I stumbled across this piece in the NY Times. It starts like this
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.”
At this point I stopped and checked two things – firstly, had I been redirected to “The Onion” without realising, and, secondly, was the article written on April 1st? Turns out the answer was “no” to both of these potential explanations. I read on.
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.”
This can’t be true. Tell me it isn’t true! Has there been a major shift in psychiatry in the US to deliberately NOT listen to patients, but to focus only on drugs? Apparently. Dr Levin misses the old style but finds he’s pretty good at the new one….
“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.” “I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”
At least in the article they interview one psychiatrist who has opted out of this shift and she hits the nail on the head
“Medication is important,” she said, “but it’s the relationship that gets people better.”
You know, I think this is the key issue here. When did we reduce “relationship” to “talk therapy”? As if a relationship between a patient and a doctor can be reduced a treatment intervention, and that drugs, of course, can be prescribed more quickly and “efficiently” than a relationship so drugs win!
If this really is true, I think it’s profoundly sad. In my opinion it’s a greater valuing of human relationships and a greater emphasis on people – patients and practitioners – that’s needed in medicine today.
Less drugs, more relating! That’s what I say!
Heroes Not Zombies 
There have always been two schools of thought in psychiatry: the neurologically-based, who essentially see the brain as an physical organ to be understood and manipulated in a scientific manner; and those who view thoughts and emotions as having origins (or, at least partial origins/consequences) stemming from more complex emergent phenomena that are not easily amenable to a purely physical understanding of the world.
The former have traditionally been more common in British psychiatry, and the latter more common in American psychiatry. The need to process more people more cheaply has driven both countries more towards the neurological perspective.
At its worst, it does indeed become the “Volkswagen mechanic” approach the psychiatrist you quote laments. It’s not a shift unique to psychiatry (though perhaps exceptionally evident there); for instance your GP colleagues have doubtless felt similar pressures to process people rapidly, which almost inevitably leads to a more mechanistic/physically-oriented approach.
But more nuanced practitioners still use the softer skills and psychodynamic perspectives in some way, if only to facilitate the more physical interventions they are proposing. They cite evidence about improving concordance rates and so on, almost by way of scientific apology for daring to think in this way! 🙂
My personal position is that I do think the brain is ultimately a physical organ, that could potentially be understood from a neurological basis. However, its sheer complexity, and interconnectivity, means that our current technological level is almost completely incapable to adequately describing it. Our imaging and pharmacological techniques are at the cave painting stage, but the brain is a Rembrandt. We can understand some broad basics, but the picture remains magical and incomprehensible, making any restoration/touch-up work we attempt somewhat risky.
Psychotherapeutic appraoches are also primitive compared to the complexity of the brain, but their great value is that they offer a different way of effecting change that relies more on the manipulation of the emergent or field-effect properties of the brain, rather than its physical nuts-and-bolts. It’s a top-down, rather than bottom-up, way of altering the way our brain works. As such, it gives us a chance to “jump ahead” in our technology level, allowing us to help people that our physical science alone currently cannot.
PS. I may use what I wrote above as the core for a post on my own blog at some point; thank you for the intellectual nudge to put some of these thoughts down on “paper”.
When did we get so important that we that forgot every person has a divine spirit.
It is by the grace of the compassionate heart that we heal.
Never anthing in a bottle will heal us on this level.
That is all we share. Your words are so useful to us.
My dog knows this stuff.