I am frequently asked if I can recommend a psychiatrist or a therapist in various locations, most recently in Des Moines and somewhere in Pakistan. Not only do I not know any psychiatrists in these places, I would not even feel confident making a referral to anyone in the community in which I currently practice. The professionals whom I trained with or worked with well enough to trust have all retired. Even those psychiatrists that I, myself, have trained have dispersed throughout the country–and some of them have retired. But I can make some suggestions.
The practice of psychiatry has changed since I was trained in the early 1960s. The use of drugs to treat psychiatric disorders was just then becoming commonplace. There were the anti-depressants and the anti-psychotic agents; and not much more. Little of my training was directed towards the use of these agents. We were supposed to learn about them by being supervised by more senior residents. There was really not much to know. In the treatment of depression we used the tricyclic anti-depressants first; and if they did not work, the MAO inhibiters, a somewhat trickier class of drugs, one of which was taken off the market a few years later because of liver toxicity. If that did not work, electric shock therapy usually did. The treatment of agitated states, and schizophrenia, in particular, involved the use of one or another of a small number of phenothiazines, of which the most familiar example was Thorazine. But most of those three or four years of residency were directed to learning how to do psychotherapy.
When I asked what the goal of psychotherapy was, I was told “to make the unconscious conscious.” I came to understand this obscure formulation to mean that a disturbed person who came to understand just how he developed his emotional problems would be free to be different. Understanding oneself was the goal of psychotherapy, and from understanding came the ability to change. I regard this as a broken promise. It turns out some things are easy to understand. Someone cannot go comfortably above the third floor because his father could not go above the third floor. Someone beaten by parents when he was growing up beats up his own children later in life. You don’t have to be a psychiatrist to understand how these behaviors develop. But the greater number of emotional problems that people suffer from turn out to be inexplicable even after long years of treatment. What is required is not some explanation that is made after the fact, such as OCD behaviors being caused by an overly strict parent, or low self-esteem being caused by sibling rivalry. A true explanation looks forward, not backwards. Given a child who is compared unfavorably to a sibling, can we predict whether that child will grow up to have low self-esteem? We cannot. This is the failure of insight therapy that the profession does not acknowledge. And it turns out patients can understand themselves—as much as that is possible—without feeling much better or handling life much better.
Psychotherapy is both simpler, and harder. The job of the therapist is to help his/her patient accomplish those goals the patient sets out for himself/herself. Given the particular strengths and weaknesses of patients, and their symptoms, how can they be helped to accomplish what they want to in life—especially since the wishes they may have are likely to be uncertain and contradictory? Coping with the fears that underlie most of the anxiety disorders requires a strategy of confrontation—but determining how far to go and when, requires judgment and skill. This is a kind of exposure therapy—also called cognitive-behavioral therapy. The other mental disorders, including depression, are treated therapeutically with variations of a supportive psychotherapy—if that term is interpreted broadly.
I like to think I learned how to accomplish these purposes during the four or five years of my residency training. I like to think that years later when I was the director of a residency training program I helped others to understand how to go about doing therapy. But the longer I am in practice and watching others do therapy, I think other factors matter more than training. I would prefer referring a patient to someone who is, perhaps, less well-trained, but who is a sensible and sensitive person.
I think psychologists and social workers are for the most part just as good at conducting psychotherapy as psychiatrists—depending on their experience and maturity. Even so, however appropriate the therapist may seem, there needs to be some fit between patient and therapist; and so, it is reasonable for a prospective patient to try more than one therapist. It is not important for a patient to like the surgeon who is going to operate on him. It is impossible for a psychiatrist, or anyone else, to conduct therapy with a patient who does not like him or her for any reason whatever. These observations are not determinative, however, in choosing a particular therapist.
Before making suggestions, I have to take note of certain changes in psychiatric practice. Partly because of a shortage of psychiatrists, and partly because of the policies of insurance companies, which encourage the use of less expensive therapists, the role of the psychiatrist has been reduced, more or less, to prescribing drugs. There are many more such therapeutic agents than there used to be, but they still tend to divide into three or four major categories. Prescribing them often turns out to be trial and error. One from group A and two from group B. Most psychiatrists rely on a relatively small number of drugs to treat the conditions they encounter. These treatment protocols differ from one doctor to the next. There is little to recommend one regimen of drugs over another.
Psychotherapy is done by other professionals, primarily psychologists. This separation of drug treatment from psychotherapy is unfortunate. Someone who prescribes drugs all day no long, and has no recourse to doing other kinds of treatment, is going to prescribe drugs for a particular patient whether he/she needs them or not. Similarly, someone who cannot legally prescribe drugs will postpone making a referral to a psychiatrist until it is clear that the patient is not recovering in therapy. This is too long to wait. But this is the current reality in the treatment of the emotionally and mentally ill. Ideally, the practice of psychiatry should include both giving drugs and doing therapy, whichever is appropriate.
So—how should someone in Des Moines or Pakistan go about finding a psychiatrist?
There is considerable information on the internet and through sources like “The Book of Medical Specialists” to locate a board-certified psychiatrist in any particular locale. When doing this research, the prospective patient should look at the training of the various psychiatrists in the area, including any research or publishing in the field that that individual may have done. The age or the sex of the psychiatrist should not matter unless the patient feels, for whatever reason, that it does matter to him or her. I recommend staying away from psychiatrists who advertise themselves as “psychopharmacologists,” for the same reason that I would avoid other physicians who describe themselves as doing “holistic medicine.” These terms are used for marketing purposes and indicate a narrowness of approach rather than any special knowledge. (I am reminded of a colleague who finished my residency program at the same time I did and printed up cards saying that he specialized in the “psychology of women” because he had previously practiced as a gynecologist. I do not consider that such a practice gives much insight into the psychology of women.)
THIS IS NOT TO SAY THAT EXPERIENCE WITH SPECIFIC DRUGS IN PARTICULAR CIRCUMSTANCES IS NOT IMPORTANT. Anyone suffering from a severe condition, such as Bipolar Disease, should seek out doctors with considerable experience dealing with that particular illness. So should someone who has been diagnosed with one of a number of relatively unusual conditions, such as Tourette’s Syndrome or Narcolepsy.
Nowadays, this search for a doctor starts with those listed on a particular health insurance plan. There is no reason to think that they are any better or worse than other doctors of similar experience who see patients only privately and who charge much more money.
Once patients have tried out a particular psychiatrist, or psychotherapist, they should consider leaving treatment under certain particular circumstances: if the therapist or psychiatrist cannot be reached easily by telephone, or if the patient is kept waiting frequently for a scheduled appointment, or if the psychiatrist is too casual or careless about the prescriptions he writes, or if it can be perceived that the therapist has a pet hobby-horse that he/she is always emphasizing—such as the signal importance of incest, or relaxations exercises, or finding the spiritual underpinnings of therapy and of life in general. It is not that there is no place for these considerations; their relevance should depend on the particular patient and not on the preoccupations of the therapist. Starting therapy appointments on time is important because it reflects a basic courtesy which is an indicator of the therapist’s respect for the patient. Therapists who are derelict in these matters can be expected to be unreliable in other aspects of treatment.
Similarly, having watched other therapists through the one-way screen, I recognize, sadly, that many patients are busy working out their own problems in the setting of doing psychotherapy. I have seen doctors who were just plain trouble-makers, who stir things up in the families they treat for their own psychological purposes.
Having offered these caveats, I want to emphasize that most therapists I have known are conscientious and caring and sensible; and I would recommend that people who are unhappy for any reason enter into such a treatment with some expectation of being helped. Psychotherapy takes time, however. (c) Fredric Neuman 2013