If you have a psychiatrist on your bipolar disorder treatment team, ask yourself this: Are you getting the most out of your relationship?
Do you come prepared for your appointments with solid information on your recent symptoms and other issues? Do you feel comfortable being honest and forthcoming? If not, you’re losing out on the benefits of this professional’s expertise.
“When people need to see psychiatrists, it makes sense to make the visit as productive and helpful as possible,” notes Kevin Turnquist, MD, a psychiatrist at Anoka Metro Regional Treatment Center in Minnesota who has written extensively about “humanistic psychiatry.”
On the other hand, do you feel that your opinions are respected? Is your psychiatrist responsive to your concerns? If not, there’s work to be done in forging a more constructive partnership.
In the best-case scenario, you and your psychiatrist are allies in the campaign for ‘recovery.’ Collaborators who each contribute to a successful outcome, as defined and dictated by you. That’s the model for “person-centered care,” which has gained traction in the mental health field in recent years.
“The idea that individuals should somehow be less than equal partners in a relationship designed to affect the quality of their own lives is pretty silly when you think about it,” points out Dr. Turnquist.
The idea of an omniscient practitioner handing down pronouncements about what’s best for you is now old school. But that’s not the only positive trend in psychiatry.
The profession began as a form of talk therapy (picture a pipe-smoking Freudian presiding over the outpourings of a tortured soul). A split occurred in the 1970s as science discovered more about the biological roots of mental illness — and developed pharmaceutical options to do something about it.
Over time, the psychiatrist’s role shifted to prescribing doctor, stereotypically doling out scripts in a blur of 15-minute appointments. Talk therapy became the province of various mental health counselors, who are not empowered to deal with medication.
But the pendulum has been swinging back toward reintegrating pharmacotherapy (treatment with pharmaceutical drugs) and psychotherapy (addressing emotional, cognitive, and behavioral issues).
That’s the ideal, says Maria A. Oquendo, MD, professor of psychiatry at University of Pennsylvania’s Perelman School of Medicine and psychiatrist-in-chief for University of Pennsylvania Health Center.
“Although [mood] disorders are biological conditions, the environment and your interaction with it has a profound impact on how symptoms evolve and develop,” says Dr. Oquendo. “In terms of how well they’re controlled, having the same person manage both aspects is a critical thing.”
The realities of the healthcare system, at least in the United States, pressure psychiatrists into “only doing medication management — not that they prefer it,” she explains.
Despite the limitations imposed by insurance reimbursement, many psychiatrists manage to work around the “meds only” model.
“It’s never just about pills, even if someone is on medications, or changing medications. If you’re not thinking psychotherapeutically as a clinician, you risk undermining the entire process,” says Sonu Gaind, MD, president of the Canadian Psychiatric Association and chief of psychiatry at Humber River Hospital in Toronto.
Of course, it’s still common to have a psychiatrist whose focus is adjusting your meds and another practitioner who handles psychotherapy. In this division of labor, the psychiatrist has been likened to a car’s mechanic and the therapist to the driving instructor.
The setup works for Holly of San Antonio, Texas, who sees a psychiatrist every three months to monitor her meds — checking in more often if medication adjustments are needed — and a therapist at least once a week, “mainly for [emotional] ‘upkeep.’”
“It’s really important to me to have this structure, which includes a good support network,” she says.
Holly says it’s not so much about who you see as about how well you get along with them. “When finding a psychiatrist or a therapist, it’s so important to make sure they have a good vibe with you. You have to feel like they’re not judging you, that they’re trying to understand you and not just looking to slap a label on you and call it ‘done,’” she says.
That’s not to say finding a psychiatrist is an easy task, especially if you live outside a major metropolitan area.
According to the Canadian Psychiatric Association, Canada has about 4,770 psychiatrists and that’s nowhere near enough to meet demand: “Many areas of the country lack adequate psychiatric services. Shortages are especially acute in rural and northern areas, even in Ontario.”
The psychiatrist shortage has made headlines in the United States. According to Boston Medical Center, the United States counts an average of 16.6 psychiatrists per 100,000 people — but this number isn’t distributed equally across states and counties. Specifically, there’s a shortage in rural counties, which only average 3.4 psychiatrists per 100,000 residents.
Data gathered by Becker Behavioral Health in June 2023 shows that Massachusetts has one psychiatrist for every 2,337 people, while Idaho has just one per every 16,294 people. And in Texas, 185 of the state’s 254 counties have no psychiatrist at all, NPR reported in 2015.
In the best-case scenario, says Oquendo, people “should feel empowered to select someone who they feel confident and comfortable having back-and-forth interactions with and selecting the next steps for treatment… Some regions don’t have all that many choices.”
The squeeze looks to get worse as more psychiatrists near retirement age. A 2019 survey by the Association of American Medical Colleges (AAMC) found that 61 percent of psychiatrists are 55 or older. And there aren’t enough medical students going into psychiatry to make up the shortfall.
From the psychiatrist’s side of the office, treating someone with bipolar can be complicated by the fluid nature of the disorder — not only in terms of mood cycling, but also because of how the illness unfolds over time.
“Because you’re not dealing with something constant, it’s sometimes difficult for clinicians to figure out what’s going on, and for the person to actually get a sense of what the problem is,” Dr. Gaind points out.
Then there are the shifts from visit to visit. If you’re depressed during a session, you may be withdrawn and uncommunicative. If you’re hypomanic, you might dismiss the idea that you even need treatment.
“That’s one of the particular challenges of bipolar for the psychiatrist — maintaining that therapeutic alliance to stay with the person through their cycling,” Gaind says.
Sometimes, that alliance evolves along with the individual. When Jacques of Toronto first started to see a psychiatrist, it was because his family doctor felt he needed more specialized help with medications to control his bipolar symptoms.
Both he and his psychiatrist have changed their attitudes over time, he says, enriching the relationship and creating a more productive partnership.
Jacques began to bring what he calls “narratives” to his appointments — summaries of things that were happening in his life and things he hoped to change. In response, he says, his psychiatrist transitioned “from the traditional white-coat decision-maker to a trusted mental health advisor.”
He still creates a narrative before each session for their discussions about what he wants in life, what is going well, and the obstacles he’s facing.
“I know what I want to tell him, so I have more control over the conversation,” he says. “I set the tone and I set the direction.”
Shame, secrecy, and timidity do nothing but waste time, he adds.
“If you don’t tell them what you really want and need, the doctor will have to start probing, and we might end up talking about something that is just not that interesting.”
There are two parts to the successful partnership that Jacques describes. First, your time and effort to assess your current status and figure out your agenda for the future. Second, a psychiatrist who is ready to listen to what you have to say — “someone who will honor the job,” in the words of Philip R. Muskin, MD, a distinguished life fellow of the American Psychiatric Association.
Dr. Muskin, a professor of psychiatry at Columbia University Medical Center, talks about the trust required to share sensitive information. Getting to that place isn’t easy, he admits.
“Everybody censors what they say in therapy until one day you slip or you realize you have to say something,” Muskin says. “Then the process moves forward.”
If you’re thinking about seeing a psychiatrist who does psychotherapy, Muskin suggests asking yourself the following questions: Can I talk to this person? Do I feel comfortable?
And here’s a doozy: Am I willing to hear what needs to be heard — even if unpleasant — and to work on it? Having a psychiatrist who hesitates to tell you hard truths won’t do you any good in the long run.
“It’s important to feel you’re getting something out of the appointments, something more than you would from chats with your hairdresser,” Muskin says.
“Is your hairdresser going to tell you you’re manic? You hire me as the psychiatrist. I work for you so you can engage in a unique kind of relationship you won’t get from anyone else.”
Although the standard advice calls for interviewing practitioners to settle on the best fit, sometimes you take what you get and work toward mutual respect. That was the case for one Pennsylvania man.
“For me, there’s no interviewing,” Brian says. “It’s about who can give me what I need for the lowest possible price.”
The financial reality also means he tries not to see a separate practitioner for cognitive behavioral therapy.
“When I meet with my prescriber, our talks often become mini/micro sessions,” he says. “We talk about medication, but all but one prescriber I’ve had since my diagnosis in 2012 has also asked me how my life is going.”
Brian considers himself an “informed consumer” and advocates for himself when necessary. He recalls one doctor who dismissed his firsthand input about a prescription they were trying.
“I complained of side effects of a medication that was ineffective for me at the new dose. He said, ‘This should be working,’ and I said, ‘But it’s not.’ After going round and round I ended up at the same dosage I had started off in the past with a different doctor,” he recalls.
“The most important thing for me is that the psychiatrist is not a ‘know-it-all.’”
Brian now has an excellent match for both his budget and his preferences as a person and an individual in care.
“I was very blessed to find someone who didn’t want so much to switch from medication to medication, but had an acute sensibility to modify medications before giving up on them.”
When the partnership just isn’t working for you, what to do?
“If things are diverging — when the patient or clinician thinks it’s not the right direction for the patient— then communication has likely broken down in the therapeutic alliance,” Gaind says. “I like to ask, ‘Are we on the same page?’ ‘Do we have the same understanding of what the issues are, and how they should be addressed?’
“Remember we’re both there for the same reason. We’re there to help the patient who wants help — or they wouldn’t be there.”
Rather than simply jumping ship, Muskin says, open up a dialogue and “be prepared to say why you think things are not going well or what you’re unhappy about.”
For example, “Maybe your doctor is always changing appointments now, or wants to see you after work when you can only see him midday. You can say, ‘I don’t think this is fair.’”
The bottom line is this: You owe it to your well-being to find a psychiatrist with whom you work well.
“Ask yourself, ‘What do I need and what do I deserve?’ When you contemplate subjects like medication or therapy, remember that we all have to make hard decisions,” Muskin says. “Do that with your life because you deserve this.”
The mental health field bristles with a veritable forest of credentials. Here is a breakdown of who’s who.
Psychiatrists have an MD degree (meaning “medical doctor”). After four years of medical school, they complete a four-year residency in psychiatry. They are the only mental health practitioners who can write prescriptions, with just a few exceptions: New Mexico, Louisiana, and Illinois now allow licensed psychologists to write prescriptions after passing a certified exam in psychopharmacology.
Psychologists in the United States typically have either a PhD (doctor of philosophy) or a PsyD (doctor of psychology), representing four to five years of graduate work after college. Someone with either degree may have a clinical practice. Those who work in academia or do research more typically have a PhD. In Canada, psychologists may have either a master’s degree or a doctorate.
Therapists — a term covering social workers, mental health counselors, marriage and family therapists, advanced psychiatric nurses, and more. They often have a master’s degree, reflecting two to three years of post-graduate training.
In the United States, an “L” as in LPC (licensed professional counselor) or LCSW (licensed clinical social worker) indicates that the therapist has a master’s plus two additional years of supervised clinical experience. In Canada, the term “registered” reflects a competency-based assessment and supervised clinical experience; there is no specific degree requirement. A “certified” counselor has received accreditation from a professional association.
Editorial Sources and Fact-Checking
Who We Are. Canadian Psychiatric Association.
White C. Investing in a Diverse Mental Health Workforce Is Critical in This Moment. Boston Medical Center. August 12, 2021.
Robertson M. All 50 States Ranked by Psychiatrists Per Capita. Becker’s Behavioral Health. June 2, 2023.
Silverman, L. Texas Strives To Lure Mental Health Providers to Rural Counties. NPR. September 1, 2015.
Active Physicians by Age and Specialty, 2019. Association of American Medical Colleges. 2019.
UPDATED: Originally printed as “You & Your Psychiatrist,” Spring 2016
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At times my Interventional Psychiatrist refers to me as Dr. (my last name). Irregardless I don’t have any medical degree or training. The point is I come prepared with my past and current behavior input, medication questions, discussion of my research and answers to his questions regarding my symptoms. The conversation is direct and honest and includes my wife. I’m confident that if I show negative symptoms he would provide solutions he was qualified to supply and recommendations for additional support (like therapy). Great article – it shows how your choices are critical to your stability.
With the shortage of psychiatrists in the USA, there are Nurse Practitioners and Physician Assistants who are board certified in psychiatry treating a majority of clients. I’m curious why they are not mentioned in the article.
I would like to mention a therapist may not be able to handle the mood extremes that people with bipolar experience. For example, we had a therapist who had never encountered someone having a psychotic episode and when my child did, they struggled to figure out what to do. They don’t have the training.
IMPORTANT! Physicians with MDs are NOT the only physicians who are Psychiatrists. Doctors of Osteopathic Medicine are also Psychiatrists! In fact, my first clinical supervisor was a Psychiatrist who held a Degree in Osteopathic Medicine. I hope this is revised in this article. Thank you!
I’ve had the same psychoparmacologist for the past 32 years. We don’t do talking therapy, but I always tell him what I think is going and he gives me feedback on his reaction as he has seen me in all kinds of conditions. I just don’t accept his recommendations blindly but over the course of the years I’ve been lucky to not have to need many changes in meds, and many of those changes Iinitiated. Depending on what is up with me I might see him once every two weeks or not for months at a time. He always promptly returns my texts or phone. I’d say we have a great deal of respect.
I had a ton of talking therapy when I first was diagnosed at age 32 because I had been living a dysfunctional life since my first depression at 16. I really was great at acting like a normal person, though I was very reclusive. In three years, she got me prepped for living my life without seeing her once or twice a week. I have used therapy when I was under extreme stress, like when both of my sister’s died of breast cancer within 13 months of each other. But it was a group that helped me most. I go off and on to the DSMA support ground when I know I need to hear the truth as spoken by those who are,like me, trying to make the best out of life.
A bad doctor in any area of medicine can ruin your life. Having a mental illness it pays to be a sophisticated consumer. Find a doctor you can communicate with and leverage his expertise. Don’t expect miracles but expect a doctor who listens and comes to his recommendation based on you, not on just the DAM and not on his/her pre-existing bias. Stability is the goal, if your are not stable your doctor’s is not successful in his treatment plan for you. You need a doctor who accepts his responsibility but you have to accept yours. It’s a partnership that requires investmeny. Face it, not all patient-doctor relationships work and you should at least try to discuss the issues rather than just moving on to another doctor who might be as bad or worse.