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Tricks and treats in psychiatry

October 30, 2013
by H. Steven Moffic, MD
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As Halloween rolls around once more, I am reminded of the many unexpected tricks and treats I've experienced in behavioral healthcare over the years. Here are some of them:

Tricks

I went into medicine and psychiatry naively thinking that all involved would be dedicated solely to helping patients. Really, I did! Over and over, I lost my idealism to academic politics, managed care cost controls of businesses, and the payoffs by Pharmaceutical companies to "thought leaders" to publicize their medications.

I also never imagined that patients and families would turn against us psychiatrists. Yet, anti-psychiatry movements, perhaps first fostered by Scientologists, now are replete with ex-patients and family members who want to put "psychiatry under the bus," as one commenter on the MadinAmerica website put it.

However, there turns out to be a grain of truth in the protests against psychiatric medication. There were more unexpected effects than I ever anticipated. I came to realize that the term "side effects" was inaccurate; these are in fact unwanted direct effects. Idiosyncratic harmful effects were always an unwanted surprise, and not rare. And, now we struggle with the knowledge that there may be some longer term harmful effects of medications that we didn't previously know about.

Psychoanalytic psychotherapy was in its heyday when I first began to be educated to be a psychiatrist. Now, it has fallen by the wayside to a large extent, being replaced by briefer and more evidence-based psychotherapies. That teaches some humility for what we do that might later be replaced by more effective treatments.

Pogo reared his head at times. There were goblins among us. These were the psychiatrist administrators who ended up prioritizing things other than the organization, colleagues, and/or patients. One I knew even bought and sold the buildings of our community mental health centers, centers which were short of cash to care for patients. That one ended up in jail.

Treats

Fortunately, the treats well outnumbered the tricks. I'm not speaking of financial treats or presents. No, hardly anyone makes a lot of money, other than administrators, in psychiatry. Nor are psychiatry patients wont to give presents, and even if they do, that often needs to be discussed and discouraged due to transference factors. The rewards have to come elsewhere. And they do.

There were so many patients that turned out to be treats. Here are just a few (disguised) examples. A young woman moved from Manhattan to a much smaller city where theatrical opportunities were less available. Despairing at first, with treatment of medication and psychotherapy, she started an innovative cultural company devoted to unusual productions. Another woman came to our not-for-profit managed care system early on, seeking a woman therapist. Just beginning, we had none in-house and at a convenient location at the time, so she was stuck with me. She stayed for most of the next 24 years for gradually decreasing sessions, becoming a leading scholar in the sociology of women in sports. A medical student with a horrendous trauma history got through medical school to become a prominent pediatrician. A patient with Schizophrenia recovered enough to become a curator of an art gallery. So many patients with gender challenges courageously - and successfully - transitioned. And, there were all the inmates who ended up trusting me enough to engage in treatment and try to change.

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H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...