COMMENTARY

Does Psychiatry Need 'Rebranding'?

Stephen M. Strakowski, MD

Disclosures

May 11, 2018

Hello. I am Dr Stephen M. Strakowski, founding chair of the Department of Psychiatry at the Dell Medical School in Austin, Texas. In previous conversations, I have talked about the Dell Medical School and our attempts to do things that are different and innovative. Today I want to take a different spin on some of those previous discussions and talk about psychiatry as a field.

I believe that psychiatry needs to do a better job of branding itself as a specialty. Why do I say that? If you watch any television or news reporting, go to the movies, or read the newspaper, you know that psychiatrists are rarely presented in a positive light. The typical scene is outdated, with the patient on a couch talking to an analyst, which is not how most of us, including analysts, practice today. Your classic New Yorker cartoon, for example, portrays us that way almost every time.

In fact, to most of the public, psychiatry is quite mysterious, and I believe that is our fault. In a specialty with a lot of stigma attached anyway, the mystery simply contributes to the stigma. By being mysterious, we are vague in our brand and about what we do, which allows other groups to brand us, and they typically brand us incorrectly.

I believe it is our responsibility and obligation to be clearer about what psychiatry is and to break down barriers so that people who need the help we can provide will actually seek it from us. I don't think we have been clear on what we do or what to expect from a psychiatrist. Unfortunately, we also are not always clear about what the evidence behind our treatments is and is not. We have a history of overstating how successful our treatments can be. I believe that also adds to some of this mystery.

Allowing Misconceptions and Stigma to Rule the Day

We have waxed and waned about where we fit within the continuum of healthcare. During some periods in history, we almost removed ourselves from the traditional continuum of medical care and our place as a medical subspecialty. Thus, it can be unclear to most of the general population where a psychiatrist fits into the continuum of medical care and why another doctor would even refer someone to a psychiatrist. The perception of "being crazy" pejoratively diminishes the experiences of people who have psychiatric conditions that need treatment.

It is not just the general population that struggles with this; it is our colleagues in other subspecialties who do not understand when they need psychiatric help for their patients. Any psychiatrist who has worked in a hospital setting is constantly astounded by the referrals we get: people who did not need a psychiatrist in the first place, but also the ones who aren't referred, and it is clear that if we had seen them earlier, we could have made a profound impact.

In the absence of being clear about what we do, misconceptions and stigma rule the day. The media portrays us as unstable or evil people. How often have you seen psychiatrists represented as criminals or masterminds doing very negative things? Or we are portrayed as incompetent. Think of Frasier, for example, a sitcom that ran for years, where both of the psychiatrists were self-centered and not particularly effective. These portrayals are our own fault because we have not clearly defined what we do. The worst consequence of this is that it prevents people who need care from getting care.

In this particular video discussion, I hope to prompt others to help me think about this issue. How do we create a new brand, and whose responsibility is it? I believe that it is all of our responsibility, all of us collectively, and I will talk more about that in a moment.

I have identified several steps toward remedying this problem. The first is the classic 12-step first step. Step zero: recognizing that we have a problem and owning it. There is little debate that we are not portrayed accurately, but there may be a debate about who is responsible for that. I believe that, at this point, it is our collective responsibility. Waiting for someone else to fix the problem is not going to work.

The next step, step one, is to develop a better definition of what psychiatry is. Step two is to place that definition within the context of the larger healthcare and mental health care environment. Step three is to better understand our treatment evidence base; to be clear as we practice that we follow the evidence, and when we are not following evidence, to be clear with our patients and with society about why we are not following it. Finally, step four is to insist that our guilds and our organizations help us market ourselves effectively and that we take the same ownership to do it ourselves.

Today I am going to focus on step one. In future videos, I will talk about steps two, three, and four.

Step One: Developing a Better Definition of Psychiatry

A group of senior leaders in several psychiatric organizations have been mulling over the definition of the psychiatry specialty and hope to get other people's ideas about it. I want to share the step one definition we have been working on and get your thoughts and input. First, psychiatry is a medical specialty. Sometimes that gets lost, certainly among the general population. Even people who know me well still do not understand that I went to medical school to become a psychiatrist. I believe that our responsibility is to make it clear that psychiatrists are physicians who study and treat disturbances in brain function that are exhibited through disruptions in cognition, affective expression, experience, and/or behavior. We are talking about behavioral brain disorders that have genetic and environmental components that contribute to dysfunction and cause distress.

Part of this challenge involves semantics. We used to talk about mental illnesses and mental health. Now the common term is behavioral health, which can be extremely confusing to distinguish from behavioral medicine. The term is also confusing in that it suggests that if people just fix their behaviors, these problems will go away, and ignores the genetic basis of many of the conditions we manage.

I have been toying with using a term like behavioral brain disorders, but I am not sure whether this is too lengthy or too difficult to understand. Most people understand the mental illness and mental health terms, although I believe that they lose their connection to neuroscience and medicine at some level. In addition, we frame our conditions within the context of life experiences and the environment, via the so-called biopsychosocial model. As we think about biopsychosocial modeling, we need to consider genetics, environments, and other factors that affect the ways people express behavioral brain conditions.

What Do We Do?

What does the psychiatrist do? I would posit that we use the expertise that we have acquired from our medical education to make diagnoses that guide evidence-based treatment decision-making. We also use this expertise when we need to leave the evidence base, when we are treating something that has failed to respond to the evidence-based treatment or for some other reason. This includes our ability to manage psychopharmacology, evidence-based psychotherapies, and now, more recently, neuromodulatory interventions such as electroconvulsive therapy and transcranial magnetic stimulation (TMS).

As we think about ourselves, what we do is not significantly different from other branches of medicine. Neurologists have the same collection of neurotropic medications, TMS for some conditions, and other neuromodulatory approaches. They have to manage people's behaviors by providing different kinds of therapies. It extends across other branches of medicine, but they have managed to include it within a context of being physicians that sometimes we have not done as well, and we need to think about that.

Finally, psychiatrists provide this expertise within treatment teams in many settings. Thus, we must define our role in those teams. I believe that psychiatrists need to lead in assessment and treatment planning because of the scope of our training. We then must acknowledge that others are more expert in other components of mental health care.

Thus, psychiatry is a medical specialty that studies and treats disturbances in brain function that predominantly affect behavior, or behavioral brain disorders. We frame these conditions in biopsychosocial models, and we use our medical expertise and training to guide diagnosis and treatment decisions both in solo practice and in the context of teams.

As we work through this definition to make it useful for the public, it has to be shortened and include some tag lines. I want all of us to start thinking about it with the goal that we improve our brand in order to help people who need our care feel safer and more comfortable to seek that care.

I appreciate your time. I look forward to your comments. I will follow with future videos discussing the other steps to see how we can develop this further and perhaps change how we, as psychiatrists, present ourselves to the general public. Thank you.

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