Interesting thread and also interesting interactions.
Why aren't we insisting to our leadership that we pour money and research resources into psychosocial interventions at the same rate?
We do, but leadership won't care if it doesn't have tangible outcomes (which are be almost impossible to satisfactorily define) and lead to overall financial stability (ie, why should we poor OUR money into all of this when it may not even be helpful!?!).
Why don't we have a free, nationally-available computerized CBT program for anxiety, so every anxious patient has at least one quality intervention available with just an internet connection?
There are plenty of online resources and I go over worksheets from various websites and make recommendations for workbooks all the time. They exist and are easily available with a basic google search (therapistaid.com, cbtonline.com, CBT Toolbox, Beck institute resources, etc).
Why haven't we dumped money into the community mental health system?
We have, how much more should we be dumping?
Why haven't we brought back asylums for the most severely ill patients?
Because they are expensive, require significant manpower and resources in a system where we already have immense shortages, and many patients historically campaigned strongly against them in political arenas. I'd look into the history of the International Conference on Human Rights and Psychiatric Oppression and the political fallout in the 1970's and 80's.
Why haven't we built a system of unlocked crisis centers as an alternative to unhelpful emergency department visits for our BPD patients in crisis?
These already exist in many places and are state-level issues. I refer my ER patients to several local crisis centers regularly.
The public cries for "access to mental health," but I don't think they realize how disappointing that access will be, if they ever get it...
This is 100% accurate, but not only because of the reasons you'd think. Most patients who NEED that level of care have the most specific and unrealistic expectations which are not realistic in our highly litigious society. As you said, if we could buck liability our system could be far more accommodating to high-need patients. However, many of the patients I see who come through the ER who would legitimately benefit from such services either don't want them or only want them on their terms which are completely unrealistic. Sometimes because the patient is severe PD and expectations are ridiculous and counterproductive to actually getting better, and sometimes because they're so psychotic that what they think they need is completely discordant with basic self-care. Additionally, the ethical argument of autonomy into play. The patient call of "who are you to dictate my life?!" will come up which was one of several driving factors leading to deinstitutionalization in the 70's and 80's.
But I also dispute the idea that your salary as a system employed psychiatrist will go down because we should be doing the sensible and logical thing (giving more weight to psychosocial interventions).
Pay is based on production, and it's far more productive from most administrative metrics standpoint to manage meds and stabilize than create long-term change through use of significant resources without tangible outcomes. So how do you justify being paid equally or near as much for giving more weigh to psychosocial interventions and how will you make that happen other than just demanding to be paid $XYZ? Genuinely curious on your thoughts there.
This is a political issue. And spreading awareness and political mobilization is EXACTLY how you start to address it.
It is how you start it, but how far will that awareness and mobilization take you in terms of actually producing change?
But social interventions will not replace clozapine, lithium or the monthly haldol shot.
They will not replace starting an antipsychotic after a FEP hospitalization.
They will not replace almost any of the work that we already do.
There is probably more 'niche' work in psychiatry in SMI and acute psychiatry than in any other field of psychiatry. Ironically, much more so than the 'snake oil' that gets sold to the worried well by Columbia and Harvard grads.
The issue is more that our resources are unbalanced because there will always big pharma knocking on the door to sell its next product instead of sensibly using our resources to help patients connect with their families, have a roof over their heads and the daily organization they need to lead a dignified life. Interventions that are just as critical as the antipsychotics.
I do not see where that fear is coming from.
This is all very true.
I work with and supervise psychologists and social workers. I have a ton of respect for the expertise they bring.
Social workers know a lot more than I do about the resources in the community and how to properly refer and what is realistic and what is not.
Psychologists are excellent in the interpersonal department. They get more intensive supervision in therapy than most psychiatrists in residency.
But the idea that they can replace us in the acute setting is laughable, and it's not just about "prescribing medications".
The reality is that they do not get the same breadth and depth of exposure as we do, which is critical in establishing clinical acumen, getting the right differential, assessing dangerousness and making the right clinical decisions. All while being extremely efficient.
Now if they want to go through the hoops of medical school, then toil through a similar residency and take on legal liability for holding patients against their will and discharging them from the hospital, they are most welcome to.
As they say--we can train any monkey to do surgery, the important thing is knowing when not to operate. In the same way, I think we do have a special authority in the sense that we have a deeper knowledge and broader context than just about anybody else in the mental health game. I can say with some confidence when something is or is not a prescription drug problem. I have worked with many excellent social workers and therapists who have never set foot on an inpatient unit, who have never seen severe and incapacitating psychosis, and who have a hard time differentiating between a psychotic BPD patient vs. someone with a genuine primary psychotic disorder.
I would love to have the ability to divert a big chunk of my panel towards robust psychosocial interventions, and spend more of my time on the patients with truly medical issues.
Because you don't know what you don't know. Just because you go to see an orthopedic surgeon and end up with a PT referral instead of surgery does not mean you should have seen a PT for that eval in the first place. We have both the depth and breadth to do diagnosis and treatment planning beyond what any therapists, social workers, or psychologists can do.
It's not that there isn't a place for a SW eval for psychosocial interventions or a psychologist eval for psychotherapy interventions but I cannot tell you how many times my evals have been worth much more than either of those disciplines can offer. It's actually a relatively low time suck of an MD's time if it's only for an initial consultation and then referred out to other services/programing/case management.
So the argument seems to be that psychiatry's major role, at least with initial treatment, should be the MH version of the ER where we triage patients to decide who would actually benefit from meds/medical care vs who primarily needs psychosocial intervention which is fair and I believe accurate. But to Clausewitz's point, for those who we categorize as not really needing meds but needing psychosocial support, why should psychiatry continue to be involved in the social aspect when there are others just as qualified, if not more qualified, and requiring less pay/educational investment to perform this work? I hate the "practice at the top of your scope" argument, but in this situation I actually think it's valid.
To the bolded, why are you not referring people to psychosocial resources? Lack of availability? Unless you've got a long history within that system, I'd take some time to explore what resources are available and reach out to them.
As I've said before, you are definitely the Evil Fairy Godperson of this forum. You're not wrong, Walter. . .
I think a lot of your analysis is accurate as far as identifying why systems work the way they do. And then you centered it around "prestige", which, you will note, is not a thing anyone invoked until you entered the conversation, and which most people have responded to with puzzlement. You may consider if you are the source of the concern for prestige in this conversation v. it being a naturally occurring tangent from the thread.
I could be wrong, but I think "prestige" is being used in a very generalized way to represent a broad set of concepts which are somewhat loosely associated (expertise and recognition of expertise/individual influence on systems, financial earnings/power, self-image/esteem, etc). In that sense, prestige is relevant and is absolutely a major political/systemic force of implementing actual change and policies that goes beyond conceptualization of systems. If we're talking about "prestige" in terms of the more basic definition, then yea, it's a somewhat random tangent with minimal relevance to this conversation.
I think our experiences must legitimately differ. Having done OP intakes and now PHP/IOP intakes for the past 5 years, I cannot tell you how many comments I have received from parents (I'm all CAP) about how much better conceptualized my description of both the diagnoses themselves and the suspected etiology or perpetuating factors are compared to assessments their child has had in the past from NPs, PCPs, LCSWs, or psychologists. I have read well north of 100 psychologic evals during this time and it is so fleetingly rare they fully encapsulate the patient, which I think is largely attributable to them having to complete very time intensive tasks (the testing itself) and because the people doing this testing often do not follow-up with patients to determine how effective their assessments are (tough doing a job you get basically no feedback on your accuracy).
I think I am an above average psychiatrist but certainly not a world beater so I would expect my experience is pretty generalizable to other psychiatrists. My organization is actually tracking the difference between masters level intake assessments versus MD intake assessments but it's too early in that data collection for me to having any results to share, certainly the other leadership also sees a difference here.
Eh, I look at child psych as an almost completely separate field from general psychiatry because of the prevalence and level of psychosocial aspects involved. The patient who would likely be mostly fine if they didn't have a completely toxic environment with constant stressors/abuse and adults/caregivers modeling awful coping skills/strategies is a lot more common in child psych than general adult psych, imo. I think a lot of what is being discussed in this thread is actually more relevant to child psych than general psych and focusing on future generations being functional adults would do a lot more good, but it's the same issues implementing change there as it is with adults.
Psychologist evals have been very hit or miss, but most I've worked with have actually been very good in terms of specific MH issues. Obviously they lack the medical education we have which does make a huge difference at times, but imo that's where we have the greatest job security.
I believe there are millions. I agree that behavioral health treatment shouldn't be the the default mechanism by which people achieve good lives. That said, where we differ is: I think a majority of people are really struggling, and Psychiatry is not the answer. It seems you think most are doing ok. We agree Psychiatry is not currently equipped to deal with what most people are needing.
Are they though? How are we defining struggling and what lens are we looking through? Maybe we're not struggling as much as we think but are setting much higher standards for what it means to be "okay" and what lifestyle we should expect which are unrealistic. Maybe in our modern world we've become so focused on feelings that we've lost perspective on other aspects of life. This is a whole other separate conversation which does have some relevance here, and I'm not trying to diminish what people are dealing with, but do want to point out that exploration of perspective is important, and I love when people on here talk about asking patients about what their expectations are.
Now add on SUD's, eating disorders, catatonia, MDD resulting in suicide attempts or chronic disability, etc and yes it's absolutely the case the numbers suggest we need more mental health treatment and not more people telling folks to pull themselves up by their bootstraps.
The other issue is that many people are not currently capable of the distress tolerance needed to face their issues. They need initial contact with the mental health care system to get to the point of being able to face their issues and not be functionally impaired. Ideally this work can be completed in a set period of time and not require lifelong work (cough psychoanalysis cough) and much of it could be done with individual and/or group psychotherapy without psychiatric involvement (potentially past the initial assessment), but it's extremely important work to be done.
100% agree with this and relates to the above. I partially attribute this to the growing societal idea that whatever someone feels should be accepted and that external causes of those feelings should be the things addressed and patients should be accommodated instead of the patient addressing internal mechanisms.
TL;DR- Lots of people feeling burnt out by the crappy system with reasonable but idealized expectations. Realism being brought into thread about burnout and decompression leading to B/l butthurt. Results: Entertaining but somewhat depressing thread. Conclusion, the system sucks and probably isn't getting better sooner and everybody recognizes it.
