Who’ll be Minding the Store? Mindfulness, Medication and the Lack of Prescriber-Therapists
If you are, as I am, a consumer of New York intellectual media, you’ll notice that as of late "Mindfulness" is everywhere. "Sixty Minutes" just did a long piece. The New York Times book review has yet another popular neuroscience book (Waking Dreaming Being by Evan Thompson). On the back of the book review, a full page ad for The Great Courses (.com of course) offers "The Science of Mindfulness" (only 59.99 on CD, 79.99 on DVD) which will "meld ancient wisdom with modern science".
But what about retail?
Well, that's me.
The spread of "mindfulness" is truly a wonderful thing, bringing with it as it does a general appreciation for the way in which various "practices" can craft and structure the brain. This "brain building" is used across the broadest possible range of endeavors, including both the healing of mental and physical illnesses as well as the promotion of health, well being and meaningful productivity.
"Mindfulness" is technically one of the thousands of forms of meditation, all of which can be subsumed under the larger term "esoteric practices." Every religion, every single one, has such practices, and in the broadest possible sense one might say that these practices are designed to further the integration of (the sloppily but generally referred to as) left and right brain.
It is certainly my belief that any and every therapist of all stripes should be a student of this material, and thus take the Great Course on Mindfulness. They should take this course, (or read the 18 books recommended in Bibliotherapy) because it is very definitely one of the two most powerful ways to influence/assist human beings. I believe that in the final analysis all effective psychotherapies work by somehow utilizing the brain’s inherent ability to change itself by what it pays attention to.
The other way is medication.
What saddens and frightens me about the mental health world is the utter lack of discussion, insight and preparation demonstrated by the fact that we are creating exactly zero professionals who are likely to be able to integrate these two powerful sets of tools. This is especially tragic because the need for such integration is so great, so pressing.
We live in a world where behavioral and emotional problems are proving themselves to be multi-layered. Attentional issues and challenges, empathic (autism spectrum) disorders, complex learning disabilities, social phobias and atypical depressions/bipolar illnesses have all proved themselves to exist on broad ranges, offering a number of different “looks,” or clinical pictures. These conditions are more often than not complicated by acquired depressions that affect arousal and energy levels.
Complicated individuals need to be addressed with appreciation of neurophysiological differences (ADD, Asperger’s, LD), inherited depressions (bipolar and serotonin), acquired depressions (arousal and motivations), and interpersonal and occupational adjustment. Then the treatment needs to be bolstered and continued by a judicious application of mindfulness and other esoteric practices.
Unfortunately our governmental medical and insurance institutions opted 25 years ago for the false economy of paying slightly less to therapists than doctors, and have spent all their time since this creating economic disincentives that have slowed the creation of prescriber therapists to a pace that makes crawling looking supersonic. This is a ridiculously wrongheaded policy. A prescriber-therapist can modulate the frequency of treatment like an accordion, increasing when needed, retrenching to monitoring when stable. Even if he's paid double the rate of any other therapist, he turns out to be cheaper by miles than “therapist only” practitioners who almost always see patients weekly or not at all, especially when they need to be combined with either GP's or “medication only” psychiatrists.
Not only is the care we deliver nowadays more expensive than it would be if medication and meditation were delivered by the same person, it is also far less likely to be effective. Neuro-plasticity-based therapies’ conversations and experiences, from mindfulness to affirmations to transference and back again, all work infinitely better in an intact nervous system. A therapist who cannot identify and then discuss and explicate the natural history of medication-responsive syndromes cannot be expected to treat them deftly, no matter how well those therapies are applied. A prescriber who spends very little time with and does not know his patients very well is unlikely, over his career, to properly understand how to insert needed therapies into conditions that are not stabilized adequately by medication alone.
We are at a unique moment in the history of neuroscience. We know more than we ever have, and we have more effective treatments than ever on both sides of the fence: better medication and more useful sorts of conversation. Our world is more stressful than ever, more digitized, more uncertain and more difficult to tolerate, let alone to thrive.
Even as the need is great, as we incarcerate our mentally ill instead of treating them, as we shovel our children in and out of special ed, as mental health care is routinely mandated by courts but rarely provided, as we hobble our social workers and psychologists with endless, meaningless paperwork and impractical obstructionist licensing protocols, we have yet to ask ourselves just what exactly it is we should be seeking in our mental health caregivers and how should we prepare them given what we know.
America lacks political will in general, and it’s sad to say it most certainly lacks the will to address, analyze and revamp the way it trains mental health practitioners and the way it delivers care.
We seem to lack the will to take care of ourselves. We do not seem to even be aware that a generation of young American physicians has chosen other careers; that we have left it to the foreign medical grads to provide our psychiatric care.
Please believe me when I tell you that there is not a single medical student in the United States who has his or her heart set on becoming an outpatient psychiatrist.
There is a great era of brain science coming around the corner somewhere, and the great need of the wired-up, drained population is already here. Until we as a nation decide to train fully empowered mental health workers who are paid well, treated well and able to use both mindfulness and medication skillfully, no matter how many classes and books and retreats we plan to teach mindfulness, soon there just won't be anybody minding the store.