still around…

Posted on Wednesday 22 July 2015

New York Times
by Richard A. Friedman
Contributing Op-Ed Writer
July 17, 2015

AMERICAN psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front. With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s. Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective…

At the same time, judging from research funding priorities, it seems that leaders in my field are turning their backs on psychotherapy and psychotherapy research. In 2015, 10 percent of the overall National Institute of Mental Health research funding has been allocated to clinical trials research, of which slightly more than half — a mere 5.4 percent of the whole research allotment — goes to psychotherapy clinical trials research.

As a psychiatrist and psychopharmacologist who loves neuroscience, I find this trend very disturbing. First, psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses like major depression and anxiety disorders; second, a majority of Americans clearly prefer psychotherapy to taking medication…

Finally, many of our patients have histories of trauma, sexual abuse, the stress of poverty or deprivation. There is obviously no quick biological fix for these complex problems. Still, there has been a steady decline in the number of Americans receiving psychotherapy along with a concomitant increase in the use of psychotropic medication in those who are treated in the outpatient setting. These trends are most likely driven by many factors, including cost and the limited availability that most Americans have to mental health practitioners. It is clearly cheaper and faster to give a pill than deliver psychotherapy…

More fundamentally, the fact that all feelings, thoughts and behavior require brain activity to happen does not mean that the only or best way to change — or understand — them is with medicine. We know, for instance, that not all psychiatric disorders can be adequately treated with biological therapy. Personality disorders, like borderline and narcissistic personality disorders, which are common and can cause impairment and suffering comparable to that of severe depression, are generally poorly responsive to psychotropic drugs, but are very treatable with various types of psychotherapy…
A couple of months ago, I had me something of a rant. It was long overdue for me:
Robert Whitaker got it started in an interview with Bruce Levine:
by Bruce Levine
March 5, 2014

Bruce Levine’s Question: Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural and political realities?

Robert Whitaker’s Answer: I think we have to appreciate this fact: any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments. If it is going to abandon one form of treatment, it needs to be able to replace it with another. It can’t change if there is no replacement in the offing. When the APA published DSM-III, it basically ceded talk therapy to psychologists, counselors, social workers and so forth…
It’s not Bob’s fault. He didn’t mean to set me off. He didn’t know that there were a lot of psychiatrists who didn’t sign the mythic Talk Therapy Cession Decree of 1980, who didn’t sign up for the ‘complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type’, and who had reluctantly left our academic positions, and just continued doing the psychotherapy we had learned to do. And he didn’t know we didn’t need any advice about how to repurpose ourselves [because we didn’t repurpose ourselves back in 1980]. Said Robert Whitaker:
… So I don’t believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild. The one faint possibility I see – and this may seem counterintuitive – is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose – but only if prescribed in a very nuanced way – then it will want to turn to physicians who understand well the problems with the drugs and their limitations. That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.
No thanks. Life without a guild is preferable. Of course there wasn’t really any Talk Therapy Cession Decree of 1980. I was just being sarcastic. But that dichotomy actually did arise in those days – the psychotherapy versus the medical model thinking Levine is talking about. Pick one or the other [how about both? or maybe the right one for the patient at hand?]. Jeffrey Lieberman just wrote a book about the horrors of the pre-1980 psychiatry he saved you from – caricaturizing psychiatrists as Freud Clones who had left real medicine for a fairy tale world, charlatans all. And a million times I’ve heard that an interest in psychotherapy doesn’t require a medical education – a wasted four years. But actually, I can’t personally imagine any better preparation than spending one’s life amid and among the suffering people that physicians attend daily. That’s what got me interested in the first place and where I learned much of what I know. And I certainly didn’t shed my medical identity, or for that matter my psychiatric identity. I prescribe medications when I think they are appropriate and might help.

But I’ll stop my rant. This blog isn’t about that old story. This blog is about honesty in science. But I guess it has been so long since someone acknowledged that psychiatrists are physicians who care for the sick, bringing to bear whatever might help – whether biologic, psychologic, sociologic, humanistic, cybernetic, etc. And that for many of our patients, psychotherapy of the kind I learned, practiced, and still practice is exactly what the doctor ordered. As for Whitaker’s thoughts about searching for a marketable skill or some new function. I guess I already have one, so I don’t need to ponder a Collaborative Care environment where I’m asked to be an expert consultant medicating patients I’ve never seen [which to me smells like malpractice].

What I came to say is that I appreciate Dr. Friedman noticing that we’re still around and that what we do fills an important need in the cosmos of care of the sick…
    July 23, 2015 | 2:51 AM

    I appreciated Dr. Friedman’s article too, even if his message has been voiced many times before by psychiatric bloggers and pundits.

    Robert Whitaker’s point about finding a marketable niche for the guild is apt, if a bit cynical. Psychiatry as a specialty has painted itself into a corner. It was none too smart to cede psychotherapy to other disciplines, play fast and loose with meds commonly prescribed by primary care, and then bet the farm on neurobiological breakthroughs that haven’t materialized. What do we uniquely offer?

    I think most U.S. psychiatrists today would claim differential diagnosis of medical vs psychiatric disorders, and management of complex or dangerous medication regimens (or TMS, ECT, and so on) that primary care can’t handle. The latter comes close to Whitaker’s suggestion that we become experts in selective, critical use of psychiatric meds. The obvious rejoinder is that we already do that.

    Granted, not every psychiatrist, not every time. But the situation is a lot like driving home on the freeway late Saturday night, when a handful of drunks makes the whole road “full of idiot drivers” and legitimately dangerous. Of the psychiatrists I know personally, nearly all prescribe conservatively, don’t spout “chemical imbalance” nonsense, and are notably sensible and empathic people overall. As Mickey says, many bring to bear whatever might help: biologic, psychologic, sociologic, etc. We need to police our own, but the situation isn’t nearly as grim as some paint it.

    Another “marketable niche” is for psychiatry to be the domain of mental health generalists: experts in the widest array of causes and types of mental disturbance, from the cellular to the sociologic, and clinicians who either offer or refer out to a wide spectrum of care and treatment. This framework pays homage to our biopsychosocial history. It doesn’t paint us into a corner; it is expansive instead of restrictive. No other discipline has as good a claim to it as we do. And frankly, it’s what good psychiatrists have always done behind the scenes, without “marketing” it to anyone.

    July 23, 2015 | 6:57 AM

    Is it possible to say that psychotherapy doesn’t *require* a medical degree but that it can enhance what a therapist has to offer. Social workers have different perspectives and traditions that can be a valuable contribution to, say, psychoanalytic institutes. Psychologists are trained in neuropsychiatric testing etc. Some of the best work I’ve seen done with very challenging patients (long-term residents on a State hospital -still in 2015) was by an occupational therapist. She did a sensory processing analysis of one of the anorexic patients who was also withdrawn and overwhelmed by the noisy unit that was hugely helpful to both the team and the patient. I don’t want to say that physicians shouldn’t be therapists, because I think that a lot of them are great, but I also think that some people get defensive (I know I do!) when it seems like physicians are denigrating the contributions of the other professionals. The field is richer if it can appreciate the diverse contributions.

    As I’ve said before, I think that (when the money is involved), people ought to be lobbying to get psychologists, psychiatrists and primary care doctors along with all of the other cognitive specialties more money. Interventional cardiologists and other procedure-driven specialties ought to get less.

    James O'Brien, M.D.
    July 23, 2015 | 10:30 AM

    I really appreciated Friedman’s article and I’m glad he brought up PTSD. PTSD is the poster child for “bio uber alles” epic fail. SSRIs, SNRIs don’t work very well at all, anxioiytics lead to a whole host of complications and the off label use of (on patent) antipsychotics especially in the military is a very disturbing trend:

    Of course, if you had to use anything off label it probably should be Prazosin (or MDMA assisted psychotherapy in some very interesting work by Mithoefer et. al., but that’s off patent so there’s really no promotional interest outside of academic papers.

    July 23, 2015 | 11:33 AM

    AH, but you folks are missing a very important fact that is coming out due to Obamacare. Most people now have to have deductibles of up to $5,000, and so they have to pay out of pocket for therapy to access their first 15 visits or so. Therefore patients are telling me to my face to save money to skip therapy and just be on medication.

    Thus the ultimate consequence so many physicians have either ignored or turned their back on the reality that Obamacare is screwing up health care in multiple arenas especially in mental health.

    Try to fix that with just some banter about where Psychiatry should go from here.

    James O'Brien, M.D.
    July 23, 2015 | 11:56 AM

    But for so many psychiatrists the moral vanity of preaching the wonders of Obamacare at cocktail parties to show the right people they have the right attitudes so outweighs the low risk of someone like me pointing out their hypocrisy and narcissism. Why? Because they have cash only practices and they probably could not arrive at such a party in an S-class Mercedes (not to mention private schools for their kids) by accepting CMS payments or any insurance for that matter.

    People today pay way too much attention to what people say and not enough to what they actually do. People are very narcissistic and psychiatrists are no exception. But that kind of shallowness and hypocrisy used to not be tolerated.

    July 23, 2015 | 7:08 PM

    I can’t imagine practicing as an MFT or MFT intern without having an ongoing relationship with a psychiatrist, and referring or consulting regularly.

    Dr. Reibord makes an excellent point about differential diagnosis, and a related issue is comorbid physical diagnoses. Obviously, if a patient has HIV, lupus or Lyme disease, the standard of care for an MFT or social worker would be to refer and consult regularly. But even more ubiquitous physical complaints have psychological sequelae that are best assessed periodically by a psychiatrist.

    July 23, 2015 | 7:22 PM

    I don’t want to toot the psychiatry horn here. We have much reason to operate from humility after the excesses of the last several decades. But I had a post-retirement experience that bears on this discussion. For several years, I volunteered in a local agency that saw children and adolescents. The staff was a collection of Psychologists, Social Workers, and Counselors. I was around for an afternoon every other week. We had a great time. They were the primary care providers, seeing most clients weekly or every other week. I saw the ones they thought might benefit from medications, or might have physical problems. It wasn’t a role that was familiar, having practiced as a “lone wolf.” But I got the hang of it.

    As it turned out, neurosis is living and well in these mountains, and so my psychoanalytic background was often called into play. We had a fine [and fun] time collaborating on the cases. There wasn’t a “boss”, just a bunch of people enjoying working together taking care of the kids. They were “our” cases.

    As if often the case in mental health, a war broke out over [you guessed it] money between the assembled therapists and the administration, and the therapists exited en masse to form another group across town. I stayed put at the agency, but the replacement therapists were a different breed. Rather than a genuine collaborative effort, they would send them to me with a generic write-up and something like “refer to psych re meds.” So I had to start from scratch with every single case, and I didn’t feel safe that the cases were being adequately followed. They didn’t want to talk about the patients, just get them “on meds.” After a couple of months, I resigned. It wasn’t a way of working that I could adapt to. These replacement therapists were just doing what they’d learned in other places, some with “tele-psychiatrists.” I continued at the adult charity clinic, much more in the familiar “lone wolf” mode. I guess I learned that working with a therapist/client dyad was pretty do-able. But just being a “med doctor” with only reported symptoms to go on was no good for me. I think of that experience every time I read about “Collaborative Care” [and shudder]:

    I liked that clinic and the kids, but I couldn’t separate therapist from med manager and make it work. So long as I was in on the overall care of the kids, I was fine. But when I tried to go along with the “psych re meds” identity, I felt like I was courting disaster for the clients [and for myself]. I tried it for a while, but it was just never going to work, at least for me…

    July 23, 2015 | 8:36 PM

    Mickey – The second situation sounds genuinely awful. I just get irritated by some doctors who think that they have *more* training than a psychologist does. They have different training.

    I mean an analyst who is a psychiatrist (which the analytic institutes used to require) isn’t necessarily a better analyst in some kind of absolute sense than one who trained as a psychologist. They bring slightly different skill sets to bear.

    With the sickest patients, it is usually a team of providers, some of whom will have very little training or education, e.g. the people who work in group homes. They benefit a lot from meeting with psychiatrists in case conferences on a regular basis, and when they do that, they’re not talking about meds. Those patients will have care managers and social workers-the people who teach them how to shop etc.-and multiple eyes will be reporting back. That doesn’t mean that the psychiatrists won’t see and talk to the patient, but they will hear about what happens in the group home, for example.

    I actually met a great internist who had trained as a psychiatrist first (with a fellowship in forensic psychiatry) who was working as the internist at a state hospital on the unit for medically complex patients. She used all of her skills, and she was the most down to earth person who respected the contributions and the observations of the other team members.

    I am very suspicious of that model of collaborative care, and I very much want there to be more psychiatrist-therapists and humane psychopharm types. But sometimes the physicians on blogs whine about how oppressed they are in a way that people from other backgrounds and professions find off-putting. (Not you.) Four years of medical school does not necessarily entitle someone to a high salary. A lot of other fields are worthwhile and ought to be paid more than they are.

    If we want something different from that model in the diagram, we have to fight for it. But that also means recognizing that in a lot of places there are not enough psychiatrists for everyone who wants and needs a therapist to see a psychiatrist as a therapist. I think that someone could choose to be a psychopharmacologist who was attuned to other issues, including, say, the meaning of the medication to the patient.

    July 23, 2015 | 8:48 PM


    Actually, that’s why the first group was so much fun. Everybody was contributing what they had and the result was greater than the sum of the parts. The division and isolation by specialty in the second group was not just a let down, it felt like a recipe for disaster to me. Money is often a big part of it, but in this case, I was a volunteer. Maybe we ought to only train the independently wealthy. I’m, of course, joking, but it would be nice to get that part off the table.

    If we want something different from that model in the diagram, we have to fight for it. But that also means recognizing that in a lot of places there are not enough psychiatrists for everyone who wants and needs a therapist to see a psychiatrist as a therapist.”

    I certainly wasn’t suggesting that only psychiatrists should be therapists. Far from it. I happen to think that original specialty is almost immaterial in learning to be a therapist. In our analytic institute where we now teach therapy, we now take all specialties – and after a while, the specialty of origin just melts into the background.

    My point is that I couldn’t do the “med” thing in isolation.

    July 23, 2015 | 11:50 PM

    MIckey – The procedure-driven specialties will be the first against the wall when the revolution comes.

    James O'Brien, M.D.
    July 24, 2015 | 1:04 AM

    Collabo-care is the APAs way of shoehorning psychiatry into ACA since they know the numbers under the current model aren’t there.

    The APA know it alls really need to talk to a few diagnostic radiologists about what happens to a specialty when people think it can be done from a distance.

    Psychiatry is voting to replace itself with cheaper labor, then a machine.

    And those same dismissive types think that Freud’s death wish is some kind of joke.

    July 24, 2015 | 3:02 AM

    Maybe we ought to only train the independently wealthy.

    In med school I wrote a little essay called “Whom would Plato choose for medical school?” In The Republic Plato argues that high office should only go to those who do not seek it. Self-interest, he thought, was incompatible with compassion for “the people.” I suggested by analogy that the best physicians would be those who care little for the trappings of career and financial success. Ah, the idealism of youth.

    James O'Brien, M.D.
    July 24, 2015 | 5:18 PM

    No one goes into medicine to get rich or they are a fool if they do. There are a lot easier ways to make money. Hell imagine if you spent 12 weeks getting a real estate license or a contractor’s license instead of 12 years of medical training and subsequently worked 80-100 hour weeks for the next thirty years, you’d become a millionaire without any debt burden unless you were incompetent. I don’t think Plato’s paradox applies at all to medicine at least private practice. Interestingly those in the public policy arena who speak the most about compassion are those who see the fewest patients.

    Plato’s ideas certainly do still apply to politics and with lobbying money becomes a magnet for antisocials and narcissists, as Dr. Hassman has often noted.

    July 24, 2015 | 7:33 PM

    When I get back from my extended leave of absence, I will post a blog at my site noting this hypothesis: perhaps Psychiatry really peaked in the late 80’s early 90’s, and all this BS sense is basically just that, BS. Whether it’s the lameness of psychopharmacology, or the stagnation of responsible psychotherapy, none the less we really have maxed out providing a level of care that’s going to be efficacious when everything is fragmented.

    But, I digress, I am headed out and won’t be looking back for some time…

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