Recently I had two referral experiences that I would like to share. The
circumstances of both were identical. An insurance company had given two
patients my name—however, the company had given out two names: that of a
mental health therapist who it said would perform the evaluation and provide
treatment and that of "a psychiatrist for your medications." It
does indeed appear that psychiatry has traded off the "50-minute
hour" for the "15-minute med-check visit." Perhaps the time
has come to change the official definition of what a psychiatrist does.
I began to wonder about this "sea change"—not just in
psychiatry but in medicine in general—and the proverbial swinging
pendulum between mind and body. Clearly one cannot have a psychogenic illness
without a brain, and as such, the neurosciences and medications are a
realistic consideration. However, it does appear that we have taken the
psychotherapy out of psychiatry.
I began to wonder how this has come about; it has been a slow and
progressive process. Periodically we read about circuit-riding psychiatrists
being subsidized liberally by pharmaceutical companies. We read about large
pharmaceutical studies. Rarely do we read about psychotherapy studies—an
exception being the article in the October 1, 2008, Journal of the
American Medical Association, titled "Effectiveness of Long-Term
Psychodynamic Psychotherapy: A Meta-Analysis."
We see pharmaceutical ads saturating the airwaves, magazines, and all
manner of reading material. We now have conflict-of-interest disclosures. One
must begin to wonder by whom and how is psychiatry being defined. Or perhaps
we should remember the Watergate metaphor and "follow the money."
I began to wonder about how our psychiatrists are being trained and what are
the philosophies that are defining their training—is it perhaps an
amalgam of big pharma, insurance companies, and who knows what else?
Progress is inevitable and realistic. I am not suggesting a return to the
past—that also had its limitations, biases, and omissions. But, to
repeat myself, we cannot have a psychogenic illness without a brain. We have
established the appropriate need to examine the pivotal role of the brain.
However, perhaps it is time for psychiatry to reintroduce the 50-minute hour
and develop an equal interest in examining the human side of that mind/body
CHESTER BERSCHLING, M.D.