Part I. You’re Going to Miss Us When We’re Gone
Picture a ragtag army, assembled in the middle of the night, holding torches and pitchforks, except they’re all kinds of short and thin, bearded, bald, and bespectacled. Now take these guys and put them in little offices across the country, gives them pens and pads and telephones, computers and paper files both, and that’s your army, brothers and sisters.
We’re your defense, your front lines, but we’re undermanned and unsupported. You’ve ignored and neglected us, undermined us, even abused us. You don’t know who we are or what we are do. And you’re about to lose us.
It’s not more security that is going to protect our children from the results of how we treat our more vulnerable members.
It’s not “close the barn door after the cow is gone” gun control that is going to slow this ever increasing and nowhere-near-yet-peaked tide of seemingly inexplicable violence.
You’re going to miss us when we’re gone.
Who are we?
We are the prescriber‑therapists, less than fifteen thousand of us nationwide. We are the guys who became psychiatrists in the 1970's and 1980's, who grew up in the 1960's, guys who expected to spend their lives talking to people and knowing them well, to give pills but also to provide therapy of all sorts. By and large, despite obstacles too legion and tedious to mention, we continue to do so. Sixty percent of us still take at least some insurance.
There’s nowhere near enough of us. Also, sixty percent of us are over 55. The number of psychiatrists has increased at only half the rate of other physicians over the past forty years. We’ve been holding back the tide of alienated madness, but very soon we are going to be retiring in droves, and there’s no one behind us.
Why do you need us?
One might better ask “What are the circumstances that produce insane murderous rage, and how can it be prevented?
To wit, here is a recipe for insane murderous rage:
Take neuro-physiological differences: Learning disabilities, Attention Deficit Disorders, Autism Spectrum Disorders, Tourette’s,…even just very high intelligence. Add inherited Obsessive Depressions: serotonin-seasonal or bipolar (better thought of, actually, as multi-polar). Then, mix in any combination of:
- Unenlightened parenting
- Poor social skills
- Social isolation, ostracism, bullying
Now add: acquired post-traumatic depressions; sleeplessness, panic attacks, chronic tension; pleasurelessness and listlessness.
Allow to percolate from isolated, part of something during high school to isolated, part of nothing in young adulthood.
The result? Obsessive Rageful Tortured Alienated Madness.
Give an obsessive, rageful, tortured, alienated madman an assault rifle and a huge magazine, and now you begin to understand.
Who can help such a person?
Not a prescriber who does not know his patient, who sees him for five minutes every other month.
Not a therapist who can’t influence the most disturbing symptoms even if they did understand the layered interaction of diagnoses that explain psychotic affective disorders.
Only a prescriber‑therapist can form the kind of ongoing relationship over many years that is the only possible antidote to psychotically violent behavior. An unhappy person with complicated multiple illnesses simply will not trust or talk to a prescriber who does not also help him with all the other issues that impinge upon his life, who has no time or interest to explain — yes, to explain — what is happening to this often quite intelligent but usually condescended-to individual. Therapists come in many varieties — very few have insight into how ongoing medication treatment should influence therapy when the patient has underlying Asperger’s or ADHD as well as several different types of affective disorders. Insight-oriented exploratory therapy without accurate diagnoses, accurate medication and adequate psycho-education is generally useless for such complicated patients. Therapy needs to be directive, pragmatic, problem-solving and integrated with varying symptom patterns.
Only prescriber‑therapists can do that, but we’re a dying breed.
Skip the dramatic presentation and what I am really proposing is that the surge in psychotic gun violence in America is the unintended consequence of the relatively recent (25 years or so) financially-motivated Balkanization of mental health care.
When health insurance companies and medical schools and the government got together and decided that it was more efficient for social workers and psychologists to provide most therapy, no matter how sick or complicated the patient, they had no intention of unleashing a tide of blood on our nation’s youth.
When organized psychiatry sold itself cheaply to drug and insurance companies, and allowed these profit-driven non-professionals to define the nature of our work and the way we are paid, no one predicted that several generations of young physicians would routinely choose other specialties.
When regulators of all stripes demanded more and more written justification for every visit, when fees are lower today than 25 years ago, when major players in the insurance world treat their panelists as adversaries; even then no one asked whether anyone would be left to care for the most troubled of us, for those with multiple complex conditions, who would know these people, really know them, enough to alter the otherwise all too frequently bloody outcome.
You’re going to miss us when we are gone.