We Need More Unapologetic Psychiatrists…..

 

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