Why are Some Psychiatrists Such Wimps?

“Most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administration politicians and have no clinical value.” ~ George Dawson, MD

With the exception of those who are in “concierge” practices who do not take insurance and treat only those who can pay significant fees, very few psychiatrists—even in private practice—are doing any psychotherapy at all—other than being supportive with their patients. As mentioned in Dr. Dawson’s quote, some don’t do it because, simply put, they aren’t given the necessary time. They have to see several patients per hour, and are also too busy filling out completely useless symptom checklists on electronic medical records. 

Others are not interested in psychosocial issues and see everything in the DSM, the profession’s diagnostic manual, as a brain disease in need of medication – even “adjustment disorders,” which by their very definition have strictly psychological and social etiologies and do not require medication. Still others won’t do therapy because it doesn’t pay well. (Even psychologists are doing less and less long-term psychotherapy because insurance companies will not authorize it and keep ratcheting down fees, and they have been advocating for prescribing privileges. However, that is not the subject of this particular post).

Medical and psychiatric newspapers are filled with stories of physician “burnout” - being exhausted or depressed over their unpleasant work situation. Business and insurance companies work hard to convince these cases that the problem resides with their stress tolerance, rather than with their stressful working situation, and that they need to practice more mindfulness.

Meanwhile, hospital beds for the chronically mentally ill – those who do have actual brain diseases and are in desperate need of medication – have started to disappear. Along with that, the Community Mental Health Centers which once treated them with close follow up have been defunded by the states and the federal government. These two developments have resulted in many of these people living on the streets or languishing in jails, which have become de facto mental hospitals.

So who’s to blame for all this? Surely tax phobic politicians and greedy business interests share the lion’s share of the responsibility. Dr. Dawkins in his blog, from which the quote at the start of the post comes, seems to think that psychiatrists have no responsibility here, because they have all been forced to conform to the whims of businessmen with zero knowledge of medicine dictating how they should practice. But don't they really?

I think one of the main problems with the psychiatrists is that many of them are really a bunch of wimps who are too friggin’ chicken to band together and say “no” to their task masters. Of course, a lone doctor who tries to do that by himself or herself can be fired or made an example of. I recall my own experience at the VA when I had the nerve to protest in the patient’s chart that I had to prescribe a drug I knew would not work for a patient with both chronic pain and depression, before I could prescribe the more expensive medication which had been shown to be the most effective for that (while the rheumatologists could use the more expensive drug first line). I was offered an “anger management” seminar to treat me because I was angry that veterans were being screwed!

But can the business interests fire every one of their docs if they all refused to go along? Hell no!

There is a national shortage of psychiatrists. When you are in demand like that, they need you way more than you need them. In fact, as a member of the professional networking site LinkedIn, I have been asked to be part of their network by 22 different recruiters in just the last two months alone! And that was pretty much representative of the numbers of recruiters trying to snag me for a position every two months for the last several years. BTW, my profile clearly states that I am retired.

What a bunch of wimps these doctors are. You’d think it would take a lot of willpower and self esteem to get into and through medical school and residency training, and it does.  But doctors-in-training are also bullied, hazed, and forced to submit to the medical school hierarchy even when they know that their superiors are in the wrong. 

Until it was prohibited a few years ago, medical interns routinely worked 36 hours straight several times per month. (This was justified by the powers that be as being necessary because, they said, if there is an epidemic, doctors have to be able to work until they drop. The only problem with this rationalization was that the last major epidemic in the United States was the flu epidemic of 1918. By the time the next one rolls around, the doctors will be out of practice for 36 hour shifts, not to mention out of shape. No, this practice was hazing, pure and simple).

In other words, doctors are trained to act like sheep, and after they finish training many still act like sheep. Psychiatrists are no exception. How irritating. So my answer is yes, we psychiatrists are indeed part of the problem.

Whatever Happened to Assertiveness Training?

My fellow blogger over at BehaveNet had an interesting entry on 4/23 that described an experience with a consultant who came to talk to a psychiatric hospital staff on the topic of "physician burnout." The consultant suggested that the psychiatric staff consider using mindfulness techniques to basically chill out about all the stresses under which they have been working.

In the mindfulness post that I wrote, which is linked above, I opined that so-called mindfulness techniques can be quite helpful under certain types of circumstances. Most important, they can help one stay relaxed and clear-headed when being subjected to environmental stressors that fall mainly into two categories: 1. Common, everyday types of stresses due to the vicissitudes of life that change from day to day and that almost all of us experience, or, 2. Those stressful environmental contingencies over which one has zero hope of changing or correcting. (Mindfulness techniques can also help one stay more relaxed when tackling situations that need to be changed or corrected).

The stresses that lead to physician burnout may not fall into one of these two categories. In fact, one of the most common causes is managed care insurance companies and business types with no medical or psychiatric expertise who are constantly telling doctors what they can or cannot do, and making their professional lives miserable. 

What this consultant seemed to be recommending was using mindfulness techniques as a means of employing something that is definitely not called for in this type of situation: passivity. 

Insurance companies and business people need us doctors more than we need them. We should be doing whatever we can to get them out of the way of effective patient treatment as well as to stop them from preventing us from having a normal and balanced work/life schedule.

The BehaveNet blogger hit the nail on the head: "Dr. Meredith's prescription of mindfulness to address the problem suggests to me a strategy to get physicians to devote adequate time to contemplation of our navels so we will learn to tolerate even more abuse and exploitation with a smile and a "Yessuh, Massah." The blogger suggests that instead doctors push back, refuse, resign, set limits, make demands, and maybe even disrupt things.

This recommendation should also be applied to what psychotherapists do with their patients.

There is unfortunately a current psychotherapy craze of teaching mindfulness techniques to help patients with major family issues to learn to tolerate their stressful family and relationship lives with more equanimity. This is crazy. Not to mention invalidating to patients, as it seems to imply that the problem resides entirely with them. Instead, therapists should be inspiring them, and teaching them how, to fix the situations that are creating their stress in the first place.

I am not saying that the patients' own behavior does not contribute to the dysfunctional family patterns of which they are a part. Clearly it does. But that just means they have to change their own behavior in reaction to the abuse, distancing, and double messages which they receive on a daily basis from their family system members. Doing so is in fact a good strategy for stopping these patterns, not merely tolerating them better.

Cognitive behavior (CBT) therapists have become the biggest champions of using mindfulness techniques for patients with these personality/family problems. This is ironic because back in the 1970's those very same CBT therapists were the very ones who labeled being passive a form of psychopathology! As also mentioned in the BehaveNet blog post, they used to advocate something called assertiveness training.

Basically, in response to mistreatment, assertiveness training theory described one helpful general pattern of responding and three dysfunctional ones. The dysfunctional ones were labeled passive (just sit there, take it, and do nothing about it), aggressive (attack the other person verbally or even physically to impose your will on them), and passive-aggressive (mad at your husband? Burn his toast).

The healthy response was called assertiveness - that meant speaking up for yourself and demanding respect without trying to bring the other person down, disrespecting their needs and viewpoints, casting aspersions on them, or in any way attacking them.

After a period of teaching assertiveness skills to their patients, CBT therapists began to back down from it little by little. They were later forced to admit that the "healthy" responses they taught might get someone beat up or killed in some situations, so it might be best to let some things go.  If you speak up when someone butts in front of you in line these days, the other person may go ballistic and hit you or even pull out a gun. Thankfully this does not happen very often if one is not aggressive, but it is a risk.

Additionally and gradually, the CBT therapists began to fall into the trap of thinking that everyone's problems are all just in their heads. Just like the psychoanalysts they replaced. Last, when it came to intractable family dysfunction, assertiveness skills just did not seem to work all that well anyway.

I have found that with ongoing repetitive family problems, the sort of generic assertiveness skills taught by CBT therapists in fact do not work. That is because family members have developed a whole repertoire of counter-moves that scream to the member attempting to be assertive, "You are wrong, change back." Some of these counter-moves are quite frightening - I described many in a previous post. All involve the person who is trying to be assertive being invalidated in some way and made to feel small for daring to speak up.

This hardly means, however, that the proper strategy for handling these problems is passivity. What I discovered is that the assertiveness training techniques that used to be taught had to be modified to fit the sensitivities and histories of each of the other family members being addressed. These modifications were different for every family, and they had to be tailored specifically to each one. No "one size fits all" here. 

Furthermore, there is no way to know in advance which strategy might work best in a given context, but there was almost always one that could be devised that could help diffuse the family drama significantly for any patient.

I discussed many different strategies in my series of posts in this blog on How to Disarm a Borderline and in another series entitled Ve have Vays of Making You Talk.

So, the CBT therapists had the right idea about assertiveness training before they kinda gave up on it and resorted to the "distress tolerance skills" that are actually part and parcel of what they used to label dysfunctional passivity. They instead should have listened to some of the ideas from family systems therapists in order to improve their therapeutic techniques. 

Mindful passivity? Plenty of time for that at a certain point in the future. As the lyrics from an old song by "Weird Al" Yankovic that used to be played by satirical disc jockey Dr. Demento proclaimed, "I'll be mellow when I'm dead."