Obviously, psychiatry has changed over time. We've gone from a field where treatment was mostly psychotherapy-- I'll purposely omit insulin shock, leeches, and lobotomy-- to one of symptoms, prescriptions, and side effects, as though these things occur outside of the context of a person's life. Ah, you've heard me rant before. And like all of medicine, it's no longer just about treating patients, it's about checking the right boxes, coding what happened in the session by the minute, those damn CPT codes, and now about the technology and the hits your fees take if you won't e-prescribe, file PQRS (?huh) data, and practice the way the insurers want, if you choose to accept insurance or work for an agency that does. With all that in mind, I saw this lovely and angsty post on Facebook, and asked the author to join Shrink Rap as a guest poster. I was so pleased when Dr. Maher said yes. Her guest post is below.
I'll be 65 next month, I will have been in private practice for nearly 40 years, and I'm trying to decide where to go from here. If you have time, would you help me think through this difficult decision?
I trained in a time and a place when psychiatric treatment, other than for the severe mental illnesses, was about psychoanalysis. Even if you didn't go on for analytic training (which I did, right after residency, at one of the most classical institutes in NYC), your primary goal was to search for and speak to the complex humanity of the other. My 4th year psychopharm course was optional.
Yes, the classical model was flawed in significant ways, but over time I took what I needed from it, I owned it and I loved it.
Then prozac arrived on the scene and I woke up in a different profession. No longer was it about meaning and humanity and insight into who you are, how you got to be that way, and the unconscious forces that led you to get in your own way. No longer was transference the mechanism of action. My field became about symptom constellations, drugs and/or skills to fix what was wrong with you.
This perspective always felt wrong to me, but over time I came to integrate the parts that felt right with the work I was trained to do, and it worked pretty well. I have a very good practice, partially private pay and partially insurance based. Aside from Medicare (helpful when some of your patients have been with you for 30 years), the other insurance I accept is the one that the NYC Dept of Education uses. Many of my patients are teachers, so their psychopathology falls within a range that I'm comfortable treating.
Once long ago, that insurance company called and asked me to take a patient off their hands. She was a paranoid, depressed, obsessional, suicidal, entitled, angry and litigious woman who fired every psychiatrist she saw, called the plan daily and threatened to sue everyone she spoke to. I told them I would only take her if I could see her 4 days/week indefinitely, no questions asked. They said yes, and she never bothered them again.
They left me alone after that. I've seen some people weekly for years without being bothered.
But times are changing, yet again. No one would remember me from that time. No one would bend the rules to allow a shrink with dynamic understanding to engage a patient like that. The billing, coding and documentation requirements, and the medical complexities, are becoming more than I feel comfortable with. I'm finding it increasingly hard to integrate the complex, struggling human being that I see with the symptom and treatment picture that I'm required to see.
I've moved into other arenas, including a not-for-profit organization, documentary filmmaking, and the development of an emotional literacy curriculum for young people. But there's no money involved in any of them. They cost money.
I love my work and I love my patients and I think they benefit from working with me. I know what I know and I know when to refer to to ask for help. When I do psychodynamic "talk therapy" (I hate when they call it that!!), I'm doing something very complex, something I'm very well trained for. But there's no code for that and very little respect for it, and I live in fear of being audited.
If you've read this far, thanks so much. I'd be grateful to hear your reactions.