Shirah Vollmer MD

The Musings of Dr. Vollmer

What Do Psychiatrists Do?

Posted by Dr. Vollmer on July 9, 2013

Private practice, county jobs, VA jobs, academic jobs, are all examples of how psychiatrists jump into a career. As I have ranted in this venue before, most psychiatrist jobs, these days, are what I call “psychopharm” jobs, meaning the institution hires the psychiatrist to be a “pill-mill”. “What’s wrong with this?” My imaginary readers ask, to help me launch into my current post. What’s wrong, is the psychiatrist should be the thought leader, the one who designs programs for the mentally ill or creates systems of care in which problems such as homelessness and substance abuse can be approached in a comprehensive, and compelling way. Checklists are not the answer, and yet, there is a large push, particularly in the public sector, for the practitioner to check off boxes, signaling that important issues are discussed. Yet, the issues of the mentally ill, be they anxiety or psychosis, is that the individual needs to feel deeply understood, and then there needs to be services which connect with their underlying pathology. Psychiatrists are in a unique position to both understand patients, as well as help other mental health professionals understand the deeply disturbing experience of mental illness. As such, psychiatrists understand the kind of social services that patients need. They also understand the kind of individual work a patient needs. Putting these two skill-sets together, creates a thought leader who should run agencies, direct programs, or design curriculum. Yet, in most institutions, those jobs are done by non-MDs. The psychiatrists fill the check-box of “psychopharmacology evaluation” and that is usually all they do. This is the big picture/small picture issue. We, as a field, have bought into the ‘small picture,’ without feeling the responsibility of the ‘big picture.’ For this, I think, my field needs to reflect and re-group.

6 Responses to “What Do Psychiatrists Do?”

  1. Jon said

    It seems to me that psychiatrists need to think back to the origins of their discipline. If I understand correctly, the eminent Austrian physician Josef Breur made important discoveries in neurophysiology. However, he also worked with a patient Bertha Pappenheim and results were published in Studies on Hysteria (1895). This patient underwent a form of verbal therapy understood as The Talking Cure. Breuer also had a young mentee, Sigmund Freud. It is rumored that Freud did much with that method. Perhaps modern medicine might still see the wisdom of work from around the turn of the previous century.

  2. Thanks, Jon. You bring up the good point that before the turn of the twentieth century, psychiatry was part of neurology, and not it’s own specialty, like it is today. With Freud introducing the ‘Talking Cure’ came a new field, which although over one hundred years old, still feels like it is in its’ infancy. Still, I think we, as psychiatrists, have responsibility to those with mental anguish, and so we need to reflect on where our career will take us over the next half of a century. With reflection comes growth, and so we, psychiatrists, need to do what we help our patients do, reflect and understand the consequences of our career paths. Psychiatry, as a field, begs for reflection. The poetry in that always gets to me. Thanks Again.

    • Shelly said

      Perhaps it is that the “Talking Cure” cannot help all the homeless, abandoned mentally people on the street. They need far more than we as a society can provide them. I realize that it is our responsibility to try to help, and you, as the mental health professionals, to lead the way, but still…how can we conquer our fear of losing the war over all of the mentally ill homeless people out there who need help? Do psychiatrists truly want to reach out and pull these people off the street and help them, or do they want to leave these people to the social agencies and shelters, and let the MD’s treat the people they can really help in their offices with medication and “talk therapy”–the ones they can “really help?”

      • Yes, this is the dilemma. The issue here is big picture and small picture medicine. I, for one, am interested in both. I want to help people in my office, but I would also like to chime into the discussion about public health policy to share my understanding of mental illness so that the systems of care can work better. Thanks.

  3. rudyoldeschulte said

    As you suggest in your post, the mentally ill do need understanding and to feel connected with another – one that can help them, even in some small way – and team leaders that know and can influence programs of treatment – in the big picture, as you put it. I think that within our ‘reflections’ on the needs – and the approaches taken – there needs to be the consideration of several of the contributing factors that have influenced the changes in psychiatric/psychologic treatment since the 1980s. Unlike one of the earlier posts, I am not referring to the narrow view of ‘talking cures’, but rather the beneficial use of many approaches and techniques that were taught at the med school – in psychiatry departments. These have changed, and have undoubtedly been influenced by many factors, such as managed care directives, inter alia. In my experience in teaching in psychiatry departments, I taught child and adolescent developmental theory and therapy in a two year long course, occurring weekly…over the course of the fellowship. I have seen references more recently to psychiatry residents that do not get any psychotherapy training or education, let alone experience psychotherapy themselves.
    In echoing your comments, I agree that much reflection (on historical influences of past 25 years and current influences) is needed to imagine the necessary changes – and the career choices that those entering psychiatry need to consider…in order to become ‘thought leaders’ in the field again…

    • Hello Rudyodeschulte…thank you so much for contributing to this discussion. Our voices need to come together to remind the rookies that their training, although valuable, has severe limitations.

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