8 Years as a Psychiatrist: A Review

I recently audited all the patients I saw in my general adult psychiatry clinic, in a random month in 2022.  What I found confirmed what I already knew to be true:  Most of my patients do not benefit from medications alone.

Here were my statistics of what patients needed from me:

5% needed medication but refused to take them
8% needed medications +/- adjustments only
8% did not need either therapy or medications adjustments
35% benefitted from therapy only (from me or another provider)
43% benefitted from therapy and medications +/- adjustments.

From my experience early on working in mental health, I had known that most patients needed more than medications and for this reason I had intensified my training in therapy in my final years of residency.

But being a therapist as a psychiatrist is very complicated.  I now understand why some psychiatrists do not do therapy and choose to focus only on medications.  Many psychiatrist also only offer a one time consultation with or without short-term follow-up  (i.e. 6 sessions).  I can certainly say that for me, patients who only require medications and short-term follow-up are very rewarding to treat and do not take an emotional toll.  This makes seeing them very sustainable, but unfortunately as you can see from the statistics above from my own practice, they are the exception.

Ironically, I was trained in a model of care where the main treatment was medication and where the follow-up after acute stabilization was minimal.  In other words, I was trained to meet the needs of only 8% of the patients who would come to see me in my general adult psychiatry practice.  I have chosen to be the kind of psychiatrist I was never taught to be: one who offers therapy, medication and longer-term follow-up (> 1 year when needed) and it has been almost impossible.
Here is why.  It has been:

Inspiring: The patients and the stories that they bring teach me a lot of lessons about life and what it means to be alive.  There are hardships I can not imagine and the patients still come, raw and vulnerable to share them with in hopes of feeling better.  It takes a tremendous amount of courage to see a psychiatrist, to lay bare your vulnerabilities and to accept help.

Confusing: As a mental health care provider in the Canadian health care system, it is very difficult to delineate what to take on when it comes to helping a patient.  Offering a diagnosis and evidence-based medication is the easy part, but it is also part of our job to see patients and their mental health in the context of their lives and their psychology.  In our training, we were told (not taught) to consider things like poverty, immigration, upbringing and relationships as important factors influencing a patient's mental health.  And though this is undoubtably true, a psychiatrist has very limited abilities to change any of these factors.  I see now that I invested in therapy training believing this was the best shot I had to modify the otherwise unmodifiable.  But what experience is teaching me now is that even therapy has significant limitations and is far more strenuous on me than I could know.  So to whom am I to provide this kind of therapy?  How do I know who will benefit?

Frustrating: I am starting to wonder if humans are capable of the change I would like to believe they are.  I am both relieved and disheartened by this conclusion.  I am relieved because I believe it will make me less angry with my patients when they do not change, even when they tell me they want to.  I am relieved because I will be less frustrated with myself, and blame myself less for the lack of improvement in the patients I see.  I have offered therapy and over 2-3 years of follow-up to patients who are no better than when they first came to see me.  I can get a patient disability benefits or a referral to support program, but this is a small consolation prize for me, someone who has honed her therapy and diagnostic skills for the better part of a decade.  I am disheartened because I really believed I could help more people.

Relentless: The suffering and the demands on a psychiatrist never stop.  The self-criticism every time a patient makes a demand above and beyond what you have already offered that tests your patience, compassion and time, when quite frankly, there are none left, adds tension to an already taut elastic band.  I trained in a system that values accessibility of health care and I internalized this value deeply into my identity as a physician.  However, what I did not know until now, is that I had interpreted this to mean, "give all patients access to all treatments available no matter your assessment of whether or not they will benefit".  This is because it is hard to say who will benefit from medication.  It is even harder to know who will benefit from therapy.  And to not offer these things after an assessment can't help but feel like you are giving up.  Further complicating things is that the outcome in therapy can be a reflection of the relationship you have built with the patient.  So you can see how when a patient does not do well, that this can be interpreted as a failure of the therapist's ability to create the "proper" relationship with the patient.
What to do when the patients we see, for many reasons (e.g. addictions, developmental delay etc.) can not benefit from the therapeutic relationship?
I have known that therapy is for those who want to change and those who can change.  Benefit from therapy IS NOT related to the degree of suffering/dysfunction experienced and expressed by a patient/client.  I have known these things, but have found them unenforceable because patients' suffering is a constant, unimaginably strong force.  And it beats up against the barriers each individual clinician puts up to safeguard her own mental health and resources.  In the Canadian mental health care system, for the sake of accessibility, no one will do this for you.

I have been burnt out or on the verge of burn out many times, and I am constantly redefining my own boundaries of who I can take on and what I can offer.  I will be honest that there are times this job is not rewarding to me, where what I can and want to offer, that what I am trained to offer is not what people want or need.  I will be honest with how this depletes me.  It is like being a finely trained back surgeon, when patients only want or need an undetermined number of backrubs.  Why is this so?  Because in the Canadian system, a finely trained back surgeon is "free" (i.e. publicly funded) and people giving backrubs are not, charging anywhere between $50-$200/hour.

This essay has been a work in progress for many years and this version has been the most coherent of all my previous attempts, which is why I am posting this today.  It has been what my mind has been working through for quite some time, but the thoughts here may change.  I believed I knew this profession when I entered into it 8 years ago, and boy, was I wrong about that.  Who is to know what I have wrong now that will come to light over the years.  I am clearly a work in progress as a psychiatrist and therapist.  I know better than to shy away from this fact.