Dilemmas of Cash-Based Practice

There is a growing movement for primary-care doctors to avoid insurance and only accept cash. Psychiatrists have been there first. What lessons can we pass along?

Choose Your Actions, Not Your Feelings

Blaming ourselves (and others) for emotions isn't fair.


One-upmanship is staying a step ahead of rivals by showing superiority. The converse is gaining an edge by appearing weak, inferior, or victimized. It's trickier but quite common.

Are Psychiatric Disorders Brain Diseases?

Prominent psychiatrists declare that all mental disorders are biological diseases. Is there proof? If not, can they say it anyway?


We each find a comfort zone between the poles of paranoia and gullibility, and proudly defend our spot at the expense of adaptive flexibility.

Hiring the One-Armed Surgeon

Working with an impaired psychotherapist is like hiring a surgeon with one arm.

We Are All Fallible Experts

Our ability to abstract, infer, and categorize is a gift. But it's also the root of prejudice and stereotyping.

Medical Professionalism Vs Commercialism

The physicians' guild may have been paternalistic and self-serving, but it also stood for high quality medical care. Will patient care suffer as commercialism and populism take its place?

Medical "Disruptors" as Adolescents

Entrepreneurs with "disruptive" business models are driven idealists and rebels, impatient with current practice. In this way they are like adolescents. Our future is in their hands, but they need guidance.

Medical Ethics Are Healthier Than Business Ethics

Traditional medical ethics puts patient welfare first. As corporations increasingly control health care, business ethics replace medical ethics. Doctors and patients must work together to defend the doctor-patient relationship.

America's Top Selling Drug

There’s nearly no end to the money the U.S. health care system will spend on problems that can be addressed more economically.

Behavioral Science Versus Moral Judgment

Learning more about the mind clashes with simple descriptions of personality. But our moral judgments of others won't surrender without a fight.

Defining the Competent Psychiatrist

What is a competent psychiatrist? Harsh critics declare the question moot, official bodies print long lists of "competencies." Is the answer in between? What does it take to understand and help troubled people?

Living Between Three and Seven

This simple numerical scale helps put feelings in perspective, and illustrates how cognitive and dynamic approaches can complement one another in therapy.

A Brief History of Psychiatry

Psychiatry can be neither "brainless" nor "mindless." Unfortunately it has tended to be one or the other for much of its history. Can we go beyond choosing sides?

Between Medical Paternalism and Servility

Excessively paternalistic doctors are reviled by many patients today. But is a servile physician better? By avoiding both extremes doctors may demean neither their patients nor themselves — and in the process deliver the best healthcare.

OpenNotes: Good Intentions Gone Awry

OpenNotes is a national initiative to let patients view their doctors' notes online. Advocates say it improves collaboration, gives patients more control of their care, and can correct factual errors in the record. Doctors and patients who use it say they like it. So why it is a bad idea?

Military Brain-Chips to Cure Psychiatric Disorders?

DARPA, the people who brought you the internet, now want to implant chips in the brains of psychiatric patients. This isn't science fiction, it's well-funded research. What are the potential risks and benefits of this high-stakes venture?

Enjoying Clinical Uncertainty

Psychiatrists (and primary care doctors, e.g., family practitioners) face diagnostic and treatment uncertainty every day. What separates those who merely tolerate this uncertainty, from those who welcome and even enjoy it?

Psychiatric Uncertainty and the Neurobiological Buzzword

Psychiatry has embraced neurobiological research, a promising area for discovery. Unfortunately, the term itself has become a buzzword, falsely implying we know the etiology (cause) of psychiatric disorders. Instead of overreaching rhetoric, the field should embrace the uncertainty that has always characterized psychiatry.

My Goal as a Therapist: To Make Myself Obsolete

Traditional therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave. Our aim, instead, should be to make ourselves obsolete.


What does it mean to be "undermedicated"? The term hides a few dubious assumptions.

Do Patients Avoid Psychiatrists for Fear of Legal Holds?

Do psychiatrists scare away patients because we have the power to commit them? If so, what contributes to this fear? It's not as simple as it first appears.

Loss of Privacy and the New Psychic Numbing

Personal privacy is quickly eroding. Ever-expanding government surveillance and social media make privacy seem old-fashioned, out of place in the 21st century. Is this inevitable, or do psychic numbing and fatalism only make it seem so?

Who Is Mentally Ill?

Everyone talks about mental illness and the mentally ill. Yet it's unclear what counts as mental illness. The ambiguity in such an important concept reflects rhetoric more than science.

Third-Party Payment for Psychotherapy: (2) Medical Necessity

Health plans base coverage decisions on "medical necessity." But most psychotherapy is non-medical treatment for non-medical problems. This ill-fitting standard casts psychotherapy as a square peg in a round hole, and senselessly and unfairly biases reimbursement.

Third-Party Payment for Therapy: (1) "Do You Take Medicare?"

Insurance coverage improves access to mental health care while adding complications. This first of two posts views Medicare from the perspective of the office-based psychiatrist to illustrate how third-party payment can interfere with optimal care.

Online Commentary: Marketplace of Ideas or Shouting Match?

Readers often post comments on news and other online media, a welcome breakdown of the one-way communication of yesteryear. Does this expand the marketplace of ideas and make discourse more democratic? Or does the freedom to post offhand comments to a wide readership impair serious debate?

Review of _Century of the Self_, a BBC Documentary

"Century of the Self" is an award-winning BBC documentary that links Freudian ideas about the unconscious to marketing and public relations in the 20th century. At the center is Sigmund Freud's nephew Edward Bernays, who believed the public could not think for itself.

Online Psychotherapy

Receiving therapy over the internet can be convenient, and it's enticing to be on technology's cutting edge. But face-to-face psychotherapy remains the gold standard. Here are pros and cons to keep in mind.