Why do psychiatrists do what they do? How— and why— is a psychiatrist different from a psychotherapist? I believe that most psychiatrists entered this field wanting to understand the many ways to understand and to treat what’s “abnormal,” but have instead become caught up in (or brainwashed by?) the promises of modern-day psychopharmacology. By doing so, we’ve found ourselves pigeonholed into a role in which we prescribe drugs while others provide the more interesting (and more rewarding) psychosocial interventions.
Exceptions certainly do exist. But psychiatrists are rapidly narrowing their focus to medication management alone. If we continue to do so, we’d better be darn sure that what we’re doing actually works. If it doesn’t, we may be digging ourselves a hole from which it will be difficult—if not impossible—to emerge.
How did we get to this point? I’m a (relatively) young psychiatrist, so I’ll admit I don’t have the historical perspective of some of my mentors. But in my brief career, I’ve seen these influences: training programs that emphasize psychopharmacology over psychotherapy; insurance companies that reimburse for medication visits but not for therapy; patients who demand medications as a quick fix to their problems (and who either can’t access, or don’t want, other therapeutic options); and treatment settings in which an MD is needed to prescribe drugs while the “real work” is done by others.
But there’s yet another factor underlying psychiatry’s increasing separation from other behavioral health disciplines: Continuing Medical Education, or CME.
All health care professionals must engage in some sort of professional education or “lifelong learning” to maintain their licenses. Doctors must complete CME credits. PAs, nurses, psychologists, social workers, and others must also complete their own Continuing Education (CE) credits, and the topics that qualify for credit differ from one discipline to the next.
The pediatrician and blogger Claudia Gold, MD, recently wrote about a program on “Infant-Parent Mental Health,” a three-day workshop she attended, which explored “how early relationships shape the brain and influence healthy emotional development.” She wrote that the program “left me well qualified to do the work I do,” but she couldn’t receive CME credits because they only offered credit for psychologists—not for doctors.
I had a similar experience several years ago. During my psychiatry residency, I was invited to attend a “Summit for Clinical Excellence” in Monterey, sponsored by the Ben Franklin Institute. The BFI offers these symposia several times a year; they’re 3- or 4-day long programs consisting of lectures, discussions, and workshops on advanced mental health topics such as addictions, eating disorders, relationship issues, personality disorders, trauma, ethics, etc.—in other words, areas which fall squarely under the domain of “mental health,” but which psychiatrists often don’t treat (mainly because there are no simple “medication solutions” for many of these problems).
Even though my residency program did not give me any days off for the event (nor did they provide any financial support), I rearranged my schedule and attended anyway. It turned out to be one of the most memorable events of my training. I got to meet (yes, literally meet, not just sit in an audience and listen to) influential figures in mental health like Helen Fisher, Harville Hendrix, Daniel Amen, Peter Whybrow, and Bill O’Hanlon. And because most of my co-attendees were not physicians, the discussions were not about medications, but rather about how we can best work with our patients on a human and personal level. Indeed, the lessons I learned there (and the professional connections I made) have turned out to be extraordinarily valuable in my everyday work. (For a link to their upcoming summits, see this link. Incidentally, I am not affiliated with the BFI in any way.)
Unfortunately, like Dr Gold, I didn’t receive any CME credits for this event either, even though my colleagues in other fields did get credit. A few days ago, out of curiosity, I contacted BFI and inquired about their CME policy. I was told that “the topic [of CME] comes up every few years, and we’ve thought about it,” but they’ve decided against it for two reasons. First, there’s just not enough interest. (I guess psychiatrists are too busy learning about drugs to take time to learn about people or ideas.) Second, they said that the application process for CME accreditation is expensive and time-consuming (the application packet “is three inches thick”), and the content would require “expert review,” meaning that it would probably not meet criteria for “medical” CME because of its de-emphasis of medications.
To be fair, any doctor can attend a BFI Summit, just as anyone could have attended Dr Gold’s “Infant-Parent Mental Health” program. And even though physicians don’t receive CME credits for these programs, there are many other simple (and free, even though much of it is Pharma-supported) ways to obtain CME.
At any rate, it’s important—and not just symbolically—to look at where doctors get their training. I want to learn about non-pharmacological, “alternative” ways to treat my patients (and to treat patients who don’t fit into the simple DSM categories—which is, well, pretty much everyone). But to do so, it would have to be on my own dime, and without CME credit. On the other hand, those who do receive this training (and the credit) are, in my opinion, prepared to provide much better patient care than those of us who think primarily about drugs.
At the risk of launching a “turf war” with my colleagues in other behavioral health disciplines, I make the following proposal: if psychologists lobby for the privilege to prescribe medications (a position which—for the record—I support), then I also believe that psychiatrists should lobby their own professional bodies (and the Accreditation Council for CME [ACCME]) to broaden the scope of what counts as “psychiatric CME.” Medications are not always the answer. Similarly, neurobiology and genetics will not necessarily lead us to better therapeutics. And even if they do, we still have to deal with patients—i.e., human beings—and that’s a skill we’re neither taught nor encouraged to use. I think it’s time for that to change.
Thought Broadcast 
And here I thought Daniel Amen was a brand.
Oh, but he is. I didn’t say I necessarily agreed with the people I met, but that I had met them, talked with them, and learned more than I might have learned from reading a paper or a book.
Daniel Amen’s pictures are very pretty, you must admit.
Continuing education for pharmacists in California has gone back and forth, but at present if it’s approved as CME it’s automatically approved for pharmacists. To a first approximation medicine is a superset of pharmacy, whereas psychology is a roughly a subset of psychiatry. A blanket decision to approve continuing education for psychologists for physicians seems entirely reasonable. Now you just need to convince 50 medical boards that this is a good idea.
I’m envisioning an interesting project – sample CE for psychiatrists and categorize it as being either about 1) psychotherapy, 2) psychopharmacology, or 3) combining or comparing psychopharmacology and psychotherapy. Not quite sure what the hypotheses are, other than that 1 and 3 will be very small. This could then help with your lobbying of the boards (see above). Sounds like a good fellowship project …
For the sake of clarity: psychology is not in any way a “subset of psychiatry.” Academically, it’s an entirely independent field, and professionally and legally, clinical psychology is in no way subordinate to psychiatry. (Not to detract from the point being made, just to be accurate.)
It’s not about fixing broken souls…
It’s about reminding each other that we’re all broken, but we have wholeness inside that surpasses all human understanding.
Once a person begins to search inside themselves, and finds this wholeness, great healing begins to take place, and all bets are off with what they can do with their lives…
Especially, the “chronically mentally ill” –
http://www.kaleidoscopes.co.za/html/heavenlykiss.html
Duane
Cranial Osteopathy treatment, (from licensed physicians) produces some amazing results (in both pediatric and adult care) for people who suffer from “psychiatric” conditions –
http://www.cranialacademy.org/benefit.html
Duane Sherry
Interesting and important post, Steve. There are some non-medication oriented mental health continuing education providers that teach mostly psychotherapy-related issues and topics that have category one medical CMEs (NICABM.com; NEEI.org). They do tell me they are hard to obtain and maintain.
I speak a great deal and I have noticed that in Europe many more psychiatrists attend psychotherapy trainings than here in the U.S. Interestingly, I get many more Family docs, internists, G.P.s and pediatricians at my mental health/psychotherapy trainings here than psychiatrists.
By the way, my fiancée is a psychiatrist and attends lots of psychotherapy workshops in addition to psychopharm. She discovered one of my workshops (about spirituality and therapy) years ago when her office subleasor got a brochure about it. She said that, as a psychiatrist, she never would have received it.
Bill,
Thanks for your response (and for reading!). You’re right: I should acknowledge that not all CME is focused on medication strategies. There are plenty that cover issues like diagnosis, ethics, medicolegal topics, suicide prevention, etc.
However, these are generally circumscribed topics that are offered in easily-digestible CME nuggets (“for the busy clinician”!). The psychiatrist who wants more in-depth training in, say, motivational enhancement therapy or managing patients with eating disorders, won’t find CME to help him/her do so.
As for me, I learned about the Summit from a good friend who worked for Sierra Tucson, while my fellow psychiatrists (including my residency faculty) had never heard of it.
It’s another subtle example of how our professional roles get shaped by forces beyond our individual control. The educational offerings seem to indicate that psychiatry is “betting the farm” on the biological understanding of mental illness. If we lose that bet, we’re in some serious trouble.
Steve,
I don’t see this as psychiatry’s bet.
The fraudulent research has been costly to the states.
It’s also been an enormous cost to the federal government – Medicaid, Medicare and Veterans Affairs.
IMO, psychiatry already lost the “bet”..
The American people lost the “farm” –
http://www.ahrp.org/cms/content/view/695/1/
Duane Sherry, M.S.
I am also a member of a profession that has very tight CPE requirements.
A lot of the courses that sound interesting and would perhaps make me a better practitioner are viewed as “things a well-read layperson with an interest in that subject would probably know already” or could pick up by subscribing to a “quality newspaper” and do not qualify for CPE credit.
So, as to this post, I can see both sides of the issue. I can see that the accrediting board would want to keep their CME requirements within certain parameters, and I can see that some psychology training could help one in the practice of medicine.
Jackie: “the accrediting board would want to keep their CME requirements within certain parameters”
That’s exactly the point. Whoever is defining the “parameters” has the ability to define the parameters for an entire discipline of medicine.
I realize I’m exaggerating here. But if a discipline wishes to stay relevant, it needs to ask questions about the body of knowledge it is imparting to its practitioners, and make sure it’s not Kool-Aid.
Your posts and comments are always very thought provoking, and complicated!
Now, I may be missing your point but when I read over your post again and reread Dr. Gold’s post, this is my take on things:
It’s not psychiatry (the discipline) that’s saying certain knowledge (say, psychology) is irrelevant, it’s that the medical establishment wants any course organizers/course offerings to be accredited before they qualify as CME providers/content. So, in Dr. Gold’s example, it sounds like the course organizers didn’t seek (and pay for) this accreditation from the medical powers that be.
I think this is how it works in every profession that requires continuing education — if an outside vendor wants in, they have to pay some tribute! It’s the old guild system at work.
This is totally off the subject but I just wanted to say that I was momentarily confused/disoriented when I checked out Carlat’s blog this morning:
http://carlatpsychiatry.blogspot.com/2011/05/horizant-second-coming-of-gabapentin.html
Ha! Yes, that was my cameo appearance. 🙂
I am active with the American Academy of Psychoanalysis and Dynamic Psychiatry. Our meetings occur just before the American Psychiatric Association convention, and are focused entirely on psychotherapy by psychiatrists. We give CME credit, and I know something (peripherally) about what it takes to keep up our accreditation with the ACCME people. I’m sure the application packet is three inches thick and the continuing need to assess the effectiveness of our educational programs in terms of meeting psychiatrists “needs and gaps” is astonishing.
But, if you want CME oriented toward psychiatrists who do psychotherapy, check us out — aapdp.org
Mariam Cohen, MD
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