Shirah Vollmer MD

The Musings of Dr. Vollmer

Mental Health is Lost

Posted by Dr. Vollmer on February 20, 2015

What does being a mental health provider mean? Does it mean that we help people breathe, eat right and exercise? Does it mean that we tell primary care doctors which drug to prescribe, after a two question or nine question paper and pencil test? Does it mean that we point people towards groups, where the individual can share their story with other folks who after a fifteen minute assessment seem to struggle from the same issues? Do we help people by stating the obvious? If we do not understand psychic pain, if we think that a quick appraisal of the person’s mental state can tell the practitioner what to do next, then there are two main problems as a result. First, patients will not get better and they will need to seek help from other sources who may prey on the vulnerable. Second, practitioners will not learn the language of deep mental processes which sabotage and destroy otherwise healthy people and healthy relationships. As a result, if the delivery system ever changed back to an in-depth approach to mental health, there would be no practitioners skilled in drilling down to the root cause of mental suffering.

Yaddy, ya, ya….same ole….rant, but today I add a new issue. As mental health care delivery transitions away from mental health providers giving direct patient care, and serving more as a consultant to primary care, then we will see two problems. One is that the practitioner caught in the midst of this change is going to be very unhappy because that is not the work they signed up to do. It would be as if you told an internist that now all they could do would be to work in the Emergency Room. They would lose their opportunity for long-term relationships because their skill set is needed for triage. This might serve the needs of the population, but for the physician, this is a low blow. If they wanted to be an ER doctor, they would have chosen that in the first place, so the ground under the feet has been ripped. Second, those choosing to enter the mental health field are choosing a career of triage, and not long-term relationships, and as such, a different type of person will enter the field. Triage is a different skill set from long-term care, and hence the mental health provider will shift from a person who enjoys relationships with patients to a person who enjoys shift work. Again, the ER doctor has a different personality than the internist, and so this is true for the changing mental health delivery system.

Words like “integration” and “patient centered medical home” speak to a primary care physician who handles the ‘big picture’ meaning that mental health is being renamed “behavioral health” to suggest that changing behaviors can change mental pain, which although sometimes true, is usually not a sustainable change. The MD  is being reserved for “prescriptions” as this is the one activity in mental health that cannot be done by another provider. As such, diagnosis and all other interventions, are being done by master level clinicians and ‘case managers’ who have less training and have a variable skill set. On the one hand, everyone would agree that the brain is a marvelous and complex organ, yet, on the other hand, helping the brain seems to be the work of simple interventions. That makes no sense.

2 Responses to “Mental Health is Lost”

  1. Shelly said

    So I guess I’m asking, what is it you want? In this one piece, you seem to state that you don’t want to be an MD who only prescribes medications nor do you want to want to be the one work with the master level clinicians and “case managers” to help drill down to the root causes of the mental illnesses. I understand that the psychiatrists are the masters of it all, but you also have to deal with the changing landscape of the times–there are primary care doctors who give out medications for mental health disorders and therapists who treat mental disorders. Where do psychiatrists fit in? If your specialty doesn’t make itself fit in, you’re soon going to find yourself out of a job.

    • Perhaps I was not clear in this post. Master level clinicians are also NOT drilling down into the root of mental distress, but rather they are being taught “quick” interventions to put people back on their feet. It is not so much that I will find myself out of a job, because there is still a need for what I do, but it is more that on a population basis, both for patients and for rising clinicians, I see a deterioration in the quality of care delivered. What I want is a revolution. I want physicians, psychiatrists, in particular, to come out with a position statement that says that we need to be in charge of diagnosis,which means we need to take our own histories, and that we need to have both long-term care patients, as well as have the role of triage. We need to remind the medical community that our diagnostic skills are critical to the triage of patients, and that our long-term psychotherapy skills are critical to the training of future mental health clinicians. We need to let the public know that prescribing medication is only a small part of what we do, considering that we do ongoing assessments and understanding of the nature of different issues that patients present with. We need to remind both our physician colleagues and the lay public that although diet, exercise and meditation are wonderful behaviors which promote physical and psychological help, there are times in people’s lives where they cannot access the part of their brain which tells them to help themselves, and so no amount of behavioral or pharmacological intervention will help, without a deeper understanding of self-sabotage. Thanks.

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