapy more attractive again. Maybe.

We are a motley lot, we psychotherapists are. We all do something similar but we come from a number of different professional directions -- medicine, psychology, social work, nursing, education. And we have varying degrees of identification with our basic professional group. I suppose this diversity of backgrounds is a strength of sorts but I believe that more and more it is a hindrance. Because we do not speak in a unified voice for ourselves and what we do. We engage in meaningless turf battles which has resulted in control of much of the field now resting with insurance companies and managed care rather than with those of us in practice.

A lot of psychotherapists have become kind of demoralized in the last 10 or 15 years as third parties have come more and more to determine what they could do. As therapy per se becomes less and less valued by these third party payers, incomes have dropped and some community clinics no longer even offer therapy at all. I suspect this will continue to be the case for those who practice in clinic settings or are dependent on insurance payments. A practice model which doesn't work all that well for physical medicine when applied to mental health and therapy becomes ludicrous, a mess of evidence-based treatments that aren't resting on good evidence, on outcome research that is only done with one modality. And on it goes.

And this is mostly our own fault -- or at least the fault of the folks who reman inside that system and who cling so stubbornly to turf that is shrinking by the day.

The siren song of money will trump any of this. And so long as volume of patients yields the most income, psychotherapy will be honored more in the breach than in practice. And as long as we have direct-to-consumer drug ads telling people that the answer to life's ills lies in medication, then patients will expect that and balk at the longer course of psychotherapy.








© Cheryl Fuller, 2007. All  rights reserved.