It is helpful, when evaluating any scientific proposal, to first examine underlying assumptions. In the editorial outlining 10 foundations of advanced care for psychiatrists (Do you practice sophisticated psychiatry? 10 Proposed foundations of care, Current Psychiatry, From the Editor, August 2015, p. 12-13), there are a number of assumptions that warrant discussion. I want to discuss just one of those assumptions: that psychiatric practice is better now than it was 30 years ago.
I argue that psychiatric care in America, as a whole, is much worse now than when I finished training in 1990, primarily because of changes in healthcare reimbursement. When I was in training, it was common for patients to stay in the hospital for a month or longer. One reason for the longer stays was because it takes weeks for anti depressants and antipsychotics to reveal their effectiveness. If, after 10 days, no improvement was seen, there was time to change medications.
With a hospital stay now averaging less than a week, today’s inpatient psychiatrists must rely on faith that the first treatment will work; the patient must hope that he (she) does not fall through the cracks after discharge; and the outpatient psychiatrist, short on time and psychotherapeutic training, might feel more like an assembly line worker than a professional.
Longer stays also meant more intense and extended periods of psychotherapy and psychosocial support than is possible now. It was common, when I was in training, for the biological camp to dismiss the benefits of psychotherapy therapy. After several decades of research, that position is no longer tenable—yet hospital stays remain impractically short.
If all of the medications developed since 1990 disappeared, I believe I could be as effective a psychiatrist as I am today. The simple, sad fact is that there have been no major psychopharmacotherapeutic advances in the past 30 years. Yes, there have been changes in side-effect profiles and improvements around the edges, so to speak, but no fundamental changes in effectiveness since the introduction of clozapine.
What about advances in treating negative symptoms of schizophrenia, you ask? I have not been impressed.
The worst change in psychiatric practice in the last 30 years, and the one that threatens to undermine our profession the most, is relinquishing psychotherapy as a major component of our practice. I do not mean cognitive-behavioral therapy (CBT), although that paint-by-the-numbers set of tools is better than nothing. I mean psychoanalytic psychotherapy, because it is the only comprehensive developmental theory of the mind and its pathology. There is no CBT of development, for example.
To practice and research most effectively, we need good theories of both mind and brain. For all our advances, we are no closer to explaining the mind through a brain-based theory than when Sigmund Freud tried with his Project for a Scientific Psychology.
Ours is, by far, the hardest, most intellectually challenging medical profession. We must be masters of neuroscience to bring forth a future when something such as a Project for a Scientific Psychology will be possible; we must do the best by our patients with available somatic treatments; but we also must be masters at understanding human emotional development and the intricacies of relationships and how these influence the function and epigenetics of our brains. We must reinforce our understanding of the mind through doing psychotherapy with a significant fraction of our patients to further that understanding and its associated skills—or we risk becoming assembly line psychiatrists.
Over the past 25 years of practice, I have learned that the 2 most important tools we have are time and our evolutionarily determined empathic capacity to enter another human’s subjective world. The first session should not be about ordering medical tests and gathering family history; it should be about establishing a relationship. It is on the strength of that relationship that the success of understanding and treatment, whether somatic or psychological, rests.
Thirty years ago, we had all the time we needed. That was, in some ways, a Golden Age of psychiatry. Imagine if we could bring together the greater availability of time of that era with the increasing biological and psychoanalytic understanding of the present. Then, we might have a new Golden Age. For that to happen, we must fight to change the reimbursement system. The quickest way—maybe the only way—to do that is to stop accepting reimbursement from healthcare insurance companies.
Jule P. Miller III, MD
Private Practice
Biloxi, Mississippi
Dr. Nasrallah responds
Dr. Miller is correct: Insurance has defiled psychiatric care, both inpatient and outpatient, including minimizing hospital days of care and reducing psychiatric visits to med-checks with no time to provide even rudimentary psychotherapy—psychodynamic or otherwise. I believe that the optimal medical model of psychiatric care must incorporate empathic capacity, which establishes the indispensable therapeutic alliance with each patient we see.