Psychiatry at a Crossroads
| Leonard Holmes, Ph.D. http://mentalhealth.about.com |
Psychiatry is having an
identity crisis. Many psychiatrists are beginning to complain that they are no longer able
to provide psychotherapy to patients. Managed care companies readily reimburse "med
checks" but balk at paying a psychiatrist's hourly fee for psychotherapy.
Pharmaceutical 
companies build huge displays to market their
products at The American Psychiatric Association (APA)
Annual Meeting. They also provide free dinner banquets followed by presentations by
well-known authorities which generally present the company's products in a favorable
light. Organizations like NAMI support pharmacological treatment for
"biologically-based brain disorders" but ignore trauma-based disorders.
Some psychiatrists are perfectly
comfortable working primarily as pharmacologists. New medications make it imperative to
stay up-to-date. Therapy skills are still useful in establishing rapport and in diagnosing
patients. Some short-term cognitive work can probably even be done in a 10 minute session.
But therapy?
The discontent of many psychiatrists was evident at the Annual Meeting of the APA in May of 1999. Prior to the meeting a prominent member had resigned in a very public way. Loren Mosher, M.D. wrote a letter to Rodrigo Munoz, M.D., the APA president. In this letter, which was circulated on the Internet, he stated "psychiatry has been almost completely bought out by the drug companies" and he proposed that the organization consider changing its name to the American Psychopharmacological Association. (Moser, 1999)
Another Psychiatrist, Paul Chodoff, M.D., presented a paper summarizing his 50 years in the profession. He also noted the change from psychotherapy to pharmacotherapy, and he identified an additional influence, the National Alliance for the Mentally Ill (NAMI). This organization is made up primarily of family members and consumers. Chodoff described a visit from an old patient and his decision to prescribe Viagra to him. He then writes:
The very next day I received a brochure from NAMI summarizing the accepted treatment for schizophrenia. After reviewing a number of pharmacological agents, it was stated that the right kind of psychotherapy was also helpful, followed by an emphatic warning that no psychotherapy that seeks the origin of the patient's symptoms in his or his family's dynamics could be considered proper. (Chodoff, 1999)
Possibly in an attempt to counter
these trends, the APA presented a balanced program which
featured some of the biggest names in the field of trauma research as well as research on
the newest pharmaceuticals. New antidepressants with fewer side effects will genuinely
help depressed persons. Trauma experts like Bessil Van der Kolk, M.D., David Spiegel, M.D.
and Frank Putnam, M.D. presented new research documenting that trauma and abuse does
result in mental disorders, and that mental health professionals can help.
Psychotherapy is the treatment of choice for these disorders, with medications
playing a secondary role.
Other psychiatrists were exploring ways do continue to do psychotherapy in an age of managed care. The pendulum genuinely seemed to be swinging back toward the view that psychiatrists have a varied role to play and that this diversity is important for the identity of the profession.
I imagine that Psychiatry's struggle for identity will continue for some time to come. If this year's APA Annual Meeting is any indication, I expect we will see psychiatry tentatively rediscovering its psychotherapy roots in spite of managed care. Current legislation which promises health insurance parity between mental illness and other illnesses should encourage movement in this direction.
References:
Chodoff, Paul. Psychotherapy--From Fifty Years Ago to Now. Paper
presented at the Annual Meeting of the Americal Psychiartic Association, May 1999.
Moser, Loren. Letter resigning from the APA, quoted by D. C. Hammond in
hypnosis@maelstrom.stjohns.edu March 21, 1999.
| Leonard Holmes, Ph.D. http://mentalhealth.about.com |
Photos by Leonard Holmes,
1999.
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