Shirah Vollmer MD

The Musings of Dr. Vollmer

Community Psychiatry

Posted by Dr. Vollmer on December 15, 2014

Does “Community Psychiatry” mean low-income pill mills or can Psychiatrists have a larger impact on community mental health, without going through the avenue of public policy change? In other words, can  a graduating psychiatrist, one with ten years of training, four of which are specialized in psychiatry, find an employment opportunity in which they are not asked to be a medication dispensing machine? Can they find a job where they are responsible for program development or psychoeducation, where they educate large numbers of people about positive mental health, or how to live a happier life?

My impression is that to be employed as a psychiatrist means you are forced into a narrow role of prescription writing, without the benefit of deep relationships with patients, or the psychological benefit of implementing system change. What if graduating medical students do not understand this horizon? What if they think they are going into a world in which mental health can be promoted by psychiatrists, not just by teaching about medication, but by promoting healthy living and healthy lifestyles, for the body and the mind? What if they come to learn that psychoeducation is mostly done by professionals who do not have medical licenses, and with the shortage of providers, the medical license is seen to be optimally used only for medication management. All other activities, such as groups, wellness activities, vocational coaching, are done by those with Master’s level degrees. I can imagine the disappointment new graduates might feel as they discover that “Community Psychiatry” does not mean helping the community, but rather it means medicating the community. which may help some, but not in a more global way which is more fulfilling, and a greater justification for years and years of training.

Psychiatry, as I frequently say, needs to re-gain its foothold into the “whole person” and not just the “medication piece.” It is possible that medical students are not exposed to this limitation until late in their training. I think we need to tell them, so the field can re-boot. Community Psychiatry should mean the psychiatrist is helping the community function in a way that decreases the mental health burden on the individual and his family. This can only happen though if psychiatrists are paid to run and design programs, not just write prescriptions.  This is my rant. I am not letting it go.

9 Responses to “Community Psychiatry”

  1. mimi said

    well said about “medicating the community.” the problem is that community mental health cannot afford the salary of a psychiatrist to use them to provide the other parts of the whole person treatment – education, vocational counseling, etc.. i also find that the psychiatrists are not really trained on resources in the community so we need those folks to still really be involved. it’s a good conversation!!! thanks, mimi

    • Oh, dear Mimi…the “can’t afford” argument makes me want to say that the community cannot afford NOT to fund psychiatrists to be program developers. Yes, I agree that training for psychiatry needs to improve, but if we can imagine that, then psychiatrists can implement programs which, in the end, could be cost-effecive. We will never know if my hunch is right though, because psychiatrists, in this moment in time, have been narrowed into a little pill-mill closet.

  2. Shelly said

    Psychiatrists should be the ones that oversee such programs, with the Master’s levels running them. There could be groups to increase wellness and to educate and offer one-on-one meetings with psychiatrists if needed, but psychiatrists have far more training than is needed for community education. My personal belief is that psychiatry is best used in-patient, where pseudo therapists help little. In this scenario, insurance also pays for hospitalization and the psychiatrist, does it not? My problem is that while I agree that “therapy is the gift one gives to oneself,” people have limited resources and long-term therapy out-of-pocket is just not feasible.

    • Yes, psychiatrists could be hospitalists, and many are, but the problem is that inpatient hospitalization is rushed, and hence judgments and medication decisions are made quickly, without the thought and care needed for the individual patient. Yes, long-term psychotherapy is costly, and not feasible for many many people, but that does not mean that the tools that the psychiatrist learns when he/she does long-term therapy should not be developed. In essence, my fear is that since long-term psychotherapy is done primarily by non-MD therapists, psychiatrists will never learn the tools to do therapy, and as such, if the tides ever change, they will not be in a position to understand the psychodynamics of personality issues. Without understanding these tools, patients will not feel understood and the spiral will continue to be negative. Thanks.

  3. Eleanor said

    Adding to the difficulties in getting long term psychotherapy….about a year ago I was sitting with extended family members…one of which is in the insurance business and I was challenging the lack of parity issues in insurance payments for mental health coverage. The response was “well we need to see proof on paper” for coverage….yeah, well good luck. I have also asked the person that handled our change in medical coverage over to Medicare plus additional coverage with a well known company why they don’t cover mental health treatment equally as they do cancer, heart disease, or whatever and the answer was something to the effect…”well that’s just the way it is”….. Then the insurance lady commented to me…”of course not to worry, you would never need that”. I get the impression, and perhaps wrongly, that the psychodynamic approaches are on their way out in this fast paced electronic medical records world of ours. Hope I’m wrong…

    • Hi Eleanor, I do not think you are wrong. I do think that psychodynamic approaches will be harder to find, and when found, will be predominantly done by non-MD clinicians. Thanks.

  4. Eleanor said

    From my experiences which, in the grand scheme of things, are limited, I don’t see deep thinking psychotherapy as something that is going to stay around to reach a decent segment of our population for any great length of time, unfortunately. I continually have to limit my opinions and use my words very carefully when mentioning anything that remotely reminds folks that our pasts inhabit our present and the importance of understanding these experiences and connections when need be. All this makes most people very uncomfortable…yes, fortunately some “get it , but not many. When help is needed, the term “counseling” (and short term) is popular. Psychodynamic approaches….forget them. (again, my experiences). Do these trends upset me…you bet they do….Todays lingo….”providers”, “clients”, “EMC”, etc. is the way our society is moving…..impersonal, mechanistic, and electronic.

    I would like to see massively funded programs in our schools…nursery through say…6th grade or so…screening children for early difficulties and then working with families from a psychodynamic prospective to help avoid major issues with the kids later on….easier said than done….

  5. Eleanor said

    My post above was meant as response to Shirah’s next blog posting…psychiatry, old vs new….. I was in a hurry and working from my iPad!

    • No worries….but thanks for the clarification….Yes, medical care is going, as you say, “impersonal, mechanistic and electronic,” for the good and bad of that, which, as we are discussing, is mostly bad, from my perspective in the area of mental health. However, few people will push back and want individualized care, and yes, this takes courage, time and often, but not always, money. For these few people, we still need “providers” to give them the care that they intuitively know they need. For those “few” people, I stay working, as day after day, I see that deep problems get better with deep work.

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