“Psychiatry in Trouble”—Can It Be Fixed?

Many readers of “Mr. Analysand” know that mental health is a family business among my relatives. While I was perfectly happy to live purely on the client side, many of my kin have dedicated their professions to the human psyche.

This includes my Uncle Jim, who—I think I can be objective here—has led a very distinguished career in the field. Known to his colleagues as James C. Beck, M.D., Ph.D., he is a professor of psychiatry at Harvard Medical School, and a senior psychiatrist in the Cambridge Health Alliance Psychiatry department.

Our family ties are a deep connection. That’s a factor in the ease I’ve always felt with the idea of therapy—always knowing Jim helped smooth the way for my ongoing adventures with Ms. Analyst.

Beck recently carried out an important mission by publishing his book, Psychiatry in Trouble: Narrative from a Damaged Profession. He grapples here with psychiatry’s current trajectory, drifting far from its roots in compassionate care to become doctors who are now depressingly disconnected from patients. He sees overprescribing of medication running rampant and covers several other tough topics. The book also includes a practical guide for people seeking professional help.

There is an important accompaniment to Jim’s perspective on psychiatry. He provides extensive personal background for much of the book, giving readers rich detail on the long path to becoming a psychiatrist. He shares his experiences of success and failure along the way, both personal and professional.

Over the decades, psychiatry became a beloved occupation for Beck. But he also saw it change profoundly, right before his eyes. Some shifts represent much-needed progress, but others are painful setbacks.

Psychiatry in Trouble is essential for anyone who wants to understand modern psychiatry. Personally, I realized my uncle’s book was an opportunity to do something I’d never done before—as you’ll see in our Q&A.

Jim, out of the thousands of articles I’ve done in my writing career, how do you feel about being the first family member I’ve ever interviewed?

This is the first time I have been interviewed by a family member since I was a child. When my mother interviewed me, it was usually because I had done something wrong or that she disapproved of. So I am delighted to be interviewed around something I am proud of or pleased that I have done, rather than about something I might have preferred that would just go away.

I’m glad I could help with that! Why was it important to you to write Psychiatry in Trouble?

It was important to me to write a book for two reasons.

The main reason is because I think something terrible has happened to psychiatry and I wanted to tell that story. When I trained, we were taught to listen to our patients, much as all good psychotherapists do.

We also learned how to use medicine for those patients who needed it, which is by no means the large number of patients for whom psychiatrists prescribe today.

Psychiatric practice focuses on prescribing; psychiatrists have become primarily pushers of pills. Today, psychiatry training focuses on medicine. Like Jacob’s brother Esau in the Old Testament, “We have sold our birthright for a mess of pottage,” and it doesn’t feel good.

The second reason I wrote the book is to describe my extensive experience evaluating women who have had sex with their psychiatrist or other therapist. This is a very bad story. I did not think anyone else would tell it, so that story is in the book.

How would you characterize the main message of your book?

The answer today is not the answer I thought it was when I wrote the book. Then, I thought the main message was what had happened to psychiatry. Now, I think the main message is a more practical one.

People need to know more about mental health providers than they usually do and reading this book will provide that information. Not just the difference between a psychiatrist and a psychologist, but what questions to ask in order to find out what you can expect from a particular provider.

What are the common types of psychotherapy? What should you look for in a psychotherapist? What can you expect from an antidepressant? Even if you are depressed, how likely is it that medicine will help?

What makes this message particularly urgent in 2021?

This message is particularly urgent now because many people have suffered with severe anxiety and depression as a result of the COVID pandemic. These people need to know what to look for, because they do need help.

I want to ask you about the journey you take the reader on. You could have merely presented your extensive credentials and gotten quickly to your main points about modern psychiatry. Instead, you describe your years of training and professional growth in great detail. Why did you feel this was important?

The truth is that initially I did not feel it was important. People with whom I discuss the book, especially my editor, Betsy Haggerty, told me that no one would be interested unless the book was also about a person. The person I know best is myself so that is where I started, and I came to believe that Betsy was right.

The quote from Joan Didion in the introduction captures the important point when she says that before we can believe a story, we must know something about the person who wrote it. She is right. Just knowing that I have professional degrees is not enough reason to believe what I say or trust my opinions. So, I wrote enough about myself so that the reader could have some idea who they were dealing with.

And of course it was extremely fascinating for me to learn so much more about your life, as well as our shared family! What were some interesting personal revelations you had in the process of recounting your personal story? How did writing the book give you fresh perspective on your professional and personal life?

The most important personal revelation is how important it has been in my professional life to practice what I have tried to convey here, about what psychiatry has been and what it could be again.

I saw with great clarity how important it has been for me to teach these values, and this approach to patient care and the work we do, to young physicians and other mental health trainees and students.

While psychiatrists today seem to be more valued for their ability to prescribe medication, your experience as a therapist and empathic listener are clearly very important to you. What makes this aspect of your experience special?

This is important because listening is what connects me with another person so I can share their experience. And when the person with whom I am connecting is suffering, and through this connection I am able to ameliorate their suffering and hopefully also to improve their lives, this has given my life a large part of its meaning.

One of the surprising tenets of Psychiatry in Trouble is that the DSM (Diagnostic and Statistical Manual of Mental Disorders) can be problematic for patient care. How would you explain the DSM to the layperson? Why is it often hurting, not helping, patient outcomes?

The psychiatrists who developed DSM in the late 1970s had high expectations that it would improve psychiatric practice by making our diagnoses more accurate, and in that it was successful.

An unintended consequence was that insurance companies used a DSM diagnosis as the only basis on which they would pay for psychiatric services. DSM diagnoses are based entirely on signs and symptoms, not at all on any information about the patient as a person or her history. In that way, DSM has been a disaster.

The multibillion-dollar pharmaceutical antidepressant industry is a major area where you call for change. You call attention to the complicity between psychiatry and drug companies in overprescribing. Do patients have any way of knowing when they’re on the wrong end of this? How can we empower ourselves as patients right now?

This is a good question and a hard one to answer. Honestly, I think the answer is that it requires work.

The book includes a discussion of self-assessment of anxiety and depression that a person can use to get some idea of whether they have a problem for which medicine may be appropriate.

Secondly, discussing with the physician who prescribed this what to look for; as evidence that the medicine is helping, how long should it take, what are the risks and possible bad consequences, and do I think the risks are worth the potential benefits?

There is a lot of good information available on the Internet and time spent reading it is time well spent, in my opinion.

Speaking of patient empowerment, you include an appendix “Seeking Professional Help.” Why did you want to include this guide?

Just what psychotherapy is, how does it work, how will you know if it's working, and what to look for in a good therapist, all can be mysterious for people outside the mental health professions. I have tried to write a down-to-earth practical guide to these questions.

I appreciated that while you express many concerns about psychiatry, you also present a road map for improving it. Does the current sociopolitical climate make you optimistic that we can get there soon?

I am not optimistic that change will occur. First, change is always hard.

Second, for most psychiatrists in practice today current practice is all they know, so they don’t really know what they’re missing.

Third, powerful forces against change exist: the pharmaceutical and insurance industries would oppose change. Current practice works just fine for them. They will fight the kind of changes I propose.

I’m so glad we got to do this interview—a family first for both of us! Here’s my last question: What do you hope that Psychiatry in Trouble will show people about psychiatry that they maybe weren’t aware of before?

Some few people may have had experience with psychiatrists who practice in the way that my book describes and endorses. I hope that reading this book will let other people know that this kind of psychiatric practice exists. There are psychiatrists who believe in and practice it.

—Mr. Analysand