Impression of psychiatry... True or not?

[mats7]

I'm looking at the schedule for the APA's IPS meeting and most of the topics are geared towards social justice, homelessness, poverty, racism, stigma, etc. Is this what most psychiatrists have to address on a day to day basis? It seems like the focus is more something I'd expect out of a social worker's meeting.

If one is interested in psychiatry, does one have to really love working holistically with that patient population, even if that means removing oneself from clinical medicine to focus on the social determinants of health? I'm sort of conflicted.

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[thoffen]

These are often the most important needs of psychiatric patients, and incorporating understanding of and commitment to advocating for these needs in our patients is often essential to recovery if possible.

That said, many psychiatrists work with populations that do not have such needs.

 

[northernpsy]

No. The IPS is not reflective of all of psychiatry. The big APA meeting is probably more reflective of the true breadth of the specialty :
http://meetmeinsandiego.com/apa

*furtive glance* Some psychiatrists are even...Republicans.

 

[sunlioness]

At my CMHC gig that's what I had to address on a daily basis in fifteen minute increments with no tools/resources to do a damn thing about it.



Sent from my iPhone using Tapatalk

 

[splik]

I'm looking at the schedule for the APA's IPS meeting and most of the topics are geared towards social justice, homelessness, poverty, racism, stigma, etc. Is this what most psychiatrists have to address on a day to day basis? It seems like the focus is more something I'd expect out of a social worker's meeting.

In 2014 this was definitely the case, but no, most of the topics for this year's IPS meeting are not geared as you say (if only!). The focus is more on things like collaborative care, telepsychiatry, integrated care, technology in mental health, correctional psychiatry, and health services. The IPS = Institute on Psychiatric Services, and is essentially the public and community psychiatry meeting of the APA. It is a fairly small meeting (compared to the massive APA meeting) but I like it much better. As the name implies it does focus on showcasing mental health services but you cannot talk about serious mental illness in public settings without discussing issues related to the social determinants of health. I am biased of course as I have always been a strong proponent of social medicine, but I don't understand how physicians cannot have at least a passing interest in the social determinants of health. The APA tried to get rid of the IPS meeting some years ago, as some of the academic bigwigs don't really like community psychiatry and see psychiatry as some sort of highfalutin brain-based medicine practiced in ivory-towers (which of course if true would consign us to irrelevance). Unfortunately, very few psychiatrists are public or community psychiatrists, and these aspects are not things that are covered in most residency training programs in any meaningful way and I think the larger proportion of psychiatrists don't think this is really part of their work.

Of course I say this, but I wouldn't last 5 minutes doing community psychiatry so bless those poor souls that do!

 

[nancysinatra]

My personal view on what psychiatrists do is, they work with people who are suffering from the above mentioned social problems, and they translate those social ills into codeable DSM diagnoses.

 

[mats7]

Yeah. I am interested in social determinants of health. But more on the community and population based level. Like... it would not be interesting to contact Social Services to make sure patients get their EBT or their heating bills paid for everyday. Getting them a cool motorized wheelchair by diagnosing them with something would be rewarding, though. May mean I am not a good fit for some residency programs?

Thanks for your insight on the IPS. Guy recommended going because a few years ago there was a few workshops on getting into residency. Seems like there isn't going to be anything like that on a normal basis since each year has a theme. Telepsychiatry seems like a money-maker. Wonder if it works for inpatients for imprisoned people.

 

[hamstergang]

it would not be interesting to contact Social Services to make sure patients get their EBT or their heating bills paid for everyday.

I didn't do anything like that during residency or in the few months since.

 

[Bartelby]

Yeah. I am interested in social determinants of health. But more on the community and population based level. Like... it would not be interesting to contact Social Services to make sure patients get their EBT or their heating bills paid for everyday. Getting them a cool motorized wheelchair by diagnosing them with something would be rewarding, though. May mean I am not a good fit for some residency programs?

I think connecting patients with services can be a good thing, but your job isn't really to hand hold them through all aspects of their life. You want to foster as much independent and dignified functioning as the patient can handle.

For instance, if you are informed about the social determinants of health you might realize that for a given patient going back to work and having more structure, social interaction and meaning built into their daily schedule might improve their mental health. You could thus help the patient get started on that process. You might also realize that the patient has low self-esteem and just presumes that people would only hang out with them because they feel sorry for them. You might challenge these distortions (because while such a thing is sometimes true it's likely at least partially distorted) and help them re-establish meaningful social contact. All of these things could fall within a psychotherapy or even a shorter "med management" visit, so you are identifying goals that are appropriate for them to obtain and helping them put that in motion. That kind of thing can be very rewarding.

 

[Jules A]

I think connecting patients with services can be a good thing, but your job isn't really to hand hold them through all aspects of their life. You want to foster as much independent and dignified functioning as the patient can handle.

For instance, if you are informed about the social determinants of health you might realize that for a given patient going back to work and having more structure, social interaction and meaning built into their daily schedule might improve their mental health. You could thus help the patient get started on that process. You might also realize that the patient has low self-esteem and just presumes that people would only hang out with them because they feel sorry for them. You might challenge these distortions (because while such a thing is sometimes true it's likely at least partially distorted) and help them re-establish meaningful social contact. All of these things could fall within a psychotherapy or even a shorter "med management" visit, so you are identifying goals that are appropriate for them to obtain and helping them put that in motion. That kind of thing can be very rewarding.

In my area most do med management only so this is something our social workers and therapists help coordinate. It doesn't make financial sense to pay a prescriber to do the leg work on psychosocial interventions. In the cases where an actual order is required I just sign what the office manager hands me.

 

[SeniorWrangler]

It's important to understand that in the USA, we have a de facto two tier (or maybe three tier) mental health system.
One tier is community mental health, where a lot of patients with public insurance and severe mental illness are seen. Much of this care is delivered by social workers, ARNP's, PA's, and other people who are not doctors. Patients in this group are often also effected by poor access to medical care, severe psychosocial stresses, homelessness, etc.

Another tier is for people with better insurance who get to see doctors and psychologists and get better access to psychotherapy and behavioral interventions. This group also has more money, more social capital, better outcomes, is more likely to come to appointments, and their insurance pays better. At the top of this group are people who pay cash for services, what they used to call the carriage trade.

This split between patient populations and between groups of doctors has been a consistent feature of American psychiatry since the earliest days of the field, when there was a split between alienists and asylum doctors and the alienists didn't want to allow the asylum doctors into their professional association.

 

[splik]

This split between patient populations and between groups of doctors has been a consistent feature of American psychiatry since the earliest days of the field, when there was a split between alienists and asylum doctors and the alienists didn't want to allow the asylum doctors into their professional association.

This is actually not the case. Alienists were asylum doctors, who specialized in 'mental alienation' and the forerunner to the American Psychiatric Association (and the American Medico-Psychological Association) was the Association of Medical Superintendrnts of American Institutions for the Insane - thus the professional association was entirely for asylum doctors. Psychiatry was an entirely asylum-based specialty until the early part of the 20th century when psychiatrists, seeking to escape the asylum (because they had to live their with their wives, and did not think the asylum appropriate for women), and wishing to do private practice, embraced mesmerism, hypnotism, psychoanalysis, and a number of other psychological healing techniques that were becoming popular at that time. In the early days, psychiatry concerned itself with exclusively asylum-based diseases - dementia praecox, manic-depressive insanity, general paresis, alcoholic dementia, Huntington's disease, and so on. Outpatient psychiatry (ie. dealing with 'nervous illness' was the province of neurologists).

where I live, we are officially still called alienists!

 

[SeniorWrangler]

You're right, the split was between asylum doctors and neurologists who saw mental health patients. My mistake. But the class-based difference has been around forever.

 

[splik]

Yeah. I am interested in social determinants of health. But more on the community and population based level. Like... it would not be interesting to contact Social Services to make sure patients get their EBT or their heating bills paid for everyday. Getting them a cool motorized wheelchair by diagnosing them with something would be rewarding, though. May mean I am not a good fit for some residency programs?

wtf? what a sad state of affairs medical education must be in these days. the social determinants of health has nothing to do with getting patients EBT cards or paying their heating bills. I would have no idea how to do this! It is about population-based care - looking at "the causes of the causes". It is about recognizing that social, political and economic factors influence mental illness at every turn: from who gets sick, the form and content of their symptoms, and the illnesses they develop, the treatments that are available, the course their illness takes, and the outcome of their life-story. It is about recognizing the social world also influences the lived experience of mental illness, including all too frequently stigma, prejudice, discrimination, inequality and exclusion.

Psychiatrists are a limited resource and very expensive. so much so, most employers won't even let us do therapy, it is certainly not in anyone's interests for us to be superannuated social workers (though as a resident you might find yourself filling in for one - which usually means getting insurance authorization for visits, calling collateral, obtaining records, discharge planning and identifying services for patients, and writing letters - all things that could reasonably fall in our roles but are often done by social workers). Psychiatrists don't tend to address the social determinants in their every day work with patient, and as described above one of the frustrating things about psychiatry is that we see people with problems that we have no hope in hell of ever helping, because their problems are shaped by forcing largely outside of our control, and psychiatric labeling is a political device that obfuscates the wider causes of endemic misery inherent in the structure of society (and late capitalism) itself.

Psychiatrists can address the social determinants of health in a number of ways: through conducting research into the social etiology of mental illness, by exploring the effects of social interventions and conditions on mental health, by educating the public about things that shape mental illness, by contributing to policy by informing lawmakers about influences on mental health, by working in communities, by providing physician leadership in departments of public health, mental health, and other governmental offices at the municipal, county, state and federal level, by recognizes how the institutions in which patients receive mental health care may retraumatize individuals by their instutional racism, homophobia or through stigmatizing patients, by being active in their communities, by being part of the conversation of the care of the mentally ill in correctional settings or in the homeless, and by developing and leading innovative services that seek to reduce inequalities in mental health care and provide for underserved or hard-to-reach populations... etc.

 

[Crayola227]

wtf? what a sad state of affairs medical education must be in these days. the social determinants of health has nothing to do with getting patients EBT cards or paying their heating bills. I would have no idea how to do this!

Ridiculously easy. They need to google the states' Department of Human Resources. Many apps for services can be found on their websites typically. Often the site and offices contain referrals or information for all manner of public assistance - food boxes, free clothing, utility assistance, etc.

For public utilities it doesn't hurt to contact them directly about assistance programs etc they may have.

 

[Salpingo]

Getting them a cool motorized wheelchair by diagnosing them with something would be rewarding, though. May mean I am not a good fit for some residency programs?

Uh... maybe PMR?

Inpatient/hospitalist work in most specialties can feel like glorified social work (although psychiatry probably more). If you're already worried about that, I'd consider some of the more procedural/diagnostic specialties. But I'm curious about your background -- most medical students (and residents) aren't aware of the social programs you mentioned. I think I was halfway through residency before I even heard of the IPS. You're not running a sting operation for a libertarian, anti-welfare think tank, are you?

 

[mats7]

Hahaha. I searched "psychiatry residency" in Reddit and one of the first threads that opened up was some guy recommending IPS a few years ago. And thanks, I was looking into PM&R, too. I worked with them a lot at the VA and it seemed my thing. I also love pain medicine. Unsure about the OR/anesthesiology, though, so psychiatry/PM&R for me.

 

[dl2dp2]

...The APA tried to get rid of the IPS meeting some years ago, as some of the academic bigwigs don't really like community psychiatry and see psychiatry as some sort of highfalutin brain-based medicine practiced in ivory-towers (which of course if true would consign us to irrelevance)...

This appears to to be a top down thing of the major organizations in our field. The new NIMH director is again a basic animal model neuroscientist. I suspect the rising tide of biological psychiatry will only rise higher. So to generally address the OP's concerns, no actually psychiatry is moving in exactly the opposite direction you are describing. Everything's geared now more toward the brain, technology, medication development, devices, etc. trying to be "medicine-y". Psychotherapy is now conceptualized literally as a medical "procedure" in CMS coding and taught as a somewhat standardized procedure. This is the party line now. When I started residency this was even less the case--I think the influence of classic "psychoanalyst-asylum runner-advocate" model of psychiatry has really waned even in the last 5 years.

Even in services research, I've noticed as one poster noted above, the emphasis has transitioned from community based advocacy to data driven "process"/"implementation" research full of acronyms, obscure protocols, quality improvement jargons, the ACO, the ACA, the PCMH, "value based care delivery", blah blah, etc. etc.

One could argue that this is all a good thing in the sense that these types of things (specialized, procedural/hard science based knowledge) tend to draw high reimbursements from CMS/insurance, but it's far from clear that this is actually what our patients really need in real life. I actually think if you are interested explicitly in social determinants of health in either practice or research, psychiatry may not be a good field to enter now in medicine (vs. preventative medicine or even family medicine).

 

[smalltownpsych]

This appears to to be a top down thing of the major organizations in our field. The new NIMH director is again a basic animal model neuroscientist. I suspect the rising tide of biological psychiatry will only rise higher. So to generally address the OP's concerns, no actually psychiatry is moving in exactly the opposite direction you are describing. Everything's geared now more toward the brain, technology, medication development, devices, etc. trying to be "medicine-y". Psychotherapy is now conceptualized literally as a medical "procedure" in CMS coding and taught as a somewhat standardized procedure. This is the party line now. When I started residency this was even less the case--I think the influence of classic "psychoanalyst-asylum runner-advocate" model of psychiatry has really waned even in the last 5 years.

Even in services research, I've noticed as one poster noted above, the emphasis has transitioned from community based advocacy to data driven "process"/"implementation" research full of acronyms, obscure protocols, quality improvement jargons, the ACO, the ACA, the PCMH, "value based care delivery", blah blah, etc. etc.

One could argue that this is all a good thing in the sense that these types of things (specialized, procedural/hard science based knowledge) tend to draw high reimbursements from CMS/insurance, but it's far from clear that this is actually what our patients really need in real life. I actually think if you are interested explicitly in social determinants of health in either practice or research, psychiatry may not be a good field to enter now in medicine (vs. preventative medicine or even family medicine).

Completely agree with what you are saying and seeing psychology having some of the same problems, but I disagree with the conclusion. I would say it is even more important that people who are interested in social determinants to join up and fight the trend.

 

[dl2dp2]

people who are interested in social determinants to join up and fight the trend...

I don't think this works, to be honest. There are layers of regulatory mechanisms for central management of different disciplines, their scope of practice, their scope of research. If you become a psychiatrist today and hoping to conduct research in social determinants as an academic, for example, you'll be fighting a losing battle and have barriers against you every. single. step. of the way. Grant funding is extremely limited and almost entirely budgeted for biological or implementation research. Program grants from state and federal sources are also almost never allocated to advocacy work. The focus of the educational programs from medical school to residency has changed dramatically, and medical students are taught from day one that "mental illnesses are a brain disease". If you are serious about working in this field, you'd need significant mentorship in structuring your research with a different focus, for example "patient oriented research" for PCORI or AHRQ grants, or epidemiology. You may need years of additional training in statistics, study design, project management, etc. It's a huge, time consuming game that people who don't know what they are doing shouldn't just "join up" willy nilly, especially when you are looking at an opportunity cost of hundreds of thousands of dollars, if not millions of dollars throughout a career, years of wasted effort, failures and frustrations.

The only feasible mechanism that I can see is to do advocacy or research in this area as a "hobby" while you run a practice. This is also btw the dominant model now for psychoanalytic practice and research. The funding for classic "cased based" psychoanalysis research and practice has almost entirely disappeared in the last two decades in institutionalized settings. These days analysts usually write and do research for free and for fun while doing private practice.

 

[OldPsychDoc]

This appears to to be a top down thing of the major organizations in our field. The new NIMH director is again a basic animal model neuroscientist. I suspect the rising tide of biological psychiatry will only rise higher. So to generally address the OP's concerns, no actually psychiatry is moving in exactly the opposite direction you are describing. Everything's geared now more toward the brain, technology, medication development, devices, etc. trying to be "medicine-y". Psychotherapy is now conceptualized literally as a medical "procedure" in CMS coding and taught as a somewhat standardized procedure. This is the party line now. When I started residency this was even less the case--I think the influence of classic "psychoanalyst-asylum runner-advocate" model of psychiatry has really waned even in the last 5 years.

Even in services research, I've noticed as one poster noted above, the emphasis has transitioned from community based advocacy to data driven "process"/"implementation" research full of acronyms, obscure protocols, quality improvement jargons, the ACO, the ACA, the PCMH, "value based care delivery", blah blah, etc. etc.

One could argue that this is all a good thing in the sense that these types of things (specialized, procedural/hard science based knowledge) tend to draw high reimbursements from CMS/insurance, but it's far from clear that this is actually what our patients really need in real life. I actually think if you are interested explicitly in social determinants of health in either practice or research, psychiatry may not be a good field to enter now in medicine (vs. preventative medicine or even family medicine).

I think that yes, if you're interested in doing this explicitly from an academic/research perspective, you are likely to be disappointed. However, from a practice/public policy perspective there are many places in community psychiatry where someone well-versed in social determinants and integrative care will be enthusiastically welcomed.

 

[smalltownpsych]

I don't think this works, to be honest. There are layers of regulatory mechanisms for central management of different disciplines, their scope of practice, their scope of research. If you become a psychiatrist today and hoping to conduct research in social determinants as an academic, for example, you'll be fighting a losing battle and have barriers against you every. single. step. of the way. Grant funding is extremely limited and almost entirely budgeted for biological or implementation research. Program grants from state and federal sources are also almost never allocated to advocacy work. The focus of the educational programs from medical school to residency has changed dramatically, and medical students are taught from day one that "mental illnesses are a brain disease". If you are serious about working in this field, you'd need significant mentorship in structuring your research with a different focus, for example "patient oriented research" for PCORI or AHRQ grants, or epidemiology. You may need years of additional training in statistics, study design, project management, etc. It's a huge, time consuming game that people who don't know what they are doing shouldn't just "join up" willy nilly, especially when you are looking at an opportunity cost of hundreds of thousands of dollars, if not millions of dollars throughout a career, years of wasted effort, failures and frustrations.

The only feasible mechanism that I can see is to do advocacy or research in this area as a "hobby" while you run a practice. This is also btw the dominant model now for psychoanalytic practice and research. The funding for classic "cased based" psychoanalysis research and practice has almost entirely disappeared in the last two decades in institutionalized settings. These days analysts usually write and do research for free and for fun while doing private practice.

I completely get what you are saying and I'm not advocating for anything as quixotic as naively going headlong at this. The smart young academic starts with where the field is at and then nudges it in the direction they feel it needs to go. If they happen to be brilliant or lucky or garner more support, that nudge can shift things dramatically. It just sounded sort of fatalistic to say this is where the field is at so if you want something different, you'll have to do something else.

 

[tr]

This appears to to be a top down thing of the major organizations in our field. The new NIMH director is again a basic animal model neuroscientist. I suspect the rising tide of biological psychiatry will only rise higher. So to generally address the OP's concerns, no actually psychiatry is moving in exactly the opposite direction you are describing. Everything's geared now more toward the brain, technology, medication development, devices, etc. trying to be "medicine-y". Psychotherapy is now conceptualized literally as a medical "procedure" in CMS coding and taught as a somewhat standardized procedure. This is the party line now. When I started residency this was even less the case--I think the influence of classic "psychoanalyst-asylum runner-advocate" model of psychiatry has really waned even in the last 5 years.

Really? I actually think a major effect of the last decade or two of research is that the biological-psychiatry contingent is being forced to become aware of the deep and inextricable connections between psychosocial events and neurobiological processes. I'd say the era of 'pure' biological psychiatry is over and the very idea is becoming exposed as a fallacy.

 

[OldPsychDoc]

Really? I actually think a major effect of the last decade or two of research is that the biological-psychiatry contingent is being forced to become aware of the deep and inextricable connections between psychosocial events and neurobiological processes. I'd say the era of 'pure' biological psychiatry is over and the very idea is becoming exposed as a fallacy.

Aren't "psychosocial events" biological as well?

 

[clausewitz2]

Aren't "psychosocial events" biological as well?

Systemic disparities are entirely the fault of our Secret Robot Masters.

 

[dl2dp2]

Really? I actually think a major effect of the last decade or two of research is that the biological-psychiatry contingent is being forced to become aware of the deep and inextricable connections between psychosocial events and neurobiological processes. I'd say the era of 'pure' biological psychiatry is over and the very idea is becoming exposed as a fallacy.

We are making two different points. Scientifically you are absolutely 100% right, and grant reviewers IMHO also like project proposals that are not just pure basic (boring!) stuff and tie in more translational stuff. I'm making a stylistic point. My gut feeling is the overall direction of the field is moving away from the *asylum runner-social justice advocate by day, passionate irvin yalom therapist by night* model of the 60s and 70s. The field is just much more bottom-line focused and if the OP thinks that we are in a field of touchy-feely social justice warriors he/she would be very disappointed. My sense is the "leadership" really just wants to reinforce psychiatry as a "medical subspecialty", and a "fancy" one at that. And given the immediate "lifestyle" advantages of this specialty, all the marketing stuff of "brain based psychiatry" is really flowing into practice and becoming internalized by a new generation of young doctors. And this is for SURE a top down effort from research, practice, education, going up and down the ACGME-NIH-CMS-insurance-hospitals axis. I go to APA and this is ALL I hear. Over and over hammered into my head. The way to advocate for more funding for the mentally ill these days is absolutely structure it as a "public health problem" (that require a "bipartisan, technology-driven solution"), not some politically polarizing end for "social justice". And in private contract negotiations, it's about how to deliver "evidence based treatment backed by neuroscience that shows results" so insurance companies would provide a higher reimbursement for the same services.

This could very well have no reflection at all in reality -- i.e. all this emphasis on neuroscience *might* be totally barking off the wrong tree, but as it stands I think the field is and will be vastly vastly more "biological"/"medical"/"technical" in the years to come. Again I think this *may be* a good thing, and I think even in the past 10 years there's been a huge upsurge of *prestige* of psychiatry both within medicine and in the public, precisely because of this sort of marketing with all the jargons and science-y things and "confidence" that comes with being an "expert" and that we know more about what we are talking about the "model" that mental illness is a "brain disease". I just make a stronger distinction between what is the marketing material and what's the "truth", which is we know less than we are willing to admit. But this is true of every field, so I don't feel like I need to apologize for all the BS.

This is also why I'm not too worried about the whole RxP thing... I suspect the growth in biological psychiatry is going to outpace the acquisition of turf from an allied discipline that has very little handle historically of this area, but I again have to say I'm not sure this kind of growth will directly translate into uniformly better, and certainly not more equitable patient care. Just like similar things (i.e. PCI in cardiology...etc.) in other fields.

 

[smalltownpsych]

We are making two different points. Scientifically you are absolutely 100% right, and grant reviewers IMHO also like project proposals that are not just pure basic (boring!) stuff and tie in more translational stuff. I'm making a stylistic point. My gut feeling is the overall direction of the field is moving away from the *asylum runner-social justice advocate by day, passionate irvin yalom therapist by night* model of the 60s and 70s. The field is just much more bottom-line focused and if the OP thinks that we are in a field of touchy-feely social justice warriors he/she would be very disappointed. My sense is the "leadership" really just wants to reinforce psychiatry as a "medical subspecialty", and a "fancy" one at that. And given the immediate "lifestyle" advantages of this specialty, all the marketing stuff of "brain based psychiatry" is really flowing into practice and becoming internalized by a new generation of young doctors. And this is for SURE a top down effort from research, practice, education, going up and down the ACGME-NIH-CMS-insurance-hospitals axis. I go to APA and this is ALL I hear. Over and over hammered into my head. The way to advocate for more funding for the mentally ill these days is absolutely structure it as a "public health problem" (that require a "bipartisan, technology-driven solution"), not some politically polarizing end for "social justice". And in private contract negotiations, it's about how to deliver "evidence based treatment backed by neuroscience that shows results" so insurance companies would provide a higher reimbursement for the same services.

This could very well have no reflection at all in reality -- i.e. all this emphasis on neuroscience *might* be totally barking off the wrong tree, but as it stands I think the field is and will be vastly vastly more "biological"/"medical"/"technical" in the years to come. Again I think this *may be* a good thing, and I think even in the past 10 years there's been a huge upsurge of *prestige* of psychiatry both within medicine and in the public, precisely because of this sort of marketing with all the jargons and science-y things and "confidence" that comes with being an "expert" and that we know more about what we are talking about the "model" that mental illness is a "brain disease". I just make a stronger distinction between what is the marketing material and what's the "truth", which is we know less than we are willing to admit. But this is true of every field, so I don't feel like I need to apologize for all the BS.

This is also why I'm not too worried about the whole RxP thing... I suspect the growth in biological psychiatry is going to outpace the acquisition of turf from an allied discipline that has very little handle historically of this area, but I again have to say I'm not sure this kind of growth will directly translate into uniformly better, and certainly not more equitable patient care. Just like similar things (i.e. PCI in cardiology...etc.) in other fields.

I just don't see the touchy-feely social justice warrior as the only alternative to an overemphasis on biological models of psychopathology. I think that the idea that we can rewire the brain solely through better chemistry as opposed to psychologically informed interventions is deeply flawed. Just for a quick example, I have several patients with schizophrenia who are stable on their medications and benefit greatly from psychotherapy from someone who has a level of training and expertise to separate the illness from both normative human difficulties and the difficulties that are secondary to a chronic illness. In my mind, the social justice types just want to "take care of them" in a way that is often too paternalistic and disempowering.

 

[tr]

This could very well have no reflection at all in reality -- i.e. all this emphasis on neuroscience *might* be totally barking off the wrong tree, but as it stands I think the field is and will be vastly vastly more "biological"/"medical"/"technical" in the years to come. Again I think this *may be* a good thing, and I think even in the past 10 years there's been a huge upsurge of *prestige* of psychiatry both within medicine and in the public, precisely because of this sort of marketing with all the jargons and science-y things and "confidence" that comes with being an "expert" and that we know more about what we are talking about the "model" that mental illness is a "brain disease".

Yeah this is psychiatrists assuaging their inferiority complex within medicine. Trying to distance themselves from their reputation as low-tech, low-prestige headshrinkers and cozy up to the new technology because you know, all you have to do is start waving a fancy magnetic stimulator around and all of a sudden you're a prestigious, technologically advanced, state-of-the-art Physician, on par with any of those muckamucks from cards or neurosurg. It seems irrelevant that your expensive intervention is actually less effective than either the old-school drug or the even older-school (and low-prestige) psychotherapy.

 

[smalltownpsych]

Yeah this is psychiatrists assuaging their inferiority complex within medicine. Trying to distance themselves from their reputation as low-tech, low-prestige headshrinkers and cozy up to the new technology because you know, all you have to do is start waving a fancy magnetic stimulator around and all of a sudden you're a prestigious, technologically advanced, state-of-the-art Physician, on par with any of those muckamucks from cards or neurosurg. It seems irrelevant that your expensive intervention is actually less effective than either the old-school drug or the even older-school (and low-prestige) psychotherapy.

Yep. Also, it feeds right into the incorrect attitude of "Psychotherapy? Anyone could do that. All you do is talk to people." Or equating it with good bedside manner or other people skills. I had those before my training. That's just the necessary foundation. Knowing what you are doing and why in the moment and effecting change in the interpersonal relating of a patient that effects their neurobiological functioning by just talking to someone is a high level skill if you ask me. Anyone can write a script for a medication. Our family practice nurse practitioners do it all day long. "Oh, you are feeling depressed or anxious lets try this and see how it works." There is usually not more thought than that, unfortunately.

 

[dl2dp2]

Yeah this is psychiatrists assuaging their inferiority complex within medicine. Trying to distance themselves from their reputation as low-tech, low-prestige headshrinkers and cozy up to the new technology because you know, all you have to do is start waving a fancy magnetic stimulator around and all of a sudden you're a prestigious, technologically advanced, state-of-the-art Physician, on par with any of those muckamucks from cards or neurosurg. It seems irrelevant that your expensive intervention is actually less effective than either the old-school drug or the even older-school (and low-prestige) psychotherapy.

yup you expressed my follow-up thoughts exactly lol
OTOH, as long as we don't believe in our own bull****, perhaps it is to be excused if more people would be engaged in the process? How far can you go with marketing to use the end to justify the means?

 

[bashir]

I just don't see the touchy-feely social justice warrior as the only alternative to an overemphasis on biological models of psychopathology. I think that the idea that we can rewire the brain solely through better chemistry as opposed to psychologically informed interventions is deeply flawed. Just for a quick example, I have several patients with schizophrenia who are stable on their medications and benefit greatly from psychotherapy from someone who has a level of training and expertise to separate the illness from both normative human difficulties and the difficulties that are secondary to a chronic illness. In my mind, the social justice types just want to "take care of them" in a way that is often too paternalistic and disempowering.

I suppose I'm a bit of a "touchy-feely social justice warrior," and I don't think there's anything about taking on that mantle that is incompatible with treating people with severe and persistent mental illness with the respect we should afford any patient and fostering their autonomy and self efficacy. Anyway, I'd love to incorporate therapy into a practice treating adults with severe and persistent mental illness someday, so I'm always excited to hear about people doing therapy with this population. If you have any reading recommendations in that realm, smalltownpsych, I'd be most appreciative!

 

[smalltownpsych]

I suppose I'm a bit of a "touchy-feely social justice warrior," and I don't think there's anything about taking on that mantle that is incompatible with treating people with severe and persistent mental illness with the respect we should afford any patient and fostering their autonomy and self efficacy. Anyway, I'd love to incorporate therapy into a practice treating adults with severe and persistent mental illness someday, so I'm always excited to hear about people doing therapy with this population. If you have any reading recommendations in that realm, smalltownpsych, I'd be most appreciative!

I haven't read that much about treating patients with serious and persistent mental illness as people with the same problems as other people. I just apply what works for other people. Yalom has a good book about group psychotherapy on the inpatient ward that talks about this. I think a student might have made off with my copy though cause it's missing.

Much of my own thinking is that patients are like everyone else with regards to their overall psychological makeup and when we focus too much on the pathological we miss what is really driving the behavior. Much of the time the patient on the unit is getting angry or upset or behaving for the same reasons that we would and the treatment is the same. Basic principles of behaviorism and empathic problem solving can help tremendously. Then helping these patients improve interpersonal skills and ability to trust and play or work well with others will pay off too. No person wants to accept help from people they don't trust. Our patients have a variety of barriers to developing that trust from their internal pathology, ways of interacting with others, and their past experiences.

 

[smalltownpsych]

This has always been one of my favorite scenes. Probably because it captures the principle of patients reacting the way that anyone else would if you took their smokes or burned their foot or even better yet their freedom.

 

[splik]

Anyway, I'd love to incorporate therapy into a practice treating adults with severe and persistent mental illness someday, so I'm always excited to hear about people doing therapy with this population. If you have any reading recommendations in that realm, smalltownpsych, I'd be most appreciative!

You should check out ISPS! There has been a lot written about psychotherapy with psychosis and this has been undergoing a major renaissance in recent years. Check out the open dialogue approach used in Finland where they are treating psychosis often without medication using network therapy and getting great results. Open dialogue is being used in the US too (massachusetts and vermont I believe) but I dont think it will be as successful. Carl Rogers' early work was with severely disturbed psychotic patients and he wrote particularly powerfully about this. Harry Stack Sullivan also did a lot of work with psychotic patients and developed the interpersonal theory of psychiatry based on this. Though Chestnut Lodge was once famous for intensive psychoanalytic treatment of psychoses (see the work of Freida Fromm-Reichmann or read I never promised you a rose garden), The Chestnut Lodge Studies began the death of psychoanalytic approaches to psychosis proper, but supportive psychotherapy was shown to be beneficial, and the studies of CBT for psychosis have confirmed that supportive psychotherapy is the psychological treatment of choice for psychosis. Lots of excellent work has come out of the UK - check out the work of Doug Turkington and David Kingdon on cognitive therapy (which is very psychodynamically influenced), as well as Phillippa Garety and Daniel Freeman. Julian Leff's work on family work in schizophrenia was also quite important. Recently using ACT, compassion focused therapy, and mindfulness approaches are becoming popular though theyve not been systematically been studied.

In Europe there has been a resurgence of interest in psychoanalytic approaches to psychosis, however I think very few patients would be able to handle this kind of work without becoming more psychotic so you need quite highly intelligent patients.

You are not going to be doing psychotherapy with these patients in a community mental health center, it is usually the wealthy or important who get personal intensive psychotherapy for psychosis. Elyn Saks (who trained in analysis herself having benefited from it for her own schizophrenia believes it is important for patients to have 5x/week meetings of some sort which is not what is on offer). Loren Mosher and Dick Warner (now both dead) are examples of psychiatrists who provided psychotherapeutic treatment to affluent psychotic patients.

 

[mats7]

Yep. Also, it feeds right into the incorrect attitude of "Psychotherapy? Anyone could do that. All you do is talk to people." Or equating it with good bedside manner or other people skills. I had those before my training. That's just the necessary foundation. Knowing what you are doing and why in the moment and effecting change in the interpersonal relating of a patient that effects their neurobiological functioning by just talking to someone is a high level skill if you ask me. Anyone can write a script for a medication. Our family practice nurse practitioners do it all day long. "Oh, you are feeling depressed or anxious lets try this and see how it works." There is usually not more thought than that, unfortunately.

Lots of people can prescribe medicine. Anyone can write a prescription, but diagnosis is pretty legit. Sort of. Practically anyone can be licensed to do therapy! LCSWs, LCTs, etc. Few can tell if you're good or not (unless they read your notes and they're super smart and good at therapy themselves), but with surgery or something, your skill level speaks for itself. Just prescribing meds or even psychotherapy is not as "prestigious" or cool of an occupation as, say, neurosurgery. It takes a whole team, minutes count, tons of technology, one wrong move and the patient is screwed unless you can fix it. A lot to do with muscle memory after a while, less thought on an individual basis from patient to patient.

They measured lay prestige of professions and specialties, and beyond pay, it was how emergent the situations are and who benefits from the care. People who treat the mentally ill, the young, and the old had less prestige. People who did routine, chronic stuff were less well-regarded, too.

But stuff like fMRIs or lab tests aren't really about ego, is it? When has anyone been impressed with a CBC? I think it's cool that mood or disorders or mental illness can be seen, that it is connected in a real way to the biological side of things. It means a lot of new potential breakthroughs in our understanding of what makes up our minds!

 

[smalltownpsych]

Lots of people can prescribe medicine. Anyone can write a prescription, but diagnosis is pretty legit. Sort of. Practically anyone can be licensed to do therapy! LCSWs, LCTs, etc. Few can tell if you're good or not (unless they read your notes and they're super smart and good at therapy themselves), but with surgery or something, your skill level speaks for itself. Just prescribing meds or even psychotherapy is not as "prestigious" or cool of an occupation as, say, neurosurgery. It takes a whole team, minutes count, tons of technology, one wrong move and the patient is screwed unless you can fix it. A lot to do with muscle memory after a while, less thought on an individual basis from patient to patient.

They measured lay prestige of professions and specialties, and beyond pay, it was how emergent the situations are and who benefits from the care. People who treat the mentally ill, the young, and the old had less prestige. People who did routine, chronic stuff were less well-regarded, too.

But stuff like fMRIs or lab tests aren't really about ego, is it? When has anyone been impressed with a CBC? I think it's cool that mood or disorders or mental illness can be seen, that it is connected in a real way to the biological side of things. It means a lot of new potential breakthroughs in our understanding of what makes up our minds!

I'm not sure what you are trying to say. I really don't care much about prestige. I would rather have money, to be honest. My point was that the complexity of the mind-body-behavior interaction is what makes psychiatry a challenging field and that limiting it to only the biochemical is reductionistic and not helpful for patients. Psychotherapy is nothing like surgery and none of my patients have ever died on the couch. When I screw up, they just walk out of the room and don't reschedule. I would be more excited about the biological side if it was really helping my patients now, but the promise is way ahead of the practice. When the day comes that we have a test that shows which neurotransmitters are out of whack and which parts of the brain and we can specifically target those then I'll get excited. I still think that the interpersonal and how that relates to regulation of emotional states and behavior is always going to be more important in my patients lives and a better path for our society to take. Do kids learn more when they have the right medicine or the right teachers, peers, family, and environment? I have quite a few years of experience that tells me the latter is much more often the case.