I’m getting tired of being blamed for the death of my profession.
My clinical practice in prison consists almost entirely of diagnostic assessments and medication management. While I do a small amount of therapy, this is usually limited to occasional crisis intervention and brief supportive counseling in the context of an intake assessment.
Fortunately, over the past 20 years, I have worked with a series of skilled and qualified psychologists, and we work very closely together. They provide cognitive therapy, anger management therapy, bereavement counseling, sex offender therapy, and a host of other services.
I step in when they need help sorting out a diagnosis, when medical conditions appear to be affecting a patient’s mental status, or when there are policy issues that demand only the intervention of a medical doctor. It’s a model that’s worked well for me and my patients. And because I’ve been at the facility a long time, I’ve gotten to know our regular patients due to their repeated incarcerations.
For many prisoners, this is the only system of mental health care they have ever known. And because the average incarceration for a felony in my state lasts 2 or 3 years, I have a wealth of previous clinical data I can refer to when needed. I am able to pace my practice at a comfortable level, and I see only the number of patients I feel I can reasonably handle in a day. I am not paid based upon the number of patients I see or how fast I “churn” them.
Nevertheless, my colleagues vent – both online and in person – about increasing numbers of psychiatrists who have med-check only practices and about the commercial forces driving this change. They fear that psychiatry training programs are placing less emphasis on teaching psychotherapy, and that leaving this treatment modality to other professionals is an abdication of care and a blow to our professional standards. Doctors with med-check only practices are vilified as being greedy or therapeutically inept, having poor social skills and always as doctors who give suboptimal care.
Sometimes I get special dispensation because I work in a prison. After all, they reason, it’s a prison – we all know that prisons are going to provide suboptimal care (if they receive any care at all), and who cares if that pedophile gets to see a psychiatrist, anyway? They’re just criminals.
Ah, it gets old.
The need to listen to one’s patients is not limited to psychiatry, and neither are the financial concerns that may lead a doctor to offer certain treatment modalities over others. If psychiatrists are pressured to increase their caseloads because of financial concerns, so are internists, family practitioners, and surgeons. And if failure to provide therapy is such a danger to the profession, perhaps we also should vilify those who choose to become basic science researchers, administrators, and non-practicing academicians?
The future of psychiatry, and medicine in general, will depend upon our ability to work with other professionals and to recognize the unique skills that each bring to the table (or bedside). The “medical home” model for psychiatry requires coordination of care between primary care physicians, psychiatrists, psychologists, social workers, and others. In this model, psychiatrists are likely to provide medication management services alone or with a non-psychiatrist therapist. The medical home model has been shown to improve general health outcomes and reduce hospitalizations for psychiatric patients in free society.
This model also has recently been shown to improve engagement with community health services for newly released prisoners and to cut reincarceration rates for mentally ill prisoners by up to 71%. Given these facts, we may have to admit that what isn’t “good” for our profession may be better for our patients.
DR. HANSON is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.