Against the Mutilation Of Clinical Psychiatry

There are today two completely different perceptions of the clinical psychiatrist's activities. Ours is that the psychiatrist is the captain of the ship, the best diagnostician, the leader in psychotherapy, the expert in differential diagnosis and in the differential use of psychotropic medications, and the best judge of the allocation of mental health resources.

The opposite perception has the psychiatrist accepting the practive of medicating a patient diagnosed and treated elsewhere. For several years a number of financial intermediaries in health care have tried to teach us that psychiatrists should mostly devote themselves to signing prescriptions. The main evidence in favor of this distortion is that some psychiatrists may be better paid for signing three prescriptions in one hour than talking with a patient during the same time.

The mutilated perception of psychiatry has unfortunately advanced even among those who believe they are protecting psychiatry. I have several examples.

A company hired by a patient's employer asked a psychiatrist to evaluate a colleague's work. The consultant was active in organized psychiatry. He wrote in his opinion that the patient's social problems were probably due to the patient's early upbringing, that the prescribed medications might not be enough, that the psychotherapy given by the psychiatrist was insufficient, and that the patient should be referred to a psychologist for further therapy.

The treating psychiatrist stood his ground. Both the social problems and the symptoms responded to his therapy, and the patient became fully functional. The psychiatrist thought the split therapy proposed by the consultant would have been less effective.

A second case illustrates the lack of communication common in split therapy. A psychiatrist was asked for his opinion about the treatment of a patient who had been in treatment for one year and was still complaining about the same symptoms. The treatment plan called for a psychologist to see the patient two to four times a month and a psychiatrist to conduct“ medication management” as needed. The psychologist had seen the patient four times in five months, and the psychiatrist twice in the same time. The patient was not aware of any communication between the psychiatrist and the psychologist. She was working with the psychologist on her self-esteem, while taking 300 mg of trazodone most nights.

Refusal to participate in split therapy is an ethical position for those who do not believe in it and are prepared to provide both psychotherapy and psychopharmacologic treatment. Split therapy may be a poor second choice when the psychiatrist is prepared to give both treatments. If the psychiatrist doubts his or her own ability as a psychotherapist, which is regrettable but likely in the current environment, there are excellent remedial courses that may help correct the problem.

The financial incentives proposed by intermediaries that favor split therapy should not deter most psychiatrists from the full practice of their profession. These incentives create quicksand in which many may drown. The temporary financial benefit does not compensate for the mutilation of psychiatry.