It’s Really Easy to be a Bad Psychiatrist
A rundown of how not to treat people with mental illness.
I’ve had three psychiatrists in my life, plus my current nurse practitioner. My NP is amazing, and I’m really glad I have her. The last two psychiatrists…not so much.
Let’s start from the beginning, though. When I was first diagnosed at age 12, my parents took me to see a man by the name of Dr. Byrd. He was a child psychiatrist in the 90s, which was an up-and-coming time to be a child psychiatrist.
I haven’t seen him in years, but I vaguely remember him looking a bit like Dr. Phil. Bald, push-broom mustache, deep voice, slight southern accent, kinda chubby face. Fairly endearing to 12-year-old me.
He would go on to be my doctor through my early 20s, staying with me for over a decade. He watched me grow from an unstable pre-teen to a stable, successful adult. He’s the one that told me that originally, they weren’t sure I’d be able to function in modern society without the supervision of my parents.
I left Dr. Byrd because he was nearing retirement and stopped taking my insurance. Even though I only saw him every three months, it was still $125 a session, which hurts when you’re starting your career.
I was recommended a psychiatrist by my (now) mother-in-law. The new doctor was an older, middle-eastern woman. She was very endearing and motherly, and also horrible at her job.
I would schedule my appointments in the morning so I could go in before work. Often, I would arrive for a 9:30 appointment to discover that she hadn’t arrived at the office yet. When she rolled in at 10, she had to see the three or four people who had appointments ahead of me.
When my turn came, I was usually allocated five minutes. It typically went that we’d have a bit of small talk, she’d ask if my meds were okay, then she’d refill my scripts without another word and send me on my way. I came to feel like the time-saver patient: when she was behind, I’d save her time by being easy and quick.
I didn’t care for that. Still, I stayed with her because finding a psychiatrist is hard. There’s not a lot of them, and many don’t take new clients.
Even so, she eventually retired and moved offices to an inconvenient location for me, so I was forced to. She was part of a group of psychiatrists, so they just funneled me to another one in the group. He was just as bad as she was.
When I went into his office for the first time, I told him that I didn’t want to be an easy, time-saving patient for him. I wanted his full attention. He smiled and nodded agreement.
Within half a year, I was the time-saving patient again. He would ask me the same questions about myself and my family, as though he didn’t retain any information about me. Then, he’d fill my prescription and send me on my way.
At my last appointment with him, my wife timed it. I was in his office for under four minutes. That was enough of that. I got a recommendation from a friend for my current nurse practitioner, who works for a nonprofit group, and I haven’t looked back.
The thing that sparked the idea for this article was a story one of my coworkers told me earlier. My job is at a mental health nonprofit, and we have recently launched psychiatric services using nurse practitioners.
We are in a major metro, but adjacent to us is a mostly-rural county with horrible mental health problems. We started services there a few years ago with a grant, and are looking to expand our psychiatric offerings there too.
My boss, who has worked for our agency for quite a while, told a story about the local youth mental health nonprofit that operates in that county. It is well-known that their services are terrible, but they are one of the only games in town.
They have one psychiatrist that sees kids in the entire county, and he’s really bad at it. Apparently, he takes clients on a walk-in, first-come-first-served basis. Families stand in line to be seen, and maybe they will be seen. Maybe they won’t. It’s a gamble.
We all marveled at how horrible that is. Imagine taking the day off work, pulling your child out of school, spending all day waiting in line to see the doctor, and ultimately being told you can’t today. It’s awful.
However, because he’s pretty much the only nonprofit child psychiatrist seeing kids in the whole county, that’s how it goes. It’s a poor, rural county, so many of the folks that live there can’t afford to drive into the city to get services. This is especially true when it’s pushing two hours to get there from the far reaches of the county.
That’s part of the reason we’re expanding our services there. The need is great — a school district there that we recently started serving had five suicides in a year, which is why we are working with them. People often can’t afford or can’t get to treatment, drug and alcohol abuse are huge problems, and the suicide rate is high.
On top of that, the availability of psychiatric services is, as I said, nearly non-existent. In the urban and suburban counties to the north, there are a fair number of providers. Crossing the county line leads to a mental health treatment desert.
I’ve written a lot about the prevalence of mental health issues and suicide. About 20% of the population will experience a mental health issue at some point in their lives. We are becoming increasingly aware of it thanks to celebrity suicides such as Robin Williams, Kate Spade, and Anthony Bourdain.
The mental health care system needs to catch up. Many of the mental health agencies in our area are overwhelmed with clients seeking therapy. The crisis hotline at my job gets tens of thousands of calls a year, and we’re a smaller hotline. Emergency departments are overwhelmed with mental health crises.
While therapeutic services are doing fairly well at adjusting, psychiatric services are not. Psychiatrists are doctors, which means med school. Med school means lots of barriers to entry. We simply aren’t training enough psychiatrists to keep up with the growing demand for their services.
On top of that, they tend to congregate in the richer urban and suburban areas, where people have higher rates of insurance and can pay more for services. Some rural counties may only have a single psychiatrist; some have none.
These factors all contribute to crappy psychiatrists. They’re impersonal, they don’t remember you, they don’t spend much time with you, and they cycle you through their system like clockwork. It’s like getting your prescription from a grumpy machine.
On top of that, everyone hates the doctor, since a lot of doctors have a crappy bedside manner. Med school can do that to you. When med school leads to you seeing mentally unstable, suicidal, homicidal, and disturbed patients? It changes you.
Honestly, though? All of this is kind of by necessity. There is a lot of demand and not enough capacity, so a psychiatrist is often pleased to get an “easy” client like me. I take my meds and am mostly stable most of the time. I’m a low-risk, low-effort patient.
So, I get cycled through. The psychiatrist doesn’t need to know much about me because I’m stable. I’m employed, insured, and can pay on time. I only really need the appointment to fill my prescription, so small talk is kept to a minimum and real effort is dedicated to other clients who need it more. If I have any mental health issues, I can take it up with my therapist.
Unfortunately, when easy patients stop being easy, warning signs get missed, and people die. It’s a bit of a trope in pop culture: the dull, uneventful life of a mental patient is upended when they decide to quit taking their meds. By the time the doctor notices, it’s too late.
So what can we do to address this?
I have come to appreciate psychiatric nurse practitioners. They require similar training to psychiatrists without having to go through med school and are more affordable salary-wise for agencies that want to hire them.
I also find that nurses give “softer” care, as they are trained to deal with the person as a person, not as a patient. That said, they still give quality care, and their work is reviewed by a psychiatrist to ensure proper diagnosing and prescribing.
In my state, a nurse practitioner needs to have 10% of their work reviewed by a psychiatrist. This has led to one local agency to develop a “spokes” model that could be replicated elsewhere. Basically, one psychiatrist oversees five or six nurse practitioners while managing a reduced caseload. The one psychiatrist is, therefore, able to manage six people’s worth of clients, plus a few of their own.
I also think an investment in telehealth systems would be beneficial. Telehealth allows a psychiatrist to serve clients remotely over video chat. Prescriptions can already be transmitted electronically (I haven’t handled a physical prescription in over a year).
Telehealth will likely become a literal lifesaver for rural counties. As I mentioned, psychiatrists tend to congregate in urban and suburban centers. That often leaves rural counties with a very small number of mental health professionals per capita. Telehealth can help address that problem.
Technology companies are getting ahead of this already — several apps allow you to connect to a therapist whenever you want for a monthly fee. As long as the therapist or psychiatrist is licensed in the state that they’re serving, they can treat people there.
Telehealth can then be combined with mobile units that travel to where the patients are. The health department we partner with in the rural county has a medical bus that travels to some of the farther-flung towns to provide a la carte medical services. We have had some success placing our therapist on that bus to provide mental health services as well.
However, thanks to the magical power of the Internet, we may be able to provide therapeutic and psychiatric services to patients in rural, far-flung places without any physical presence there. This is especially helpful when the internet is dodgy in some of the smaller towns. Placing a mobile unit with an internet hotspot in a local church parking lot for a day can reach a lot of people.
Ultimately, like any profession, there are plenty of bad psychiatrists. Some are probably perfectly good but have to be bad by necessity. Sometimes, you can only allocate five minutes to a patient because you’re just that backlogged.
I try not to begrudge my past psychiatrists too much. They were doing the best with what they had, and I’ve been stable enough in my adult life that I generally warrant less attention than many.
That said, don’t be afraid to shop for a new psychiatrist if yours isn’t working for you. I encourage you to consider nurse practitioners, as they are incredibly qualified to do their jobs and may cost you less money overall.
Be strong, take your meds, be honest with your mental health professionals, and find doctors and therapists that work for and with you. You are not a quitter if you change therapists or psychiatrists — you are looking out for your own best interest.