The Profession That Everyone Needs But Nobody Wants

Mental illness is widespread in society; so is reluctance to seek care.

When I meet people at social events, the conversation frequently takes a predictable turn:

“So, Jeff, what do you do for a living?”

My reply that I am a psychiatrist is met with one of two responses: awkward silence and a quick exit, or “Do you mind if I ask you a question?”

In either case, more than a few of these new acquaintances will contact me in the weeks that follow, seeking help for either themselves, a family member, or a friend.

This uneasy pursuit of psychiatric services is even more ironic when the purpose of the event is related to mental illness. For example, I was recently the guest speaker at a fundraiser for mental illness research hosted by a prominent socialite whose son suffered from schizophrenia and had committed suicide some years earlier. After I was introduced to speak, I began my comments, as I often do, with the following question: “How many of you know someone with a mental illness?” As I paused and scanned the audience of 50 or so well-educated and sophisticated guests drawn from the hostess’s social circle, few hands were raised. Instead, many attendees became suddenly busy searching their handbags or checking their smartphones by way of averting their attention.

As I mingled with the guests at the reception that followed, I was further struck by their evasive responses to my query. While they were quick to praise the hostess’s courageous efforts to raise awareness about mental illness, very few revealed any direct or personal experience with it. Rather, they appeared to regard it as they would a hurricane that devastated a Caribbean island or a forest fire in California—an important issue deserving of public sympathy and support, but one that did not affect them personally.

Prior to departing, however, more than a few asked me for my card. And in the weeks and months that followed, almost half of the attendees—including the owner of the restaurant at which the event was held—eventually called me seeking help for either themselves or a family member.

Don’t get me wrong—in these cases, I am only too happy to help. After all, that is my job. The fact, however, that so many people would solicit my clinical guidance for their most intimate concerns through these chance social meetings, rather than seeking treatment through the usual medical channels—such as referral from their primary care physicians—struck me as unusual. These incidents attest to two inconvenient truths: the high prevalence of mental illness in the population, and the lack of awareness and grave discomfort that people feel about seeking help for mental health issues.

A Persistent Reluctance to Seek Care

As if I needed more proof of the ubiquity of mental illness and the dire need for accessible care, another incident drove it home in a different way. A childhood friend recently called me—ostensibly he wanted to say “hello” and catch up, but we soon arrived at the real reason for his call. He revealed that he had been taking a medication for his nerves, prescribed by his PCP, for many years. But in recent months, the medication had ceased to work (and no wonder, as the incorrect medication had been prescribed and at the wrong dose—a common problem when psychotropic drugs are prescribed by non-psychiatric physicians), and he felt the need to see a psychiatrist. I was floored—although he had had numerous opportunities to seek psychiatric care through a PCP referral, other influential connections, or myself, with whom he communicated on a regular basis, it had taken him until now to actually do so. If it had been chest pain, shortness of breath, headaches, or gastrointestinal symptoms, I doubt he would have waited so long.

I realize that many factors contribute to these protracted delays and anomalous paths to mental health care. First, the level of awareness and ambient knowledge of mental illness among the public is certainly limited. After all, how does a person without intimate knowledge of mental illness distinguish the emotional vicissitudes of daily life from the symptoms of disease? Rather than immediately seeking out a qualified psychiatrist, many people would rather apply to a professional from a less stigmatized or more affordable discipline for help: a therapist, counselor, clergyman, social worker, or psychologist. They may question whether their problems are truly serious enough to warrant psychiatric treatment.

Or they may harbor skepticism about the legitimacy of psychiatry as a medical specialty. How does one take seriously a profession whose practitioners were commonly referred to as “shrinks?” I wrote a book for the lay public that addresses this very point. Shrinks: The Untold Story of Psychiatry describes the megalomaniac charlatans (e.g., Wilhelm Reich), preposterous theories (e.g., “refrigerator mothers”), and therapeutic mishaps (e.g., prefrontal leucotomies) that have characterized psychiatry’s checkered history.

But psychiatry has changed. Following World War II, a series of scientific advances (including the advent of psychopharmacology, neuroimaging, genetics, and neuroscience) transformed psychiatry from the stepchild of medicine into a bona fide scientific discipline. The creation of the National Institute of Mental Health (NIMH) in 1949 further propelled the profession into the medical mainstream. Only a few generations ago, the greatest obstacles to the treatment of mental illness were the lack of effective treatments, unreliable diagnostic criteria, and ossified theories of mental illness.

But today, psychiatry has a foundation of scientific knowledge (incomplete but rapidly growing), a reliable system of diagnosis (albeit lacking in validated laboratory tests), and treatments with proven effectiveness (medications, psychotherapies, and brain stimulation). Now the greatest impediments to treatment are not gaps in scientific knowledge or shortcomings in medical capability, but the enduring social stigma of mental illness, a lack of faith in the competence of psychiatrists, and the difficulties in actually finding one.

Barriers to Affordable Care

Gaining access to a good psychiatrist with a timely appointment and at an affordable price is unfortunately no easy task, even for those who possess significant resources (of all medical specialties, psychiatrists have the lowest rate of insurance acceptance). Although the field and knowledge base of psychiatry have reached a point of scientific credibility and clinical effectiveness, it is still difficult for people in need to get competent care.

A celebrity whom I recently met at another social event, for example, later called me to ask my advice about his 19-year-old daughter. He told me tearfully that growing up, she was the apple of his eye—smart, talented, and possessed with a winning personality—until she got into drugs in high school and became psychotic. Over the next three years, she was in and out of hospitals, given various diagnoses, and treated with numerous medications that caused her to gain weight, dulled her sparkling personality, and, in the words of her father, turned her into a “zombie.” Understandably, she had reacted negatively to her therapeutic experiences, to the point that she had begun to refuse to see a doctor or take medication. Desperate and not knowing what to do or where to turn, her father remembered our meeting and called me.

What struck me about his call was not his concern for his daughter (which was extreme) but his distress over his prior experience in seeking care for her. He had called dozens of psychiatrists. Most informed him that they were not taking new patients. The few who did agree to see his daughter gave him different—and often contradictory—diagnoses and treatment recommendations following their consultations, which he paid for out of pocket. He finally called me simply seeking credible information about what was wrong with his daughter and reliable counsel as to what could be done for her. I ended up providing more than advice, as we arranged for his daughter’s hospital admission and implemented a treatment plan that fortunately proved effective. In the end, it was simply a matter of sound diagnosis and appropriate treatment.

But not all such stories have happy endings. I have witnessed the tragedies of suicide and lethal violence result from delaying treatment or soliciting help from underqualified persons. While treatment from a mental health professional such as a therapist, counselor, or other non-medical discipline may indeed be appropriate, as a rule it is best to start with the most highly trained mental health professional available. A psychiatrist or psychologist experienced in the care of persons with mental illness will best ensure that the problem is thoroughly evaluated and accurately diagnosed. If less complicated forms of treatment (e.g. counseling or psychotherapy) are warranted, an appropriate referral can then follow.

Thankfully, the historical limitations of psychiatry’s capacity to treat mental illness no longer apply. Yet we psychiatrists must still overcome the stigma that deters people from seeking treatment and the practical barriers that impede their ready access to competent care.

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A version of this article originally appeared in Psychology Today.