I don’t much understand the way much of Psychiatry is practiced today. Somewhere around the time that managed care began to transform the field of medicine, an artificial schism between the brain and the mind seemed to emerge: the role of psychiatrist seemed to be arbitrarily compressed into one of pharmacologist alone; psychotherapy became the domain of the non-MD clinician. The construct of “split-treatment” was born from this division. Patients would see the Psychiatrist for medication and a psychologist, social worker, or counselor for any necessary therapy. Hopefully, some communication between the two treating parties would yield some semblance of a unified therapeutic approach. In ways I still cannot comprehend, Psychiatrists were supposed to know how to intelligently prescribe medications without necessarily understanding the assorted factors that contributed to how this particular human was developing these particular symptoms. How these symptoms manifest; what they represented to the individual; what factors drove their presentation -- all of these were deemed less relevant to the decisions of what and when to prescribe.

I graduated medical school just as this fissure in the field was emerging. Managed Care Organizations seemed to have decided that Depression and Anxiety were to be treated as illness states that required no more personalization of care than the treatment of Hypertension or Diabetes. The field of Psychiatry shifted to a model in which every psychiatric symptom could be traced to a faulty synapse or imbalanced neurotransmitter. Colleagues would joke about conceptualizing Depression as a “Prozac-Deficiency Syndrome.” Advances in Neuroscience seemed to foster an increasingly reductionistic approach to psychiatric care. When I started medical school, this was not how I envisioned my role as a healer. By the end of my residency training, I was determined not to allow myself to buy into a “damaged-care” model that seemed to be the antithesis of a holistic understanding of illness and wellness.

I began my private practice with a commitment to seeing each of my patients for some level of individual therapy. If I was to prescribe medication, I needed to know the human beneath the Serotonin. If I didn’t take the time to listen to the narrative, how would I possibly understand the significance of the symptoms? I realized that as I came to understand each patient’s journey, I also discovered symbolism, significance, and paths to healing. Over time, I also found that -- probably for a collection of reasons -- medications prescribed seem to work more effectively in the context of relationship. When the patient feels understood, there is an openness to healing that might otherwise have been obstructed.

As I explored different forms of psychotherapy and pharmacotherapy, I continued to sense that the most key ingredient in any given therapeutic approach was one of relationship. It is here that the patient and the clinician meet, join, and eventually trust. It is here that a shared journey towards healing begins. Almost irrespective of the specific tools I bring along, it is a sincere willingness to be present with my patient in their challenges that allows for trust to emerge. Relationship, I decided, was the most effective medium through which medication, psychotherapy, empathy, and understanding could be delivered. It was with this mindset that I sought to design a clinical practice that supported just that.

eric fier, md