not define it…

Posted on Saturday 22 March 2014

by Carolyn Rodriguez, M.D., PH.D.; Jonathan Amiel, M.D.; and Jeffrey Lieberman, M.D.
March 20, 2014

The beginning of a psychiatrist’s career after residency or fellowship is an exciting, but daunting, time. Whatever career path he or she is pursuing—clinical practice, academics, public sector, or industry—the transition from trainee to professional is critically important and often stressful. There is the challenge of having primary responsibility for one’s own patients. The desire to become comfortable in a new work environment and with new colleagues. The understanding that no matter how thorough our training has been, there remain difficult situations that arise in practice, testing our knowledge and mettle. APA well understands the need to support psychiatrists at this stage of their development and even has a special name for them: early career psychiatrists [ECPs]. Every psychiatrist and member of APA has faced this juncture in their careers. Consequently, we recently reviewed APA membership survey data to learn what special needs and services applied to this important constituency of our profession.

We were surprised to see that while resident-fellow members saw value and were pleased with APA membership, many weren’t continuing their membership as they entered the field and the professional workforce. We wondered whether this may be due to the fact that, in a changing and challenging environment, we may too often focus on the challenge of the moment over our longer term professional needs and enrichment. This problem was particularly concerning since APA membership is especially helpful early in one’s career for educational and mentoring resources. And more importantly, young members strengthen APA and shape the Association now and for the future.

To examine this issue, we co-chaired a work group of ECP members and two senior APA advisors to find out what APA was — and wasn’t — doing to support the needs of psychiatrists just starting in the field and what could be done better. Based on the work group’s recommendations, APA, with the full support of the Board of Trustees, is focused on making sure that the needs of psychiatrists just starting their careers are optimally addressed…
Conflict of Interest Statement: One’s view of recent history at large is irreconcilably bound to one’s own personal experience. And the study of history often involves a critical review of what the people of the time said about the period under the microscope. I had been an Early Career Physician already in the field of Internal Medicine. For me, being an Early Career Psychiatrist was the second time around. And what a time to enter the fray – in the middle of what is now called "the crisis of the 1970s". To say psychiatry was changing is beyond an understatement.

In some ways, I was lucky. I was torn between two compelling interests – the hard science of medicine and the human experience of illness. I had already had my identity crisis before arriving in psychiatry training and made my choice, so I was running on my own motor towards the latter. I had no idea that psychiatry itself was about to go the other way, and during my Early Career Psychiatrist days, it did. But I didn’t. And again, I was lucky. I was able to have a rewarding career doing what I chose to do, even though it was isolated from mainstream of psychiatry. I have a thought about what Dr. Lieberman et al are saying in this article, but it’s idiosyncratic, biased by my own path.

Cultivating the Next Generation Of Psychiatrists: People talk about the neoKraepelinians [Robins and Guze etc.] or the DSM-IIIs Robert Spitzer as the movers and shakers of the changes in psychiatry in 1980, but that credit really belongs to Mel Sabshin, the Medical Director of the American Psychiatric Association from 1974 to 1997. His book, Changing American Psychiatry: A Personal Perspective, tells the story from his front line perspective. He was a strong and beloved leader who did what he set out to do – change American Psychiatry.  I didn’t even know he existed at the time. The APA under Sabshin took the reins of the direction of psychiatry and lead the radical changes we all already know about, some of which were positive and long needed, some of which were either ill-considered or had inadvertent negative consequences.

The above article is really about the APA’s continued waning membership roles, and why young psychiatrists see APA membership as superfluous. I wasn’t so young when I let my APA membership expire. At that time, the APA was leading psychiatry in a particular biomedical direction that had little to do with my life and practice. In contrast, I didn’t see the APA taking leadership at all in areas that were of interest to me, but rather following Managed Care and PHARMA who were shaping and redefining psychiatry in their own image. So the APA was more than superfluous. It was a negative force that I couldn’t do anything about, but I sure wasn’t interested in supporting.

The way the story’s told, psychiatry needed a Melvin Sabshin to consolidate power to motivate change, and that may well have been absolutely true. I wasn’t around for that so I don’t really know the answer. But there were some unaddressed consequences that linger. The first was that the APA hadn’t read Bion’s books about groups and became lethal – extruding the psychoanalysts and the psychologically minded almost en mass [exception: Aaron Beck’s CBT], actually assigning us to the status of scapegoats. That attitude unfortunately bled over into the APA’s relationship with the other mental health professions. So people like me didn’t actually withdraw from the APA, we were marginalized. But more importantly, the APA under Sabshin consolidated and centralized the power, and never gave it back. History is filled with similar stories – a strong leadership that brings off a coup d’etat as a reform movement, creating the environment for a future oligarchy in the process. Sometimes, that’s the only way to get the job done [by revolution], but the wise know that a subsequent restoration of balance is essential.

The APA didn’t do that, and continued to hold the reins tightly – going on to became a power base for a biomedical ideology that seems primarily allied with the forces of industry. In the last decade, the ideologically driven APA attempted to "do it again" by using the revision of the Diagnostic Manual to further change psychiatry to fit a particular view just as Sabshin and Spitzer had done [but with a different agenda]. But the "second coming" fell very flat. Even the title of this article contains the problem – Cultivating the Next Generation Of Psychiatrists. It implies a centrality that exists primarily in the minds of the APA leadership, but apparently not in the minds of the majority of psychiatrists or its newest arrivals. A professional organization is meant to represent and serve that profession as a whole, not define or even cultivate it…
    March 22, 2014 | 1:15 PM

    Thanks for the historical perspective, Mickey. I think the folks who are more interested in private practice or psychotherapy are definitely not well-served by the current APA, which seems focused on cultivating the next generation of academic psychiatrists more than anything else.

    What I wonder is, why isn’t this “silent majority” more organized & vociferous? Is it an aversion in general to being part of a hierarchical power structure? Is it that they’re just too busy doing the day-to-day work of caring for patients? Is it that the changes to psychiatry have happened at a slow enough rate (like climate change) that people just don’t have a sense of urgency? Or what about the notion that one reason why folks choose psychiatry is that it tends to have controllable work hours, and thus psychiatrists are more likely to be people who enjoy their free time & interests outside of work?

    I’d be curious to see more of your thoughts on this.

    March 22, 2014 | 1:34 PM

    I think that your are far too optimistic in your assessment of what the APA is trying to do. The fact is that they are so weak and politically ineffective that by default they cycle academics through the Presidential position. When your main focus is supporting “collaborative care” and your membership is the specialty (by far) is the top specialty refusing private and public insurance and accepting cash only – it is clear that the organization is totally out of touch with the membership. The arrogant approach to maintenance of certification and the failed petition is another example.

    I think the silent majority is working under the illusion that they will somehow survive by themselves providing cash only care. They probably will for a generation or two, but beyond that the profession is dead in the water. The epitaph will be: “They were steamrolled by managed care and the government and never confronted that ugly reality.”

    The only exception was Harold Eist.

    Steve Lucas
    March 22, 2014 | 3:26 PM

    Some time ago this question was asked about the AMA. The consensus was that it also was out of touch, representing only a small minority of practicing physicians, while the rolls were made up of students, academics, and those having their dues paid for by employers.

    The AMA has the advantage of the RUC, which provides it with a certain level of importance, and income through the sale of billing codes.

    The pill for every person and every person on a pill mentality of modern medicine has lead one psychiatrist to describe himself as an elevator operator, raising and lowering medications. Another psychiatrist blew up at a meeting when he was told he would now see 40 patients per day in a hospital setting, he assumed he would no longer be eligible for a job at that location.

    Psychiatry is but the latest in a long line of medical specialties hijacked by a few for personal gain, while leaving the vast majority of those behind who are committed to the practice of good medicine.

    I will skip my usual clergy rant.

    Steve Lucas

    March 22, 2014 | 4:35 PM

    Present company excluded, o.k.? I’m going to rail about the “it” and the new crop of “it”.

    When your main focus is supporting “collaborative care” and your membership is the specialty (by far) is the top specialty refusing private and public insurance and accepting cash only – it is clear that the organization is totally out of touch with the membership.

    Yes! Doctor Dawson, thank you, yes. The classist nature of the institution is glaring, especially when considering that those who pay cash for seeing a psychiatrist and for inpatient psychiatric treatment can avoid the whole stigmatizing processes and devaluing that goes with being given a label and then being expected to accept a life sentence for it, shut up about it, and then take your medicine like a good little girl or boy— for the rest of your life. ‘Have problems with that medication? Then raise the dose, and add a new med. There’s no cocktail too complex for those simple little messed up brains, is there? Whatever happens, it is you, dear little broken brained consumer, that is the problem. Those side effects you find so debilitating, bizarre, and unlike anything you’ve ever experienced is just revealing that you’re more broken than we thought. Let’s add another diagnosis, what a mess you are— you have comorbidities, ya’ see, and are treatment resistant! What a problem child you are; you lack resilience. Well, sucks to be you, let’s raise that another 50 mgs and add Abilify as an adjunct. What? You don’t think an adjunct is what you really need right now? Agnosia. Denial. Petulance. Incovenience! If you could only see you as I see you you’d want to be drugged to the gills.’

    And not only are the majority not facing their professional reality, they’re not facing themselves as people with too much power over the vulnerable people they think they’re so dedicated to helping. The hubris, the smugness, the genuine lack of interest in individuals, their lives, and their own narratives does not help. This does harm and is a genuine mind-****ing of outrageous proportion. They’re literally brainwashing a lot of people into believing that their problems are rooted solely in their biology. It robs people of their narrative and dismisses their lives with a casual disregard that is pathological on its face.

    It takes a whole lot of marketing and shilling disguised as science and caring to convince so many people that this extremely limited view of human suffering is helping and is operating within sound scientific reasoning. And that encourages intelligent and educated people that one of out four people in our species has an indogenous brain disease that keeps them from being sane and exercising their agency like the three out of four, so they must be medicated for their own good and everyone else’s safety. I can hardly believe that people believe that— do they look around them and see any evidence that one out of four people are mentally ill and in need of medication for life? It’s preposterous.

    Since psychiatrists no longer have to go into therapy themselves, they are not confronted with themselves and their biases. Psychiatrists should be personally grilled regularly by psychologist, social scientists, philosophers, medical doctors who understand the diseases that have “psychiatric” symptoms, neurologists, and geneticists who are too well educated and self-aware to let them the new crop of psychiatrists think themselves experts on “mental illness” that is “evidence based” and biologically determined. The “it” of psychiatry has seized the humanities and dismissed most of what it is to be human in an effort to be a science. It’s dehumanization being carried out with every prejudice and implicit bias being used against people who are suffering from dehumanization, prejudice, bias, and alienation.


    There is a chance that a critical mass of good people such as yourselves in the mental health fields can put the field in order before GPs and prescribing nurses attempt to drug and dismiss one out of four people for the sake of their HMOs evaluations of them with even less understanding mental/psychological/and social anguish than the status quo in psychiatry. Or perhaps, vending machines would be more efficient. It’s all about efficiency, right? And capital. It’s amazing what an institution will do for a shareholder, isn’t it? Or what an academic will do for a grant.

    March 22, 2014 | 4:36 PM

    You know, I’ve suspended thought about the inner workings of our colleagues or even the fate of psychiatry as a specialty. I picked it because of interest and that never waned. Thinking about all the strangeness about it during the quarter century after 1980 just gave me a headache and there’s was nothing I could see to do that would matter.

    But when I realized how much the new psychiatry rested on lousy [and sometimes non- or even anti-] science and sloppy practice, I got interested in at least calling attention to that. I’ll admit that finding out that the chairman of the department where I was affiliated was simply a crook in bed with an entire industry lit something of a fire.

    I gave my patients statements with CPT and DSM-whichever codes, but otherwise left the dealings with insurance to the insured. I was on no panels and only talked to an insurance company approval person one time in 25 years. I’m told I couldn’t get away with that now, but I was told that then too. Obviously, I negotiated a lot of fees, which was fine by me. But those were all my own choices.

    I made those choices not on economic grounds, but because I saw the Managed Care, panel/approval system as arbitrary at best, and often detrimental. The one approver I mentioned was an ENT moonlighter who suggested I put the patient on Prozac. Ironically, she’d already been put on Prozac before I saw her, and developed an akathisia that almost ended her up in the hospital. That was enough approvers for me.

    If I had to guess, I would probably say that most current practitioners have made some private peace with their plight, are making a modest living, and look forward to retiring. I doubt that the fate of the specialty and the APA are much represented in their minds. If I hadn’t started volunteering and seen what outrageous medications patients were taking, and hadn’t spent thirty years around a department chaired by someone who was exposed as such a mega-crook, I too might have stayed focused on a lot of other things that I also find interesting.

    I agree with George about one thing. I kind of liked Summergrad when I saw him as a way-over-trained psychiatrist who’s into Buddhism. But then I read the “Collaborative Care” article…

    March 22, 2014 | 5:11 PM

    Wiley, you go, grrrrl.

    Sandra Steingard
    March 22, 2014 | 7:04 PM

    Having discovered Richard Noll on this blog, I decided to read his book, American Madness. It tracks the concept of Dementia Praecox through the early part of the 20th century. I am only a chapter in but I already find it if great interest.
    I mention it here because of his discussion of the evolution of psychiatry as compared to the alienists and the neurologists. Neurologists “took” every thing for which pathology could be determined.
    Now I leave Noll so anything incorrect is my fault.
    Psychiatric disorders were considered “functional” which eventually was interpreted as psychological and then in the modern era reconceptualized as brain based but with an as yet unidentified pathophysiology.
    During this time, other professions arose to address the same problems that psychiatrists addressed. I am talking primarily about psychologists and social workers.
    If the APA and NIMH choose to continue to focus on identifying the underlying pathophysiology of all things it has claimed as illnesses, why not just end psychiatry and collapse it into neurology? I do not see any point in separating these fields. I can think of no intellectual rationale for this.
    Mickey, the fact that analysts were originally psychiatrists in the US was because Freud was a physician but it never seemed that medical training was necessary for one to be a psychoanalyst. That was just an artifact of history.
    In some way it would be clearer- if you are looking to get a medical opinion on the biological basis of your ailment, see a neurologist. If you want to take a psychoactive drug to address some symptom, a neurologist can prescribe this.r
    If you ae looking for some other understanding of your complaint, just go elsewhere.

    March 22, 2014 | 8:28 PM

    As it stands now, neurologists don’t know a thing about psychiatric drugs. But if the keys to the armamentum were handed over to them, neurologists probably would learn pretty quickly about the high rates of adverse effects and withdrawal difficulties — unlike psychiatry, neurology admits the drugs affect the nervous system and might actually recognize iatrogenic effects.

    My guess is the reason neurology hasn’t taken over psychiatry already is that neurologists don’t want to deal with the vagaries of human emotion.

    March 22, 2014 | 9:09 PM

    I am not sure you are right about neurology but my main point is that the division is a historical artifact that has no rationale today. I am going to elaborate on this in a future blog.

    March 22, 2014 | 9:55 PM

    The APA is about cultivating profit and selling self serving messages to reinforce drugs and biology, period. Oh, and this week we learn the AMA is now warning doctors how Obamacare is going to put them at risk for not getting reimbursed if patients don’t keep up with their premiums, when the damn sign up isn’t keeping track of this in the first place.

    Leadership, authority, and influence of our culture, how more corrupt can they get? And physicians have the gall to ask who will represent them. Idiots!

    March 23, 2014 | 3:00 AM

    Yes, Joel, the ACA will cause inconveniences for every life it saves and every bit of relief it provides.

    My thoughts on this thread and the thoughts it inspired are too long to post here. That would be rude. So, if you’re interested, you can read it here

    When I’m talking about me in this essay, I’m talking about psychiatry.

    March 24, 2014 | 8:39 AM

    Sandra, who would be able to help people through crisis, be able to prescribe some drugs, if necessary, and have the authority to authorize insurance payments for in-patience care and/or a certain amount of a (temporary) disability rating in tandem with a program that attempts to stabilize a person until they’re ready to support themselves? Though the power has been abused, there is still a need for professional help for severe emotional/psychic distress. Is this something that needs to be hashed out so that GPs, psychologists, social workers, psychiatrists, the patient, friends and family that a patient wants to include?

    March 24, 2014 | 8:39 AM


    berit bryn jensen
    March 24, 2014 | 9:26 AM

    Biomedical psychiatry is in bed with global big pharma, making big bucks by harming and killing gullible people in need of comfort, sleep, practical assistance, friendly help, freedom from oppression…
    To understand this ingrained resistance to see the suffering in front of their eyes, and unscientific foundations of their trade, I’ve found history in broad terms enlightening, including history of medicine and psychiatry and economics.
    Economist and blogger ( Yves Smith the other day likened Washington DC 2014 to Paris 1780.
    Empires do fall, but established, consensusseeking experts rarely dare see or predict that walls are crumbling, as in Europe 1989. When enough people realize that their trust has been betrayed, that their and their children’s value to kleptocrats of all stripes, in this age too, are as chattel, to be usurped and discarded, resistance and unrest follow. Revolution next?
    Corrupt biomedical psychiatry dishing out deadly drugs, in bed with global industries of death and destruction cannot last. After us the deluge, Nemeroff et al, like Louis XIV, Jeltsin, GWB, Blair, Obama…

    March 24, 2014 | 3:02 PM

    A lot of ordinary psychiatrists call themselves “neuropsychiatrists” these days, “psychopharmacologist” having fallen out of fashion.

    March 24, 2014 | 3:53 PM

    If future psychiatrists don’t want to be called neurologists (which is what they should be called in Insel’s Brave New World), then let’s call them neuriatrists– “psych” should not be used.

    March 25, 2014 | 2:14 PM

    If the research of Insel’s Brave New World pans out as expected, we can call them “mythiatrists.”

    March 25, 2014 | 8:38 PM

    I am going to articulate this idea in a future blog. However, these neurologists would do everything you address. As with many specialties, in my little thought experiment I imagine there would be sub-specialists. One focus of this specialty would be to study psychoactive substances and to be able to prescribe them if and when they are indicated – an d not for fabricated constructs that we call diagnoses but for symptoms that improve with those drugs. Believe me, there is already a tremendous overlap in the drugs that neurologists and psychiatrists currently prescribe.
    There are plenty of other well trained people who can help people in crises. My CMHC employs ~ 1000 people. Less than 10 are physicians.

    March 26, 2014 | 2:15 PM

    I’m looking forward to that blog post, Sandra.

Sorry, the comment form is closed at this time.