The “Chapter that Wasn’t Written” in Shrink Rap should have been on the changes in psychiatry due to insurers. Recent posts have underlined the effect of pharmaceutical companies and the ways in which they have distorted data and biased the attempts to have an evidence-based practice. While these comments have a lot of validity, I think the influence of Big Pharma on the field has been exaggerated. There is another culprit which has had a more pernicious and less easy to combat effect on psychiatry.
When insurance companies started to severely limit psychotherapy and reduced reimbursements drastically, the entire field of psychiatry changed. They made practicing purely a med management model much more profitable than talking to patients. Worse, they created an atmosphere in which a doctor who saw his patients frequently was considered to be doing something unnecessary. Just a short time ago there was no need in Maryland to explain to one of the “reviewers of medical necessity” even twice-a-week psychotherapy. Such treatment rapidly became impossible to get approved.
The training programs changed to reflect the economic reality. Psychiatric residents once had extensive training in psychotherapy. Many residents were in psychoanalysis. No more. Becoming expert on how the mind, as opposed to the brain, works has been abandoned to psychologists and social workers. As always, Philosophy Follows Funding.