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Psychiatrists in Community Mental Health

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The illusion is that "the right combination" of medications can make people feel "normal". When I inquire about how "normal" feels, most don't know. As far as I can tell, many have never felt "normal", which they generally define as the absence of feeling. They have not learned (probably their families did not know) that feelings (and even, sometimes, extreme feelings) are part of life. They have not learned that we humans regulate each others' moods and emotions. They have not learned how to soothe and comfort themselves.

As psychiatrists, I believe we must push back against the role in which we have been placed. In the way I see psychiatry being practiced in community mental health, I suspect a nurse and a computer algorithm would do a better job than we are doing at lower costs. Certainly, a nurse practitioner without a computer would do at least an equal job at lower cost. We need to take back the original meaning of the word psychiatry, as doctors of the soul. We need to do more than write prescriptions. We need to attend to the medical needs of our patients as well as the psychiatric. We must consider how their other diseases and medications are affecting their moods and emotions and behavior. We must pay more attention to cognition and memory. We must delve into the quest for meaning and purpose that all humans must make.

How could we do this? I have discovered some small maneuvers that may help. I am starting two groups. The people who count the money have determined that I can meet for an hour if I have three people, for 90 minutes if I have 5 people, and for two hours if I have six people. That's the formula, since three group visits equals the income from two individual visits. I'm trying a "hearing voices" group to help patients manage their voices (the medication mostly doesn't make the voices go away; it just makes them more bearable). My other group will be for people who are not hearing voices, more like a talking circle, narrative therapy group. We'll see if anyone comes. This gives me much more time to hear people's stories. I have also discovered the trick of asking patients to come half an hour early if they don't mind waiting. Then, if I have a cancellation and they are there, I can see them for an entire hour. I have also carved our three hour slots which I can control so that I can see three people weekly for an hour each.

I have other plans. I want to explore how to combine medical care with psychiatric care, how to reinstitute family therapy, thereby opening the wall between adult and child, and more. We'll see what will happen. The downside for some psychiatrists is that this is harder work than just writing prescriptions. It takes more time. It requires a larger emotional investment. The upside is that it brings meaning and purpose to the job.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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