“Contain their pain” was somewhat of a mantra I learned to embrace during my training as a psychiatrist. In psychodynamic theory, it is the concept of the healer being a “container,” one who holds the patient’s anguish, makes sense of it, and ideally returns to them something more digestible and tolerable. This is why I love psychiatry, what I believe makes our specialty special. The stories of my patients are more than a checklist of symptoms. Prescribing or adjusting medication was something I felt to be complementary to this process, not my sole purpose.
Over the years, this valuable skill of ours has weakened due to the rising demand for services, high costs, and diminishing reimbursement rates. Care is delivered in siloed spaces and a system that favors a busy schedule in the fee-for-service model, pressuring us to rely on reductionistic interventions, calling us “prescribers.” The end result for an outpatient clinician is a caseload that is heavily skewed toward “established” patients who still have to wait weeks or sometimes longer for help or guidance if they are facing a new or recurring challenge.
Waiting this long leads to mental health crises and utilization of high-cost interventions. For the psychiatric clinician, this compromises their own mental wellness to squeeze these sick patients in during the little break time they have. What happens when that clinician gets stressed, burned out, takes time off, or leaves?
Who will be the container?
It is not sustainable for someone’s mental health to be managed by one professional. Not for the clinician and not for the patient. It also leads to very few checks and balances with how the clinician is practicing. I know I can get comfortable, even complacent at times because of a packed schedule — not changing out my toolbox for new ideas, or missing something because I was recycling the same questions and interventions in an effort to stay efficient.
We have seen some healthcare systems offer the solution to this dilemma in the collaborative care model. It is a team consisting of a PCP, a social worker, and a psychiatric expert with whom the social worker reviews the panel of patients. This allows the psychiatrist to “see” a handful of patients in much less time. It is a consultation model that provides efficiency and expertise, but not perhaps the containment that is often the intangible healing source for patients. Something that is not exactly measurable, but may explain why we call patients “treatment-resistant,” or “difficult,” or “too complex.”
Mental illness is never simple, and mental wellness is a lifelong journey. But a large majority of patients may not become “complex” if they don’t have to wait months to meet their always and forever psychiatric healer.
At my organization, we’ve seen this work in psychotherapy, in a model we adopted from other healthcare systems called the behavioral health consultant. A patient can see a therapist right away for a few visits. Many do not get referred after that to longer-term therapy. Their challenges are contained, sorted through, and handed back to them, empowering them to be the experts of their mental health journey. There will, however, always be patients with complexities who would benefit from establishing with a therapist for a longer period of time. In those cases, the consultant serves as a bridge to a therapist offering longer-term care.
Why could we not do that with psychiatry?
What if a patient who needs a psychiatric evaluation could see an expert the very next day? Instead of the typical approach of PCPs, which is telling their patient they have to wait weeks, maybe months for an evaluation? Consider for example R, a 19-year-old college student with a history of moderate anxiety well-controlled with therapy and medication who suffers a drug-induced psychotic break, seen in the ED where his symptoms clear, but then discharged to follow up with “your regular doctor.” He’s given an appointment with a rapid access psychiatric clinician who listens to his story, collaborates on a plan that includes medication, and follows up with primary care. What if he decompensates? He can return instantly to the psychiatric clinician who decides his situation is growing complex and bridges him with appointments until he can see a traditional long-term psychiatrist. After 18 months of stabilization, he returns to follow up with primary care, but knows at any stage of his mental health journey he has a team now that he can readily access, who all know his story.
Does this undermine the motivation of those who specialize in mental healthcare? Don’t we want to form long-term relationships? Isn’t that part of the healing? I will admit, I get immense satisfaction from this, from the gratitude of patients and families who say after years of working together, “What would we do without you?” But it also gnaws at me, that maybe this creates a problem for a subset of patients. Maybe an unhealthy dependence on one clinician. For those with complex challenges, wouldn’t it be better if it was, “What would I do without my team?”
Healthcare is changing and becoming financially unsustainable. We must pivot our culture and beliefs to one of “we” instead of “me,” and hopefully reimbursement will start to reward these new collaborative models that demonstrate improved outcomes, rather than pay a clinician for simply completing a visit or a procedure. They will reward the healthcare system and the clinicians for quality and outcomes instead.
