The field of psychiatry (which, for purposes of my discussion includes clinical psychology, even though they are not the same thing), is fundamentally divided — between care providers and patients. Perhaps in no other area of medicine are patients and providers so deeply divided as in this one.

I would like to say at the outset, that many people who work in the field of psychiatry, are as caring as could be. They have to be, as the work they do is often difficult, the hours impossible, and the pay lousy; they must be motivated to remain in the field. In my remarks, I do not mean, in any way, to impugn their sincerity or compassion. The very fact that I’m able to write this, is a reflection on the fine work of about a dozen wonderful people. I’d be remiss not to make this clear.

The problem is that they are hamstrung: By the fact that there is little to no research going on, in the field of mood-disorder psychopathology and the root causes of mental illness; by a medical system which relies too heavily on medication and a small number of psychotherapy strategies, none of which by itself is very effective; by a system, both medical and legal, which doesn’t treat mental illnesses the same as physical illnesses; by managed care and government-insured medicine that strives for short-term gains at a long-term cost, to the detriment of everyone, including insurance clients and taxpayers whose money they claim to be saving; and by increasing budgetary pressures that often make it impossible for them to provide patients the kind of care they actually need.

This is a rather stunning indictment of the system, you may be thinking. And you’d be right. What’s more, I meant every word of it. The field of psychiatry absolutely must be reformed, from the ground up, and managed care and government will have to be part of that reform. Without sweeping, systemic reforms, however, small changes cannot do any good, and will likely make an already-dismal situation even worse.

It’s all or nothing. Going halfway is worse than doing nothing at all.

For those suffering from mood disorders, hopefully this blog will help you see there’s a reason why you probably don’t feel any better, even if you’ve been part of “the system” for years.

What makes the divide between care-provider and patient a much wider gulf in psychiatry than in any other field of medicine, is the fact that many patients with psychiatric illnesses have impaired judgement; this means providers take on a “we know what’s best for you even if you don’t” attitude. The reasons for this are fairly obvious: If you have a broken leg, you know the best treatment is to set the bone, set it in a cast, and allow it to heal; and if needed, perhaps take pain-killers for a short time. Nothing about having your leg broken robs you of this knowledge. But … having a psychiatric illness, even depression, can potentially rob the patient of his/her good judgement.

This is not true of everyone, to be sure, but it is true of some, and it’s natural that care-providers develop what might otherwise be considered a condescending attitude. In many cases they are right to presume they know better than their patients, because (let’s be honest here!) they often do.

The problem lies in patients who are not necessarily judgement-impaired by their illness; either it’s not very severe, or it just doesn’t manifest that way in them. The care-provider is in a tight position in these cases; they have to discern the patient’s level of judgement, then proceed accordingly. In today’s world of conflicting reports about all things medical, it’s possible for patients with good judgement to fear certain treatments, and shun them. The care-provider must figure whether the patient is being rational or not.

One ends up with patient and care-provider staring at each other across a murky gulf, each guessing at what to do, and worried about taking the wrong step. This does not happen in any other area of medicine, unfortunately. As for what to do about it … it would be, perhaps, better to have alleviated some of the murk ahead of time, by providing people with a more sound conception of what mental illness is, and how its treatments work; instead we get mass-media reports with dire warnings, and dramatic shows in which people with mental illness are prone to extreme behaviors.

This makes psychiatry inherently much harder than it needs to be. And it needs to stop.

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