What's killing psychiatry?

Part 2

by Lisa Birk

Remember the archetypal Woody Allen psychiatrist? The one bathed in soft light, head cocked, listening to Woody's story for 50 minutes every week? If that archetype were an animal, he'd be on the endangered list.

The premise of traditional psychiatry was that the individual mattered. The doctor's insight and empathy mattered, and the patient's story and feelings mattered. Those values were reflected in the practice of psychiatry itself. Referrals were word-of-mouth, based on a knowledge of patient and therapist. Confidentiality was the basis of the relationship. Treatment sometimes included drugs, but always included talk therapy, in which the patient had the psychiatrist's full attention. The length of treatment was a private matter between doctor and patient.

The premise of the new psychiatry is that profit matters. Profit depends on efficiency, and efficiency is based on statistics. Same as any other industry. How long does it take the average worker to bolt a fender onto a car? A worker who takes longer knows he has to speed up or lose his job.

The principles of managed heath care, which now govern the psychiatric treatment of all but the very rich, apply the same efficiency standards to therapy. How long does it take the average doctor to "fix" the average patient's depression? How can efficiency be improved? The result of this approach is that every element of therapy is becoming mechanized; at worst, psychiatry has become a matter of referrals by zip code, over-reliance on medication, and treatment whose duration is determined by statistics-wielding bureaucrats.

What happens when a profession charged with the most delicate of tasks -- treating the human psyche -- is driven by the most mechanistic sciences -- statistics, chemistry, economics? This story is about who benefits and who loses under this new system of mental health care, and what is happening to psychiatry itself.

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Lisa Birk is a freelance writer living in Cambridge.