Adam Blatner

Words and Images from the Mind of Adam Blatner

Psychiatric Practice: Not What It Was

Originally posted on April 15, 2011

A colleague recently asked me why I was not still in practice. I felt awkward, because if I kept up with the news, I could be just as good a clinician as I ever was—and my wife said she thought I was pretty good—as have some colleagues, etc. But the field has changed!

In the olden days I wasn’t so paranoid about making a possible mistake. A few brushes with predatory malpractice lawyers who involved me in ambiguous distant fault-finding—I was in no way accountable for the final dismal outcome—reminded me how much medical practice has become uncomfortably defensive. We can no longer afford to take any chances, rely on the healing potential in each soul. While a more positive attitude might operate to the benefit of 9 of 10 clients, the 1 out of 10 who denied drug use, suicidal thoughts, or in other ways understated the true fragility of his condition—and then committed suicide—would end up leading to the psychiatrist or treating clinician being sued. It seems to me and many others that this has become an entitled and litigious culture. So that in part accounts for the overuse of medicines, etc. The physician is consciously or unconsciously responding to the probing of a lawyer in court saying, “So you didn’t think this patient needed medicine, eh?”

My own career emerged between the decline of psychoanalysis and the growing dominance of “biological” psychiatry.  I was more action oriented, more of a humanistic psychiatrist, more eclectic than others who were more tied into psychoanalysis—which I thought had become too rigid. On the other hand, in the mid-late 1970s psychiatry swung from its having been dominated by psychoanalysis to the other extreme, which is a domination by neuro-science, psycho-pharmacology, and the like. This trend has some genuine value, but it has also been over-played. (We should recognize that 90% of the psychotropic drugs—for depression or anxiety, etc.—are being prescribed by non-specialty physicians, family practitioners, internists, etc.— and they are not infrequently prescribed in doses that are greater than what the client needs, or less, or not adequately adjusted.) So being “in between” is an awkward role.

Also, as one who is still identified as a psychiatrist (even though I’ve been retired from practice for over a decade), people stereotype me: I’m either associated with unpleasant experiences (by them directly or through the reports of relatives and friends) for what seemed like non-compassionate drug-pushers; or with the old cartoon caricature of psychoanalysis. Admitting my professional background evokes prejudice in either or both directions.

Admittedly, this prejudice in part is fueled not only by excesses in practice and distortions of cultural caricatures, but also the fear that people’s diverse nature will be labeled as abnormal. I recently met a charming and playful woman (probably in her 60s) who was a bit defensive on hearing I was a psychiatrist. She had some relatives who unfortunately didn’t know how to take her playfulness, and so was a little afraid that I (as a psychiatrist) would think she was abnormal. (I didn’t—I thought she was great.)

It seems that the clinical fields (many cannot differentiate a psychiatrist—who is a physician, an M.D.) from a psychologist) during the 20th century have not made a clear place for a wide variety of quirks that, from a wiser perspective, are really interesting qualities. Some folks dream with extraordinary vividness, some have psychic experiences, some have mystical spiritual experiences, some are playful, etc. But the 20th century didn’t recognize these mental states as valid, and people felt they might be thought of as peculiar if not slightly insane. This woman had heard in her circle of an over-diagnosis of “bipolar disorder,” as if that had become almost fashionable. She was worried that her really rather delightful mood swings from ordinary to enthusiastic might be viewed as a “disease.” She enjoyed herself. I reassured her, but privately, I contemplated the prevalence of subtle anxiety when people are in the presence of those whose job it is to help others.

So psychiatry has been in transition, and I am not happy with many of the changes. I have extra concerns about this because I think that on the positive side, psychiatry and depth psychology have brought to our attention a wealth of ideas about how people fool themselves, and this and other insights need to be brought into the mainstream in this century as much as basic science became a mainstream cultural development in the last century. My solution is to promote this idea in spite of not actually being “in practice” any more.

One Response to “Psychiatric Practice: Not What It Was”

  • Barbara Shapiro says:

    Reading your entry hit many an experiential note with me. I trained in Beacon with Zerka, shortly after Moreno’s death, and had a brief but memorable experience “in practice” so to speak.

    That was awhile ago and I must agree with your assessment of the state of the professions helping, or is that, harming others. I really wish “First do no harm…” was taken seriously by the medication experts!

    Speaking about what I would call a bad “practice” of “objectively” pathologizing behavior that is simply spontaneity, deserves repeating…hopefully to prevent one’s joie de vivre from turning into a regimen of RX’s.


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