Mary C. Vance, MD

Parallel Process

Four Things to Know About Psychiatry

Factors you may not see that impact rapport

Posted Jan 01, 2017

Walking into a doctor’s office is intimidating enough. Walking into a psychiatrist’s office can be even worse: Not only are you entering an unfamiliar environment, but you are asked and indeed expected to share—with a stranger—intimate details about yourself that you may not even tell your family or friends. On top of that, the stranger may then summarize your life story in a word or two and then hand you a prescription for a pill that has the power to change your brain, for better or for worse. All after spending only a few minutes with you.

Or at least that’s the fear.

Craig Sunter/Flickr
Source: Craig Sunter/Flickr

Many patients I’ve cared for carry these sorts of apprehensions about seeing a psychiatrist. I can understand where they’re coming from. Psychiatry is different from other areas of medicine. Mental suffering is different from other forms of illness. When your body is sick, it impacts your body. When your mind is sick, it impacts your person—the very essence of who you are, of what makes you you. And that’s unsettling on a deep level. No wonder some patients are slow to trust mental health care providers. No wonder it’s common to experience dissatisfaction about psychiatrists and the system they work in.

However, putting things into perspective can help clarify why your psychiatrist plays the role that he or she does, and what gets in the way of rapport-building. Here are four things about psychiatry I wish all patients could know:

1. Psychiatry is a frontier, and there are still many unknowns.

Although descriptions of psychic disorders date back to antiquity, the practice of psychiatry in its contemporary form only began to take shape in the late 19th and early 20th centuries, when psychiatry split off from neurology as a distinct medical specialty. Modern psychotropic medications first emerged in the 1950s, ushering in an age of “biological psychiatry” wherein mental suffering was medicalized and increasingly understood from the vantage point of neuroscience and related fields.

Psychiatric research is produced in vast quantities today, but we remain far from the answers we are seeking. Although promising leads exist, the fact remains that the field has not reached a consensus on the biological etiology of any mental illness. Similarly, there are fewer clearly defined treatment algorithms in psychiatry than in other medical specialties.

This is why different psychiatrists might give the same person different diagnoses. This is why each patient’s treatment is highly individualized and often cannot be accurately cross-compared.

Psychiatry is still finding its way. But that need not be a reason to lose hope. Rather, it is an invitation for each psychiatrist-patient team to join together to optimize each patient’s treatment using their own experience as a guide.

2. Psychiatry is often asked to fix social ills—but that is beyond its scope.

As a scientific discipline, psychiatry attempts to identify, define, and treat mental suffering through a medical lens, using the language of mental illness. But given the evolving nature of this field, it is not always clear what constitutes a mental illness—what may actually be a larger social ill that we are shoehorning into a psychiatric diagnosis.

For example, dialogue about violence is often linked to dialogue about mental illness in politics and the media. Although raising informed awareness of both issues is laudable, it would be a mistake to firmly connect the one with the other when evidence shows a much weaker link. Doing so both further stigmatizes an already stigmatized population, and puts up psychological blinders that prevent us from asking deeper questions about the problem of violence in our society.

Similarly, individuals from impoverished neighborhoods are much more likely to be diagnosed with mental illness as compared to those from non-impoverished neighborhoods. Knowing this, two potential solutions emerge: better care for the mental illness, or better care for the neighborhood. Both would ideally be implemented, but such findings raise the question: Which is the surface symptom, and which is the root cause? It is from thinking about issues like this that the “social determinants of health” are increasingly being investigated by psychiatrists and other physicians.

Psychiatrists vary in their beliefs about how much of a role they should play in broader societal issues beyond mental illness. Patients, steeped in mixed messages about what psychiatry can and can’t do, may turn to their psychiatrists with questions that are not answerable from the perspective of the field.

Keeping that in mind can help to explain and lessen the frustration that both psychiatrists and patients experience when they are asked, as individuals, to cope with issues that are bigger than themselves.

3. Psychiatrists can do more than just prescribe medications.

As doctors, psychiatrists are uniquely positioned to understand the ins and outs of the body as well as the mind. Their training, which encompasses four years of medical school followed by four years of psychiatric residency, enables them to diagnose basic medical and complex psychiatric conditions, to prescribe medications, to administer somatic therapies (e.g., electroconvulsive therapy or ECT), and to deliver psychotherapy, among other things.

But if that’s the case, why do patients sometimes get the impression that psychiatrists are only interested in prescribing medications?

There are many ways of approaching this question, but perhaps the most complete answer comes from the systems perspective. Consider the following factors of today’s mental health care system:

Michael Chen/Flickr
Source: Michael Chen/Flickr

1) With few exceptions, psychiatrists are the only mental health care providers who can prescribe medications.

2) There is a national shortage of psychiatrists.

3) As a general rule, psychiatrists are reimbursed by insurance at higher rates for medication visits than for therapy visits.

4) Medication visits are allotted a much shorter time than therapy visits.

By the numbers, then, it is more cost-effective to have psychiatrists focus on medications. The system, therefore, increasingly restricts their role to just that. Doing so extends their reach but gives them little time to perform a holistic assessment of each patient, and lowers their job satisfaction.

Understandably, patients might interpret such interactions as cold and careless. Psychiatrists, in turn, might feel unappreciated for the care they provide. As a result, patients and psychiatrists can end up at odds with each other, when neither is actually to blame.

4. The broken mental health care system frustrates psychiatrists, too.

Wait times to see a psychiatrist are shockingly long. Patients who need a psychiatric hospital admission may end up sitting for days in an emergency room for one of the vanishingly small number of beds available. Individuals with mental health needs are often shunted into the criminal justice system, which is ill-equipped to address their concerns. Despite efforts to introduce parity, many insurance companies still systematically treat behavioral health as “lesser” than physical health.

The impact that such a broken system has on patients and families is immense and tragic (although this series gives a lopsided presentation of the association between violence and mental illness, it hammers home the point). People suffer, and die, while awaiting care. And their loved ones endure untold hours of worry and grief.

Psychiatrists are well aware of this. They see their patients suffering, and it pains them, too. However, they often feel like—and are treated as—cogs in the wheel. That, indeed, does little to empower them to be agents of change. On the contrary: Physician burnout is an epidemic problem, and it has the potential to compromise patient safety and care.

What’s important to realize, for both patients and psychiatrists, is that they are on the same team, working towards a common goal. In addition providing patients with the best care possible in the system as it is, they can band together to change the system—a long and arduous process, but worth it for both of them.

Nothing substitutes for a warm, caring, mutually respectful doctor-patient relationship. This is especially true for mental health, when the establishment of trust and rapport is so crucial to effective diagnosis and treatment.

But during the times when these are difficult to achieve, it may help to understand why—from a perspective that extends beyond the individual patient and psychiatrist, to the state of the field and the state of the system.

The next time you walk into your psychiatrist’s office, I hope the experience is a healing one. Every individual deserves compassion and care. If you don’t feel that to be the case, I hope you and your psychiatrist can work together to find, understand, and maybe even help address the root cause of the problem—even when that root cause extends beyond the office and into the world.

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