The role of psychotherapy in public psychiatry today.

It was the annual “changeover day” at the county adult outpatient clinic. The psychiatric residents with a year’s experience, confident and well trained at their level, had left, and the current residents, anxious and new to the game, were arriving. The transition was moving along as expected. The usual chaos ensued with the clinic’s chronic psychotic patients, who were confused by staffing changes. They appeared at the clinic at unscheduled times looking for prescription renewals. New patients, who had been given appointments at staggered times throughout the morning, arrived en masse at 7 a.m. Some came with children. One was in a wheelchair, another was on crutches, and several were accompanied by distraught family members. Welcome to the beginning of a new academic year. On the first day of the changeover, the staff psychiatrists evaluate the new patients, and the beginning residents observe them. After that the residents are on their own. First on my schedule was Jane, a 41-year-old single mother with her 14-month-old daughter in tow. With great urgency, agitation, and pressured speech, she told us that she had bipolar disorder and was a substance abuser who had been clean for five years. She had relapsed for one month in the sixth month of her pregnancy and had stopped taking her medication because she didn’t want to believe she was “really bipolar.” She had not resumed taking her medication, and now, she said, she was “falling apart.” Her longtime boyfriend had left her after she had purposely become pregnant and decided to have his child. She needed to quickly manage her agitation and racing thoughts because in three days she would be starting a class that was expected to result in a steady job. While Jane flooded us with this and other information, she was trying frantically to entertain her frisky toddler, letting her tear apart her pocketbook, including emptying and chewing her wallet. All the while Jane also apologized for her self-perceived inadequacies. The next patient was Sam, a 54year-old married, unemployed man who had been diagnosed 25 years ago as having schizophrenia. Sam was well groomed and neatly and appropriately dressed—in stark contrast to his thought processes. He had stopped taking his medicine several months earlier when his local mental health clinic had closed. He was now disorganized, alternately hostile, paranoid, and sadly depressed. He told us he lived with his wife, daughter, and two grandchildren in a onebedroom apartment. Last night, he said, his wife of 27 years told him that she had filed for divorce and that he must move out. As we listened to Sam’s disorganized presentation, it was scary for us to imagine how he had managed to navigate the Los Angeles freeway system and arrive unscathed at the clinic. When he spoke of threatening to strangle his wife, we knew we had sufficient clinical and legal reason to hospitalize him. He would not be driving home. What is the role of psychotherapy in understanding and treating Jane and Sam and the many other patients in the clinic with a panoply of diagnoses such as panic disorder, dysthymia, posttraumatic stress disorder, and major depression? For that matter, why am I, a psychoanalyst, working in this setting? Why, at this time, has Psychiatric Services decided to initiate a column on psychotherapy? Why wasn’t there such a column before?