Richard Perry/The New York Times
DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.
But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”
Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.
Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.
Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.
Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.
Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”
Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.
“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.”
It is impossible to do psychopharmacology without cognitive advice and content. The latter is a form of rehab, similar to physical rehab and exercise after an orthopedic operation. It is indispensable to the successful orthopedic operation. No surgeon would denigrate, short change a patient on it without hurting his outcomes.
For example. One has to say this or fail in treatment.
Your Abilify will reduce your impulsivity and will solely give you 5 seconds to think before acting. It does not give you the correct answer about what to do, nor coping skills, nor skills in getting what you want and need.
A year later, patients say, I have been doing it for months. Abilify taught me to think first. I can do it on my own. They stop the Abilify with their doctor, and many are right. They no longer need it, duplicating its effect with irreversibly learned skills.
Those skills are the rehab, the exercise of the operated limb. Does an orthopedic surgeon berate herself for not doing rehab, but for merely prescribing it for others to do? No. Nor should we berate ourselves for not doing extensive psychotherapy. The surgeon may briefly describe the exercise needed for success of the operation to the patients, and so may we. But sitting there practicing repetitive rehab is not the best use of time.
As to conflict of interest evidenced by withholding the possibility of response to psychotherapy.
All professions have a conflict of interest in making more money, the more people have problems, and less the more problems are solved. Professionalsim, pride in craftsmanship, and need to enhance reputation are all motivations for accuracy of advice, rather than trying to rip off the patient.
But try to give a bereaved person anti-depressant instead of counseling, they get a bunch of side effects, do not return, and bad mouth the psychiatrist to the referring family doctor or pastor. No psychiatrist will want that.