In Sunday’s blog entry, “The Astonishing Power of Listening,” I undertook to write a second entry that would be about the March 6 New York Times front-page article headlined “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.” Gardiner Harris, the journalist who wrote that story, is smart and has done brave and important work in exposing other serious problems in the mental health system.
Because this blog appears on the website for my forthcoming book about war veterans, please keep in mind that every concern raised here goes double for vets. This is both because the fact that war has shocked and devastated them is often wrongly labeled “proof” that they are mentally ill and because in the military and the VA systems, they are increasingly likely to be loaded with psychiatric drugs.
It is worth taking a look at some of the important and troubling information Harris provides in his latest piece, as well as at some serious problems with the way it is written. It is possible that the problems result from an editor’s changes rather than from the writer himself, especially given Harris’s sterling history.
Harris tells much of the story indicated in the headline through the experiences of Dr. Donald Levin, a 68-year-old psychiatrist who used to do a lot of “talk therapy” and currently does nothing but prescribe psychiatric drugs to patients. When patients come to him and start to talk about heartbreaking, real life problems, he sends them away, saying he is not their therapist. Was it brave of Levin to acknowledge this practice publicly? Or is he so out of touch with some of the most basic ways of being human and being in one of the “helping professions” that he doesn’t even know how he sounds? Is our society so structured, even overwhelmed by the medicalizing of human problems that even a longtime psychiatric practitioner thinks at some level that this approach is acceptable? Harris quotes Levin as saying, “I had to train myself not to get too interested in [my patients’] problems.” Would you see a psychiatrist if he told you that was his attitude?
Levin says he feels shame that some of his patients say he is important to them, when he barely knows them. How troubling and revealing that he attributes that shame not to healthy causes but to the fact that he “was trained in a different era.” And in our era, there are plenty of colleagues who will tell him that his shame (and maybe his own missing of deeper human connections with his patients?) is unprofessional, even neurotic.
Levin’s current practice of treating “1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart,” in contrast to his practice in 1972 of treating “50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each” does not set him apart from most psychiatrists. Harris tells us that in 2005 a government survey revealed that only “11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.”
Some of the most disturbing features of this article are statements presented with no journalistic balance, no comments from people with other views. The statements purvey the notion that prescribing psychiatric drugs is mechanical, simple, and effective. Well, mechanical it certainly often is in the sense that it is often done without much heart, but it is not mechanical in the sense that it is easy to know what medication will have what effects, both positive and negative. Yet Levin’s statement that in his current work he is “like a good Volkswagen mechanic” goes unquestioned. So does his statement that “there’s not a lot to master in medications,” as well as former American Psychiatric Association President Steven Sharfstein’s assertion that brief psychiatric consultations are “very reminiscent of primary care. They check up on people; they pull out the prescription pad; they order tests,” with not even a nod to the vast difference between treating physical problems that can show up on a physical exam or lab tests and treating emotional pain. The above statements are appalling assertions in light of, oh, well, so many things, but for a start, how about (1) recent admissions by major drug companies that they are cutting way back on research on psychiatric drugs, because so little is still known about how they even work; (2) Robert Whitaker’s devastating revelations in Anatomy of an Epidemic about the World Health Organization and National Institute of Mental Health data showing that, though psychiatric drugs help some people some of the time, on balance they do more harm than good; (3) the skyrocketing practice by psychiatrists and even family doctors of prescribing drug cocktails, multiple psychiatric drugs at once for the same person, when almost nothing is known about how these drugs interact with each other?
Sure, I know that journalists only get a certain number of column inches for any given story, and it’s hard to keep the writing flowing smoothly for the reader if one keeps interrupting to present opposing views, so perhaps this one’s hands were tied. Still, it would be lovely to see more stories in which nothing of such importance goes unchallenged.
See what you think about this sentence from the article: “Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate.” Does that strike you as an apologia for the high fees that many psychiatrists charge? For how many years should psychiatrists be excused for such fees on the grounds that they are still needing to pay off the costs of their training? Levin himself says his current way of working is based on his wish to live in a certain style in which they have been living for 40 years — a far cry from, “I’m still trying to pay off my med. school tuition and the costs of my psychiatric residency.” At the extreme end of the spectrum, no doubt, Harris points out that some psychiatrists charge $600 or more to treat investment bankers, and “top child psychiatrists charge $2,000 and more for initial evaluations.” Just recently, a friend told me she had repeated, 15-minute appointments with a psychopharmacologist whom she paid $450 for each visit. That doctor is earning $1800 an hour.
Harris does a great job of letting Levin show us how he operates: “He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview.” Since “their own unhurried way” involves hearing the patient’s troubles as the patient sees them rather than in the mold created by the prefabricated set of questions, one wonders if it occurs to Levin that he might be missing important information. Yes, he does, because he describes how, through an entire meeting with a patient, he is focusing on the man’s distractibility, and only at the end of the brief session does the patient say he had been thinking of killing himself. Levin spent a full 10 minutes more than the scheduled time with this man because of the mention of suicide. Ten minutes. Wow.
Where years ago, Levin “often saw patients 10 or more times before arriving at a diagnosis,” he now makes that decision in the first, 45-minute visit. No one should underestimate the harm that getting a psychiatric diagnosis can do: People have lost health insurance, lost custody of their children, lost the right to make decisions about their medical and legal affairs because of receiving what might seem like a fairly innocuous diagnostic label. Should the risks of those losses be based on a single, 45-minute visit? And I have often heard from lawyers whose clients were given diagnoses of serious mental illness after 10- or 15-minute meetings with a therapist.
Levin acknowledges that “people want to tell me about what’s going on in their lives as far as stress…and I’m forced to keep saying, ‘I’m not your therapist.’” Whoever would have thought that a psychiatrist would consider it not part of his role to listen to the causes of people’s suffering?
Undoubtedly, we will hear protests that this guy Levin must be exceptionally steely. All I can say is that after about four decades in the mental health field, I have met some deeply caring, helpful therapists and at least as many who, like Levin, try to justify what they do but take much of the humanity out of their interactions with those who come to them for care. With that humanity missing, small wonder that Levin is disappointed when one more patient appears in his office after he thought he was finished.
Contrast that with Dr. Patch Adams, who argues that the more that doctors take love and joy out of their work, the more exhausted they will be, and the faster they will burn out. Adams describes the exhilaration he feels as a result of connecting deeply and intensively with his patients. Not only psychiatrists and other therapists but laypeople as well have much to learn from Adams about the healing powers of love and joy.
The focus in this blog has been on psychiatrists, because all psychiatrists, having M.D.s, can prescribe drugs. Until recently, psychologists could not. But the American Psychological Association is pushing hard for states to give psychologists the right to prescribe drugs, they have had some success so far, and it is likely that more states will soon be added to the list of victories for that APA. We can expect, somewhere down the line, to see a New York Times story about how psychologists are doing much less talk therapy and much more prescribing of drugs. Many of my colleagues are already breathtakingly quick to refer their patients to psychiatrists, family doctors, and others with M.D.s for the purpose of getting them on these pills.
 http://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing/dp/0307452417/ref=sr_1_1?ie=UTF8&qid=1299565035&sr=8-1 And Harris’ statement that “Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression [my italics] is a whopping understatement compared to what Whitaker reports about the dangers, for many people, of psychiatric drugs.
 http://www.amazon.com/gp/search/ref=sr_tc_2_0?rh=i%3Astripbooks%2Ck%3APatch+Adams&keywords=Patch+Adams&ie=UTF8&qid=1299567214&sr=1-2-ent&field-contributor_id=B001K7U3UY See both of Adams’ splendid books: Gesundheit and House Calls.