Why This Psychiatrist Isn't Practicing Psychotherapy

In expectation of their forthcoming book, the Shrink Rap folks did a post soliciting inquiries about psychiatry. Predictably, among them was: why aren't more psychiatrists doing psychotherapy? There are a number of ways to answer this, the simplest and least sophisticated being: shrinks are increasingly co-opted by Big Pharma and choose big bucks over introspection and integrity. That happens, of course, but it isn't the whole story.

Another way of looking at it is just the division of labor. People tend to get better at what they spend a lot of time doing. In recent decades huge numbers of psychologists and social workers entered the therapy arena, and not only do they often do therapy as well as a psychiatrist could--often they do it better. Why don't internists offer physical therapy, or detailed nutritional counseling? Because there are specialists who offer those services. Yes, they do offer them somewhat cheaper than an internist could or would offer them, but the more important point is that those specialists get really good at what they do.

To assume that psychiatry without formal psychotherapy (of the explicitly defined, 50-minute variety) is nothing more than pill-pushing is a warped and shrunken view of the medical role. The medical dimension of psychiatric practice has its own healing frame and ritual, the management of which calls for nuanced understanding of human nature and diagnosis; that is, psychiatry should offer a unique professionalism. Psychiatry without psychotherapy should not be confined to the peddling of antidepressants any more than internal medicine without physical therapy or nutritional counseling should be defined by the peddling of muscle relaxants or oral hypoglycemics.

As Freud himself believed, an M.D. after one's name does not endow one with unique therapy skills. As a psychologist reminded me years ago, people tend to do what they are trained to do. And as a commenter responded to a previous post on this topic (I can't seem to find it, so I paraphrase), people tend to practice what they believe. That is somewhat limiting (there are a lot of things I believe in more than in psychiatry, but it is necessary to pay the bills), but more or less true. I practiced ECT for years, but I don't "believe in" ECT more than in therapy. There is also, crucially, the matter of personal fit.

There are a lot of good therapists out there, and there are a lot of primary care physicians able to offer an SSRI (for better or worse) for transient or mild conditions. But people seem to have a hard time finding intelligent psychiatrists to offer, if nothing else, prognosis and understanding if typical treatments don't seem to work. One can have and apply a knowledge of the history, sociology, and philosophy of mental disorder without feeling the need to provide formal psychotherapy. I have done the latter in the past, and perhaps I will do it again, but for the time being it is more interesting in the abstract than in actuality.