Value-Based Care, Population Health, Mid-Level Encroachment--Should We Stop Seeing So Many Patients?

[hippopotamusoath]

So here we are. It's 2023. Healthcare is way too expensive, mid-levels are being heavily deployed as an attempt at cost containment. Hospital systems are moving towards "value-based care" and "population health," i.e. a focus on outcomes and prevention vs. fee-for-service. We have an enormous projected shortage of psychiatrists.

And as a nice cherry on top, medical intervention itself tends to be a hugely unproductive method of decreasing mortality. A lot of the public health data is fascinating--medical interventions on the whole are actually not that useful in terms of reducing mortality. And insofar as they reduce mortality, they tend to extend years of disability, not years of healthy life.

I take this all in, and think that it's incredibly wasteful for me to spend probably 80% of my time seeing patients. I see them one at a time. I treat them in a way that is evidence-based for psychiatry, but that's not saying much. I see many of them monthly.

My impact, and your impact if you work like me, is very minimal. You treated a few thousand patients. Hopefully you helped them. Based on the available evidence, your help was largely placebo in many cases.

So now we have incredibly long training, and a huge deficit in available providers, doing something that has a pretty small impact on our community's health...

So should our field move away from primarily treating patients? We have a unique position. We have seen every part of the mental health landscape. We probably have a better ability than just about anyone else to understand the system from a macro-level.

Maybe I shouldn't be spending 80% of my time seeing patients. Maybe I should spend 10% of my time doing that, and 90% of my time working on conveying to the public via think tank work/lobbying/whatever that suicide prevention isn't a clinician/patient problem, it's a public health problem that involves comprehensive coordination of the building code (locked windows in high rise buildings), gun reform (safe storage/access laws, etc.), mental health access, optimization of transitional care from inpatient, etc.

I'm curious if anyone else has had thoughts like this, and if so, what conclusions did you come to?

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[Fan_of_Meehl]

So here we are. It's 2023. Healthcare is way too expensive, mid-levels are being heavily deployed as an attempt at cost containment. Hospital systems are moving towards "value-based care" and "population health," i.e. a focus on outcomes and prevention vs. fee-for-service. We have an enormous projected shortage of psychiatrists.

And as a nice cherry on top, medical intervention itself tends to be a hugely unproductive method of decreasing mortality. A lot of the public health data is fascinating--medical interventions on the whole are actually not that useful in terms of reducing mortality. And insofar as they reduce mortality, they tend to extend years of disability, not years of healthy life.

I take this all in, and think that it's incredibly wasteful for me to spend probably 80% of my time seeing patients. I see them one at a time. I treat them in a way that is evidence-based for psychiatry, but that's not saying much. I see many of them monthly.

My impact, and your impact if you work like me, is very minimal. You treated a few thousand patients. Hopefully you helped them. Based on the available evidence, your help was largely placebo in many cases.

So now we have incredibly long training, and a huge deficit in available providers, doing something that has a pretty small impact on our community's health...

So should our field move away from primarily treating patients? We have a unique position. We have seen every part of the mental health landscape. We probably have a better ability than just about anyone else to understand the system from a macro-level.

Maybe I shouldn't be spending 80% of my time seeing patients. Maybe I should spend 10% of my time doing that, and 90% of my time working on conveying to the public via think tank work/lobbying/whatever that suicide prevention isn't a clinician/patient problem, it's a public health problem that involves comprehensive coordination of the building code (locked windows in high rise buildings), gun reform (safe storage/access laws, etc.), mental health access, optimization of transitional care from inpatient, etc.

I'm curious if anyone else has had thoughts like this, and if so, what conclusions did you come to?

I think we have the opposite problem in healthcare. Too much admin, top-down / bottom-up / side-to-side bureaucratic management algorithms, buzzwords, slogans, emails, double/triple/quadruple documentation, checkers that check on the checkers of the checkers of those who see patients.

I think we need more people seeing patients, but that's just me.

 

[hippopotamusoath]

I think we have the opposite problem in healthcare. Too much admin, top-down / bottom-up / side-to-side bureaucratic management algorithms, buzzwords, slogans, emails, double/triple/quadruple documentation, checkers that check on the checkers of the checkers of those who see patients.

I think we need more people seeing patients, but that's just me.

Definitely agree we have too much red tape. But if we need more people seeing patients, should it be psychiatrists? And if so, how do we pump enough of them out given the constraints of our system? Or should we be managers of mid-levels or something like that?

Emotionally, I prefer your viewpoint. I want to just flood the mental health landscape with high-quality psychiatrists. I just don't think that is possible given the economic and educational constraints we live under. I think the way the wind is blowing, it could make more sense to try to push our field upward into higher-level leadership roles...

 

[Fan_of_Meehl]

Definitely agree we have too much red tape. But if we need more people seeing patients, should it be psychiatrists? And if so, how do we pump enough of them out given the constraints of our system? Or should we be managers of mid-levels or something like that?

Emotionally, I prefer your viewpoint. I want to just flood the mental health landscape with high-quality psychiatrists. I just don't think that is possible given the economic and educational constraints we live under. I think the way the wind is blowing, it could make more sense to try to push our field upward into higher-level leadership roles...

You raise some very good and very practical points. I think that medication / psychotherapy have been so 'normalized' to the point that--in many cases not only is there no longer a stigma, but it's almost considered 'fashionable' to claim certain diagnoses/psychopathology and getting mental health care is so 'mainstream' that demand for psychiatrists certainly outstrips supply in a lot of areas. I dunno, though, I am extremely leery of 'operating' on a societal level with respect to psychiatry/psychology. To me it just makes it a completely different field or profession (more akin to politicians, public relations, etc. and these are professions against which I have an extremely negative bias). I believe that intervening at the level of the individual is so central to the practice of psychiatry or psychology that it becomes something entirely different when trying to operate at the level of society and a lot of the principles and ethical models tend to break down.

"Men go crazy in congregations but they only get better one by one..."
-Sting?

 

[PikminOC]

So here we are. It's 2023. Healthcare is way too expensive, mid-levels are being heavily deployed as an attempt at cost containment. Hospital systems are moving towards "value-based care" and "population health," i.e. a focus on outcomes and prevention vs. fee-for-service. We have an enormous projected shortage of psychiatrists.

And as a nice cherry on top, medical intervention itself tends to be a hugely unproductive method of decreasing mortality. A lot of the public health data is fascinating--medical interventions on the whole are actually not that useful in terms of reducing mortality. And insofar as they reduce mortality, they tend to extend years of disability, not years of healthy life.

I take this all in, and think that it's incredibly wasteful for me to spend probably 80% of my time seeing patients. I see them one at a time. I treat them in a way that is evidence-based for psychiatry, but that's not saying much. I see many of them monthly.

My impact, and your impact if you work like me, is very minimal. You treated a few thousand patients. Hopefully you helped them. Based on the available evidence, your help was largely placebo in many cases.

So now we have incredibly long training, and a huge deficit in available providers, doing something that has a pretty small impact on our community's health...

So should our field move away from primarily treating patients? We have a unique position. We have seen every part of the mental health landscape. We probably have a better ability than just about anyone else to understand the system from a macro-level.

Maybe I shouldn't be spending 80% of my time seeing patients. Maybe I should spend 10% of my time doing that, and 90% of my time working on conveying to the public via think tank work/lobbying/whatever that suicide prevention isn't a clinician/patient problem, it's a public health problem that involves comprehensive coordination of the building code (locked windows in high rise buildings), gun reform (safe storage/access laws, etc.), mental health access, optimization of transitional care from inpatient, etc.

I'm curious if anyone else has had thoughts like this, and if so, what conclusions did you come to?

Midlevels don't decrease the cost of healthcare for the consumer, they just reduce overhead for the employer.

 

[Fan_of_Meehl]

So here we are. It's 2023. Healthcare is way too expensive, mid-levels are being heavily deployed as an attempt at cost containment. Hospital systems are moving towards "value-based care" and "population health," i.e. a focus on outcomes and prevention vs. fee-for-service. We have an enormous projected shortage of psychiatrists.

And as a nice cherry on top, medical intervention itself tends to be a hugely unproductive method of decreasing mortality. A lot of the public health data is fascinating--medical interventions on the whole are actually not that useful in terms of reducing mortality. And insofar as they reduce mortality, they tend to extend years of disability, not years of healthy life.

I take this all in, and think that it's incredibly wasteful for me to spend probably 80% of my time seeing patients. I see them one at a time. I treat them in a way that is evidence-based for psychiatry, but that's not saying much. I see many of them monthly.

My impact, and your impact if you work like me, is very minimal. You treated a few thousand patients. Hopefully you helped them. Based on the available evidence, your help was largely placebo in many cases.

So now we have incredibly long training, and a huge deficit in available providers, doing something that has a pretty small impact on our community's health...

So should our field move away from primarily treating patients? We have a unique position. We have seen every part of the mental health landscape. We probably have a better ability than just about anyone else to understand the system from a macro-level.

Maybe I shouldn't be spending 80% of my time seeing patients. Maybe I should spend 10% of my time doing that, and 90% of my time working on conveying to the public via think tank work/lobbying/whatever that suicide prevention isn't a clinician/patient problem, it's a public health problem that involves comprehensive coordination of the building code (locked windows in high rise buildings), gun reform (safe storage/access laws, etc.), mental health access, optimization of transitional care from inpatient, etc.

I'm curious if anyone else has had thoughts like this, and if so, what conclusions did you come to?

This just occurred to me. This is a serious question and not meant in a malicious manner.

What in the world makes you think you can change 'society' using principles of psychiatry/psychology if you are saying that you feel ineffective in helping individuals who compose that society?

What I mean is, it strikes me as patently obvious that it is far more realistic to have a goal of helping some reasonable subset (even if it is only 20 or 30 percent) of your caseload make significant improvements in their well-being. I don't think that is an unreasonable expectation at all.

But--if you can't help individuals--what sense does it make for you (or anyone else) think that you're somehow going to 'transform' entire societies?

 

[TexasPhysician]

Midlevels don't decrease the cost of healthcare for the consumer, they just reduce overhead for the employer.

Correct. Mid levels are not about healthcare cost containment. They increase costs.

 

[Celexa]

So here we are. It's 2023. Healthcare is way too expensive, mid-levels are being heavily deployed as an attempt at cost containment. Hospital systems are moving towards "value-based care" and "population health," i.e. a focus on outcomes and prevention vs. fee-for-service. We have an enormous projected shortage of psychiatrists.

And as a nice cherry on top, medical intervention itself tends to be a hugely unproductive method of decreasing mortality. A lot of the public health data is fascinating--medical interventions on the whole are actually not that useful in terms of reducing mortality. And insofar as they reduce mortality, they tend to extend years of disability, not years of healthy life.

I take this all in, and think that it's incredibly wasteful for me to spend probably 80% of my time seeing patients. I see them one at a time. I treat them in a way that is evidence-based for psychiatry, but that's not saying much. I see many of them monthly.

My impact, and your impact if you work like me, is very minimal. You treated a few thousand patients. Hopefully you helped them. Based on the available evidence, your help was largely placebo in many cases.

So now we have incredibly long training, and a huge deficit in available providers, doing something that has a pretty small impact on our community's health...

So should our field move away from primarily treating patients? We have a unique position. We have seen every part of the mental health landscape. We probably have a better ability than just about anyone else to understand the system from a macro-level.

Maybe I shouldn't be spending 80% of my time seeing patients. Maybe I should spend 10% of my time doing that, and 90% of my time working on conveying to the public via think tank work/lobbying/whatever that suicide prevention isn't a clinician/patient problem, it's a public health problem that involves comprehensive coordination of the building code (locked windows in high rise buildings), gun reform (safe storage/access laws, etc.), mental health access, optimization of transitional care from inpatient, etc.

I'm curious if anyone else has had thoughts like this, and if so, what conclusions did you come to?

I don't think you become someone who knows how to help a lot of people without seeing them except by first seeing a lot of people.

I don't think you can stay someone who knows how to help people effectively without seeing them directly if your clincial skills atrophy and/or you aren't on the ground enough to know the landscape.

I do think there's an important role for figuring out how to maximize our value. Most therapy as performed is useless. Ive started thinking very hard about how apps could be used to magnify--not replace--1:1 contact. I don't think it's an effective use of my time as a fully trained psychiatrist to do basic courses of cbt for anxiety and depression for a patient. But it's probably an effective use of my time for me to do meds, and also direct a patient through a manualized course of cbt on an app, if it exists in such a manner I can review their activity and talk to them about it. Less time than the traditional once a week 1:1 with a therapist, but more than being entirely self directed (which almost no patient, even the high functioning ones, can do).

And I also damn well agree midlevels don't reduce cost to the healthcare system overall. Used properly they extend the number of patients a physician can provide expertise to. Used solely as replacements for physicians, they generate more costs through higher amounts of testing, misdiagnosis, etc.

Also, I try and maximize my effectiveness through teaching. Not just other psychiatrists. I hope that I am able to teach medical students who DON'T become psychiatrists some skills while they are with me they can carry forward.

 

[PikminOC]

Definitely agree we have too much red tape. But if we need more people seeing patients, should it be psychiatrists? And if so, how do we pump enough of them out given the constraints of our system? Or should we be managers of mid-levels or something like that?

Emotionally, I prefer your viewpoint. I want to just flood the mental health landscape with high-quality psychiatrists. I just don't think that is possible given the economic and educational constraints we live under. I think the way the wind is blowing, it could make more sense to try to push our field upward into higher-level leadership roles...

As soon as the boomers are dead the population won't be that big.

 

[SmallBird]

I think the situation is an absolute, dystopian nightmare and there is no evidence of any coordinated or sustained effort to make it better. I believe that it is possible to help people who have various forms of psychological suffering. I also think that it is very difficult, requires a deep breadth of knowledge, spending a long time with that person over time, and frequently, for anything meaningful to change, will require influences outside the boundaries of what we can offer in hospitals and clinics. But I think that two things have happened and continue to happen: 1) we have massively broadened the scope of difficulties that get viewed as psychiatric in nature, such that probably 100% of people born today will at some point meet criteria for some 'disorder' in their lifespan, and 2) our treatments have gotten dramatically worse, for the most part overusing the tool of only mildly effective medications, and abandoning long studied traditions because they weren't amenable to quantitative evaluation according to highly specific epistemic paradigms. I situate the problems as being 1) in the leadership of our field, who have sold out patients to focus on neuroscience with almost no clinical fruit borne thus far; 2) the degradation of psychotherapy training; 3) the greed of people who happily accept the role of 'prescriber' to be able to leave the hospital by 1pm and make more than $500k. I don't think midlevels are responsible for the inability of psychiatry to articulate any discernible standard of care and the willingness of psychiatrists to practice in a facile manner in order to make more money.

Edit: Splik's practice is a notable exception

 

[calvnandhobbs68]

I think the situation is an absolute, dystopian nightmare

First of all, this is going to be absolutely culture and location bound….”the situation” from any medical and societal standpoint is going to be extremely different from the USA vs say China or Brazil.

I also think there’s a bit of drama and handwringing in these types of posts. If you think today is a dystopian nightmare….just wonder what you think about the state of society, medicine and psychiatry in the 19th century. Like ya know what about that civil war that killed 3% of the entire United States population. What about that one time when child labor was active, underpaid, extremely dangerous and completely legal in the US until the 1920s? What kind of impact do you think that kind of stuff had on people’s “mental health”? I mean one could go on and on about how much more dystopian the past was than currently for both society and medicine in the United States. One could go on about how much more dystopian the PRESENT is for many people in countries outside a subset of developed countries in the world.

2) our treatments have gotten dramatically worse, for the most part overusing the tool of only mildly effective medications, and abandoning long studied traditions because they weren't amenable to quantitative evaluation according to highly specific epistemic paradigms.

Are you talking about psychoanalysis or psychodynamic psychotherapy vs CBT?
I mean there were longstanding traditions of bloodletting to release bad humors and treating people with elemental mercury. Not exactly sure why something being long-standing means it’s the correct thing to do. I’m also not sure what evidence you have that treatments have gotten “dramatically worse”.

 

[VA Hopeful Dr]

As soon as the boomers are dead the population won't be that big.

Not sure that's exactly true:

U.S. population by generation 2022 | Statista

Millennials were the largest generation group in the U.S.

www.statista.com

 

[SmallBird]

First of all, this is going to be absolutely culture and location bound….”the situation” from any medical and societal standpoint is going to be extremely different from the USA vs say China or Brazil.

I also think there’s a bit of drama and handwringing in these types of posts. If you think today is a dystopian nightmare….just wonder what you think about the state of society, medicine and psychiatry in the 19th century. Like ya know what about that civil war that killed 3% of the entire United States population. What about that one time when child labor was active, underpaid, extremely dangerous and completely legal in the US until the 1920s? What kind of impact do you think that kind of stuff had on people’s “mental health”? I mean one could go on and on about how much more dystopian the past was than currently for both society and medicine in the United States. One could go on about how much more dystopian the PRESENT is for many people in countries outside a subset of developed countries in the world.




Are you talking about psychoanalysis or psychodynamic psychotherapy vs CBT?
I mean there were longstanding traditions of bloodletting to release bad humors and treating people with elemental mercury. Not exactly sure why something being long-standing means it’s the correct thing to do. I’m also not sure what evidence you have that treatments have gotten “dramatically worse”.

When I say dystopian I am referring to mental health treatment, not society overall, where, as you say, things have been worse before. I am referring to the fact that we are investing an absurd amount of energy in resources like case management and treatment plans and millions of people are taking pills that won't help them because people with lots of intelligence are working in systems that prevent them from doing a good job.

 

[G Sheb]

We’ve practically made little to no progress in 30 years.
I think if we look at medical specialties we’re probably in a unique place.
The biggest fraud has been trying to sell our field as scientific when it’s absolutely not.
But I don’t think the situation was better in the heydays of classical psychoanalysis. It was much worse actually. That was another fraud as well.

 

[smalltownpsych]

We’ve practically made little to no progress in 30 years.
I think if we look at medical specialties we’re probably in a unique place.
The biggest fraud has been trying to sell our field as scientific when it’s absolutely not.
But I don’t think the situation was better in the heydays of classical psychoanalysis. It was much worse actually. That was another fraud as well.

Our field is completely scientific, it is just that too many people don’t understand limitations of science when applied to complex and inherently unpredictable phenomena and many others have a vested interest in misleading those people. Psychoanalysis was not a fraud, it was limited in its efficacy and didn’t have all the answers, but it was a revolutionm in thought that led to much of what we “know” now.

 

[G Sheb]

Our field is completely scientific, it is just that too many people don’t understand limitations of science when applied to complex and inherently unpredictable phenomena and many others have a vested interest in misleading those people. Psychoanalysis was not a fraud, it was limited in its efficacy and didn’t have all the answers, but it was a revolutionm in thought that led to much of what we “know” now.

Our diagnoses are not scientifically validated. They are not based on proper understanding of etiology and pathophysiology, as science-based medicine actually is.
DSM claims that diagnoses are based on supposed statistical clustering of symptoms, but that is another false claim. There is very little evidence in the literature supporting these clustering. Basically it's what 'experts' think symptoms cluster, or put it in another way, 'should' cluster.

As for psychonalaysis, lol!! Freud is essentially a pariah in actual scientific circles nowadays. Much of what actually "know" (as in, scientific knowledge) has absolutely nothing to do with Freud. He certainly tried to sell a bunch of prejudices, an unscientific method that later transformed into a cult, as actual science or a 'revolution'. There are some parallels with what's been happening in the last 20 years or so. Basically psychiatry trying desperately for validation by portraying itself something that it simply is not.

Point is, if we're not clear eyed at where we're at, we cannot move forward.
But there are all kinds of market and industry pressure to push the field in certain ways, and admitting shortcomings does not sell.

 

[Fan_of_Meehl]

Our field is completely scientific, it is just that too many people don’t understand limitations of science when applied to complex and inherently unpredictable phenomena and many others have a vested interest in misleading those people. Psychoanalysis was not a fraud, it was limited in its efficacy and didn’t have all the answers, but it was a revolutionm in thought that led to much of what we “know” now.

Agreed. And the essence of good psychotherapy involves teaching clients to actually BE SCIENTISTS who study their own patterns of thinking/feeling/behaving and how these patterns are successful (or unsuccessful) in realizing their goals/values and then run 'behavioral experiments' to try out new patterns of thinking/feeling/behaving until they achieve better results. And while the therapist does not necessarily 'give advice' or make specific suggestions (or, at least, doesn't push them on the client), the therapist does definitely draw upon the basic scientific literature applicable to mental health to inform his/her discussions with clients regarding optimizing their adjustment and functioning.

Exercise / behavioral activation helps depression. Practicing gratitude helps depression/demoralization/hopelessness. Adopting a personal organization system (even if it is just a pencil and a notebook) composed of at least: (a) a calendar; (b) a 'to do' list; and (c) a place for taking notes--if utilized--will DEFINITELY help with self-organization and accomplishment of personal goals. Exposure, if done right, DOES lead to lowered anxiety. The examples from basic behavioral science are endless. It's just that we have to do the work of idiographic (specific to the individual patient) case formulation, hypothesis generation and testing (along with the client) and there are no 'one-size-fits-all' recipes or formulae or protocols that will 'apply themselves' to the individual patient. It is hard work (for both therapist and client) but I've yet to see a case where both therapist and client were working hard at making progress on a mental health related issue and utilizing the scientific method and the scientific literature and failed to make at least some significant progress over time.

 

[smalltownpsych]

Our diagnoses are not scientifically validated. They are not based on proper understanding of etiology and pathophysiology, as science-based medicine actually is.
DSM claims that diagnoses are based on supposed statistical clustering of symptoms, but that is another false claim. There is very little evidence in the literature supporting these clustering. Basically it's what 'experts' think symptoms cluster, or put it in another way, 'should' cluster.

As for psychonalaysis, lol!! Freud is essentially a pariah in actual scientific circles nowadays. Much of what actually "know" (as in, scientific knowledge) has absolutely nothing to do with Freud. He certainly tried to sell a bunch of prejudices, an unscientific method that later transformed into a cult, as actual science or a 'revolution'. There are some parallels with what's been happening in the last 20 years or so. Basically psychiatry trying desperately for validation by portraying itself something that it simply is not.

Point is, if we're not clear eyed at where we're at, we cannot move forward.
But there are all kinds of market and industry pressure to push the field in certain ways, and admitting shortcomings does not sell.

I agree that there are significant problems with our diagnostic manual and there are problems with how we conceptualize “mental illness”. That being said, it is quite a step from where we were with earlier DSMs and the old model that was based on Freud which is easy to criticize knowing what we know now. I think if people had known about the limbic system and how that interacts with the frontal cortex back then, then it would be a little easier to reconcile concepts such as id and ego and then the later stuff based on Freud such as attachment and object relations.
By the way, Freud has been “being discredited by the scientists” for at least the 50 years I’ve been around and a lot of what he observed and developed still influences us nonetheless. Ever seen a defense mechanism, just for one example?

 

[Marasmus1]

Our diagnoses are not scientifically validated. They are not based on proper understanding of etiology and pathophysiology, as science-based medicine actually is.
DSM claims that diagnoses are based on supposed statistical clustering of symptoms, but that is another false claim. There is very little evidence in the literature supporting these clustering. Basically it's what 'experts' think symptoms cluster, or put it in another way, 'should' cluster.

As for psychonalaysis, lol!! Freud is essentially a pariah in actual scientific circles nowadays. Much of what actually "know" (as in, scientific knowledge) has absolutely nothing to do with Freud. He certainly tried to sell a bunch of prejudices, an unscientific method that later transformed into a cult, as actual science or a 'revolution'. There are some parallels with what's been happening in the last 20 years or so. Basically psychiatry trying desperately for validation by portraying itself something that it simply is not.

Point is, if we're not clear eyed at where we're at, we cannot move forward.
But there are all kinds of market and industry pressure to push the field in certain ways, and admitting shortcomings does not sell.

Dr. Amen?

 

[G Sheb]

I agree that there are significant problems with our diagnostic manual and there are problems with how we conceptualize “mental illness”. That being said, it is quite a step from where we were with earlier DSMs and the old model that was based on Freud which is easy to criticize knowing what we know now. I think if people had known about the limbic system and how that interacts with the frontal cortex back then, then it would be a little easier to reconcile concepts such as id and ego and then the later stuff based on Freud such as attachment and object relations.
By the way, Freud has been “being discredited by the scientists” for at least the 50 years I’ve been around and a lot of what he observed and developed still influences us nonetheless. Ever seen a defense mechanism, just for one example?

I mean, if you want to credit him with "transference", "defense mechanism", "unconscious belief" or something, sure, go ahead. But this imo is fairly negligible to the edifice he tried to build.
The idea that you can sit someone on a couch, objectively analyze them to "cure" their mental illness, that there's a structure of the mind that he 'uncovered', the oedipal complex, psychosexual development..etc, was pretty much all a scam. Freud and his later followers in academia for decades sold their stuff as an actual science and did tremendous harm to countless patients, essentially brandishing his sexist and social prejudices as some kind of objective truth. I think he left some influence in popular culture, but no field of science actually respects him.

Much like selling "chemical imbalance" in the early 90s or I guess "changing brain circuits" now (duh).
Sure, we're trying to be more empirical, but we need to look in the mirror, we are not a scientific field, not yet, and maybe never. We just like to act like we are.

 

[PikminOC]

Not sure that's exactly true:

U.S. population by generation 2022 | Statista

Millennials were the largest generation group in the U.S.

www.statista.com

When baby boomers were at their peak they were the largest group. Every generation thereafter has been smaller. Boomers are dying which is making the millennials look like the largest group now.

 

[splik]

As for psychonalaysis, lol!! Freud is essentially a pariah in actual scientific circles nowadays. Much of what actually "know" (as in, scientific knowledge) has absolutely nothing to do with Freud. He certainly tried to sell a bunch of prejudices, an unscientific method that later transformed into a cult, as actual science or a 'revolution'. There are some parallels with what's been happening in the last 20 years or so. Basically psychiatry trying desperately for validation by portraying itself something that it simply is not.

Well for all his flaws, Freud was very influential in developing a theoretical framework for mental life. Eric Kandel, the nobel laureate and neuroscientist/psychiatrist, wrote that "psychoanalysis still represents the most coherent and intellectually satisfying view of the mind." As Jung described him, Freud was the neurologist who brought psychology to psychiatry. Before Freud, psychiatrists had little interest in the psychological aspect of their patients lives. He himself recognized that his case histories "lacked the serious stamp of science" but also knew that this idiographic approach was important (as it has been to field of neuropsychology where single case histories have been very important to understanding of the workings of the brain). The central tenets of psychoanalytic theory - that what's past is prologue, our subjective consciousness is unique and should be respected, we are less aware of our actions for motivations than we like to think, our past relationships play out in the clinical relationships, and our minds have carefully developed methods to ignore what we cannot acknowledge - are still influential to psychiatric practice today. Modern psychoanalytic psychotherapy, mentalization-based treatment, transference focused psychotherapy, schema therapy, dynamic interpersonal therapy (which are all "evidenced based" approaches) all owe something to Freud and psychoanalysis.

Freud, as a neurologist, also believed that we would one day be able to understand things like memory at the synaptic level (presaging the discovery of long term potentiation). He also said "all of our provisional ideas in psychology will presumably one day be based on an organic substructure." And while many American psychoanalysts - with their "can do" approach which Freud himself despised - tried to treat a wide range of problems from schizophrenia to homosexuality, Freud's aims for psychoanalysis were much more modest. He only claimed that analysis could "transform hysterical misery into common unhappiness." And while we can argue the merits of just how much of psychoanalytic thinking is scientific vs belongs to the humanities, while many of his ideas have been discredited (as happens with scientific theories over time), and the Freud hagiographies replaced by biting criticisms of him, for better or worse, he still remains the most influential thinker in psychiatry (more so than Krapelin, Jaspers, Alzheimer's, Esquirol, Pinel etc).

Also, Freud and his followers, were the ones who brought the psychiatrists out of the asylums and into the community. Private practice psychiatry came about in the United States because of psychoanalysis. AA Brill, who arguably did more to bring analysis to the US than anyone, wrote that the reason he learned analysis was because he wanted to get married, and the asylum (where psychiatrists used to live) was no place for a wife!

Freud was a flawed figure no doubt, modern psychoanalysis has evolved and bears little resemblance to the original talking cure, and psychoanalysis itself is not a major psychiatric intervention by any stretch. But psychoanalytic theory still represents one of the most comprehensive and compelling theories of mind, and its basic tenets are as relevant to psychiatric practice as ever.

 

[G Sheb]

Well for all his flaws, Freud was very influential in developing a theoretical framework for mental life. Eric Kandel, the nobel laureate and neuroscientist/psychiatrist, wrote that "psychoanalysis still represents the most coherent and intellectually satisfying view of the mind." As Jung described him, Freud was the neurologist who brought psychology to psychiatry. Before Freud, psychiatrists had little interest in the psychological aspect of their patients lives. He himself recognized that his case histories "lacked the serious stamp of science" but also knew that this idiographic approach was important (as it has been to field of neuropsychology where single case histories have been very important to understanding of the workings of the brain). The central tenets of psychoanalytic theory - that what's past is prologue, our subjective consciousness is unique and should be respected, we are less aware of our actions for motivations than we like to think, our past relationships play out in the clinical relationships, and our minds have carefully developed methods to ignore what we cannot acknowledge - are still influential to psychiatric practice today. Modern psychoanalytic psychotherapy, mentalization-based treatment, transference focused psychotherapy, schema therapy, dynamic interpersonal therapy (which are all "evidenced based" approaches) all owe something to Freud and psychoanalysis.

Freud, as a neurologist, also believed that we would one day be able to understand things like memory at the synaptic level (presaging the discovery of long term potentiation). He also said "all of our provisional ideas in psychology will presumably one day be based on an organic substructure." And while many American psychoanalysts - with their "can do" approach which Freud himself despised - tried to treat a wide range of problems from schizophrenia to homosexuality, Freud's aims for psychoanalysis were much more modest. He only claimed that analysis could "transform hysterical misery into common unhappiness." And while we can argue the merits of just how much of psychoanalytic thinking is scientific vs belongs to the humanities, while many of his ideas have been discredited (as happens with scientific theories over time), and the Freud hagiographies replaced by biting criticisms of him, for better or worse, he still remains the most influential thinker in psychiatry (more so than Krapelin, Jaspers, Alzheimer's, Esquirol, Pinel etc).

Also, Freud and his followers, were the ones who brought the psychiatrists out of the asylums and into the community. Private practice psychiatry came about in the United States because of psychoanalysis. AA Brill, who arguably did more to bring analysis to the US than anyone, wrote that the reason he learned analysis was because he wanted to get married, and the asylum (where psychiatrists used to live) was no place for a wife!

Freud was a flawed figure no doubt, modern psychoanalysis has evolved and bears little resemblance to the original talking cure, and psychoanalysis itself is not a major psychiatric intervention by any stretch. But psychoanalytic theory still represents one of the most comprehensive and compelling theories of mind, and its basic tenets are as relevant to psychiatric practice as ever.

You can find all kind of contradictory statements Freud has made.
Yes, he said his stuff lacks the serious stamp of science, but he also realized he'll never be able to sell his theory in academia this way.
In fact a basic tenet of psychoanalysis is "psychic determinism", which was a half assed replication of theories of physics at the time. One can also read the first couple of chapters in The Interpretation of Dreams and see that Freud was actively trying to promote his theory as scientific, and objectively true; and of course, he was famed for his obstinacy.


Dora read in modern eyes is an absolute classic example of gaslighting, sexism, re-traumatization. Essentially trying to blame a woman for her experienced sexual trauma.

Psychoanalysis as practiced by Freud was a little more than a brainwashing session. Under the guise of "knowledge", which apparently only Freud had access to. A classic example of what a scam looks like.

It is true that some concepts have remained useful, essentially from experience through the art of therapy (essentially, transference, countertransference) with much of these concepts developed after Freud, but that would not be an accurate reflection of the legacy of psychoanalysis, which imo was far more damaging than beneficial. Up until the early 90s, more than a decade after the DSM removed homosexuality, LGBT candidates were still banned from analytic institutes!

I do not think he is more influential than Bleuler or Kraeplin on the practice of modern pscyhiatry, though he does indeed retain some influence especially in some of those increasingly struggling psychoanalytic institutes. It is probably embarrassing for us that residents are still tested on his stages of psychosexual development when literally no scientist would take them seriously.

I actually do like modern intersubjective psychoanalysis, but it bares little resemblance to the kind Freud practiced, and has much more in common to the interpersonal tradition (a Freud contemporary, developed pretty much in parallel), which is rooted in the humanities, empathy, narrative, nonjudgmental exploration, relative equal standing between the therapist and the patient and de-emphasis on "theory" and "structure of the mind".

 

[clausewitz2]

Well for all his flaws, Freud was very influential in developing a theoretical framework for mental life. Eric Kandel, the nobel laureate and neuroscientist/psychiatrist, wrote that "psychoanalysis still represents the most coherent and intellectually satisfying view of the mind." As Jung described him, Freud was the neurologist who brought psychology to psychiatry. Before Freud, psychiatrists had little interest in the psychological aspect of their patients lives. He himself recognized that his case histories "lacked the serious stamp of science" but also knew that this idiographic approach was important (as it has been to field of neuropsychology where single case histories have been very important to understanding of the workings of the brain). The central tenets of psychoanalytic theory - that what's past is prologue, our subjective consciousness is unique and should be respected, we are less aware of our actions for motivations than we like to think, our past relationships play out in the clinical relationships, and our minds have carefully developed methods to ignore what we cannot acknowledge - are still influential to psychiatric practice today. Modern psychoanalytic psychotherapy, mentalization-based treatment, transference focused psychotherapy, schema therapy, dynamic interpersonal therapy (which are all "evidenced based" approaches) all owe something to Freud and psychoanalysis.

Freud, as a neurologist, also believed that we would one day be able to understand things like memory at the synaptic level (presaging the discovery of long term potentiation). He also said "all of our provisional ideas in psychology will presumably one day be based on an organic substructure." And while many American psychoanalysts - with their "can do" approach which Freud himself despised - tried to treat a wide range of problems from schizophrenia to homosexuality, Freud's aims for psychoanalysis were much more modest. He only claimed that analysis could "transform hysterical misery into common unhappiness." And while we can argue the merits of just how much of psychoanalytic thinking is scientific vs belongs to the humanities, while many of his ideas have been discredited (as happens with scientific theories over time), and the Freud hagiographies replaced by biting criticisms of him, for better or worse, he still remains the most influential thinker in psychiatry (more so than Krapelin, Jaspers, Alzheimer's, Esquirol, Pinel etc).

Also, Freud and his followers, were the ones who brought the psychiatrists out of the asylums and into the community. Private practice psychiatry came about in the United States because of psychoanalysis. AA Brill, who arguably did more to bring analysis to the US than anyone, wrote that the reason he learned analysis was because he wanted to get married, and the asylum (where psychiatrists used to live) was no place for a wife!

Freud was a flawed figure no doubt, modern psychoanalysis has evolved and bears little resemblance to the original talking cure, and psychoanalysis itself is not a major psychiatric intervention by any stretch. But psychoanalytic theory still represents one of the most comprehensive and compelling theories of mind, and its basic tenets are as relevant to psychiatric practice as ever.

All very well said.

Freud's work, like that of most important and genuinely original thinkers, has the quality of seeming like deeply profound and insightful observation about 50% of the time, and bat***t nonsense 50% of the time. I feel like he may be relatively unique in having passages and sentences of both in very close juxtaposition in his texts.

 

[hippopotamusoath]

This just occurred to me. This is a serious question and not meant in a malicious manner.

What in the world makes you think you can change 'society' using principles of psychiatry/psychology if you are saying that you feel ineffective in helping individuals who compose that society?

What I mean is, it strikes me as patently obvious that it is far more realistic to have a goal of helping some reasonable subset (even if it is only 20 or 30 percent) of your caseload make significant improvements in their well-being. I don't think that is an unreasonable expectation at all.

But--if you can't help individuals--what sense does it make for you (or anyone else) think that you're somehow going to 'transform' entire societies?

Just to clarify--at the individual level, I believe I help my patients. As you say--one at a time, most of them get better. But I am one person. I'm not sure how big my census is, but maybe a few hundred people? So, I help individual patients, but that impact--one psychiatrist, seeing patients one by one, is a pretty minimal return on investment considering the sheer amount of effort and time I have put into learning this profession. And to me it seems almost wasteful, considering how broad an understanding I have of the entire mental health system (inpatient, outpatient, IOP, PHP, addictions, CL--I, and most of us, have had some experience at every level of care. How many can say that?)

So, I could see patients one by one for my whole career, and I could help a certain amount of people. Or, I could spend 1/4 of the time seeing patients, and 3/4 applying my clinical knowledge to other things that could help. How many people would it help if I were able to meaningfully contribute to passing safe gun storage laws? Statistically, it would probably prevent far more suicides than I've prevented seeing patients in clinic.
The idea that teaching a population to wash their hands is infinitely more productive than having doctors treat infections, one by one.

Many of us hate the idea of mid-level encroachment. But do we have an answer? People need to be cared for, and there is a gigantic deficit of psychiatrists, and no meaningful path towards solving the problem. So to me, that says--well, we need to figure out how to have a force-multiplying effect with the psychiatrists we do have. And that might be a broader push in our profession towards teaching, scholarly activity, political involvement, etc. But it feels deeply unsatisfying to me to have the answer be that some small segment of the population gets adequate care, and the rest suffer.

I hope that clarifies my position somewhat.

 

[Stagg737]

Our diagnoses are not scientifically validated. They are not based on proper understanding of etiology and pathophysiology, as science-based medicine actually is.

That really depends on how you define "scientifically validated". The DSM is a pretty poor excuse of a "bible" or "gold standard" for our field, but there are plenty of other models that do a better job of explaining pathologies than many medical conditions that we consider to have "strong evidence". Our understanding of the pathological basis of things like primary hypertension or HLD are surprisingly poor when you actually take of deep dive of the literature and the actual causation for effects of many medications is only a layer or two deeper than our understanding of a lot of psych meds.

 

[Fan_of_Meehl]

Just to clarify--at the individual level, I believe I help my patients. As you say--one at a time, most of them get better. But I am one person. I'm not sure how big my census is, but maybe a few hundred people? So, I help individual patients, but that impact--one psychiatrist, seeing patients one by one, is a pretty minimal return on investment considering the sheer amount of effort and time I have put into learning this profession. And to me it seems almost wasteful, considering how broad an understanding I have of the entire mental health system (inpatient, outpatient, IOP, PHP, addictions, CL--I, and most of us, have had some experience at every level of care. How many can say that?)

So, I could see patients one by one for my whole career, and I could help a certain amount of people. Or, I could spend 1/4 of the time seeing patients, and 3/4 applying my clinical knowledge to other things that could help. How many people would it help if I were able to meaningfully contribute to passing safe gun storage laws? Statistically, it would probably prevent far more suicides than I've prevented seeing patients in clinic.
The idea that teaching a population to wash their hands is infinitely more productive than having doctors treat infections, one by one.

Many of us hate the idea of mid-level encroachment. But do we have an answer? People need to be cared for, and there is a gigantic deficit of psychiatrists, and no meaningful path towards solving the problem. So to me, that says--well, we need to figure out how to have a force-multiplying effect with the psychiatrists we do have. And that might be a broader push in our profession towards teaching, scholarly activity, political involvement, etc. But it feels deeply unsatisfying to me to have the answer be that some small segment of the population gets adequate care, and the rest suffer.

I hope that clarifies my position somewhat.

I hear ya. Absolutely. Your position makes sense. I guess we all have to find what we believe to be the best paths for us to take to do the most good in the world with what we've got and I believe that's what you're trying to do. I respect that, even if I may have a different perspective (that I think we do the most good, in the end, by helping individuals, one on one).

 

[smalltownpsych]

Just to clarify--at the individual level, I believe I help my patients. As you say--one at a time, most of them get better. But I am one person. I'm not sure how big my census is, but maybe a few hundred people? So, I help individual patients, but that impact--one psychiatrist, seeing patients one by one, is a pretty minimal return on investment considering the sheer amount of effort and time I have put into learning this profession. And to me it seems almost wasteful, considering how broad an understanding I have of the entire mental health system (inpatient, outpatient, IOP, PHP, addictions, CL--I, and most of us, have had some experience at every level of care. How many can say that?)

So, I could see patients one by one for my whole career, and I could help a certain amount of people. Or, I could spend 1/4 of the time seeing patients, and 3/4 applying my clinical knowledge to other things that could help. How many people would it help if I were able to meaningfully contribute to passing safe gun storage laws? Statistically, it would probably prevent far more suicides than I've prevented seeing patients in clinic.
The idea that teaching a population to wash their hands is infinitely more productive than having doctors treat infections, one by one.

Many of us hate the idea of mid-level encroachment. But do we have an answer? People need to be cared for, and there is a gigantic deficit of psychiatrists, and no meaningful path towards solving the problem. So to me, that says--well, we need to figure out how to have a force-multiplying effect with the psychiatrists we do have. And that might be a broader push in our profession towards teaching, scholarly activity, political involvement, etc. But it feels deeply unsatisfying to me to have the answer be that some small segment of the population gets adequate care, and the rest suffer.

I hope that clarifies my position somewhat.

Some of your thought process around this aligns very closely with mine. A huge mistake that we made in psychology was fighting the midlevels in a turf war as opposed to getting more involved in a leadership role. A big part of my career has been clinical leadership and the beauty is that I have the one on one skills to backup what I teach.

When it comes to small percentage getting good care and others not, I think that we do have to be realistic about looking at resources and that people with more resources will have more opportunities. It doesn’t mean that the people with less need to starve. I think that our expectation in this country used to be that we would all get excellent care and most of the working people were getting that. When we try to make the services for the very bottom of the curve equivalent to the majority that’s where we screw the majority. The top end of the curve isn’t really the problem, they have always been able to get the best of everything in all societies regardless.

 

[wellbutrin.girlfriend]

Just to clarify--at the individual level, I believe I help my patients. As you say--one at a time, most of them get better. But I am one person. I'm not sure how big my census is, but maybe a few hundred people? So, I help individual patients, but that impact--one psychiatrist, seeing patients one by one, is a pretty minimal return on investment considering the sheer amount of effort and time I have put into learning this profession. And to me it seems almost wasteful, considering how broad an understanding I have of the entire mental health system (inpatient, outpatient, IOP, PHP, addictions, CL--I, and most of us, have had some experience at every level of care. How many can say that?)

So, I could see patients one by one for my whole career, and I could help a certain amount of people. Or, I could spend 1/4 of the time seeing patients, and 3/4 applying my clinical knowledge to other things that could help. How many people would it help if I were able to meaningfully contribute to passing safe gun storage laws? Statistically, it would probably prevent far more suicides than I've prevented seeing patients in clinic.
The idea that teaching a population to wash their hands is infinitely more productive than having doctors treat infections, one by one.

Many of us hate the idea of mid-level encroachment. But do we have an answer? People need to be cared for, and there is a gigantic deficit of psychiatrists, and no meaningful path towards solving the problem. So to me, that says--well, we need to figure out how to have a force-multiplying effect with the psychiatrists we do have. And that might be a broader push in our profession towards teaching, scholarly activity, political involvement, etc. But it feels deeply unsatisfying to me to have the answer be that some small segment of the population gets adequate care, and the rest suffer.

I hope that clarifies my position somewhat.

Your sentiment resonates a lot with me-- I've found that engaging in advocacy work can be a satisfying remedy to some of my chronic existential dread. 🙃

Have you ever looked into advocacy work your local psychiatric association is doing? In my state, they are begging for psychiatrist engagement and are pushing some great efforts to increase access to mental health care, improve mental health care quality, and address other social determinants of health. If advocacy is something you're curious about, which it seems you definitely are, I think it would make sense to explore the ways you can make a difference and engage with opportunities for advocacy in your community. By exploring these opportunities, I suspect you'll better be able to answer your own question of what a meaningful balance of patient care and advocacy work might look like for you.

Your perspectives (and the perspectives of everyone contributing here) are extremely valuable to patients both at an individual and population level. I don't think this is a matter of whether the profession should shift away from patient care--it doesn't need to be a binary. Certainly, however, the profession would benefit from increased physician engagement in advocacy work.