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Now I am mad. I finished an article last week that I was reading to review for this blog, and set it down because I wanted to re-read parts of it before deciding about how to write it. After procrastinating for days, I am up against a self imposed deadline (end of the weekend) and I can’t find the friggin’ article anywhere. I never throw anything away inadvertently, and this is so unlike me. It probably got mixed up with a batch of other newspapers and wound up in last Thursday’s recycling, Greenie that I am.

But we know what THEY would say. Lost the article on purpose. Expressing some inner conflict about the review, or the article, or the blog itself, and IF you could come to terms with those feelings, you wouldn’t need to lose the article in the first place. Aha! Go figure that the article was on psychoanalysis! My Life in Therapy–What 40 Years of Talking to Analysts has Taught Me –— was a funny, enjoyable, yet painful summary of Daphne Merkin’s run-in with psychoanalysis. At first, I couldn’t decide if the article was some sort of comedic rant on the subject, as– she just wasn’t serious, was she? Her experience couldn’t have gone that way could it? One begins to realize that she recounts things that really one could only know if they had been in analysis themselves. So she had been there, but……

Through comedy and humor, Ms. Merkin writes about alot of different situations during her decades of psychoanalysis.Not all were funny, though. Although from the patient’s perspective, this well written article interestingly serves as the counterpoint, or bookend to the last article I reviewed, the psychiatrist who could only give meds. Here it is the psychiatrist who could only analyze–the polar opposite. Being a New Yorker myself, I suppose I can say, “Only in New York,” as the association to as lengthy an analysis in our popular culture leads to Woody Allen, who likewise in interminable analysis, in this article actually offers her a referral to his analyst.

My Life in Therapy recounts what is both good and bad about psychoanalysis. The psychiatrist as analyst takes a neutral stance and through tthe results of their training uses techniques so as not to inject themselves into the treatment. In this way, the motivations, wishes, decisions can wholly be understood as belonging to the patient. It can allow for a much more intensive understanding of one’s internal self. However, Ms. Merkin sometimes finds herself on the short end of that “neutral” stick–an analyst is closing his practice due to terminal illness, and instead of simply informing her of that when she applies to be a new patient,  he tells her that he cannot invest his time into her care. She is left wondering all kinds of things about her acceptablility as a patient, rather than the fact that the decision had nothing to do with her at all.

In the end, Ms. Merkin decides after 40 years, that maybe she doesn’t need to talk all of her issues over with an analyst, that it is not worth the time or the money or the emotional investment, and that she could do reasonably well on her own. It could be said that her analysis had a reasonable outcome on that basis–she was able to reach a psychological independence, finally. My beef is that the analytic stance would not allow the question to be asked, “After all this time, why are you still here, and what has happened that you can’t do this on your own?” My agenda perhaps, not hers, it would be argued – if she wants to come, let her come. But I think to allow her to come and take her money after all that time, without asking that question, is almost like taking advantage of her conditionand repeating something from her past.

When I did my psychiatric training, we learned both psychodynamic principles and medication treatment and how to blend them together. But the king of the hill back then was the psychoanalyst, who commanded the highest regard due to the mystique of psychotherapy and the often-inabilty back then to treat psychiatric problems ably with medications.  I decided not to trek up that hill, but to dwell amongst the “regular” psychiatrists. Regular enough to learn to try to distinguish what was pscyhologically based, what was biochemically based, and to be able to talk about whatever was necessary without having to tell the patient that I couldn’t help them because my appointment structure for medications only wouldn’t allow it.

I had to go around my house and look for the article one last time. Of course, now that this review is finished, I did find it under a mass of papers I was sorting on my dining room table. I guess you could say that I didn’t need it any more.

I had the notion that I would slowly attack the pile of articles that I had amassed over the last 7 months and be able to comment about them fairly easily in this blog. I did not consider the possibility, or rather the actuality that there would be additional articles demanding my attention as well.

And so it is with Mind Over Meds — How I Decided My Psychiatry Patients Needed More From Me Than Prescriptions, a recent article from the Sunday New York Times magazine section. I have so many reactions, it is hard to organize them in a coherent fashion. But, I will try.I will have to leave my pile of other articles for another time. This article is written by a psychiatrist, self defined as a psychopharmacologist, who comes to realize that focusing on medications only, may not be in the best service of the patient! Duh, is all I have to say. Actually, I have a lot more to say on the subject than that.

I trained as a psychiatrist before the coming of Prozac and most of the other newer and fairly effective medications that are used in 2010. In the early 80’s when medications did not seem to work as well, one was left with having to sit with the patient and talk to them to try and help them get better. I went to a psychiatric training program, University of Colorado Health Sciences Center, that focused on teaching psychodynamic psychotherapy, but also incorporated medications or psychopharmacolgy into the treatment as an intrinsic part of the whole. It was in the early days of the rise of the primacy of medications in psychiatric treatment, even if way before Prozac. My training taught me how to talk with patients and how to listen to what they were trying to tell me.

There is no question that medications can cure or treat certain psychiatric symptoms. I still remember working with a very suicidal patient years ago, when medications could just not relieve his depression or  suicidal thinking. We spent session after session developing a checklist of things to do for distraction when he became suicidal. But, we could talk til doomsday and never really impact the depression or the suicidal thinking. Along came the new SSRIs and guess what?  The new class of antidepressants not only eliminated the depression, but completely wiped away the suicidal thoughts as if they had never been there.  Without a trace! As a psychiatrist, and as a psychotherapist, the results were incredibly powerful — medications had a life changing potential.

But just as similarly, the person who comes in who may have some trouble with sleep, motivation and sadness, may not quite benefit from an antidepressant, and instead, need some time in psychotherapy to sort out what in their life may be causing her to feel out of sorts, and what might they want to about it. Providing medications and psychotherapy, in this instance, I can assess whether the psychotherapy is allowing the complaints to remit, or whether a medication needs to be added.

Dr. Carlat indicates in this article that it is easy to learn  the science: the criteria, diagnostic categories, differential diagnosis and match it all up with medications. He recognizes that learning psychotherapy is another story. It is not my purpose in this article to review the pressures he touches on in this article that have pushed the psychiatrist to become a psychopharmacologist. However, I strongly feel that medications and psychotherapy are just two of the  tools found in my tool bag that are used to help a person when the situation warrants. Just like the washing machine repairman, who needs the very large pliers and belt to remove the drum when it is not working (and only that tool will work for to fix this problem), the psychiatrist should be able to apply their art and know what is called for in the situation: medication, psychotherapy, both, or even neither.  Patient sessions can be 15, 30 or 45 minutes to tailor the appointment to the need of the patient. It does not have to be “one size fits all” and say “over the course of 15 or 20 minutes, this is about all I can offer” ! (exclamation point is mine)

It alarms me that I get referrals for treatment where the patient or referring party comments on the fact that they can’t find a psychiatrist who provides both medications and psychotherapy in a combined treatment. Dr. Carlat relies on studies and statistics to back up his conclusions. While that approach may be helpful to the general public (e.g. only 29% of psychiatrists provided psychotherapy in addition to medications in 2004, or that it is more cost effective and decreases the number of sessions when the psychiatrist does both the medications and psychotherapy), it all seems so far removed from my everyday reality. Ultimately I feel that it is the patient that suffers.

After reading this article, I really feel like a not-quite-extinct-yet-prehistoric-animal, or perhaps a lonely voice from the wilderness. Thankfully, Dr. Carlat adds his voice to the mix that there is value and benefit for a psychiatrist to be able to prescribe medications and perform psychotherapy. I am very worried that the coming changes in healthcare, which have yet to unfold, will not support this benefit and push more of us to have to provide medications only.

for further thoughts on this subject, see my entry “What is a Psychiatrist ?” on the home page of my