Waffling - A Rare Window Into Psychiatric Advocacy

 

Consider the following thought experiment:

[Ask yourself if you can think of a well-known proponent of psychiatry.  And if you can is there is a list of proponents as available to your thought process as the easily recalled list of detractors.]

First of all – Congratulations to the author for coming up with that thought experiment and wish I had thought of it myself.  Most psychiatrists are hard pressed to think of a single name.  The proponent  that came to my mind was Harold Eist, MD the only American Psychiatric Association (APA) President I recall who was a staunch advocate for front line psychiatrists, patient privacy, quality psychiatric care and the only outspoken critic of managed care.  But beyond that – nobody comes to mind. I have certainly worked with and become aware of first-rate clinicians, teachers, and researchers – but all of that seems to end when it comes to facing the withering attacks of many against the profession. At that level – the thought experiment is an immediate success.

This thought experiment was proposed by Daniel Morehead, MD in his article It’s Time for Us to Stop Waffling About Psychiatry in the December 2 edition of the Psychiatric Times.  He proposes the experiment after presenting a small sampling of the inappropriate and repetitive criticism against the field.  I started writing this blog with a similar intent and noted from the outset that responding to antipsychiatry rhetoric often resulted in attacks not from the originators of the diatribes – but often psychiatrists themselves. I was contacted by an expert in antipsychiatry philosophies who advised me that it was apparent that many psychiatrists seemed to have self-hatred and associated hatred of the specialty that they were practicing.  I viewed that as somewhat harsh – but did acknowledge a tendency towards self-flagellation as typically evidenced by acknowledging responsibility for criticisms that had no merit.

In Dr. Morehead’s paper – he reviews examples of attacks that nobody in the field seems to respond to and the resulting potential damage.  In his bullet points he lists the political arguments about biological versus psychosocial models of illness and treatment, the familiar identity crisis that only psychiatry seems to have, the accusations of corruption and conflicts of interest, books that describe psychiatry as either a completely failed medical specialty or one struggling for legitimacy as a medical specialty, psychiatric diagnosis is routinely attacked, and medications that have led to deinstitutionalization and have literally saved the lives of hundreds of thousands of people are vilified.  And that is a short list.

His conclusion that these criticisms “generate an image of psychiatry that is both wildly distorted and profoundly destructive” is as undeniable as his observation that there are rarely any responses to these diatribes from psychiatrists or other physicians. I would actually take it a step further and suggest that in many of these cases psychiatrists or other physicians are in the habit of piling on even in cases of the most extreme unfounded criticisms.  In fact, you can find many examples of this in the comments sections of my blog.  In the body of his paper Morehead takes on three common criticisms that are often viewed as definitive by people outside the field including the memes that psychiatric illnesses are somehow less real than physical illnesses, psychiatric medications make conditions worse, and psychiatrists are biological reductionists who are only interested in prescribing pills and some pharmaceutical company conflict of interest makes that bias even worse. I have addressed all of these fallacious arguments and many more on this blog. Morehead certainly provides adequate scientific refutations to these memes and concludes that:

“We live in an intellectual culture that has habituated the public to think of psychiatry as flawed, failed, corrupted, and lost.”

If only that were true. I think what most psychiatrists (and physicians in general) fail to grasp is that these endless arguments have nothing at all to do with science or an intellectual culture. In fact, the best characterization of these arguments is that they are anti-science, anti-intellectual, and rhetorical. Because this is a political and rhetorical process these fallacies give the appearance that they can’t be refuted. Those advancing these arguments seem to “win” – simply by repeating the same refuted positions over and over again.  In some cases the repetition goes on for decades - as long as 50 years! This tactic is a time honored propaganda technique and I would not expect it to go away by confronting it with science or the facts.

We have seen this clearly play out in other medical fields during the current pandemic. Government scientists who have been long term public servants are attacked and attempts made to discredit them – not on the basis of science, but on the basis of rhetoric.  The attacks are not made by scientists but most frequently by people with no qualifications, attempting to rationalize their attacks by whatever information they can glean from the internet or just make up. In some cases – the conspiracy theories being advanced are the same ones that psychiatrists observed in the late 20^th century as applied to some clinical conditions.  Many of these attacks have gone from anti-science attacks to attacks on a personal level including threats against the scientist or his family. Financial conflict of interest can be significant as anti-science stars take on celebrity status floating for profit social media and mainstream media companies. Sponsors and believers in the anti-science message flock to these sites and generate significant revenues to maintain the message and the celebrities.  This discourse is the farthest possible from an intellectual endeavor.

This same anti-science and anti-intellectual posture is working against psychiatry and it has similar roots in the postmodernist movement.  Postmodernism was basically a movement against realism and in the case of science - facts.  Postmodernist discourse emphasizes relativism and an inability to construct reality.  One of the best examples is history. A postmodernist approach concludes that due to the limitations of language – actual history is not knowable.  The historian is merely telling one of many possible stories about what really may have happened. That has popular appeal as it is commonly acknowledged that history as taught in American schools clearly omitted a lot of what actually happened to and the contributions made by large populations who were marginalized by racist ideology.  That is as true in medicine as in any other field. But does that mean that the limitation of language and the application of current social constructs make the study and recording of history unknowable? Probably not and the problem with postmodernism is how radical the interpretation – can it be seen to encourage skepticism rather than outright rejection for example.

In the case of science as opposed to history, philosophy, and the arts – postmodernism does not have similar traction. The main features of science including an agreed upon set of facts irrespective of demographic or cultural features and science as a process does not lend itself to political or rhetorical criticism.  In the case of psychiatry, that is not for a lack of effort. The continuous denial that mental illness exists for example stands in contrast with the cross cultural and historical observations that severe mental illness clearly exists, that it cuts across all cultures, and that there is significant associated morbidity and mortality. It is however a classic example of postmodern criticism that it often suggests mental illness is really a social construct to maintain the power structure in society. The associated postmodern meme is psychiatry as an agency for social control over the eccentric defined as anyone who does not accept the predominate bourgeois narrative.

I first encountered this idea when I critiqued a New York Times article about the DSM-5 that suggested it was a blueprint for living (2).  That is an idea that is so foreign to any trained psychiatrist aware of the limitations of the DSM that it borders on bizarre.  And yet – here was a philosopher in the NYTimes making this claim along with several defenders in the comment section. At the time I was not really aware of this postmodernist distinction and responded just from the perspective that it was a statement that was not based in reality. Nonetheless, there were several defenders of the statement.  In retrospect all of this makes sense. Postmodernist critiques can amount to mere rhetorical statements. If you believe that reality is merely a battle of competing narratives – blueprint for living becomes as tenable as the reality of the DSM – a restricted publication with obvious limitations to be used only by trained individuals in a restricted portion of the population for clinical work and communication with other professionals. The large scientific and consensus effort is ignored – as well as the fact that societal control over anyone with a mental illness is the purview of law enforcement and the court system.

Similar repetitive postmodernist arguments are made about all of the examples given by Morehead in his paper.  For psychiatrists interested in responding to this repetitive and inappropriate criticism – it is important to respond at both the content level as Dr. Morehead has done but also the process level because the process level is pure post modernism and at that level realism or the facts on the ground may be irrelevant.

That brings me to what I would refer to as a second order criticism. Suppose you do respond to the criticism as suggested and suddenly find yourself being criticized by the same peers that you hoped to support?  Let me cite a recent example. Drapetomania is another criticism leveled at both psychiatry and the relationship that modern psychiatry has frequently claimed with Benjamin Rush, MD – a Revolutionary War era physician who has been described as the Father of American Psychiatry.  Of course, Rush was never trained as a psychiatrist because psychiatry was really not a medical specialty until the early 20^th century.  He was really an asylum physician with an interest in mental illness and alcohol use problems.  He also advised Gen. Washington on smallpox vaccinations for his troops and treated people during Yellow Fever outbreaks. In other words he functioned as a primary care physician at the time.  Drapetomania and Dr. Rush are connected though a meme that suggests that the southern physician who coined the term also “apprenticed” with Rush.  Drapetomania was proposed as a diagnosis by Samuel Cartwright to explain why slaves running away was a sign of psychopathology rather than rational thinking. Cartwright himself was a slave owner and there was widespread interest among his peers in racial medicine. Despite this peer interest and the Civil War being fought around the issue of slavery – nobody ever used the diagnosis. It was openly ridiculed in some northern periodicals and largely ignored in the racial medicine publications. Rush was affiliated with the University of Pennsylvania Medical School over the course of his career and Cartwright graduated from a Kentucky medical school.  There is no evidence he ever matriculated at Penn or met Rush.  Despite that history drapetomania has been consistently marched out as a psychiatric “problem” and evidence of a failed psychiatric diagnosis for the last 40 years.  The implicit connection with Rush is also made – suggesting that as a mentor he may have had something to do with the racist pseudodiagnosis.

I did a considerable amount of research on drapetomania and connecting of Cartwright to Rush.  I was very fortunate to have definitive work available to me from Rush biographer Stephen Fried (4) and historian Christopher D. E. Willoughby (5).  The details of all of that research are available in this post that illustrates the lack of connections of drapetomania to Rush and psychiatry but also a very long period of time where it was not actively discussed.  Szasz (6) resuscitated the word when he published an article in 1971 that essentially concluded: 

“I have tried to call attention, by means of an article published in the New Orleans Medical and Surgical Journal for 1851, to some of the historical origins of the modern psychiatric rhetoric. In the article cited, conduct on the part of the Negro slave displeasing or offensive to his white master is defined as the manifestation of mental disease, and subjection and punishment are prescribed as treatments. By substituting involuntary mental patients for Negro slaves, institutional psychiatrists for white slave owners, and the rhetoric of mental health for that of white supremacy, we may learn a fresh lesson about the changing verbal patterns man uses to justify exploiting and oppressing his fellow man, in the name of helping him.” (4)

If you feel somewhat disoriented after reading that paragraph it is understandable. Szasz not only uses an example with no connection at all to psychiatry, but he creates a completely false narrative by using Cartwright’s racist work as a metaphor for psychiatry and then accuses psychiatrists of being rhetorical. This unbelievable screed was published in a psychiatric journal and the Szasz meme has continued in all forms of media since that time. It also happens to be a classic postmodernist technique of essentially making up a competing narrative and then writing about it like it is true.

Post-modernist memes like this invention by Szasz essentially cut across all of the inappropriate criticisms covered by Dr. Morehead and more. They are basically a vehicle for anyone with no knowledge of psychiatry to bash the field repeatedly over time and recruit like-minded postmodernists to do the same. The best examples of this process include the historical memes dating back to a time before there were any psychiatrists and the familiar themes of identity crisis, chemical imbalance, antidepressant withdrawal, epistemic injustice, psychiatric disorders as disease states, biological reductionism, the Rosenhan pseudo experiment, and more.

These memes are complicated by the fact that psychiatrists themselves are probably the only predominately liberal medical specialty and post modernism has an uneasy relationship with liberal or left-wing politics and overtly Marxism. This may leave many psychiatrists on the one hand feeling that their specialty is being inappropriately criticized, but on the other feeling like the criticism is justified on political grounds – even if it is grossly inaccurate or just made up. As long as it seems to be a liberal criticism, they support it. This may be the reason why the drapetomania meme was included as a legitimate topic in a recent American Journal of Psychiatry article on systemic racism (7).  It may also be why when I attempted to present my drapetomania idea another psychiatrist objected on the grounds of “social justice”.  How is a groundless accusation leveled against the profession a measure of social justice?  

In order to stop waffling, these complex relationships and the rhetoric of post modernism needs to be recognized. As I hope I pointed out – it is as unlikely that these memes will respond to factual refutation any more than I would expect antivaxxers or COVID conspiracy theorists to respond. A basic tenet of postmodernism is that the facts or actual history can never really be known with any degree of accuracy and it is always a matter of competing narratives. That may work to some degree in the case of disciplines where relativism exists, but it does not work well in medicine or science.

There needs to be a far more comprehensive strategy to counter postmodern rhetoric and its use against psychiatry. It needs to be limited in scope at first. It should be recognized in psychiatric publications so the memes are stopped at that level. Drapetomania is a prime example, but as noted above there are many others.   Trainees and residents in psychiatry need to be aware of this rhetoric in order to avoid confusion and demoralization. During an era when we are all more aware of our biases than at any other recent time, political biases that lead to acceptance of inaccurate rhetoric at the cost of the profession also needs to be recognized.

If that can be done – the waffling will be over.

 

George Dawson, MD, DFAPA

 

References:

1: Daniel Morehead. It’s Time for Us to Stop Waffling About Psychiatry. Psychiatric Times December 2, 2021. Vol. 38, Issue 12.

2: Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

3: Gutting, Gary and Johanna Oksala, "Michel Foucault", The Stanford Encyclopedia of Philosophy (Summer 2021 Edition), Edward N. Zalta (ed.),  https://plato.stanford.edu/archives/sum2021/entries/foucault/

4:  Fried S. Rush: Revolution, madness & the visionary doctor who became a founding father. Crown Publishing Group, a division of Random House LLC; New York, 2018

5:  Willoughby CDE.  Running Away from Drapetomania: Samuel A. Cartwright, Medicine, and Race in the Antebellum South. Journal of Southern History
The Southern Historical Association Volume 84, Number 3, August 2018 pp. 579-614; 10.1353/soh.2018.0164

6: Szasz TS. The sane slave. An historical note on the use of medical diagnosis as justificatory rhetoric. Am J Psychother. 1971 Apr;25(2):228-39. doi: 10.1176/appi.psychotherapy.1971.25.2.228. PMID: 5553257.

7: Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. doi: 10.1176/appi.ajp.2021.21060558. PMID: 34270343

Graphic Credit:

Wikimedia: CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/, via Wikimedia Commons" https://commons.wikimedia.org/wiki/File:Waffles.png https://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Waffles.png/512px-Waffles.png

The Kenosha Trial

 

I watched the Rittenhouse trial closing arguments on 11/15/2021.  Let me preface these remarks by saying that this post is not a commentary on the guilt or innocence of the defendant.  It is not a commentary on his behavior, speech, or mental status.  It has absolutely nothing to do with psychiatric evaluation or treatment. This post is all about common sense and how that has been suspended in the United States - especially over the past 10-20 years.

This post is about open carry laws in the United States. Open carry laws make it possible for people to carry firearms publicly without risk of arrest or search for merely having possession of those firearms. The original intent of these laws was to reduce the risk to hunters and target shooters when they were transporting their firearms home.  There are still regulations in many states about how those firearms need to be transported but the original open carry laws were to make sure that there was not a problem carrying the firearms to the home where they would be stored.

Over the past 10 years, we have seen a striking change in how firearms are carried in public and it is the direct result of these open carry laws. The most striking change has been the appearance of heavily armed men open carrying military style semi-automatic rifles and handguns. They were also often wearing bullet proof vests, body armor, and helmets. In some cases, they were also disguised so that their facial appearance was obscured.  Some of these groups were self-identified as militias or paramilitary groups.  Militias always have a sacred role in firearm debates in the United States because when the Second Amendment was written and approved 230 years ago – this was the wording:

“A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

The Second Amendment is interpreted unambiguously by gun advocates as a Constitutional right to own firearms and the most open interpretation is firearms of any kind and as many firearms as a person wants.  The sheer number of firearms possessed by Americans is a matter of public record available in many places so I do not plan to repeat it here. Record gun violence in the United States is also a matter of public record due to suicides, homicides, and accidental deaths.  The United States also has record number of mass shootings each year that can also be found in the public record and I will not repeat it here.   

For now, I want to briefly focus on the concept of militia and the idea that it is well regulated.  Militias are defined as able bodied residents between the ages of 17 and 45 years old who can be called to defend a specific state or the United States.  Private militias acting outside of the federal code definition are illegal.  That includes all groups who are not called to duty by a state governor or the federal authorities.  Even if these groups appear to be uniformed and operating under some command structure, they are illegal organizations.  All 50 states prohibit private militias from doing what state authorized militias do.  They are also prohibited from engaging in paramilitary training and in some states brandishing firearms in a way that it could be construed as threatening. Apart from these laws about militias, states also have terroristic threat statutes, and statutes that restrict firearm access to anyone with a history of domestic violence. There is a patchwork of additional law regarding background checks, safe storage of firearms, and collecting statistic data on firearm violence.  There is a currently a loophole in background checks because unlicensed private gun sellers are exempt from conducting background checks on potential purchasers.    

For at least 20 years, gun advocates and lobbyists have pushed open carry and concealed carry laws to the point that they are both unnecessary and a threat to public safety. There is no better example than when groups of private militias or heavily armed private citizens show up at public events or protests. History illustrates that these events can lead to confrontations, injuries, and even deaths when they are managed by law enforcement or the state militia – the National Guard. Is it realistic to think that untrained private citizens or illegal militias will do a better job?  Is it reasonable to have open carry laws on the books so that these individuals or groups can potentially function in a number of ways that contradict other laws about assuming police functions or threatening other citizens?

The only logical conclusion you can come to is that both heavily armed private citizens or unregulated militias with a stated purpose of assuming the function of well regulated militias or law enforcement have no standing at all and are much more likely to add more heat than light to the situation.  They knew that in Tombstone, Arizona back in 1881, when they passed the ordinance at the top of this post. This ordinance (in one way or another) precipitated the Gunfight at the OK Corral. We need to recognize that heavily armed citizens roaming around in our communities is unnecessary and a recipe for disaster.  Open carry laws need to be rolled back to 1881 or about 130 years after the Second Amendment was passed.

I anticipate plenty of blowback about that opinion. My only goals are public health/public safety and preventing both unnecessary deaths and the kinds of confrontations that led to this trial in Kenosha. I also wanted to get this opinion out there before there was a verdict by the jury, because at that point those opinions on what happened will fall along partisan lines. Few people seem to recognize the seriousness of this issue – both in terms of the high personal and financial cost of gun violence – but also the destabilizing effect it has on the country.      

I also realize that there is a sense of hopelessness in the United States that we will ever have sensible firearm rules resulting in safer communities.  For a generation there has been a massive misinformation campaign about gun rights. It is possible to have a Second Amendment the way it is written and have safer communities.  Rolling back open carry laws is the place to start. 

 George Dawson, MD, DFAPA

 

References:

Transcript Prosecuting Attorney Closing Remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-prosecution-closing-statement-transcript

 

Transcript Defense Attorney Closing remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-defense-closing-statement-transcript

 

Supplementary 1: (posted on 11/19/2021 @ 12:49 PM):

I just saw the news that the defendant in this case was found not guilty on all charges.  Staying with the theme of this post that verdict is all the more reason why open carry laws need to be rolled back. I expect the usual posturing about the need for firearms to be used for self protection, but the public health issue remains - people bringing firearms to public gatherings or even to the local supermarket is a setup for violent confrontations and their outcomes. I encountered a statistic today that armed demonstrations are six times likely to turn violent than unarmed demonstrations.  If physicians and their professional organizations don't feel they can change the law - they can advocate for common sense measures and provide the supporting data.  Primary prevention of gun violence needs to start long before there are any court proceedings. 

Supplementary 2: 

I recalled today that I took an NRA Hunter's Safety Course when I was ten years old in a remote northern part of a state.  That course was taught by a military veteran who vetted us before we could even get in to the course.  He made us promise that we would no longer play with toy guns.  The main rule of the course was "Never point a gun at another person whether you think it is loaded or not."  Somewhere along the line that rule seems to have been lost by modern gun advocates. 

What is Psychotherapy and What’s in A Code?

 

After a recent discussion about psychotherapy done in psychiatric treatment – I decided to write this post in order to capture the complexity of some of these sessions. I hope that this post serves multiple purposes including a demonstration about how business management affects psychiatric care and the range of services that people receive in psychiatric follow up appointments. The audience for this post will be people seeking psychiatric services, psychiatrists of all orientations, and anyone interested in quality psychiatric care.

The fundamental unit of psychiatric care comes down to what tasks need to be completed in a set time frame and there are a lot of variables. Rather than list those variables – it is probably easier to describe a limited or rationed task scenario and compare that to an abundant task scenario.  Most peoples experience with psychiatrists in the US will fall somewhere between the extremes.  From a scheduling perspective there are no assurances that what a patient needs on a particular day will be the session they are scheduled for.

In the most limited care, the patient is seen for follow up or “medication management”.  These visits developed as part of a coding scheme that suggested that psychiatrists could see patients for very brief (5’-15’) periods of time with an exclusive focus on the medication a person was taking, whether it was effective, and whether they were experiencing any side effects. To speed up the process, many clinics have templates that are rapid checklists of symptoms and side effects.  In some cases, as the patient speaks the psychiatrist is checking off items on the list so that at the end of the session, a couple of sentences can be typed and the note is complete. Depending on the setting, additional information that might be acquired in the rooming procedure during a standard medical appointment (like pulse and blood pressure) may or may not be collected. Before psychiatrists started using standard billing codes like the rest of medicine, there were codes that assumed this limited care could be completed in anywhere from 5’-15’.  As far as I know - no other medical specialty had codes that were as restrictive.  In some clinics patients would be seen for that period of time every 6 months.  That duration and frequency of medication focused visits might work well for some people, but there is an understandable concern about quality when it is applied on a population wide basis. That concern is amplified where patients have more medical and psychiatric complexity (high risk for medical or psychiatric complications).   

At the other extreme, a psychiatrist may see a patient for 30-60 minutes in follow-up. A psychiatrist who typically sees people for 30 minutes would review the efficacy and side effects of any psychiatric medication.  They also may cover more medical or neurological considerations and following another condition like the patient’s problem with hypertension, diabetes, or neurological conditions.  In the remaining time, there is a detailed discussion with the patient.  In the case of a 50'- 60’ appointment, the psychiatrist is most certainly providing psychotherapy in addition to medical treatment. They may be providing psychotherapy exclusively.  Standard billing codes can be used, there are also psychotherapy add on codes and a separate psychotherapy code. Over the years, a lot has been written about the financial incentive for seeing many more of the briefer visits per hour than longer sessions involving psychotherapy. Practice setting tends to be the overriding factor.  If you are employed in a clinic or hospital, there is some administrator telling you how many people you need to see in a day.  That number is referred to as physician productivity.

There is a lot of confusion about what constitutes psychotherapy. At its core, psychotherapy is a teaching experience where the therapist attempts to assist the patient in solving problems that complicate their psychiatric disorder or affect their ability to adapt to life situations.  That can cover a lot of ground including inflexible thought patterns, stressful relationships and current or past stressors. It can also be a very focal problem that might require some directive education like sleep hygiene, diet, and exercise modifications. The teaching needs to occur in the context of a relationship that is both empathic and collaborative.  That collaboration is often referred to as the therapeutic alliance to indicate that the physician/therapist and the patient are aligned to focus on and resolve a mutually agreed upon set of problems. The common view of psychotherapy is that it needs to be long in duration and that the therapist “analyzes” the patient during that time. That description comes from psychoanalytic therapy that is a very specific therapy done be relatively few psychiatrists and it does not represent most of the brief psychotherapy done in treatment sessions.

There has not been a lot of study of psychotherapy in psychiatry in the real world. The best single study by Mojtabai and Olfson (1) and it is the most often quoted.  The most notorious quote is:

“ …..third-party reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits.”

That led to the expected provocative articles about psychiatrists abandoning psychotherapy or being too motivated by money.  The reality of what it takes to keep a practice open in the face of paltry reimbursement was never mentioned. Some articles got so extreme they called for the end of psychiatry, replacing the greedy psychiatrists with therapists trained to prescribe. The authors of the article provide a much more balanced perspective including their opinion that many psychiatrists were still providing some kind of therapy and that their measures of what constituted therapy may have undercounted the therapy provided.

Polarized viewpoints of what actually occurs when a psychiatrist sees a patient probably described very little of what happens in real life sessions. From working in various settings with psychiatrists of three generations, there are many styles of practice and how psychotherapy is integrated – even into very brief sessions.  I was fortunate enough to work with a psychiatrist who ran a clozapine clinic and a separate clinic for long-acting injectable medications.  Both clinics were probably the largest in the state. He would typically see people in 20’-30’ appointments based on the complexity of the care they needed on that particular day. He was an expert in psychopharmacology and medicine as it applied to that patient population. But more than that he was empathic and knew the relevant life details of all of his patients. There was obviously a high degree of patient satisfaction and engagement in treatment.  One of the obvious markers of his success was patient interest in this physician after he made a career change.  His former patients would approach me in the hallway and ask me how he was doing or if I had heard from him. They would talk about him in the most positive terms. I don't recall seeing that happen with any other psychiatrist who moved on.

Papers on the minimum time needed to provide a psychotherapeutic encounter have been written for the past 40 years now. With the advent of managed care – many of them emphasize how the rationing aspect has reduced the time for both verbal and medical interventions. The latest guidelines for residency training emphasize the need to learn psychotherapy but beyond advanced interviewing techniques cognitive behavioral therapy or CBT seems to be the predominate paradigm – even though residents are still exposed to a variety of paradigms from their supervisors and mentors. 

The best single paper I have found that describes the psychotherapeutic aspect of medical treatment within the confines of a “medication management” session and its considerable constraints was written in 2018 (2).  The authors argue for the need for a human-to-human connection consistent with the existential orientation in psychiatry in order for treatment with medications to work.  The main features described are empathic listening and alliance building. One of the primary ways they are realized in the sessions is a focus on the patients own description of the problems or progress. 

As I read through this paper, I realized that I had been conducting outpatient visits in this manner over the course of my career but that nobody had previously described it in these terms or suggested why it had been so successful.  But even as I read this brief paper – I realized that the description was incomplete. It did not describe the many active psychotherapeutic interventions that I had used over the years.  I learned most of them as supportive psychotherapy in residency and they include interventions that would now be described as behavior therapy, cognitive behavioral therapy, and brief psychodynamic therapy and they all happened in the constraints of brief sessions that were generally 20-30 minutes long – in addition to whatever I needed to cover about the medications and other medical conditions.

These 20’-30’ sessions are currently No Man’s Land in the field of psychiatry. It is easy to extremely pessimistic about them.  As I previously noted they can be a political football – since any bias can be projected onto them. That is probably why there has been so little research in the area. It is as if the managed care and CMS template for these codes is an inescapable reality. Everything on the template is all that occurs in one of these sessions. I would propose a thought experiment to counter. If you are a psychiatrist seeing patients in these sessions and billing these codes – do you cover more information than what is in the bullet points for these sessions? Is the patient predictable from session to session – is more lengthy clarification needed? Are there any sessions where the entire session has very little to do with medications?  Are there any sessions dedicated to crisis intervention and only verbal interactions about that crisis? Do you see family members during these sessions and discuss their concerns? When you assess whether a person is experiencing suicidal thoughts do you know how to discuss them in a therapeutic manner?  If the answer to any of these questions is yes – it is highly likely that some form of psychotherapy is happening – even if you do not consciously pull up a psychotherapy technique that you learned and used in the past.  That psychotherapy happens whether you decide to record it on a template or not.

I think this area requires a lot more study. The information transfer between two people that can occur in 20’-30’ minutes is vast – even if it is semi-structured. The first step is determining what really happens in these brief sessions.  If anyone does that study, I think we will find out that the treatment that happens is much more than medication management.

 George Dawson, MD, DFAPA

 

References:

1:  Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008 Aug;65(8):962-70. doi: 10.1001/archpsyc.65.8.962.

2:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177.

Graphics Credit:

Photo by Eduardo Colon, MD

 

When did Asylum Directors and Alienists Become Psychiatrists?

 

I am very interested in the answer to this question.  Readers of this blog will recognize the timeline (click to expand) at the top of this post as one I originally did to disprove any connection between psychiatry and drapetomania.  Several books and about 20 papers later, I am very interested in knowing more about this transition.  When the Association of Medical Superintendents of American Institutions of the Insane (AMSAII) was founded in 1844, there were only 13 Asylum Directors at that time. There was no formal education.  After completing medical school, physicians either spent some time working in an asylum or announced their interest and were appointed to these positions. In some cases, sons followed fathers into these positions after they attended medical school.  There was no residency training at that time.  Over time, additional physicians were employed at asylums but there was still no formal psychiatric education and none in medical school.

The American Medico-Psychological Association (AM-PA) was founded in 1892 primarily to accommodate the increasing number of asylum physicians who were not directors.  This organization began publishing the American Journal of Insanity in July 1844 and it was continued until May 1943 when it became the American Journal of Psychiatry.  The AM-PA transitioned to the American Psychiatric Association in 1921.  Between 1880 and 1920 there was a journal Alienist and Neurologist that I am using as a proxy for alienists in the US.  The literature at the time reflects the use of both terms (alienist and psychiatrist) in the same literature – even though the term psychiatrist was coined by Reil in 1808.

So the questions remain.  How did this transition between asylum directors, alienists, and psychiatrists occur?  When did modern psychiatric training start? Another indicator is the early establishment of psychiatric hospitals and clinics.  I recently added the New York State Psychiatric Institute (NYSPI) and Johns Hopkins to the timelines for establishing education and research program in 1895 and 1913 respectively. Johns Hopkins is considered to have established the first residency programs in Internal Medicine, Surgery, and Gynecology in 1889.  The Phipps Clinic opened at Johns Hopkins in 1913 under the leadership of Adolph Meyer.  It was described by Shorter as a German-style psychiatric clinic. I was having some difficulty getting adequate documentation on the first residency programs in psychiatry until today.    

Today I got the first solid information on psychiatric residents from NYSPI.  In July of 1930, there was an initial reference to 3 psychiatric “internes” being appointed. I was very grateful to receive that information from a colleague on Twitter who was kind enough to ask an archivist at this institution about this information.  The American Board of Psychiatry and Neurology was formed in 1934 so there were probably several residency programs at that time.

If you are a residency director, archivist or historian for a large medical school program and have similar information on the first residency program at your institution – I am very interested in hearing about it and will place your program on the timeline.

I am also very interested in the actual numbers of asylum directors, alienists, and psychiatrists at all points in time across the span of this timeline.  I have very accurate information for the past several decades.  I am very interested in any historical information on how the numbers of these subgroups varied in the late 1880s to mid 1900s.  I appreciate any data that can add to this timeline.

 

George Dawson, MD, DFAPA  

Shorter E.  A History of Psychiatry.  John Wiley & Sons; New York; 1997: p 111.