Category: Blog

When you see a psychiatrist, you probably expect the evaluation to be about one thing: understanding what is happening to you and determining what, if anything, should be done about it. But there is another part of psychiatric care that patients may not see.

That is the role that health insurance can play in psychiatric diagnosis and treatment.

For many patients, insurance is simply a way to pay for medical care. But psychiatric care has a complicated relationship with insurance because reimbursement, documentation, and diagnosis are closely connected.
And that matters.

Psychiatry Has Had a Longstanding Parity Problem

For many years, mental healthcare has been treated differently from other areas of medicine by the American healthcare system. Federal mental-health parity laws now require many health plans to apply comparable financial requirements and treatment limitations to mental-health and medical/surgical benefits. Even so, patients and clinicians continue to encounter requirements involving authorization, medical necessity, networks, reimbursement, and other restrictions.

There is another issue that deserves attention: the role of diagnosis.

Consider what happens in other areas of medicine.

If a patient sees his or her PCP, and no problem is found, the PCP gets paid. If blood tests are done, and they’re normal, the doctor gets paid. If a woman has a yearly exam with Pap smear, and it’s normal, the doctor/gynecologist gets paid. If a patient has an X-ray, and it’s normal, the radiologist gets paid. If an appendix is removed, and it turns out not to be inflamed (there is no appendicitis), the surgeon gets paid. 

If a dermatologist does a biopsy, and it’s normal, the dermatologist gets paid. If a child has a yearly school exam, and the child is well (they’re called well child exams), the pediatrician gets paid. But if someone sees a psychiatrist, and expects to use medical insurance, the psychiatrist only gets paid if a diagnosis, of certain types, is made. So psychiatrists who expect to bill a patient’s insurance are forced to make diagnoses, even if there is no diagnosis.

The Problem With Psychiatric Diagnosis

When psychiatric services are submitted to insurance, diagnosis and documentation are generally part of the billing process. The diagnosis helps establish what condition is being treated and why the service is being billed.

That creates an important question:

What happens when a patient needs psychiatric evaluation or care, but the clinician does not believe that a particular psychiatric diagnosis accurately describes the patient? This is where, in my experience, the relationship between psychiatric diagnosis and insurance reimbursement becomes concerning.

Insurance requirements can create incentives around diagnosis that patients may never see.
A patient may leave a psychiatric appointment with a diagnostic label and assume that the psychiatrist arrived at that diagnosis simply because it was the most accurate description of the patient’s condition.

But the relationship between diagnosis and insurance is more complicated than that.
In my professional experience, I have seen circumstances in which psychiatric diagnoses do not adequately describe the person sitting in front of the psychiatrist. I believe patients should understand that a diagnostic label appearing in their medical record does not necessarily tell the whole story of what a psychiatrist believes is happening.

That does not mean that every psychiatric diagnosis is wrong, or that every psychiatrist allows insurance considerations to influence clinical decisions. It means that patients should understand that insurance reimbursement and clinical judgment are not always completely separate issues.

A Diagnosis Is Not the Same Thing as Understanding a Person

I also believe patients sometimes place too much importance on the diagnostic label itself.
A diagnosis can be very useful to a psychiatrist or other treating professional. It can help organize clinical thinking and guide treatment. But that does not necessarily mean that the diagnosis is the most important thing for the patient to know.

Psychiatric symptoms are complicated. The same symptom can have many possible explanations, and a person’s circumstances, history, relationships, physical health, experiences, and environment can all matter. A diagnostic word may summarize part of that picture, but it does not necessarily explain the person.

For that reason, I rarely consider it useful to give a patient a diagnostic label simply because a label exists. I am more interested in understanding what the patient is actually experiencing and determining what may help. There are circumstances in which knowing a diagnosis can help a patient understand the need for treatment or become more committed to addressing a problem. But the diagnosis itself should not become a substitute for understanding the person.

Insurance Can Also Affect Treatment

The influence of insurance does not necessarily stop with diagnosis.
Insurance plans can affect which medications are covered, whether prior authorization is required, whether a patient must try another treatment first, which providers are considered in-network, and what services the plan will reimburse.

As a result, there can sometimes be a difference between what a psychiatrist considers clinically appropriate and what an insurance plan readily covers.
That difference can matter.

If a treatment is changed because of insurance requirements, the patient may understandably assume that the new treatment was chosen solely because the psychiatrist believed it was the best choice. Patients may not always know what considerations entered into that decision.

Why I Do Not Accept Insurance

These concerns are among the reasons I do not accept insurance. I have chosen to keep my fee low so that I can remain accessible to patients without making insurance reimbursement part of the clinical relationship.

For me, this allows the focus to remain where I believe it belongs: on the patient. I want to be able to evaluate the person in front of me, consider the circumstances surrounding that person, and determine what I believe is appropriate without making an insurance company’s reimbursement requirements part of that decision.

This does not mean that insurance is inherently bad or that every insurance-covered psychiatric treatment is inappropriate. It means that I believe there is value in keeping the clinical relationship as independent as possible from the financial requirements of an insurance system.

What Should Patients Ask?

If you receive a psychiatric diagnosis, you have every right to understand why it was given.
You can ask:

• What led you to this diagnosis?
• What symptoms or circumstances support it?
• Were other explanations considered?
• What purpose does this diagnosis serve in my treatment?
• What treatment are you recommending, and why?
• Are there other reasonable treatment options?
• Did insurance requirements influence any part of my evaluation?
• Did insurance requirements influence my diagnosis?
• Did insurance requirements influence the treatment being recommended?
• Are there insurance requirements that affect what treatments are available to me?

You can also ask your insurance company what your plan covers and what requirements apply.
Most importantly, remember that a diagnosis is a clinical tool, not a complete description of who you are.
And insurance coverage is not the same thing as clinical judgment.
The two can overlap, and patients deserve to understand when they do.

The Goal Is Appropriate Care

Psychiatric care should begin with the person, not with a billing code. The goal should be to understand what the patient is experiencing, consider the possible explanations, and determine what approach is appropriate.

Insurance can be an important resource for patients. But patients should also understand that the requirements of an insurance system can become part of the environment in which psychiatric diagnoses and treatments are made.

That is why I believe patients should ask questions, understand their options, and remember that the most important issue is not simply “What is my diagnosis?”

It is:

“Do we understand what is happening to me, and are we addressing it appropriately?”

Your child seems different lately. Maybe they’re more irritable, sleeping oddly, pulling away from friends, or struggling in school in a way they weren’t a few months ago. You find yourself wondering: is this just a phase, or should I be worried?

Almost every parent asks this question at some point. Children are constantly changing — their moods, their friendships, their sleep, their attention, their grades. Growing up is not a smooth, steady line. It has ups and downs.

That means an occasional rough patch does not automatically mean your child has a mental health disorder. But it also doesn’t mean you should ignore what you’re noticing. This guide walks through what’s typically normal for kids and teens, what signs deserve a closer look, and how to know when it might help to talk with a professional.

What Counts as “Normal” for Children?

Kids don’t develop in a straight line. Emotional ups and downs are part of how children grow, especially as they move through different stages of development.

A few things that are usually a normal part of childhood and adolescence:

1. Mood swings, especially around big transitions (a new school year, puberty, a move)
2. Occasional irritability or pushing back against rules
3. Wanting more privacy or independence as they get older
4. Short-lived changes in sleep or appetite around a stressful event
5. Temporary friendship conflicts or a shift in who they hang out with
6. A dip in grades after a hard test, a busy season, or a change at home

Context matters a lot here. A child going through a parental divorce, a move, a new sibling, or a tough friendship breakup may act differently for a while — and that’s a reasonable response to a real life event, not necessarily a sign of a psychiatric condition.

The key word is temporary. Most everyday behavior changes ease up on their own within a few weeks, once the child adjusts or the stressful situation resolves.

When Should Parents Pay Closer Attention?

Some changes deserve a closer look — not because they automatically mean something is seriously wrong, but because they’re less likely to simply resolve on their own.

Generally, it’s worth paying more attention when a change is:

• Persistent — lasting several weeks or longer, not just a few bad days
• Severe — noticeably more intense than the child’s usual ups and downs
• Getting worse over time rather than improving
• Showing up in more than one area of life — for example, at home and at school
• Interfering with daily functioning — sleep, eating, friendships, schoolwork, or family life

A single hard week rarely needs a professional evaluation. A pattern that keeps repeating, or keeps getting worse, is a different story.

Emotional and Behavioral Signs Worth Noticing

These are examples parents sometimes ask about. None of them, on their own, point to a specific diagnosis — they can have many different causes, from a stressful event to a sleep problem to an underlying mental health condition. What matters is whether the pattern is persistent, out of character for your child, and affecting their daily life.

1. Sadness that lingers for weeks rather than days
2. Worry or fear that seems excessive or hard for the child to control
3. Irritability or anger that feels much more intense than usual
4. Pulling away from friends, family, or activities they used to enjoy
5. A noticeable, lasting change in typical behavior or personality
6. Ongoing trouble concentrating, beyond typical distractibility
7. Sleeping much more or much less than usual
8. Eating noticeably more or less, or changes in weight
9. A real drop in school performance that continues over time
10. Losing interest in hobbies or activities they once looked forward to
11. Frequent emotional outbursts that seem hard for the child to manage

Seeing one or two of these occasionally is common. What’s more meaningful is when several of them show up together, or when they don’t let up over time.

Changes at School

School is often where parents first notice something is off, simply because it’s structured and easy to compare to past performance.

It’s worth paying attention to:

1. A meaningful drop in grades, not just one lower test score
2. New difficulty focusing or completing classwork
3. Behavior problems in the classroom that weren’t there before
4. Conflict with teachers or a sudden change in relationships with classmates

School struggles don’t always point to a mental health concern. They can reflect a learning difference, a social issue, a family change at home, or simply a harder curriculum this year. Still, when school difficulties are new, ongoing, and paired with emotional or behavioral changes, it’s a reasonable reason to look closer

Social Changes Worth Watching

Friendships shift constantly during childhood and adolescence — that alone isn’t a red flag. Kids naturally outgrow some friendships and form new ones as their interests change.

What’s more worth noting is a pattern of withdrawal: a child who used to enjoy time with friends and now consistently avoids social situations, seems isolated, or has stopped trying to connect with peers altogether. That kind of ongoing pullback — especially alongside changes in mood or sleep — is different from a normal shift in a friend group.

How Parents Can Support Their Child

You don’t need special training to be genuinely helpful here. Some of the most useful things parents can do are simple and ongoing:

• Listen without jumping to judgment. Let your child finish explaining before offering solutions or corrections.
• Ask open-ended questions. “What was that like for you?” tends to open a conversation more than “Are you okay?”
• Keep routines steady. Regular mealtimes, bedtimes, and family rituals give kids a sense of stability during unsettled periods.
• Support healthy sleep. Sleep affects mood, focus, and behavior more than most parents realize.
• Stay connected to school. A quick check-in with a teacher can offer perspective you don’t get at home.
• Build in one-on-one time, even briefly, so your child has a low-pressure opening to talk.
• Watch for patterns, not single moments. One bad day tells you very little. A repeated pattern tells you a lot more.

None of this replaces professional care when it’s needed — but a supportive, steady home environment makes a real difference either way.

When Should a Parent Consider Professional Help?

If you’ve been noticing a pattern that’s persistent, affecting more than one area of your child’s life, or simply doesn’t feel like your child anymore, it’s reasonable to talk with a qualified children’s mental health professional.

This doesn’t mean something is necessarily seriously wrong. A child mental health evaluation is often more about understanding what’s happening than confirming a diagnosis. Sometimes it brings reassurance that your child’s experience falls within a normal range. Other times, it identifies something that would benefit from support — and catching that early tends to make things easier, not harder.

You also don’t need to have it all figured out before reaching out. You don’t need to know whether it’s anxiety, ADHD, depression, or something else. That’s part of what an evaluation is for.

If you’re in the Biscayne Park or greater Miami area and have a genuine concern about your child, Dr. Alfred G. Jonas, MD offers child psychiatry evaluations designed to help families understand what’s going on — without assuming the worst before you’ve even had a conversation.

Frequently Asked Questions

How do I know if my child’s behavior is normal?

Most behavior changes tied to a specific event — a move, a friendship conflict, a stressful week — and that ease up within a few weeks are considered typical. Behaviour that’s persistent, intensifying, or affecting several areas of life is more worth a closer look.

When should I worry about my child’s mental health?

Consider paying closer attention when changes last several weeks, feel out of character for your child, or interfere with school, friendships, sleep, or family life. A single difficult day or week is rarely cause for concern on its own.
Not necessarily. Parents do not need to diagnose their children. If something feels meaningfully different or concerning, or a trusted adult such as a teacher raises a serious concern, professional guidance can help provide perspective.

What are common signs of emotional difficulties in children?

excessive worry, ongoing irritability, withdrawal from friends or activities, trouble concentrating, and changes in sleep or appetite are commonly discussed examples. These signs can have several possible causes and are best understood in context.

Can stress affect a child’s behavior?

Yes. Stressful events — a family change, academic pressure, a friendship issue — can temporarily affect a child’s mood, sleep, appetite, and behavior. This is a normal response and usually improves as the child adjusts or the situation resolves.

When should a child see a mental health professional?

When changes are persistent, severe, or interfere with daily functioning at home or school, it’s reasonable to consult a children’s mental health professional for an evaluation and guidance.

Can school problems be related to mental health?

Sometimes. A drop in grades or new classroom difficulties can reflect an emotional or behavioral concern, but they can also stem from a learning difference, a social issue, or other factors. A thoughtful evaluation considers the full picture.

How can parents support a child’s emotional well-being?

Consistent routines, open and non-judgmental conversations, healthy sleep habits, staying involved with school, and paying attention to patterns rather than isolated incidents all support a child’s emotional health.

Does seeking professional help mean something is seriously wrong with my child?

Not necessarily. An evaluation is often about gaining clarity and understanding, not confirming a serious problem. It can provide reassurance just as often as it identifies a concern worth addressing.

The Bottom Line

Children change constantly — that’s part of growing up, not a warning sign by itself. The goal isn’t to scan your child’s every mood for red flags. It’s to notice real, persistent patterns and take them seriously when they appear.

If something about your child’s behavior, mood, or daily functioning genuinely concerns you and isn’t improving, you don’t have to figure it out alone. A conversation with a qualified children’s mental health professional can help you understand what’s happening and what, if anything, comes next.

The job of the children is to become Capable and independent including independence of their parents.  The job of parents is to permit and even encourage their children to become capable and  Independent including independent of them (parents) 

If on the day that offspring  are mourners  at their parents’  funerals  they panic because they don’t know what to do without their parents, then everybody fails. Offspring will become independent people they might and might not take after their parents and they will create their own lives. Parents will watch their offspring  make mistakes. They will tell themselves they would not make it. They will watch their offspring  make mistakes that the parents already made. Offspring will learn a lot more  from making mistakes than they will from having their parents tell them not to make mistakes. Parents need to learn to bite their tongues.

 An essential part of growing up for children, and especially for adolescents,  is separating from their parents.  Sometimes this is messy,  and sometimes it seems more controlled.  Parents should watch, and not automatically  assume that separation  is a sign of a problem.  The bigger problem is the offspring who do not create independence from parents.

A friend is worried about someone. A family member says a relative seems different. The person has pulled away from everyone. Ignoring the signs is not an option anymore. That is why more people are scheduling a psychiatric consultation.

The idea sounds simple. Talk to a doctor about mental health. But when people start searching, things get confusing. One website talks about medication. Another talks about therapy. Another says to just wait. Meanwhile, the person keeps struggling.

What Is a Psychiatric Consultation?

Think about going to the doctor for physical stuff. A cough that just won’t go away. A pain in your back. A fever that keeps coming back. Mental health works the exact same way.

A psychiatric consultation is just a visit to a medical doctor who specializes in mental health. You talk about what you’re going through. The doctor listens — no judgment, no rush. And together, you figure out what’s really going on.

That’s why more and more people are paying attention to it.

Why Are People Finally Seeking Help?

Mental health struggles used to stay hidden. Mental health struggles were often kept hidden, support was rarely sought, and countless individuals endured their pain in silence for years.

That has changed. People admit they feel overwhelmed. People talk about their anxiety. Families discuss mental health openly. Workplaces now offer support. A psychiatric consultation fits how people approach health today.

People seek help because they want relief from constant sadness. Many people hope for better sleep, increased energy, healthier relationships, reduced stress, and, above all, the chance to feel better every day.

1. Start With One Simple Question

How long has this been going on? Many people skip this step. Feeling down for a few days usually passes. Feeling down for weeks suggests something different. A psychiatric consultation works best when someone stops delaying.

Many people put off help because they think things will improve. Weeks later symptoms have worsened. Paying attention to warning signs matters.

2. Do Not Ignore the Signs

People push through the pain. Behind a smile, they continue working, fulfill everyday responsibilities, and hide the fact that they are quietly struggling.

The question is not what can I handle. The question is what signs should I pay attention to.

Persistent sadness, sleepless nights, withdrawing from loved ones, and difficulty concentrating can all be signs that professional mental health support may be needed. Signs you need a psychiatrist include persistent sadness that will not lift. Excessive worry that takes over everything. Sleep problems that never fix themselves. Social withdrawal from friends and family. Difficulty with daily tasks. Using substances to cope. Unexplained physical symptoms. And most urgently, thoughts of self-harm.

If someone experiences these signs regularly, they matter. If symptoms persist week after week, professional help becomes necessary.

3. Think About Your Typical Day

Morning comes and waking up feels exhausting. Work feels overwhelming. Conversations feel draining. Simple tasks feel impossible. Instead of pushing through alone, a psychiatric consultation could change everything. A person talks to someone who understands. A doctor listens without judgment.

A treatment plan develops based on individual needs. That is where modern mental health care makes a difference.

4. How Long Has This Been Going On?

Nobody likes talking about how long they have struggled. But it matters. Lingering symptoms mean persistent sadness that will not go away. Constant worry that never stops. Disrupted sleep every night. Strained relationships with everyone close to them.

Before choosing a psychiatric consultation, check how long symptoms have lasted. Even the best self-care cannot fix problems that require professional help.

5. When Should You Stop Waiting?

Years ago people avoided mental health care. Stigma kept them away. Fear stopped them from reaching out. They did not know what to expect.

Today many people book an appointment. The psychiatrist talks with them. The person shares their struggles. Help finally begins. A psychiatrist appointment removes uncertainty and fear. Less waiting means less suffering.

6. What Happens When You Keep Waiting?

Things do not improve on their own. The sadness gets deeper. The worry grows stronger. Relationships suffer more. Work becomes harder. Symptoms continue to worsen.

This is why timing matters. Before deciding to wait longer, ask whether things will really get better. What if they get worse instead. What is the real cost of delaying.

Good support becomes essential the moment someone realizes they need it.

7. What Will You Really Pay by Delaying?

The cheapest option rarely tells the full story. There may be lost relationships. Missed opportunities. Declining health. Greater suffering that could have been avoided.

A timely psychiatric evaluation is not always the most expensive choice. Getting help sooner gives better results and fewer problems overall.

8. Can You Get Help Without Medication?

Many individuals hesitate to take medication because of possible side effects or a desire to explore therapy and other treatment options first. A psychiatric consultation offers various treatment paths.

Recovery looks different for everyone, with treatment options ranging from therapy and lifestyle improvements to medication or a carefully tailored combination of all three. The treatment plan depends on individual needs.

9. Will the Right Psychiatrist Work With You?

Every psychiatrist has their own style. Every patient has their own needs. A proper psychiatric consultation includes a thorough evaluation. Accurate diagnosis. Clear explanations. Personalized treatment. Ongoing monitoring. Open communication.

Finding the right person takes time. Taking extra time to find a good match pays off.

10. What Happens When You Get Help?

Better mental health means fewer difficult days. Stronger relationships. Improved sleep. More energy. Clearer thinking. Greater satisfaction with life.

That is why people continue scheduling psychiatric services for mental health.

Conclusion

Choosing a psychiatric consultation is not about illness. Quality mental health care focuses on improving emotional well-being, connecting individuals with professional support, enhancing daily life, and reducing ongoing mental health challenges.

The right psychiatric evaluation quietly does its job. Symptoms improve over time. People start feeling better. Relationships grow stronger. Life moves forward in a positive direction. That is what every person truly wants.

Frequently Asked Questions

What is a psychiatric consultation?

A visit with a medical doctor who specializes in mental health. The doctor listens, asks questions, and figures out what is going on. More thorough than seeing a regular doctor.

How do I know when to see a psychiatrist?

When sadness, worry, or stress lasts for weeks and affects work, sleep, or relationships. If daily life feels harder than it should, that is a clear sign.

What happens during a psychiatrist appointment?

The doctor asks about symptoms, medical history, sleep, appetite, and daily struggles. They may order lab work. Then they create a treatment plan.

What are the signs you need a psychiatrist?

Feeling down for weeks, worrying constantly, sleeping poorly, pulling away from people, struggling with daily tasks, using substances to cope. These are clear signs.

What does a psychiatric evaluation include?

Current symptoms, medical history, family history, lifestyle factors, and sometimes physical tests. It shows the whole picture for proper treatment.

Do I need a referral for a psychiatric consultation?

Some insurance plans need a referral, but many psychiatrists accept self-referrals. You can book directly without seeing another doctor first.

Can a psychiatrist help without medication?

Yes. Psychiatrists offer therapy, lifestyle advice, stress management, and other approaches during a psychiatric consultation. Medication is just one option.

How long does a psychiatric consultation take?

The first one’s the longest — about 45 to 90 minutes. They gotta get the full picture. After that, follow-ups are shorter, like 15 to 30 minutes, just to check in on how you’re doing.

How do I find psychiatric services for mental health?

Start with your insurance provider’s list. Ask your primary care doctor for a referral. Check out online reviews. Or ask people you trust if they know someone good. Word of mouth goes a long way.

What if I am nervous about my first psychiatrist appointment?

Totally normal. Most people are. Just bring a list of questions. Write down your symptoms so you don’t forget anything. And remember, the doctor’s there to help, not judge.

Psychotherapy has played an important role in the evolution of mental health care. Understanding its history, purpose, and value can help explain why it remains an essential treatment option today.

The history of medicine is millennia long.  It has been characterized by genuine curiosity, it has sometimes been misguided or wrong, it has included gradual, and wonderful, development and understanding, and even those considered qualified to manage it have been increasingly highly regulated.  That is not to say that there has not been a snake oil industry, charlatans, and a focus on money — there most certainly has — but the general trend is toward improvement, better understanding, and better results.  Unfortunately, that has been much more true in other countries than it has in this one.

The history of psychiatry has been much harder to track and characterize, in part because of very long stretches of time when the concept of (separately understood and diagnosable) psychiatric conditions was either not understood or not accepted.  And because a significant proportion of what we would call psychiatric problems has been subjective, or subject to varying interpretation, then the confident recognition and understanding of psychiatric problems has been slower, and sometimes less confident, to rely on.

It is loosely fair to say that the history of psychiatry, at least in this country, is about 200-250 years old.  Benjamin Rush is a marker.  And concepts of psychiatric diagnoses and treatments have been very unsteady, and unreliable anyway.

Even today, in what we might like to tell ourselves are enlightened and advanced times, concepts of psychiatric diagnosis, and especially treatment, are not clear, and not agreed.  There are several reasons for this stalling and misdirection, not least of which are things like the common human wish for something new (whether or not it’s true or real), and the incessant effort on the parts of various actors to get other people’s money.  And in medicine, and psychiatry, that is effected by making a diagnosis (whether or not it’s true, or real), and “treating” it.

We tried — we really did try — to make all of this objective, but much of the effort really never worked well.  If, for example, we felt we had reason to think that clinical depression was caused by underactivity of dopamine, norepinephrine, or serotonin, we could never, in any given patient, find out which neurotransmitter was underactive.  That would in theory have led us to identify, based on what we knew, or felt we knew, about which antidepressants increased the activity of which neurotransmitter, which antidepressant would be the “right” one for which patient.  And we’re talking about urine tests, blood tests, and even spinal fluid tests.  When we have relied on monoamine oxidase inhibitors (MAOI), which increase all three of the neurotransmitters the underactivity of which we told ourselves was the cause of clinical depression, those don’t work much of the time, either.  (I prescribe MAOI more than anyone else I have known, and I’m very familiar with them, but I never expect unquestioned success. 

They do work better than any other antidepressant medications, but not nearly 100%.)  And the same, in a way, is true of antipsychotics.  Some are very closely chemically related to others.  But of pairs like that, one might work very well, and at low dose, and a closely chemically related one might not work at all, even at high dose.  For clinical depression, the thing that works better than anything, and still not nearly 100%, is electroshock treatment, and no one has any idea how that works.

In my opinion, the high water mark for psychiatry has been psychotherapy.  And that’s been uneven, too.  There are several or many “schools” of psychotherapy, and some of them have essentially no theoretical basis.  I feel Freud came closest to excellent value, not because each of his particular theories or conflicts was shown to be correct, but because he more clearly introduced a concept of the unconscious, and because he focused on the impact of childhood, or the “formative years,” on continued development.  These contributions are sustaining and overarching, and I have found them to be of central value.

The problem with psychotherapy is that it can take time, and it requires hard work and dedication, on the parts of the patient and the therapist.  In the sense that what “forms” in the “formative years” is “formed,” no one simply becomes someone he or she is not, because of insights developed in psychotherapy.  But there are some gains to make.  The patient can come to understand, in a conscious way, what was unconscious (but still exerting a powerful influence), and the patient then has the option to work on making some changes.  When I was in training in psychiatry, it occurred to me that the value of psychotherapy for what we call personality disorders was that the patient could learn to see him- or herself coming.  One of my professors (they’re called “attendings”) coincidentally put it in a different way.  He said psychoanalysis (that’s what he did) for personality disorder smoothed some of the rougher edges.  For problems that are not personality disorders, the results are much more prominent, and easier to arrive at.

So, back to the theme of this communication.  I am a psychiatrist, and I’ve been one for over 48 years.  Psychiatrists in training, or the younger ones, these days, do not learn psychotherapy.  It’s too hard, and neither the training programs nor the trainees want to bother.  Writing prescriptions is much easier, and it’s more likely to satisfy everyone, even if the prescription doesn’t work, or is based on the wrong diagnosis.  So, when the old-timers, like me, are gone, there won’t be any good mental health treatment.  There will still be loads of wrong prescriptions for wrong diagnoses, and even some brief and aimless conversations.  But I hear about it all the time, even now: mental health treaters who don’t exert themselves, and don’t accomplish anything, because they don’t know how, and can’t be bothered, and they’re watching the cash register.

Mental health professionals have a variety of jobs.  Some of them, such as psychologists, specialize in testing for a variety of indicators.  The testing itself does not accomplish any goal except to identify strengths and weaknesses, and to suggest directions.

All mental health professional, including psychologists, have to engage the patient, to encourage (and monitor for) the best effort, and to help establish a direction and support the patient in his or her effort to move in that direction.

Perhaps the most important job of mental health professionals is to form some concept as to what makes people tick.  Some conditions are idiosyncratic, can happen to anyone, and need specific treatment.  Most conditions depend, for understanding them, on an overarching theory about why people develop and function as they do, what influences that functioning, and how functioning can be addressed when it is maladaptive for the individual.  If, for example, the mental health professional thought that what makes people tick is neurotransmitters, then the treatment approach would be something that adjusts neurotransmitters.  There are a few things that are thought to do that, and perhaps the commonest one is adjusting neurotransmitters (brain chemicals) with medications.  So a professional who thought the main determinant was neurotransmitters would tend to write a lot of prescriptions.  There are few reliable concepts of which neurotransmitters need adjusting for which conditions, and which medications will adjust them as intended.

The problem with this approach is that there is no agreed sense of balance or imbalance of neurotransmitters, so the concept of choosing a medication to adjust them is somewhat blind.  And there are very many medications, with new ones frequently developed (mostly for the financial benefit of drug companies), and professionals/prescribers/psychiatrists who have their own preferred medications.  A medication is preferred because of training, habit, experience, or for some other reason.

A common alternate, in a sense, theory of what makes people tick is their “formative years.”  Childhood is commonly referred to as the formative years for a reason.  A mental health professional who believes that formative years are the most powerful determinants of what makes people tick will gravitate, in a sense, to psychotherapy, as a way of understanding what has formed the patient, and as a basis of forming a psychotherapy direction.  There are various forms of psychotherapy, some having nothing to do with others, and as with medications, some representing vogue, or a wish for something new, more than “tried and true” benefit.  And some forms of psychotherapy, such as behavior therapy (“systematic desensitization”) for something like PTSD is abandoned in favor of medication treatment, because the latter is easier, if essentially ineffective.

The related thing that mental health professionals have to understand, or even just try to figure out and decide, is how and why whatever treatment they customarily use works.  Theories about this are variable, and these theories are more often offered as concepts than they are proven.

As a personal matter, I have come to have vastly more confidence in psychotherapy than I have in medication treatment.  I have spent far more of my career dismantling medication regimens that were never needed, or not for a long time, than I have beginning medication treatment.  This, of course, depends on the diagnosis.  For some diagnoses, medication treatment is the first choice, and maybe the only necessary intervention.  For most, that is not the case.  Psychotherapy is vastly harder for the treater than is medication treatment, and the patient commonly enough thinks it’s harder, too.  But the results are very different, and successful psychotherapy results in a much more independent, flexible, and self-sufficient patient.  To simplify one of the differences, medication treatment is treated as the prescriber’s responsibility (not the patient’s), and patients allow themselves to expect perfection.  Psychotherapy is a partnership between treater and patient, and it results in an acceptance and tolerance of imperfection.  Since almost nothing is ever perfect, then psychotherapy is more realistic than is medication treatment (except in those clinical situations where medication treatment is essential and central).