What Happens on Sacramento Street?

Old-fashioned psychiatry seen anew.

Posted Nov 12, 2009

Sacramento Street is a pleasant east-west boulevard that runs north of Golden Gate Park in San Francisco.  One section of Sacramento, together with adjoining side streets, forms a neighborhood in which many of the city's private-practice psychiatry offices have been located for generations, many fashioned from subdivided and re-purposed Victorian homes. The area sometimes is jokingly called "Couch Hollow," a playful pun on another part of town called Cow Hollow. Yes, my office is on Sacramento Street.  However, I'm using the name not to highlight my particular office, but a certain approach to psychiatric practice.

Over the past 30 years or so, American psychiatry has increasingly shifted its focus to biology, genetics, and medication. Despite roots in Freud and the psychoanalytic tradition, clinical psychiatry now often supplies only the drug component of a comprehensive mental health treatment. Any psychotherapy is conducted separately by a non-physician such as a psychologist, marital and family therapist, or social worker.

To be sure, this arrangement has its advantages.  Non-physicians often charge less for therapy and many are well trained. There are far more to choose from.  But there are disadvantages, too. Recall the well-known adage: "If all you have is a hammer, then everything looks like a nail." If a psychiatrist only prescribes medication, most patients will look like "med patients" and will receive prescriptions. We've seen huge increases in medicating anxiety, shyness, poor concentration, and other problems that previously were considered personality issues. In addition, the psychological meaning in taking medication, and in the doctor-patient relationship surrounding it, can be overlooked when psychiatrists are reduced to medication specialists. The whole person can be lost amidst the neurotransmitters and receptor sites. Symptoms may improve, yet the patient feels no better.

A few regions have resisted this trend in psychiatry. Major cities such as New York, Boston, and San Francisco continue to attract psychiatrists with a psychological bent, doctors who see patients as minds and bodies, not one or the other. San Francisco's "Couch Hollow" is one such outpost, where old-school therapeutic perspective tempers cutting-edge pharmacology.

"Sacramento Street Psychiatry" will be about medication and therapy, separately and in combination. Since I have been an educator my whole career, I'll also share my thoughts about teaching psychiatry to trainees. We'll look at important psychological lessons regarding continuing medical education (CME) for physicians, social stigma, psychiatric diagnosis, and other issues. There's a lot happening on Sacramento Street.