There are 1,123 psychiatrists in Washington, more than any other kind of doctor. There are more psychiatrists here than twice the combined number of all the cardiovascular specialists, dermatologists, gynecologists, urologists and proctologists. There are more psychiatrists here than three times the combined number of all the psychiatrists in Nebraska, New Mexico, Idaho, Montana, South Dakota and Alaska.
There are four times as many psychiatrists in an apartment building at 3000 Connecticut Ave. (known as the Freud Hilton) as in all of Wyoming. The American Psychiatric Association, in its latest count, says there are more psychiatrists per capita in Washington than any other metropolitan area in the world.
These are unsettling numbers. An outsider to the world of Washington psychiatry might wonder: What are all these psychiatrists doing in the nation's capital? Are peoples' minds more likely to go on the fritz in Washington than their hearts, bladders or bowels? Is Washington really that much crazier than Nebraska?
Psychiatric insiders, too, are troubled. The numbers make health insurance executives groan, psychiatric reformers wince and they put many Washington psychiatrists on the defensive.
"Washington is the mother lode of psychiatry," grumbles James Gillman, a vice president at Blue Cross/Blue Shield. Nearly one of every two patients in private psychiatric offices in Washington is covered by the "Blues," which recently cut mental health benefits for federal workers. To Gillman's disgust, Washington's federal workers and their families covered by the Blues (nearly 750,000 people) have acquired a taste for psychiatry far in excess of federal employes across the nation. "Bonanza is a good word for what psychiatrists have here," Gillman says.
"If, overnight, you spirited all Washington psychiatrists down the Potomac River and out to sea, the vast majority of their patients would be all right," claims renegade psychiatrist Dr. E. Fuller Torrey, clinical director of a ward for schizophrenic mental patients at St. Elizabeths Hospital here. "I think what psychiatrists are doing in this city is wrong. It is a grievous misallocation of resources. I think they should be ashamed of themselves for frittering away their medical skills talking to the worried well."
"Who is E. Fuller Torrey or anyone else for that matter to define the quality of suffering in this city?'' retorts Dr. Irwin H. Marill, a psychoanalyst, chairman of the education committee of the Baltimore- D.C. Psychoanalytic Institute and a consultant in matters psychiatric to the U.S. State Department. "I reject the idea that the only people who are suffering are backroom patients screaming and hallucinating."
An estimated 80,000 Washington area residents each year make some attempt at better living through psychiatry. Their problems range from "transient situational adjustment reaction" (unhappiness, for example, over a failed love affair) to violent psychosis. Washington psychiatry is practiced in elegant private offices with leather-bound books, oriental rugs and discreetly placed boxes of perfumed tissue. It's also practiced in psychiatric wards that smell of urine, where locked cabinets are filled with vials of antipsychotic potions and boxes of spinal needles.
Contrary to popular belief, psychiatry nationally is one of the lowest paid medical specialties. Unlike surgeons who can treat several patients an hour and who commonly make more than $150,000 a year, psychiatrists are restricted in the patients they can see because most of them rent their time by the hour. Psychiatrists in Washington, however, are hardly deprived. They earn about $90,000 a year.
Psychiatry is a bewildering swamp of competing therapies. Included among the more than 200 psychotherapeutic options are Adlerian, Freudian, Frommian, Jungian, Rankian, Reichian, Reikian, Rogerian, Sullivanian, behavorial, group, sexual, familial, transactional, primal scream and eclectic (which means a blend of whatever seems to work) schools. Psychiatrists disagree, frequently with venomous personal attacks aimed at each other, on the proper role of psychoactive drugs and the usefulness of any "talking cure." What's more confusing, at least for an outsider trying to figure out what's going on in Washington, established psychiatrists often have little knowledge of what their colleagues, especially those they don't agree with, are doing. As long as they attract patients, psychiatrists feel little compunction to tell their colleagues or anyone what they do in their private offices.
The profession's penchant for secrecy and its swampy mix of disciplines tend to muck up any effort to uncover what direction Washington psychiatry is going or even where it's been. Psychiatry, like an spastic centipede, seems to be going in a hundred different directions at once. One simple way to assess the tastes and predilections of psychiatrists in Washington is to look at two of their recent patients. The two come from wildly dissimilar islands in the psychiatric swamp, one from a psychiatric ward, the other from a private office. First, the psych ward:
Janet Wilson (not her real name), a single black woman, in her early 30s, was diagnosed this fall as "severely depressed" and "acutely suicidal." She was admitted to Wing 1F, the psych ward, at Washington Hospital Center. Wilson arrived at the hospital by way of the Area B Community Mental Health Center on Spring Road NW, an overcrowded, understaffed District of Columbia facility that treats primarily inner-city poor. The Area B center, an outpatient clinic unable to treat someone as acutely ill as Wilson, referred her to the psych ward at Howard University Hospital. When Wilson found no available beds at Howard, she came to the Hospital Center.
Wilson is a short, stocky woman who constantly looks angry. Her forehead is knit, her lower lip protrudes and her eyes flit about suspiciously. She speaks haltingly and her psychiatrist has told her she is a "slow learner." Born and raised in the District, Wilson graduated from local high school in the 60s. A year after high school, she had a baby. Her first and only job was as a nurse's aide when she was 16 years old. She shares a Northwest Washington apartment with two relatives. It was one of her relatives who first brought her to the mental health center.
One morning in Wing 1F, Wilson had a 10- minute interview with Dr. Ricardo Galbis, a respected Cuban-born psychiatrist who works part- time at the Hospital Center. The interview was conducted in a narrow, poorly lighted room with yellow walls, a table and seven white plastic chairs. Dr. Galbis, reading from a metal-bound patient file that a nurse had given him, asked Wilson how she felt after taking her medicine. For about a week, she'd been taking a drug called Norpramine, one of the relatively new antidepressants which, for some patients, alleviate depression far more effectively than years of talk therapy. The medicine also causes dryness of the mouth, blurring of vision and sometimes it doesn't work.
"After I took 'em, I wasn't so nervous or somethin'," Wilson told the doctor. She also said that her major interests in life are "cartoons on the TV and the classifieds in the newspaper." Asked what she planned to do when she left the hospital, she said, "I guess I'll go back home and be looking at newspapers or TV." Wilson had little else to say.
A Medicaid patient, Wilson left the Hospital Center after 15 days to return home. If she becomes chronicly ill, requiring more than just temporary acute care at the Hospital Center, she has no alternative but to go to St. Elizabeths Hospital. For more than a year, that sprawling 125-year- old federally run mental institution in Southeast Washington has been in danger of losing its hospital accreditation. Patient care, among other things, has been found inadequate there.
Dr. Galbis says that Wilson did not respond well to the anti-depressants and that "it's hard to tell what helped her" improve enough to leave the hospital. She is enrolled now in a District-run vocational rehabilitation program, but Galbis says she could be easily "lost again."
Janet Wilson, in many ways, is a boring, dead-end patient for a psychiatrist. She has no money and no insurance other than Medicaid, which places sharp limits on outpatient psychiatric care and is accepted by only one-third of the psychiatrists in Washington. She has limited ability to talk about what's bothering her. Drugs don't seem to help her much. Her prognosis, without some kind of continuing care, is for recurrent, debilitating bouts of depression.
Consider now another patient of Washington psychiatry, one who visits a private psychiatrist in upper Northwest:
Claudia Grant (not her real name), a single white woman in her mid-20s, was diagnosed last spring as suffering from "depression with a tendency to allow herself to get into relationships where she takes punishment." Since last March, she's been coming in the late morning twice a week to the office of Dr. Richard Ratner, who practices in the "Freud Hilton" at 3000 Connecticut Ave. Grant found the psychiatrist through her own doctor, an internist, who referred her to his friend Ratner.
Grant, an attractive blond, slim and of medium height, is intelligent and miserable. She was an "A" student at a private women's college on the East Coast before moving to Washington three years ago to accept an entry-level professional job at a federal social service agency. Early this year her love affair with an older, married man fell apart. The man, with whom she works, dropped Grant and encouraged her to move back to her parents' home in California. She had an abortion.
In Ratner's office, which is lined with books and carpeted in blue plush, Grant sits on a sofa covered with brown corduroy and talks for 50 minutes twice a week about her self, her relationships with men and her family. Ratner, who frequently smokes a pipe, sits across from Grant in a tan leather recliner. The doctor says Grant is receiving "intensive analytically oriented insight psychotherapy," which means he believes much of his patient's unhappiness has roots in "problems with her parents."
"She was an oldest child and the only way for her to get attention at home was to be good, dutiful and obedient. Her mother counted on her to take care of the younger children and would not listen to her problems. Her mother was ambitious for the girl, pushing her to be a lawyer. But she didn't want to. Her interest was medicine. She grew up being very helpful, but never thought of herself. Her parental problems are part of the reason for her destructive relationships with men," Ratner says.
Ratner says Grant was nearly "paralyzed" with unhappiness when he first saw her and has improved markedly in the past nine months. "She went through a period of hating the man who treated her so badly, but now she has put him behind her," Ratner says. Since Grant's problems are rooted deep in her past, it will take considerable time before she and her doctor can dig up and unravel the neurotic conflicts that draw her into destructive relationships.
A GS9, Grant makes about $15,500 a year and is covered by the Blue Cross/Blue Shield high option insurance plan, which pays 70 percent of all her outpatient psychiatric bills to a lifetime limit of $50,000. That amounts to $42 of the $60 a session Ratner charges. His fees are the going rate for psychiatrists in the city.
Cutbacks announced this month in mental health coverage under the Blues mean that Grant's insurance will cover only 50 sessions a year. So in January, she will For more than a year, probably start seeing Ratner once a week. Without her insurance, Grant would be hard pressed to afford seeing Ratner at all.
The key to understanding psychiatry in Washington is that most psychiatrists prefer to treat the Claudia Grants of the world, not the Janet Wilsons. And Washington, to the enduring professional and financial delight of psychiatrists here, is blessed with inordinant numbers of people like Claudia Grant.
Several nationwide surveys have shown that the most desirable patient in psychiatrists' offices is the YAVIS-- a patient who is young, attractive, verbal, intelligent and successful. Washington out- YAVISes any major city in the United States.
Washington has the nation's highest average household income ($29,648 after taxes), the nation's most educated population (32 percent of area residents graduated from college) and the nation's highest proportion of working women (60 percent of the women here work and, not surprisingly, they keep the 104 local women psychiatrists quite busy).
An American Psychiatric Association study of private office practice in the mid- 1970s found that the percentage of lawyers receiving private psychiatric treatment ranges from 12 to 19 times higher than their actual percentage in the national workforce. Washington has 21,000 lawyers, more per capita than any city in the nation. Figured another way, there are 18.69 lawyers for every local psychiatrist.
The APA survey of psychiatrists and their patients also found that "fully 96 percent of all private psychiatric patients are white." Washington is no exception to this pattern. Just 30 of the area's 1,123 psychiatrists are black. The great bulk of private offices here are located in wealthy, predominately white areas--Northwest Washington (most near Connecticut Avenue) and in Montgomery and Fairfax counties. There are just three practicing private psychiatrists in the District east of the Anacostia River, an almost exclusively black area.
"All this says very clearly there are two societies, black people and white psychiatrists. The two don't mix," claims Dr. Charles Prudhomme, 73, a retired black psychiatrist who's been in Washington since the 1930s. Culture has as much to do with this as racial prejudice, says Dr. James L. Collins, a black psychiatrist who is chairman of the Howard University Medical School department of psychiatry: "The biggest single problem is that many psychiatrists can't identify with poor people."
While almost all medical care in the United States is more accessible to the rich than to the poor, psychiatry has its own peculiar problems jumping class and cultural barriers. In open-heart surgery, a surgeon, if he is so inclined, can do just as good a job on a poor black patient as on a rich white one. But in most psychotherapy, where the subtleties of language and shared culture are a key to good treatment, the best-intentioned psychiatrists often face intractable barriers in giving equally good care to rich whites and poor blacks.
So, for the most part, psychiatrists in Washington treat patients that are a lot like themselves--highly educated and psychologically sophisticated.
"There is a critical climate here in Washington that accepts psychiatry. It has a lot to do with the intelligence of the community," says Dr. Steven S. Sharfstein, a psychiatrist at the National Institute of Mental Health (NIMH).
"The population that comes to Washington because it is the capital of the nation, the political city of the world, are people who not only encounter, but seek stress," says Dr. Walter Reich, a Washington psychiatrist and lecturer in psychiatry at Yale University.
Washington, psychiatrists here say, is cursed with anxiety--anxiety over work, success, family, loneliness. "There is no doubt that these people in private psychiatrists' offices are troubled. The limitations on self-expression here are extraordinary," says Dr. James Gordon, a psychiatrist in private practice and chief of adolescent services at St. Elizabeths. "I've lived in several cities and nowhere have I seen so much conscious suppression of thoughts, ideas and feelings. People here are afraid to be spontaneous. Many feel they are playing for high stakes; they don't have room to fail."
Maladies endemic to Washington, according to more than 20 psychiatrists interviewed, include: professional frustration among young, idealistic strivers who come to Washington to revolutionize the world and find themselves drowning in the banal slobber of government; confusion and deliquency among affluent teen- agers who grow up with absent, inconsistent parents; love loss among young women victimized by aggressive, achieving men who are cognitive giants and emotional dwarfs.
Washington is not unique in its thirst for psychotherapy. Nationwide, "talk therapy" is a $2-billion-a-year industry. Demand for therapy has resulted in a gaggle of "alternatives" such as "hot tub," ''rage," and "sex surrogate" therapy.
Psychotherapy tastes in Washington tend to be conservative, that is, leaning toward the one-on-one, let's talk-about-your-childhood model of Sigmund Freud. Although the influence of Freudian psychoanalysis (which assumes that human beings are motivated by sex and aggression, and that infantile sexuality is the key to most adult neuroses) has faded in Washington psychiatry in the past 20 years, the city's 235 psychoanalysts still make up the single largest like-minded faction.
Across the country, analysts find it increasingly difficult to attract patients willing to enroll in a lie-on-the-couch therapy that costs nearly $11,500 a year and requires up to seven years of four-times-a-week sessions. But Washington, at least until the recent insurance cuts, bucked the trend. In an American Psychoanalytic Association survey, analysts here reported that they have more patients in analysis than their colleagues in other cities and that they have a higher degree of satisfaction "with referrals and income."
"We (analysts) consult at the highest level of government and society. Our influence is considerable," says Dr. Edwin Marill, a senior analyst and leader in the Baltimore- D.C. Psychoanalytic Institute. "That psychoanalysis is utilized by the highly educated and important people in this city is not discriminatory or elitist, it speaks to a reality. Psychoanalysis has a diffusion, a mushrooming effect among the caretakers of society in Washington,' "
Cutbacks in the Blues mental health coverage, however, may well snuff out Washington as the nation's shining light of psychoanalysis. The cuts translate into a $5,900-a-year jump in the price of analysis for the average patient. The out-of-pocket cost of analysis will balloon in January from $3,500 to nearly $9,400 a year.
"You can kiss analysis goodbye under these cutbacks, except for wealthy patients," says Dr. E. James Lieberman, a local psychiatrist.
Only about 6 percent of psychotherapy patients in Washington are into full- blown analysis, but many, if not most, once-a-week psychiatric patients here find that conventional Freudian theories about unconscious motivation related to infant sexuality still have considerable influence.
Michael Maccoby, a well- known psychologist, anti- Freudian thinker and director of a Harvard University program that studies work in the federal bureaucracy, suspects there is "collusion" in Washington between Freudian psychiatrists and their patients, a collusion that directs patients away from work-related problems back to their frequently irrelevant childhood.
"Psychoanalysis doesn't question values. It takes them as a given. It also gives people a routine. It is regular. There are rules. You lie on the couch and the psychotherapist sits in a certain position. It is bureaucratic. The therapy fits the fundamental bureacratic belief that if you conform to the rules, in the long run you're going to be all right. People here feel a need to conform," says Maccoby. "Compared to the intellectual community in New York, Washington is a heavy, unimaginative city: self-important, with a very high premium on position."
Dr. Paul Chodoff, a prominent local psychoanalyst who lost his faith in Freud a few years ago, says that part of the popular appeal of traditional- thinking psychiatrists in this town is that they are well- known, brand-name commodities, much like Mercedes automobiles, Brooks Brothers suits and Haagen-Dazs ice cream. "The sophisticated people in this town feel that Freud has some proof. They think all the authorities say Freud is a great man and why not go to him."
The proportion of Washington area residents seeing psychiatrists is not much higher than the national average, about 2.4 percent compared to 2 percent nationally. But the structure of psychiatric practice here is radically and somewhat ironically different from the national norm. The capital of the federal bureaucracy relies primarily on psychiatrists in private offices while people in the rest of the country mostly see psychiatrists in clinics and hospitals, according to John Krizay, a health economist. Less than half of U.S. psychiatrists are in private practice, but 82 percent of Washington psychiatrists are in full or part-time private practice.
Washington is chock-full of institutions and agencies that draw psychiatrists to the city: four medical schools, The Washington School of Psychiatry, the Washington Psychoanalytic Institute, the Baltimore-D.C. Psychoanalytic Institute, NIMH, St. Elizabeths, Walter Reed Army Hospital, Bethesda Naval Hospital and five private mental hospitals. Yet private practice has lured hundreds of these psychiatrists away from the institutions.
The reason, in one word, is insurance. In a four-year period surrounding the 1967 arrival of the generous outpatient mental health coverage for federal workers under Blue Cross/Blue Shield, the number of psychiatrists mushroomed by exactly 50 percent, the sharpest such increase in the area's history.
By 1980, the Washington- psychiatry-insurance connection had become extraordinarily strong: Washington had 24 percent of national enrollment under the Blues' most generous mental health plan but 50 percent of all claimants. In the past three years, 81 percent of those who've "maxed out" on psychiatry (that is, exceeded the Blues' $50,000 lifetime limit on outpatient bills) have been from Washington.
Other than severely limiting long-term analysis, it remains unclear what effect insurance cutbacks will have on the shape of outpatient psychiatry in this town where four out of five patients already see their psychiatrist fewer than 50 times a year. Local psychiatrists will lose about $5.6 million worth of outpatient business, forcing some of them to find jobs in institutions or take sharp cuts in pay, according to Sharfstein, the NIMH psychiatrist with an interest in the economics of private psychiatric practice. "Some psychiatrists may be forced be forced to move to another area in order to practice," Sharfstein says.
Cuts in the Blues for mental patients in hospitals, which will reduce the number of days of full-coverage from 365 to 60, should have little effect on adults who normally stay in hospitals less than month. About 15 percent of children and adolescents in psychiatric hospitals stay longer than 60 days. They may be forced by the cuts to leave private hospitals and move into crowded public institutions.
Psychiatrists here clllusion thataim that insurance companies have unfairly singled out mental health coverage for cuts because they are prejudiced against psychiatry. "The insurance people think us psychiatrists and our patients are a bunch of sissies. They want everyone to be tough, handle their own problems and save money," says one local psychiatrist.
Health economist Krizay says that liberal insurance coverage for federal workers has worked in Washington like a kind of "voucher system" that subsidizes private practitioners and, at the same time, steals potential patients, money and demand from public facilities. The net result, according to Krizay, is that private psychiatric care is excellent and the "public sector has totally failed."
"It's a terrible paradox. Considering the number of psychiatrists in Washington, a terribly small amount of attention is paid to mental health problems in the District," says Dr. James Gordon, chief of adolescent psychiatric services at St. Elizabeths.
Community mental health centers in the District, which were created in 1963 as a way to reach poor people, are viewed by many area psychiatrists as slag heaps of bad management, red tape and depressingly ill patients, a view privately held by some District officials who run the centers. Mental health centers in the suburbs are considerable better, especially in Montgomery County. But tight budgets and staff reductions have forced many of the centers to try to squeeze more and more money out of their patients.
Private psychiatrists in Washington don't totally ignore the poor. The current president of the Washington Psychiatric Society, Dr. Harold Eist, directs the D.C. Institute of Mental Hygiene, a private clinic that regularly treats some 1,500 low-income patients at reduced fees. Eist is trying to build links between private psychiatrists and poor people in Washington. But many psychiatrists here say he's fighting a lost cause and that psychiatry by its very nature is somewhat elitist.
With the abundance of YAVIS patients, one might assume that Washington psychiatrists are one big, happy, affluent family. Not so. Psychiatrists are terrified that cuts in the Blues will cripple their practices. In addition, many psychiatrists despise each other.
"One of the things that psychiatrists do is not get along with each other," says Dr. Rex Buxton, a senior Washington psychoanalyst. "The basic reason is arrogance. Boy, can they be mean and vicious. One will accuse another: 'Why you don't even do analysis.' That's our way of calling someone a son of a bitch."
The backbiting has all the fervor of arguments between religious prophets claiming to have seen the One True Way. Unfortunately, there is no proof that the One True Way exists. No scientific evidence exists showing that any one kind of psychotherapy--from seemingly endless psychoanalysis to so-called "brief therapy"--works any better than any other kind. In the absence of science, many psychiatrists defend their preferred therapy simply by insulting all colleagues who reject it.
"There is an immediate reaching for the ad hominem gun in psychiatry,"says Reich, of Yale. And there's one overwhelmingly popular insult that local practitioners love to load in their ad hominem gun: Procrustean. The word alludes to Procrustes, the fabulous robber of Greek mythology who tied travelers to an iron bed and amputated, mutilated or stretched their limbs until they fitted it. A dozen psychiatrists here volunteered the word procrustean as the perfect description of what their colleagues are and what they aren't.
The word is heard so often that it's useful to imagine a Procrustean Meter that measures the hidebound potential of local psychiatrists. At the high end of the meter, are the psychoanalysts--constantly accused of trying to mold their patient's problems to the dated insights of a 19th-century Viennese neurotic named Freud.
In the middle of the meter, are the eclectics. The largest group of psychiatrists, th clllusion thatey accuse their one-discipline colleagues of myopia.
At the low end of the meter, is the anti-psychiatrist E. Fuller Torrey, who's been characterized in a published letter as "the self-appointed disrober, assassin and undertaker of the Body Psychiatric." Torrey believes that virtually all his colleagues--excepting those who give drugs to the severely ill--are procrustean.
"There is not really maliciousness to what the psychiatrists are doing. They have accepted the most lucrative way, the path of least resistance, the greatest prestige--all without thinking very much about they should be doing.
"The most highly trained psychiatrists in this city see the least sick patients, people who are not sick at all in my opinion. The better psychiatrist you are, the more selectivity you have. It is as if the best trained surgeons are lancing boils while the worst- trained, most inexperienced surgeons do cardiac bypass surgery," Torrey says.
The victims of Torrey's tirades accuse the doctor of being biased, insensitive and misinformed. Local analysts and psychotherapeutically oriented psychiatrists claim that Torrey glorifies "cookbook" psychiatry and ignorantly dismisses the suffering of sophisticated people who can only be helped with insight, not drugs.
Washington, over the past 20 years, has attracted so many psychiatrists that many now believe the town is saturated, especially in light of the recent insurance cuts. Like many of his colleagues, Dr. John McGrath, a prominent psychoanalyst and past president of the Washington Psychiatric Society, advises young psychiatrists to practice elsewhere.
"I tell young psychiatrists not to come to Washington," says McGrath, who's established a thriving practice that forces him to turn away patients. "Although, I'm awfully glad I chose to come here."