IN TREATMENT

          In Treatment is an HBO television series. An actor, Gabriel Byrne, plays the role of a psychiatrist who talks to patients. Each of the 30 minute segments show this psychiatrist listening actively to a single patient.  “In Treatment provides an irresistible peek at the psychopathology of everyday life — on someone else’s tab,” said a review at the time of the first season. The dialogue is excellent and one is impressed at the gentle concern and wisdom of this “doctor.” 

But hold on.  In most sessions, the physician in In Treatment writes no prescriptions at all.  There is little or no discussion at all of the myriad drugs used for depression, stress reduction, attention deficit disorders, schizophrenia, paranoia, or insomnia.

What’s wrong with this picture? The problem is that In Treatment does not show its audience what psychiatrists are doing today. In actual practice, most of what they do is to refill prescriptions for meds that lower stress levels, help a person to sleep or help to manage depression, anger or anxiety.

If you want to talk to someone about what bothers you, best that you NOT make an appointment to see a psychiatrist. Instead go to a psychologist, social worker, minister, priest, rabbi or a family practice physician (although these days family practice docs usually are unable to spend much time talking to patients).

The New York Times began an article by Gardiner Harris (March 5, 2010) on changes in the evolving role of psychiatrists with this quote: “I had to train myself not to get too interested in their problems and not to get sidetracked trying to be a semi-therapist.”  Dr. Donald Levin is now a psychiatrist whose practice no longer includes talk therapy. Levin clearly informs his patients: “I am not your therapist.”

What does Dr. Levin do? He prescribes medications, usually after a brief consultation, to each patient. Early on his career he treated perhaps 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each (perhaps 100 different patients a year). 

Now he follows 1,200 people in 12 to 15-minute visits for prescription adjustments that are sometimes months apart. In the past he knew his patients’ inner lives better than he knew his wife’s. Now he often cannot remember his patients’ names. At the start of his career his goal was to help his patients become happy and fulfilled. Now his goal is to keep his patients functional. Now he sends people who want counseling to other clinicians that are less expensive.

What a change in a person’s job description. His new career represents a remarkable loss of intimacy in how he deals with his patients’ problems.

Dr. Levin found the transition to his new practice difficult. In his words: “I had to train myself not to get too interested in their problems and not to get sidetracked trying to be a semi-therapist.” He finds that seeing patients this way leaves him unfulfilled.

A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.

So where does a person who want to speak to someone about troubling issues go for help?

There are many possibilities as noted above. In addition Twelve Step programs like Alcoholics Anonymous, Emotions Anonymous, and Overeaters Anonymous often have members quite adept at providing a listening ear and making informed suggestions for a variety of problems. 

Robert A. Hatcher MD, MPH
Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, Georgia