The Future of Mental Health

The field of mental health encompasses many different professions. It is good for the public as well as teachers and psychologists in training to know the lay of the land, and to understand current practices in the field of psychiatry, because many referrals are made to this profession. The New York Times recently reported the story of one psychiatrist whose practice has changed from regular talk therapy to to short 15-minute medication adjustment sessions that occur much less frequently. This particular doctor explains in the article why he believes the kind of practice he conducts is now necessary because of the way psychiatrists are reimbursed for their services, and he refers patients who need more traditional talk therapy to psychologists, social workers, and mental health counselors:

DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: 'Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.'

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. 'I had to train myself not to get too interested in their problems,' he said, 'and not to get sidetracked trying to be a semi-therapist.'

If you read the entire article, you will learn how this doctor has instituted different efficiency-based business techniques that are a virtual script to get patients in and out of the office itself in the shortest possible time. He explains that this is necessary for him to keep the kind of lifestyle he was accustomed to before the insurance industry made sweeping changes in the 1990s and 2000s in the manner in which physicians are reimbursed by insurance companies. These, he explained, forced him to change the manner in which he practices medicine. There are many thoughtful comments in the ensuing blog discussion. One may wonder if this doctor is making necessary changes to keep up with the times, or question, as Evander Lomke, Executive Director of the American Mental Health Foundation does, whether or not "money is in, and sadly help (not among all, but among too many in the field experiencing the inevitable pressures of time and money) is out."

And do church teachings and opinions on social justice—recently discussed back and forth on America as they apply to public sector workers such teachers, police, and fire fighters (who may earn in "rough figure" ranges, with benefits, between $60,000 and $130,000)—apply to specialists in a field such as psychiatry where salaries are commonly in the $150,000-200,000 range? Some doctors are even wondering if they should consider establishing labor unions for physicians, not only for salary protection, but to allow them professional freedom so they—instead of management by insurance companies—may continue to set and practice standards based on their professional training, competence and guidelines.

William Van Ornum