Where Have All the Psychiatrists Gone?

A lot of people are whores; it is just a question of naming the price. Even in psychiatry. The psychiatrist interviewed — and he does sound like a fairly decent fellow — says he can only do drug therapy. He cannot change to a talking practice that pays less because he and his wife want to maintain a certain lifestyle in retirement. He just pushes drugs and says it is not that hard. Let me tell you, it is hard if you do it right. Most drugs now used in psychiatry have not even been around long enough for long term side effects to be known. I have yet to meet a doctor, except maybe me, who understands the responsibility of reviewing the advantages and risks of psychotropic drugs. Drugs which occasionally kill people, prior to writing a prescription for same. But moreover, there is something called a “metamessage” – or what is communicated, but is not said. A patient with panic attacks gets a prescription for antidepressants, thinking that is all that he needs. So he believes that whatever problems he has in life come from some kind of biochemical glitch; the “chemical imbalance” that patients say they have that is not their fault.
I have my own classic explanation of the “fight or flight“ syndrome. It’s about Fred Flintstone seeing a saber tooth tiger and having to decide whether to clobber it or to run like hell. Maybe people could have better lives if they could learn what their “saber tooth tigers” are.
Like panic attacks. Relaxation training can diminish panic attacks or maybe even get rid of them without drugs. When do the panic attacks happen? If someone jou
als this they may find out why, and be able to do a better job of dealing with the major conflicts in their life. Projections need to be made, like how long the patient may need the drugs and when to try to get off them. The projection can be made as a function of the patients’ age, with current knowledge. The field I chose, after knocking around in several others, has been decimated. All talk therapy has been delegated to less credentialed folks. This is despite the fact that it has been shown, time and time again, that many psychotherapy patients get better when they have both a desire to get well and the belief the person treating can make them better. I’ll bet there are a lot of people accepting whatever insurance pays for while going 0 for 2. The New York Times did well to pick this psychiatrist for study. The complaint that doctors do not speak to patients any more is a valid one. When I was in residency, I remember being told that the average family practitioner interrupts a patient after less than 30 seconds and ends a visit in seven and one half minutes, so we had to be better listeners. I tried. But the tyranny of time is, in effect, the tyranny of money. He was amazed people respected him, with the rapidity of the interaction. In other words, there really are still some folks around who know how to help people get better just by talking to them. We are no longer paid for it, so my guess is people with problems who can’t tolerate or don’t want drugs are not doing a very good job of getting better.

In talk therapy, we have a great tool. It was invented by Freud and it has worked for a very long time. The business aspect of “medicine” has stopped us from using it, effectively or well, if at all. But hey, at least most psychiatrists can still count on a certain lifestyle in retirement.