I am not sure he would agree with the characterization but I came up with this title when I decided to comment on Daniel Morehead, MD. I have never met him but I have read everything he has written in the Psychiatric Times. He is director of residency training in general psychiatry at Tufts. In the most recent column, I notice the heading Affirming Psychiatry – that I wish I had thought of. That was one of the primary goals of this blog when I started writing it 13 years ago.
This month’s column was titled Psychotherapy: Lies Cost
Lives (1). He starts writing about a
New York Times column about psychotherapy that starts positive but rapidly
shifts to ambivalent. He points out that this is characteristic of most
headings that have to do with psychiatry and speculates about the origins. Controversy, mouse clicks, and advertising
dollars for sure. He lists several
titles and several themes of articles that with similarities and points out the
only logical conclusion:
“The take-home message is that psychiatry rests
on shaky foundations and does not quite know what it is doing, rather like
someone feeling their way through a darkened room. Psychiatry, as usual, lags
behind the breezy confidence of other medical fields, where no one wrings their
hands about whether antihypertensives really work or whether surgery is just a
lingering form of inhuman medieval butchery.”
That is certainly one way to describe journalistic
gaslighting. I have offered several explanations for it on this blog. First, folk psychology. Trying to figure out
basic motivations and behavior of the people we encounter on a day-to-day basis
is an adaptive human skill. Many people
think that psychiatry is therefore just common sense and that anyone can do it
– at least until they encounter problems severe enough to where that level of
common sense fails completely. Second, there is the impression that anyone who prescribes psychiatric medications is basically equivalent to a psychiatrist. That is a trivialization of the psychiatric skill set and training. Third, antipsychiatry is a cottage industry in the US and other countries and our
detractors have had an inordinate amount of success in getting their rhetoric
published in both the popular press and professional publications. The previous
post on this blog was all about that. There are no other equivalent movements
attacking other medical specialties even though their good outcomes are
equivalent and their bad outcomes are generally much worse. Fourth, , the reality is that about 40,000
psychiatrists go to work every day in the US.
The demand for psychiatrists is high. That demand is fueled by
successful treatment and a niche that is unfilled by other medical staff. Fifth, at least part of that demand is because
psychiatrists have unique skills. We are the treatment providers of last
resort, and other specialists know that and refer patients at all levels of
acuity. The only way that happens is if you know what you are doing.
Psychotherapy is part of that skill set and that is the focus of Dr. Morehead’s column. The science is there, even though there is a constant debate about clinical trial design and replicability. Specific brands of psychotherapy have been investigated and shown to work. There is also research into important non-specific factors in psychotherapy that branded therapies have in common. Even more basic than that are the interviewing techniques and courses taught to second year psychiatric residents focused on facilitating information exchange with patients for both diagnostic formulation and intervention. Communication is a critical skill in psychiatry. In this era of checklists, screening, and electronic health records – it is easy to forget there is a much larger set of important information and like all things it requires a lot of training to do it right. It is that body of information that allows for the treatment of each patients as a unique person. Personalized medicine has become a buzzword lately but from a communication perspective psychiatrists have been providing that for decades.
These basic skills in
talking with people and talking in therapeutic ways are hardly ever mentioned
in discussions about psychiatrists. Criticism of psychiatry commonly seeks to
portray psychiatrists unidimensionally - as excessive prescribers of medication
rather than communicators. Throughout my
career the number one reason I was consulted was to establish communication
with a person and figure things out where nobody else could.
Even in the case of prescribing medications, there is
typically a lot more going on than a discussion of medications. One of my colleagues
established the largest clozapine clinic and long-acting injectable medication
clinics I have ever seen. When he moved
on, his patients asked me regularly where he was and how he was doing. They valued the relationship with him even
when he was providing a unique medical service. Ghaemi has written about existential
psychotherapy and how it can occur during appointments that are medication
focused (2,3).
The overall message that Dr. Morehead is trying to convey
is that psychiatrists cannot let others characterize what we do. When that happens there are multiple agendas
operating that can lead to the clear distortion that psychiatry is not quite up
to the level of other medical disciplines.
There is typically an overidealization of those other branches of
medicine with a focus on innovations that often do not materialize. The real message rarely gets out and that is –
psychiatrists are uniquely trained, we are interested in problems that nobody
else is and that other physicians often avoid, and we are good at what we
do. It is highly problematic that
journalists seem reluctant to get that message out to the public. When I first
read Dr. Morehead’s writing I found it refreshing because there are very few psychiatrists who want to get that message out. Most will cave in to
the first suggestion of a level of uncertainty that every specialist in
medicine has to deal with – the persistent risk no matter how small and the
lack of a guaranteed outcome.
I look forward to a new generation of psychiatrists who can
start to set the record straight.
George Dawson, MD, DFAPA
Supplementary:
Decided to add this explanation anticipating the typical criticism: “Well he is arrogant isn’t he? We always knew he was arrogant. All psychiatrists are arrogant!” When I say unapologetic – I mean unapologetic
for just existing and trying to help people. That is the level that psychiatrists are forced
to operate at that no other medical specialist is. There are the usual
misunderstandings, errors, and adverse outcomes in psychiatry that there are in
any other medical specialty. There are psychiatrists who are burned out, forced to practice in a way that they would rather not, and even personality disordered - just like any other specialty. But in
those other specialties the assumption is that these problems are handled on a case-by-case
basis by the responsible physician, clinic or hospital administrative structure, or medical board. There is no similar assumption in
psychiatry. Instead, there is an
assumption that the entire profession can be condemned for some adverse
outcome, unprofessional conduct, historical event, or any unreasonable criticism that someone can
come up with. As I have pointed out in the previous post - many criticisms are fabricated or just absurd.
So when you read these unrealistic criticisms about
psychiatry in the papers – keep in mind that there has been a doubling down on
the rhetoric unlike what happens with any other specialty in medicine. Use that
knowledge to moderate your reaction to it.
References:
1: Morehead D. Psychotherapy:
Lies Cost Lives. Psychiatric Times 40(11).
Published online on November 10, 2023
https://www.psychiatrictimes.com/view/psychotherapy-lies-cost-lives
2: Ghaemi SN.
Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger.
American journal of psychotherapy. 2001 Jan;55(1):51-64.
3: Ghaemi SN, Glick
ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical
Practice: Advocating a Humanistic Approach to the" Med Check". The
Journal of Clinical Psychiatry. 2018 Apr 24;79(4):6935.
Photo Credit:
Many thanks to Eduardo Colon, MD
