Wednesday, September 13, 2006

Behind Closed Doors

[posted by dinah and this may be part 4 in a multi-part series on psychotherapy, but i'm not exactly sure]

Let me begin by telling you about The Martian. This was a patient who was treated by ClinkShrink on the inpatient unit when we infant psychiatry residents together, and I assumed his care as an outpatient. He was a weird little guy who dressed like he'd popped out of another century. He was college-educated, worked, lived alone, didn't drive (this is notable in Baltimore, our mass transit system is awful), had no friends, had never dated (he was middle-aged), had never had sex, but he wanted to get married. How that might happen wasn't clear, but he did let me know that he would never have sex with a wife. The depression that had resulted in his hospitalization had responded well to medication; he came to see me for therapy and to continue the medication. Why The Martian? Ask Clink, she chose the nickname.

He came, he talked. I discussed him with my supervisor. The patient had a dream about the therapy. The supervisor said this was common early on. He said I was doing a good job. At some point, I forget why, he stopped coming, still unmarried, still a martian, but not depressed, and I'm not aware of any problems-- if I'm remembering correctly, he left pleased with his treatment.

Residents change supervisors every six months. My next supervisor was someone Fat Doctor might call Famous Psychiatrist (oh, we trained at a place where there are lots of Famous Psychiatrists, this one can be Very Famous Psychiatrist). I'm not Fat Doctor, so I'll just call him my supervisor. He heard about the case and wanted to know why the patient was coming. "So, he's coming to therapy because he wants to get married?" Well no, but probably that would be an okay goal by supervisor. I didn't know what to say. "Why are you letting this patient talk about his childhood?" Wow? I was a very new psychiatrist, I thought the patients were supposed to talk about their childhoods. Please don't tell my former supervisor, but years later, I still let patients talk about what they want in therapy, even if I do begin with a bit of role induction and some general directions, and even if I do sometimes point out that they might want to use the time a little differently. How come the last supervisor thought I was doing okay with this case? How come the patient hadn't seemed displeased or shocked by his care?

It's common knowledge that if you consult a surgeon, she'll recommend surgery-- well, mostly, it's kind of a joke, sort of not really, but you get the point. If you see an acupuncturist about your pain, you get acupuncture, if you see a physical therapist, you get physical therapy, and most internists/general practitioners/family practice docs would probably prescribe an antibiotic if you showed up with a fever, productive cough, and infiltrate on CXR.

And most psychiatrists will prescribe an anti-depressant, probably an SSRI--for a first time affair, if you show up complaining of depressed mood, anhedonia, sleep, appetite, libido changes, guilt and suicidal ideation. And most psychiatrists will prescribe an anti-psychotic agent if you're hearing voices or having delusional beliefs that the FBI is watching you through gadgets they've surgically implanted in you while you slept.

But what psychiatry doesn't have a consensus on is how long we see our patients for (oh somewhere between 5 and 55 minutes a session) or how often (somewhere between once a day and once a year) we see them, never mind whether we call what we do "psychotherapy" or how, exactly, we define and justify what it is we're working on during those psychotherapy sessions. Do we need to "justify" seeing patients for psychotherapy? Well, sort of: insurance companies want treatment plans, and as a society we spend a lot of money on psychotherapy...if it's your own funds it's one thing, but a significant portion of psychotherapy dollars come from insurance and government dollars. Even as psychotherapist who believes that therapy can be tremendously useful, I'm all in favor of thinking about why we're doing what we're doing and if it is effective and makes sense.

From a patient's point of view, especially the first time around (-- ah, mental illnesses are often either chronic or recurrent, there is a learn-as-you-go patient phenomena), the patient is someone who is suffering: a psychiatrist is recommended by a friend, a family doctor, an ER/inpatient unit, an insurance plan, and the patient goes. The very same patient could walk into ten different doors and be told he needs ten different things: anything from start this medicine, it takes a month to tell if it's going to work/ or more accurately to tell if it's not going to work: "come back then" to "you're a perfect candidate for psychoanalysis, five times a week and it will take years." Granted, even I don't think many psychoanalysts make such a recommendation on the first visit, but once or twice a week psychotherapy is often suggested. Or cognitive behavioral therapy with a more definative number of suggested sessions. Or, the patient is handed a prescription and told to see someone else for psychotherapy. In community mental health centers, where many people with chronic mental illnesses or limited resources, get their care, treatment is, if nothing else, a bit more uniform (I've worked at a bunch of clinics, in Baltimore, but also briefly in Louisiana during my Katrina stint, and it was the same there). Patients are seen by therapists (generally social workers), somewhere between once and twice a month, more often for some patients if the therapist and patient both have the time and interest, and the patient sees a psychiatrist-- monthly in some clinics, every 90 days in others if things are going smoothly. Still, I've seen new patients in a clinic-- depressed with some suicidal ideas, started them on a medication, and as I've walked out of the room, heard the therapist give them an appointment to return in a month and " go to the ER if you feel suicidal" (hmmm, I was thinking more along the lines of Come-Back-In-2 to 3-Days...).

I'm rambling (I'm prone to that), but my point is, despite practice guidelines, DSM-99R diagnostic guides, and lots of efforts to prove that what we do is useful, psychiatry continues to lack consensus about what it is we do, particularly with regard to psychotherapy, and we don't even have an adequate or consistant vocabulary to define what really happens when we sit alone in a room with a patient. I'll go on to say that while we might all agree on how to log what medications we prescribe (name, dose, route, number of pills, refills), we don't even have a consistant agreement about what it is we write in notes that go in the charts.

Okay, I'm off to do something.....


Anonymous said...

I have two thoughts about this topic:

1. Income generally determines whether or not a patient receives psychotherapy, how often and for how long. Those who can self pay have the widest array of options; those with Medicaid or no money have the fewest.

2. Maybe, just maybe psychotherapy is not a medical treatment at all and is not amenable to the kinds of measures of effectiveness, outcome and standardization that medical research prefers.

Fat Doctor said...

This is interesting. First of all, I probably wouldn't have called him Famous Psychiatrist but maybe Jerk Psychiatrist. But enough about me.

Many of my patients are tapped into one of the two local county health departments. One county has a psychiatrist that does therapy and med management. The other county has two psychiatrists that manage meds only. The patients check in only for a problem, otherwise every six months, then they see a "counselor" (which I assume means anything from social worker to psychologist to nurse practioner?). To me, the docs who don't do the therapy aren't seeing the whole picture.

I think I do more therapy in my office with these folks than they do in theirs. And I've had limited training. Maybe I'm messing these patients up really badly. Maybe I should talk about this with...a therapist.

DrivingMissMolly said...

I've been seeing a therapist for a couple of years now for free since I work at a university as does he, and seeing him is a benefit available to us.

It is only lately that I have become disatisfied, if only because I cannot see a measurable difference in my life and how I feel about it.

I saw a new psychiatrist last week for the first time ($350), and mentioned my confusion as to whether continue therapy with therapist or to see new psychiatrist for therapy. Am I just being resistant or difficult? At some point I would expect to see an improvement in the way I feel and I'm not feeling it.

My point as relates to this post is that new psychiatrist took no medical history and didn't ask me many questions. He let me talk. Somehow, I expect more. My insurance won't kick in until I meet a $2000 out of network deductible and I want a game plan.

I see Dr.Resident Supervisor & Professor again today ($190). He said he was going to contact my therapist and my prior two psychiatrists who he used to supervise (residents I saw as a grad student).

I hope he gets it together because I *need* him to get it together.

Suicide is cheaper.

Dinah said...

My quick thoughts:

We use psychotherapy to treat psychiatric illnesses and it seems to help-- I suppose that makes it a medical treatment. Certainly there are psychiatrists who put little stock in it. It clearly isn't as amenable to outcomes research as say mortality rates from a given surgical procedure. I'm not not much for answers, just like throwing out the ideas.

Never "Jerk Psychiatrist"...though certainly this supervisor has stimulated lots of to think about (he's known for it). "Why are you letting this patient talk about his childhood" is a Great question. I think now I could do a better job of articulating Why. Anything that someone said to me fifteen years ago that I'm thinking about now was clearly worth saying.

The initial session (or few sessions) with a psychiatrist are for evaluation, not psychotherapy. It's a different process with a different purpose and generally this includes coming up with a differential diagnosis and thinking about treatment options. Usually the shrink asks some questions...

Steve & Barb said...

[devil's advocate here]
yes, but a stroke or a traumatic brain injury can also be shown to cause neurological change, but I wouldn't call it a medical treatment.

Thus, some kind of brain change may be necessary to be considered a medical treatment, but is not sufficient.

It seems clear to me that both psychotherapy and pharmacotherapy cause changes at the neuronal and systems level in the brain, they just go about it in different ways. As a psychopharmacologist, I like to think of myself as like a brain surgeon, except I use millions of nano-scalpels.

Dinah said...

Roy, sweetheart, I guess consider yourself anything you want but stay away from my brain....

NeoNurseChic said...

Roy - can you help me with my pharmacology homework then? LOL j/k - I'm a pharmacology junkie! (Wait...that really doesn't sound right, does it?)

At any rate - just wanted to say hello from England! I'm the one from Bingham, Nottinghamshire, UK...depending on how that turns up on your google analytics. ;)

Take care!
Carrie :)