After thirty two years of being a psychiatrist and psychotherapist, I am embarrassed to say that I was confused about a number of things that made me less effective than I could have been. I didn’t do it intentionally, but to any patients and their families that I worked with without knowing the following, I apologize and want to tell you that there is still hope.
What I didn’t see clearly were the distinctions between Psychiatry, Psychotherapy, Counseling, Psychosocial Rehabilitation.
I hope the following helps and I invite any and all to weigh in on this in the comments.
- Psychiatry – the role of psychiatry as it is now practiced is to stabilize a patient’s neurobiology (Axis I) through psychopharmacology or ECT or TMS so they can then benefit from psychotherapy (Axis II).
- Psychotherapy – the role of psychotherapy is to stabilize a patient’s personality so they don’t take things so personally, don’t overreact, don’t jump to conclusions, don’t blame others, themselves, make excuses or feel self-pity. In other words to realize that what is is, and what isn’t isn’t. Until this becomes stabilized, counseling is of little assistance (imagine trying to serve a tennis ball while standing on mud).
- Counseling – the role of counseling is similar to being a consultant, but assessing problems in life, work and relationships and proposing actional solutions.
- Psychosocial Rehabilitation – this is the stepchild of the whole system, and yet this is where the rubber hits the road or the crap hits the fan and all the prior efforts fail, when the patient relapses. What would be the result of cardiac or orthopedic surgery if there was not cardiac rehab or physical therapy. The long term results would be dire without either, and yet just as the cardiac or orthopedic surgeon has the hubris to think that what they do is all important, psychiatrists and psychologists have the same hubris to think that their treatment without rehabilitation will be effective. And if these mental health professionals think that a polite and respectful but dysfunctional or toxic family is going to follow through on what you prescribe or suggest, then it’s the mental health professional who is crazy. Mental, alcohol and drug rehabilitation has to take place where the patient lives and where through the loving, compassionate and skilled care of professionals going into the patent’s residence and literally holding them by the hand to take them to doctor’s and therapist’s appointment, engage them in recreational activities, teach them interpersonal and even budgeting skills, the patient internalizes these new habits and makes them their own.
I wrote last week about such an organization called the Life Adjustment Team (LAT), which I believe is the model for rehabilitative efforts of the future. Several insurance companies have been so impressed by the cost savings of avoiding re-hospitalization that they have created special CPT codes for services provided by LAT.