Shrink Rap

A Matter of Perspective

2012-01-23T19:15:00.000-05:00

Often, when two people can't get along, it seems like the issue is one of communication. People say things that are ill-phrased, or the person hearing a statement assumes an intention that is not meant to be. Sometimes, a well-worded conversation fixes the problem, often with words such as, "I'm sorry that upset you. I never meant it to come off that way and I meant to say X." A misunderstanding, it happens all the time. I sometimes suggest that people read the book Difficult Conversations by members of the Harvard Negotiation Project. The book talks about the value of feeling heard, and how it is important to understand the intentions of the other party. You can't imagine how often I hear stories about people that sound a little off, and when I ask why someone would say or do those things, I hear theories of how the other party is jealous, or just enjoys watching my patient suffer, or is manipulative, or sometimes the stories have quite complex theories dating back to an event that occurred long ago and doesn't seem that memorable. Now the theories could be right, people are jealous, or manipulative, or sadistic, but often I can think of alternative explanations that would explain the same story, and I do think that it may be valuable to ask someone their intentions when things go wrong.

Sometimes, people hit a place where nothing can be said that is right by either party. There are irreconcilable differences. One person may talk of their heart-wrenching distress and weep their story, while the other hears it as "there he goes again trying to get my attention with his tears," and the crying party feels like their honest and sincere attempts are useless on someone with a hard heart. You can find your own variations on this theme, I'm sure.

I've started to wonder if I have perhaps come to this place with our Shrink Rap commenters. I feel like I say something and the response indicates that my comments were misinterpreted.   I try to clarify, it just gets worse, and our comment streams now end with readers insulting the blog, me (apparently I'm someone's nightmare shrink and jail would be preferable--which leads me to wonder why such a person would read our blog), and my choice of topics to discuss. If I talk about an observation I've made, people get angry because of a scenario they've extrapolated that to, which was never what I meant in the first place. Attempts to clarify seem to be futile. I don't feel heard, and clearly, some of the commenters don't either.

And sometimes I feel like readers don't want a discussion at all. A story is written in, and I often sympathize with the story because our readers write in about very touching, and often tragic, difficulties.   They also sometimes seem to feel that it is the Shrink Rappers' obligation, job, or destiny to right the wrongs they see in psychiatric practice and I do believe we've let these readers down. Sometimes, I feel terribly bad for the person who has been victimized, but I'm also aware that I've heard only one side of the story, and I may talk about what the other side might be. And while I don't believe people should suffer, I do sometimes feel that it's helpful to see other perspectives. It enables a search for a solution to occur with a more thoughtful dialogue. But it also means that I sometimes sound unsympathetic in that my answers are read as "Yes, but..." From my point of view, that's part of the discussion, and if you want to say something and want us to respond with absolute sympathy, having heard half of a story that often demonizes our profession, and you don't want to know how the other side might look at it, then I don't think Shrink Rap is the place to come.   I am not likely to write a post about how psychiatrists are all evil and manipulative control freaks who want only to incarcerate, abuse, and poison their patients. And it's not that I don't believe there may be evil shrinks out there, or stories of abuse, or nasty and disrespectful nurses, and I certainly do believe there are psychiatrists who practice quick, uncaring psychiatry for the sake of a bigger paycheck, but sometimes I want to consider other possible explanations.

Let me give an example from recent posts. I put up an article from USA Today on how involuntary commitment is so unpleasant and that if it were more humane, it might not be so awful. I put it up because I agree with it. People wrote in to talk about the abuses they've suffered, and that is fine, it's what I expected. But several people complained about being searched, and how it was offensive and insulting and given their past histories and diagnosis, this was inappropriate. I understand their pain and humiliation, but what doesn't get mentioned is the perspective of others when things go wrong. The patients are new to the unit, the staff has no idea who is dangerous and who is not, and psych units can be very unpredictable places. Some of the policies are made as reactions to bad things that have happened, and often patients have assaulted other patients, or the staff, and suicide attempts (and completions) are not that uncommon. A patient might be insulted at being searched, but is he also insulted when searching is not done and he's stabbed by another patient who came in with a knife taped to his leg? Wouldn't that lead to the same "unbelievable" cry? And to read our blog, one would think that no psychiatric patient might ever care about the safety of the hospital staff or their right to be concerned about it.   It's not that I don't empathize with commenters' suffering, it's that I'd rather there was just a token nod to why it may be necessary. Why does a four-year-old have to remove and x-ray her flip-flops to get on a plane. Do we really think she's going to blow it up? No, but perhaps we think that if they stopped x-raying children's flip-flops, then a terrorist might then use them as a vehicle for a bomb. Or maybe it's all ridiculous and we should be a little bit more thoughtful about our security procedures.

One commenter was distressed about being strip-searched and made the statement that other hospitals don't all do this. Not my field of expertise, but it does seem to me that if one can say "I understand why it's done, I want you to understand how damaging it is," and then go on to say that other institutions don't do this and propose other, less damaging means of addressing the same issue (?metal detectors, drug dogs, pat downs, body scanners, whatever) perhaps there is some power to this. Maybe you get people looking and they say Wow, the institutions that don't strip search patients actually have a lower violence rate (I don't know this, but we do think it's possible that there would be less violence if patients aren't enraged). But someone is going to read my comments about staff and patients being in danger as meaning that I think it's fine to violently rip people's clothes off them, and for the record, I don't.

Another commenter asked if I do this to my patients, this 'yes, but' thing. Sometimes I do. If a patient is telling me a story about an interaction with another person that sounds unlikely to me, I may ask the patient why he thinks he got the reaction he did. Would it be honest to sit there and listen to something that doesn't sound right without challenging someone to think about it in new ways, or to propose some other possible explanations? Let me give an example from a recent Shrink Rap topic. If a man talks about how his adult son has estranged him and he has no idea why and he presents theories that sound unlikely (my son wants to control me, he's jealous, he always favored his mama, you name it), and I have a sense of what might be part of the issue from other things he's told me, I might ask, "Do you think the fact that you don't approve of his wife and the way that they are raising their children might be making him uncomfortable?" Or I might ask if the son may have found it difficult to get his approval when he was younger, or if how the father used to treat him before he stopped drinking might be a part of this.    But it a patient doesn't want to hear this, if they need me to be all in their court, and if they insist I'm wrong (and after all, I wasn't there, so my theories may well be inferior theories), I back off.   The truth is that no matter how troublesome the patient's behavior is or has been, they are my patient, they are the one I am obliged to help, and sometimes I feel around for the best way to do this. No, I don't always get it right.

I don't know if this helps, but I suspect it will inflame things. Commenters may say I'm getting defensive again, and they'd be right. I read some of the comments and think, "You'd say this in my living room?" Because if you're someone who might behave in this manner, there is no way you'd be invited in to my living room.

Follow Up on Sam and Our Survey

2012-01-21T13:20:00.000-05:00

Remember Sam, the student who applied for a competitive internship and didn't know whether to check yes or no for the question about whether he has a psychiatric disorder? If you forgot the discussion, you can read it here: http://psychiatrist-blog.blogspot.com/2011/11/tell-me-ethical-dilemma.html

I thought I would let you know that Sam checked yes on the box that asked if he had a psychiatric disorder. I thought I would also let you know that Sam was chosen for the competitive internship.
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Last week we asked readers who have been certified to psychiatric units if they would want to be involuntarily hospitalized again if they became ill and imminently dangerous again. 63 responses, one person hit submit without answering, and here is the final tally:

Summary See complete responses

If you became psychiatrically ill again and presented an imminent danger to yourself or others, would you want to be involuntarily hospitalized again?

Yes		20	32%
No		42	67%

When Adult Children Shun Their Parents

2012-01-19T11:30:00.002-05:00

Over on Shrink Rap News, a post will be going up about my random thoughts about adult children who essentially divorce their parents. In the families I'm talking about (and I know many), these aren't extreme situations--the children did not suffer from abuse, neglect, or deprivation at the hands of their parents. When they were children, the parents tried to be attentive, caring, and to provide for them as best as they could (which was sometimes rather well). The parents likely made mistakes, because parents are not perfect, but the issues are current ones...and often ones the parents themselves can't articulate. In these cases, the adult children have severed ties even though the relationship was close, and they themselves might say they had good childhoods. Why the estrangement? I suppose it's different in each case, and often there are issues with parental divorce, the relationship with the child's spouse, a sense that the parent is too critical, too judgmental, or perhaps too intrusive and controlling. The adult children may feel they are being used or manipulated. I talk about some of my theories, and they may well all be wrong. None of it science, just what I've gathered from listening. If you'd like to read my thoughts, I invite you to surf over to CPN's Shrink Rap News. And, of course, I'd like to hear your story. You can check over there sometime around noon.

If you're interested, I'll also direct you to a website run by someone dear to me: MOTHERRR! -- about rebuilding mother-daughter relationships. While my post talks about estrangement from the vantage point of the parents, this site looks as mother-daughter difficulties from the perspective of the adult child.

The Privileged Patient

2012-01-18T07:44:00.001-05:00

I'm still dwelling on these discussions we've had about the inpatient experience. A number of readers commented that they weren't like other patients on the ward who weren't educated, who used drugs and were in and out of jail. I took that a little personally since those "other" inpatients are my correctional patients. I like working with them and I don't like it when people dismiss them as being "just criminals." I also found it a bit ironic that the people who are quick to claim peer kinship with staff are also quick to disclaim equality with forensic patients. You really can't have it both ways. My offender patients deserve to be taken seriously, treated with respect and given humane care whether you want them in your community or not.

I don't like the idea of framing treatment in terms of who is more 'deserving' of care. I don't think you can put a rating scale on suffering or prioritize trauma. Nevertheless, when it comes to the spectrum and amount of services that are needed my forensic patients are right up there. They may not be very literate, they've got poor social supports as well as mental health and addiction problems. Oh, and chronic medical problems that go untreated because they have no insurance. They're facing an uphill battle just to reach a "normal" place in society. For my patients, success means having a place to live, a job, people who care about them, maybe even a car and a girlfriend. That's a lot to have when you're starting at zero. Yet when it comes to apportioning services and access to treatment these are the first folks to get cut.

Some inpatient units do have patients of privilege---people who aren't starting at zero---and these patients really do seem rich (figuratively and literally) in comparison. But forensic patients are increasingly part of our mental health care system. When we talk about making the system better they have to be part of that discussion.

The Opinionater on The Age of Anxiety

2012-01-16T20:23:00.010-05:00

Before I start, two things: 1) if you'd like to hear our interview with Dan Rodricks on WYPR today, go here. 2) If you've ever been forcibly certified to a psychiatric unit and you haven't taken our poll yet, please do so here. And now for our next post:

Over on the New York Times "Opinionator," Daniel Smith has an article called ""It's Still the Age of Anxiety. Or is it?" Smith talks about W.H. Auden's Pulitzer Prize winning1948 poem, The Age of Anxiety, (it's boring, he tells us, as well as 'illusive, allegorical and at times surreal') and he tells us about his own anxiety. Smith writes,

From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Smith concludes that it's not the world we live in, and that it's perhaps dangerous to make that assumption. He notes, " If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun."

What do you think? Are we more anxious than we used to be? And why is that? Is it the world we live in--now or in 1948? Or is it just our own personal psyches?

Note, the graphic above is from a book by Andrea Tome.

Our Interview with Dan Rodricks on WYPR

2012-01-16T16:14:00.007-05:00

If you missed our interview on Midday with Dan Rodricks, you can still listen by clicking on the Download link, or clicking on the My Three Shrinks icon to the left will open up a browser player in a new window.

Monday January 16, 1 - 2 pm: Everything you could know about psychiatry in a 50-minute hour

What is psychotherapy, how does it work? What is psychoanalysis, and why don't all shrinks practice it? Our guest this hour three Baltimore psychiatrists -- answer questions about how they work with patients. Our guests: Dr. Steven Daviss, chairman of psychiatry at Baltimore Washington Medical Center; Dr. Dinah Miller, in private practice; and Dr. Annette Hanson, a forensic psychiatrist with appointments at the University of Maryland and Johns Hopkins Hospital. They write a blog together and are authors of “Shrink Rap: Three Psychiatrists Explain Their Work,” published by Johns Hopkins University Press.

Download

Midday producer Michael Himowitz says of the book: "This is a remarkable book. I was prepared to endure it, but it turned out to be well-written without being glib pop-psychology, informative without being overly laden with jargon, and surprisingly candid about psychiatry’s failings and problems. They should have named it Shrink 101, because it really covers the basics about navigating the disorganized and confusing world of mental health care."

Involuntary Commitment: Would you do it Again?

2012-01-14T20:14:00.003-05:00

Ah, we're back to an old topic, involuntary hospitalization. Some people say they'd rather die than live through a week in a hospital again. I actually have not ever heard anyone say that about jail. I thought I'd ask if everyone feels that way. If you are very much against the idea, but have not been involuntarily hospitalized yourself, please-please-please, don't take my poll.

Thank you and Go Ravens!

Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

What We Need

2012-01-14T11:14:00.002-05:00

OK, I've gone back through the comments on my last post as well as on Dinah's forced treatment post. I think I've come up with a list of what people have identified as things that need to be added, improved or changed. I'm going to talk to myself in this post, thinking out loud a bit about what each item means to me and how to implement them. Feel free to follow along, add, edit or just ignore me. Like I said, I'm thinking out loud in public.

1. An emergency ear
     Even people on an inpatient unit need a crisis contact. A friend to call, an outside volunteer, better access to visitors like family, or a hospital ombudsmen. Patients may not want to or can't access staff, which is a problem. Purposely or unconsciously, inpatient staff discourage patients from approaching them about problems. Patients feel they have no recourse when they are treated poorly or unprofessionally. Some hospitals use after-the-fact patient satisfaction surveys, but personally I'm reluctant to solve a problem by using a form. There needs to be a neutral mediator or ombudsman who is easily accessible to an inpatient. Perhaps allowing an outpatient therapist to hold sessions during a hospitalization would be helpful. (I know there may be financial and bureaucratic issues related to all the items I'm discussing---for the time being let's ignore that. This phase is just outlining the problems and needed solutions.)

2. Professionalism
This item is closely related to item #1. If this item were fixed then item #1 might not exist. What most people may not know is that medical schools recognize this is an issue and now incorporate assessment of professionalism into every medical student and resident evaluation. National professional organizations are also thinking about ways of building this into ongoing licensure processes by requiring physicians to solicit evalutations from their patients. There are also now loads of online 'rate-your-doctor' sites. This is just for physicians, though. I'm not sure how to go about evaluating professionalism for hospital security staff who put someone into seclusion. The psych aides or techs would likely fall into the nursing department realm, and there's no reason there couldn't be a patient feedback loop for that profession as well.

3. Regret
Ah, this is the tricky one. Some commenters said they wished their doctor would have told them that the doctor felt horribly about having to commit someone. Well, when a patient is in crisis it's really not the time to focus on the doctor's feelings. The point is well taken though that mental health providers should be able to talk to the patient afterward about the experience of involuntary treatment, what it was like (for both parties) and ways to avoid it in the future. See item #4.

4. Outpatient crisis plan
I've seen some nursing admission forms that routinely ask patients on admission what they do when they are feeling angry or upset, and what helps them feel better in times of crisis. This almost never involves social connections though, which commenters here say they want more of. This is related to #11, the ongoing discharge plan. Who is in your social support system? Are they helpful are hurtful? Who can you reach most easily? Have you actually used this support system in the past or are you b.s.-ing to get out of the hospital (honesty is going to have to cut both ways, now!)? Hospital lengths of stay are so short now there is almost no purpose to a trial pass or day pass. The general thinking is that if you're well enough for a day pass you must be well enough for discharge. The generic 'return to emergency room' is far from an ideal crisis plan. Perhaps some temporary ongoing outpatient relationship, similar to what internal medicine does: discharge from hospital, to be seen in inpatient doc's own outpatient clinic within X days, until more permanent or preferred outpatient care is arranged.

5. Decent food
Oy, I am the Shrink Rapper with zero food skills. Either of my co-bloggers will confirm that. Nevertheless, it seems evident that medically appropriate, religious or personal preference diets should be available. This one just doesn't seem that complicated, but I don't question that it's a problem.

6. Clean, comfortable environment
Ditto #5. This is one item where patient satisfaction surveys actually could be useful. If month-by-month discharge surveys are all saying you've got bugs in your bathroom, you've got a problem.

7. More autonomy over medications
Pharmacotherapy is always a balancing act between the level of symptoms a patient can live with versus the burden of side effects that they have to carry. I would throw in this thought as well: the people in your support system have to live with your symptoms, too, so they should also be considered. Can we engage family and friends in this balance? If so, how?

8. Meaningful activities
I get this, totally. It's tough when you have an inpatient unit that contains both patients who are so ill they need help bathing and dressing as well as multiply-graduate degreed professionals. William Styron once called occupational therapy 'organized infantilism.' These individualized treatment plans that every team has to fill out should be made useful in some way, and this is where this item should be addressed. What meaningful activities would an educated, high-functioning professional want to do (or feel up to) doing? Most of the units I've worked on have not served many of this kind of patient so I'm open to suggestions here. You also have to address the question: if you're well enough to do (high functioning activity X), do you really need to be in the hospital? That's the question insurance companies will be asking your doctor.

10. Alternative and complimentary treatments
     People want things to do besides (or in addition to) taking medication. I'm guessing this means things like emphasizing regular activity or exercise, proper diet, decent sleep but also activities like yoga or tai chi, bibliotherapy (journal keeping, poetry or other writing), music therapy, and so forth.

11. Ongoing discharge planning
     I've already covered this a bit, but this would refer to the feeling that people are just dropped outside the door of the unit after discharge with no further contact with the inpatient team. There are already some programs available like day hospitals or partial hospitalization programs, but I don't think this is what people are asking for. I'm thinking more along the lines of returning to the inpatient unit for an "outpatient" visit, if that makes sense, while making the transition to a traditional outpatient practice.

12. Humanize (or de-traumatize) the observation process
     This is the last and toughest point. How do you humanely take someone's clothes away while putting them in physical restraints on continuous observation? I know, some people will say this should never be done but that's just not the world I live in. Some people are dangerous when they get sick. Psychiatrists have to make sure everyone in the unit is safe, in addition to protecting the patient. Making sure everyone is trained to recognize and intervene early is important, to prevent seclusion and restraint. Working with the patient early on to identify coping skills and practice those skills, and make sure people on the unit are trained in verbal de-escalation techniques. This won't obviate the need for seclusion in all situations, but it should help minimize its use.

OK, I've spent a fair amount of time thinking about this post, reading old comments, writing and speculating and I'm running out of steam. More later. The last three or four items are going to be the longest, I think. Dinah and Roy, feel free to jump in with your thoughts. This is the stuff of inpatient interviews.

The Shrink Rappers on Midday with Dan Rodricks: Monday, January 16 @ 1 PM

2012-01-14T06:00:00.003-05:00

Midday with Dan Rodricks

We joined ~~will be joining~~ Dan Rodericks on WYPR, 88.1 FM on Monday from 1 to 2 pm. You can listen to it or download from WYPR. ~~If you're local, please listen. If you're not, live streaming information is on the WYPR website at http://www.wypr.org/listen-live.~~

~~We'll put up a link after the show, and information to call in or email is shown below.~~

Midday is WYPR's daily public affairs program heard from noon-2pm, Monday-Friday. Hosted by longtime Baltimore Sun columnist Dan Rodricks, the program covers a wide-range of issues selected to engage, inform, and entertain the listening audience. Topics range from the latest news, to local and national politics, to social, medical and cultural trends, featuring the best new books and most engaging authors, newsmakers and guests.

Dan has won numerous regional and national journalism awards, and he has frequently been cited as Baltimore's favorite columnist by Baltimore magazine and the City Paper. Previously, Dan was a commentator on WBAL-TV, host of a talk show on WBAL-AM, host of documentaries on Maryland Public Television and, from 1995 to 2000, host of the popular Rodricks For Breakfast show on WMAR-TV. He is the author of two books about Baltimore and lives in the city.

Executive producer: Vanessa Eskridge
Engineer and Director: Tom Welch

I'm Sorry

2012-01-13T06:58:00.001-05:00

Rob wanted to know if I was reading the comments on Dinah's post about involuntary treatment. He thinks that psychiatrists may read these comments, shrug and say, "Well, sometimes it's necessary."

I did read the post, and the comments. I can tell you that the decision to involuntarily admit or treat someone is never a "shrugging" issue. This is something psychiatrists hate to do. I mean, literally hate. We know it's something that can destroy a therapeutic relationship and undermine someone's willingness to seek care in the future. We know that psychiatric units can be horrible places to be and that admission is expensive, humiliating and sometimes traumatic. The decision to seek involuntary treatment is not done lightly or easily. You and some others may feel it should never be done, but I think that's an issue that may never get resolved between us. Maybe someday medicine may develop better ways to diagnose and treat mental illness, or society may evolve and decide that psychiatric patients are worthy of the time and money spent on other suffering people but we're not there yet. We deal with the present, as it stands, with what we've got.

Remember that there are comments that you don't read here. The missing comments. The comments that can't be posted because the suffering people are dead. On behalf of those folks, and the people who care about them, I'm sorry. I'm sorry that psychiatry as a profession and the mental health system failed you. I'm sorry that you had to hide your suffering from your friends and family, or maybe from your doctor, because you thought you had no choice. Clearly, something needs to change.

This is why Dinah posted about the issue and why I'm following up. As a group, we need to figure out better ways of doing things. The Shrink Rappers don't have the answer. We need to hear concrete ideas and suggests. General comments like, "Stop treating me like a child" or "Don't be a jerk" honestly aren't helpful. The commenter who suggested that patients should be allowed to have cell phones on the unit, to call friends or family when in crisis on the unit, now that's the kind of idea we psychiatrists need to hear. The discussion about post-discharge aftercare and the continuity gap is crucial. Please tell us more about that and about what kind of services or support would have been useful and what we need more of. I like the idea that this could also help catch people in early relapse. We need to answer the questions about these services: what, when, where, who and how.

Now let's get started.

Baby's First Laptop

2012-01-11T07:15:00.000-05:00

I just stumbled across this on the Amazon web site and had to post it. People have been writing lately about the effects of technology on kids, but I guess it's not that serious since we're making 'real' technology for babies now. What's next? Baby-safe web sites? Infant chat rooms? Babble blogs? (Oh what, we've got those already...)

Forced Treatment: Does it Help?

2012-01-09T20:49:00.001-05:00

Go for it, I know we have many readers who oppose forced treatment.

In "Opposing View: Forced Care Doesn't Work" by Joseph A. Rogers in USA Today discusses the usefulness of forced treatment. While some would contend that people who are sick may become dangerous, lack insight, or be so sick they can't see themselves as ill, Rogers contends that by forcing people into treatment, they get turned off on the idea of getting care and that a better solution to the problem is to make psychiatric care something patients want to get. Rogers writes:

Studies have shown that what works is not force but access to effective services. We don't need to change the laws to make it easier to lock people up; existing laws provide for that when warranted. Instead, we need to create and fund effective community-based mental health services that would make it attractive for people to come in and receive care, and that would support them in their recovery.

I don't know if better access to good care is the whole answer, but it's not a bad place to start.

Podcast 65: Copyrighting the Brain

2012-01-08T19:33:00.038-05:00

Roy wants to remind APA members to VOTE! in the APA elections.

Roy talks about our Top 25 Posts for 2011.

ClinkShrink talks about copyright issues with the Mini-Mental Status Exam (MMSE). We talk about what the MMSE is, what it measures, and why some folks are bothered by the copyright issues. Roy mentions an alternative, the MoCa, which may be used clinically without any permission needed.

Roy mentions his Clinical Psychiatry News article in the Shrink Rap News column discussing the October SAMSHA meeting on electronic health records in behavioral health. He talks about continuity of care documents (CCD) and XML (Clink and Roy have now lost me in Geek Speak), which gives the outline about what was important about that 'episode of care,' or doctor's appointment, and the 17 categories of things that are documented. This was a stakeholder meeting to come to a consensus about which behavioral health elements should be included in the CCD. Roy talks about something called Granular Consent.
* * * * * * * * *

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

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What Makes a Good Psychiatrist?

2012-01-06T20:16:00.000-05:00

A while back, I wrote a blog post called What Makes a Good Therapist. Readers were kind enough to write in and help clarify what characteristics they like in a therapist. Recently, a number of friends have asked me for referrals for psychiatrists, and it's occurred to me that the question of what makes a good therapist is only partially related to that of what makes a good psychiatrist, and this is a really difficult topic to address.

Why is it so hard to figure out what makes a good psychiatrist?   I believe it's because we've had this traditional biological/psychological split in psychiatry. In the old days, some training institutions were known for teaching residents to be good psychotherapists---and by psychotherapy, I mean psychodynamically-oriented psychotherapy, and a segment of these trainees would then go on to become psychoanalysts. Other institutions were known for teaching their residents-in-training how to use medications effectively.

As time has gone by, the emphasis in resident training has shifted towards the evaluation and diagnosis of psychiatric disorders and treatment with medications, and now the younger psychiatrists are good at this, but there has been a shift away from training psychiatrists to do psychotherapy, and people vary with how important they believe it is for both therapy and medications to be done by the same person. Now throw in another variable: financial pressures favor short appointments, so some psychiatrists will see one patient in an hour, while others may see four or more patients in an hour. There is nothing inherent in a medication-model that says appointments should be brief, and many psychiatrists who do not do formal weekly (or more often) psychotherapy sessions, still see patients frequently and for full sessions, especially when they are having a rough time.

So here's my problem when a friend asks for a referral to a private practice psychiatrist, and it's often for a relative, or a friend-of-a-friend: I don't know what the patient needs.   While quick med-check 15 minute appointments probably do a lot of people a lot of good, I don't refer people to anyone who works this way; I just don't think it makes for good psychiatry and I don't believe that medications should be prescribed from a checklist of symptoms taken out of the context of what is transpiring in the patient's life and what is meaningful to them.    But after crossing off the 4 patients/hour shrinks, I'm still left with that idea that I'm going to refer someone who needs mostly therapy to one psychiatrist, and someone who might need some tinkering with medications to another psychiatrist. Sometimes patients know they want to at least consider medications. Some patients have an idea about what they need, but a large part of having a professional evaluation is to figure that out. If they've been to someone and are unhappy with their care, figuring out what they haven't liked can be a good place to start.

Over on KevinMD, Dr. Raina wrote a post a while ago about what makes a good, competent psychiatrist.    I'm going to do my own list here.

A good psychiatrist....

Spends an adequate amount of time with a patient and asks targeted questions that enable him/her to at least try to figure out a diagnosis and treatment plan.
Listens, really listens, and conveys concern to the patient.
Is respectful of the patient's concerns and feelings.
Has a good understanding of medications and their safety issues and interactions.
Stops medications if they haven't worked after a reasonable trial.
Respects a patient's wishes to lower doses or change medications if there are side effects, provided this is a reasonable thing to do (it usually is, but not always).
Is cognizant of the possibility that the risks of medicines may outweigh the benefits.
Uses addictive medications with appropriate caution, as if anyone is exactly sure what that means.
Is hopeful and optimistic. No one needs a shrink to tell them they are going to have an awful life.
Is flexible enough to try another treatment or approach (and another and another) if the first ones don't work.
Seeks consultation when the going gets rough.
Sees patients in distress frequently. Sessions every three months may be fine for someone who is doing well, but "come back in three months" is not reasonable if the patient is not doing well and a medication change is needed. Phone contact may be a reasonable alternative.
Includes family when it is indicated and the patient wishes this.
Communicates with other physicians and therapists if necessary.
Gets patients in quickly if there is an emergency. "My next appointment is six weeks, if you can't wait go to the ER," doesn't cut it for me.
Is conscientious and respectful of the patient's time. Returns phone calls and generally runs at least sort of on time (15 minutes late is one thing, consistently 2 hours late is another thing).
Is warm and empathic and has a manner that makes it easy for patients to feel comfortable confiding in him/her. Unfortunately, this is a very personal thing and one person's wonderful shrink may be another patient's evil monster. It's also probably the characteristic that is most subjective and most important to patients.

Please note that my Good (ideal?) Psychiatrist criteria apply only to the outpatient setting in a world devoid of monetary pressures. The pressures on psychiatrists in institutions are such that logistics may make these ideals impossible to uphold. Also, this is life in my ideal 'bubble' world, in areas where there are shortages of psychiatrists, upholding these standards may be impossible, and it's not good psychiatry to practice in such a way that 95% of the population go with no care because the psychiatrist is spending so much time with 5% of the population.

You know how this works: please add you thoughts on the good psychiatrist to our comments below!

Ducking Around

2012-01-02T21:42:00.001-05:00

Ooooh, let me tell you: I love vacation. I really love vacation. I'm back. It's cold here, and I spent the day unpacking and doing laundry, and getting ready to start my week. I returned calls, went in to the office and checked my mail, emailed, postal mailed, and watched the Ducks win the Rose Bowl. Sad, because even though we Shrink Rappers like ducks, I have my own personal Badger out in Pasadena cheering for Wisconsin, and it's a sad football day for him, I'm sure.

Roy did a great job of holding down the blog. Please give him a hand. Clink was off on another one of her adventures. For some reason, vacation is not fun for her if there isn't the possibility that she'll fall thousands of feet, get eaten by some form of wildlife, or have her life depend on properly functioning equipment while she gurgles beneath the sea. She's the only person I know where "I had a fantastic time" is followed by an injury report.

Roy's Happy New Year duck was taken from the Havre de Grace annual New Year's Duck Drop. From the Aegis:

It was a glorious night for ringing in a new year. Temperatures, unusually inviting for a New Year's Eve in Harford County, hovered around 43. Wind was non-existent. And many people had gathered around the Havre de Grace Middle School grounds for the annual Duck Drop and fireworks to welcome another new year.

In other stories around the web, if you're a distracted duck, you might have notice that it's hard to find Ritalin or Adderall-- perhaps another example of DEA limits allowing Big Pharma to be being overly ducky about reducing supply of the cheaper, generic medications. From the The New York Times, do check out "A.D.H.D. Drug Shortage Has Patients Scrambling."

And if you're a duck contemplating filing for Social Security Disability, do read Dr. Steve's post on Thought Broadcast about The Curious Psychology of "Disability." With 41 comments on that post, I'm going to swim away from the temptation to comment myself.

And finally, for those ducks who want to know the latest on Electronic Medical Records, check out Shrink Rap News over on CPN for "Notes from SAMHSA's EHR Summit." If that doesn't make you want to be served up with orange sauce, then nothing will.

So I love vacation, but I did miss all the Shrink Rappin.' Happy New Year to everyone!

From Clink: I don't have a duck in this race, so I thought folks might enjoy a seahorse instead. He's black with white stripes and seems to be perched on top of the green moray eel's head. Yes, the eel was that close.

No significant injuries this time. A slight jellyfish sting and lots of no-see-'ums, that's it.

Happy New Year to Our Readers

2011-12-31T23:03:00.000-05:00

Saying goodbye to 2011 and a warm welcome to 2012.

We wish you all a healthy and happy New Year.

Be safe.

Merry Christmas!

2011-12-25T12:43:00.000-05:00

Best wishes to our readers, listeners and followers. May you have peace, blessings and good health now and in the New Year.

NYT: When Lobotomy Was Seen as Advanced

2011-12-24T12:56:00.002-05:00

This is an eye-opening essay about how lobotomies were used back in the day.
[posted via email]
From The New York Times:
ESSAY: When Lobotomy Was Seen as Advanced
New research indicating that Eva Perón was lobotomized not long before her death is a reminder of how enthusiastically this operation was once embraced.
http://nyti.ms/tRibGb

NYT: Story about Antonio Lambert and Peer Counseling

2011-12-24T12:53:00.002-05:00

This is a great story about turning around ones life with addiction and mental illness, giving back by training others to do peer counseling, which is such a proven strategy that Medicaid will pay for it.
[posted via email]
From The New York Times:
LIVES RESTORED : After Drugs and Dark Times, Helping Others to Stand Back Up
The mental health care system has long made use of former patients as counselors, like Antonio Lambert, an ex-convict turned mental health educator in Delaware.
http://nyti.ms/uxDM2Y

Podcast 64: Brain Freeze

2011-12-22T06:46:00.067-05:00

Happy Holidays, everyone. We taped this a few weeks ago, but Shrinky Podcasts always make for good holiday chatter. Today we talk about
1) Brain Freeze-- inspired by a Well article in the NYTimes for 11/10 on Rick Perry's Brain Freeze. You'll note that in this podcast, Dinah reads Roy's mind, and no has brain freeze from eating cold ice cream. We kind of ramble, and so what else is new? We talk about memory and attention and learning and Dinah explains why men don't take out the garbage during football games. Clink talks about the scientific phenomena of "brain overload."

2) Siri-- ah, we did this podcast right after I got my new iPhone and it was new and exciting and I was working on an article on Siri and the Psychiatrist. We ask Siri where we can buy a duck and when the world will end. Apparently we have 5 billion years. And Sigourney Weaver was 62 years, 1 month, and 5 days old at the time we recorded.

3) Prison Food-- inspired by a lawsuit in which a prisoner contends that the soy-based food being served in prison is 'cruel and unusual punishment' which caused him cramps. Clink talks about how prison food is handled. She also talks about nutrient rich Nutraloaf that can be eaten without utensils and she discusses an NPR story which includes the recipe for anyone who would like to try nutraloaf.

If you'd like to try it:
Special Management Meal
Yield - Three Loaves

• 6 slices whole wheat bread, finely chopped
• 4 ounces imitation cheddar cheese, finely grated
• 4 ounces raw carrots, finely grated
• 12 ounces spinach, canned, drained
• 2 cups dried Great Northern Beans, soaked,
cooked and drained
• 4 tablespoons vegetable oil
• 6 ounces potato flakes, dehydrated
• 6 ounces tomato paste
• 8 ounces powdered skim milk
• 4 ounces raisins

From Clink: You mispelled nutraloaf. Don't worry, I fixed it. Also, by pure coincidence today's correctional nursing topic on Lorry Schoenley's Blogtalk radio show was all about managing food allergies in corrections. For those of you who want to know what happens to inmates with peanut allergies, here it is directly from someone in the know.

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Does Mental Illness Make People Better Leaders?

2011-12-20T23:26:00.001-05:00

We've talked before about whether people with mental illnesses can be politicians (or pilots, or doctors). Today, on Midday with Dan Rodricks on WYPR, psychiatrist Nassir Ghaemi, author of A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness makes the case that in good times, we need sane and stable leaders, but that in difficult times, "insanity produces good results" and that in hard times those with mental illness are better leaders. He talks about how mood disorders lead people to be more realistic, empathetic, resilient, and creative. Want to hear more? Click HERE to listen.

Kind of nice to hear a positive take on psychiatric disorders for a change. Tell me what you think.

Missed Opportunities?

2011-12-18T23:24:00.000-05:00

Before I begin, I wanted to let you know that ClinkShrink wrote a post called Can You Tame Wild Women? over on our Shrink Rap News blog this week.
____________________________
When we talk about psychotherapy, one aspect of what we look at is the process of what occurs in the therapeutic relationship. This is an important part of psychodynamic-based psychotherapy, meaning psychotherapy that is derived from the theories put forth by Freud. Psychoanalysis (the purest form of psychodynamic psychotherapy) includes an emphasis on events that occurred during childhood, and a focus on understanding what goes on in the relationship between the therapist and the patient, including the transference and counter-transference.

In some of our posts, our friend Jesse has commented about how it's important to understand what transpires in the mind of the patient when certain things are said and done. Let me tell you that Jesse is a wonderful psychiatrist, he is warm and caring and attentive and gentle, and he's had extensive training in the analytic method, he's on my list of who I go to when I need help, so while I want to discuss this concept, I don't want anyone, especially Jesse, to think I don't respect him. With that disclaimer.....

On my tongue-in-cheek post on What to Get Your Psychiatrist for the Holidays, Jesse wrote:

When I say the Shrink should look at the context, even in small matters a gift might come with a subtext: "I just told you some terrible things about me and I want to be sure you still like me." It can be a bribe. It can be a seduction. It can simply be a gift given out of gratitude. The important concept is that we think about everything. Unlike a physical examination done by an internist, everything that occurs might be some window into how we can help the patient, and we do not want to lose that opportunity.

So wait, the patient comes to me because he symptoms of a mental disorder, often depression or anxiety, or problems controlling his behavior, or he's overwhelmed with stress and isn't coping well. Why is it so important that we understand every aspect of the sub-texted interactions? How does this cure mental illness? Why is it bad to accept (or not) a gift and move on? Why do we have to think about everything? And if it's really important, won't it come up again? Is it really crucial that we not lose that opportunity? Maybe I just want to take the cookies and say 'thank you' because

A) I don't want to hurt my patient's feelings,
B) it can be difficult to look at the meaning without upsetting the patient or putting the patient on the defensive and so the patient has to be fully on-board for this type of therapy and those patients generally don't bring gifts (ah, maybe we should be asking all analytic patients why they didn't bring gifts, now that might yield interesting information), and
C) I like cookies.

So the truth is that on these posts, the comments are always the most interesting part, so do write in and let me know what you think, not specifically about the cookie/holiday gift example, but about how important it is to understand the interactions that occur within the context of the psychotherapeutic relationship.

Just so everyone knows that I am still Jesse's friend, I am posting the video he sent me of his late grand-chinchilla, Chinstrap. And yes, Jesse had a grand-chinchilla. He does assure me that Chinstrap was having a good time in this video, because I wondered.

And I'd like to thank Steve over at Thought Broadcast for providing the graphic for today's post.

Shrink Rap

A Matter of Perspective

Follow Up on Sam and Our Survey

When Adult Children Shun Their Parents

Top 21 Most Discussed Shrink Rap Posts in 2011

The Privileged Patient

The Opinionater on The Age of Anxiety

Our Interview with Dan Rodricks on WYPR

Involuntary Commitment: Would you do it Again?

What We Need

The Shrink Rappers on Midday with Dan Rodricks: Monday, January 16 @ 1 PM

Midday with Dan Rodricks

I'm Sorry

Baby's First Laptop

Top 25 Shrink Rap Posts of All Time

Forced Treatment: Does it Help?

Podcast 65: Copyrighting the Brain

Top 25 Most Popular Shrink Rap Posts from 2011

What Makes a Good Psychiatrist?

Ducking Around

Happy New Year to Our Readers

Merry Christmas!

NYT: When Lobotomy Was Seen as Advanced

NYT: Story about Antonio Lambert and Peer Counseling

Podcast 64: Brain Freeze

Does Mental Illness Make People Better Leaders?

Missed Opportunities?