Saturday, July 21, 2007

Let Me Make Myself Perfectly Clear

Over the last two weeks, ClinkShrink and I have written a series of posts about the flow of information between therapist and patient, and the flow of information between those parties and their blog readers! Let Me Tell You About Myself looks at the issue of therapists divulging to patients that they themselves have a mental illness. Let Me Tell You About My Patient went on to talk about confidentiality issues in therapy when the psychiatrist has a blog, and Let Me Tell You About My Doctor asks whether it's okay for a patient to write blog posts about their physicians. These posts received a lot of comments, discussion, and brought up a lot of feelings on the part of the both our readers and we three bloggers.

Let me tell you that while I love to stir things up a little, I've been surprised.

To be clear: I can only recall a few posts of our now 506 (yup) posts where I discussed a patient scenario-- the descriptions, the demographics and the issues at hand were all confabulated to the point of fiction and the patients were not recognizable, they are essentially literary Avatars. The posts were about me and my feelings. Of the few (maybe 2-3) posts where I've painted a scenario, the possibility arises that patient could visit the blog and say, "Hey, here's my doc, and I'm a criminal, and she wrote a post about being uncomfortable about treating someone who's a criminal (See: The Patient As Criminal) but I don't drive a Porsche, or wear a Rolex watch, or have 3 kids, or even own a blue suit." The "patient" might have some discomfort learning that I'm uncomfortable (hmmm, Tony seems to know Dr. Melfi was pretty ill at ease).

The truth is, I feel a twinge whenever I so much as mention the existence of a patient. A what if scenario.... so remember my post about my chaotic day where I told a patient (no details about patient at all) that I'd return her call but I then threw my cell phone, with her phone number, into my washing machine? I wondered, what if this patient told all her friends, "I called this ditzy shrink who lost my number in her submerged cell phone," and then her friends saw my post, they'd know who her doc was! Funny, but I don't worry about what if she runs into a friend in my waiting room, who then knows who her shrink is.

I guess the real issue here is one of discomfort, my own and yours, and the theoretical discomfort of any patients who stumble across this. Readers have made comments discussing how they wouldn't like their psychiatrists to have a blog, how they'd worry about their confidentiality, and how it might be uncomfortable to know their psychiatrist in the way that Clink, Roy, and I have let ourselves be known on Shrink Rap. Mine is a more intimate and playful voice than I use with patients. Clearly I might be a little uncomfortable sharing this world depending on my patient's response, and truly I hope I don't make my patients uneasy.

I think the bigger issue is one of Who we Hope our Docs will be outside the office and how much a professional is obligated to live their personal life to a set of fantasized standards-- we'd all like to think our physicians are upstanding, totally moral, law-abiding, healthy-living, paragons of practice-what-they-preach and the existence of a blog threatens that fantasy. It's just docs and shrinks, it's all the folks we see as taking care of us from our yoga instructor to our elected officials and many of us have feelings about what our presidents do with their cigars.

There is no issue at Shrink Rap about ethical violations, power struggles, damages, breach of trust, or lawsuits-- things that came up in our comment section. It's all about comfort and discomfort, I saw the issue as being smaller than the discussion grew it to. This is not to scold, it's just to express my surprise.

Finally, my thoughts about patients blogging about their docs. If the doc is written about in a derogatory way with any possible identifying information, then I think there are better ways of complaining about a doc. If you're writing about your sessions, if your blog post is therapy for your therapy (!), and your shrink is identifiable, I guess I think you should let that be known to the doc. I don't believe that because someone has a psychiatric disorder, anything they say is immedicately discounted. I just don't. Mostly, it's about human courtesy and mutual respect. We're still all just figuring out the rules here.

So Roy asked me not to stir everyone up. I hope this is okay.
And please remember to tell us who you are on our sidebar.


Anonymous said...

I fully expect that, out of the office, shrinks or any docs for that matter, will display the same human failings and frailties as anyone. They have relationship troubles, get divorced, fight over Facebook with their kids, don't even know their kids are on Facebook (!), may have a mental health disorder, smoke, drink, swear, fart, argue with their siblings over their mother's will . In short, all the good stuff. I don't give a rat's posterior about any of that as long as they behave professionally and as long as they are basically decent, well intentioned sorts, who may screw up at times. When they do screw up, I darned well expect them to take a look at that if the screw up affects their dealings with me.So, in their capacity as a professional, they had better act professionally. Blogging is a whole new world, yes? There are two of you who are right out there. Clink is really good with the undercover thing. The other two bloggers are out, one openly, and the other blew his cover(he tells people he has a blog now anyway so I guess he can afford to be lazy that way).So, you write that this is a blog by psychiatrists, for psychiatrists. Haven't been keeping up to date with your poll, but it seems that psychiatrists are in the minority of your readership. I will take it then that the bloggers are the psychiatrists that this is all for.Okay.
If you haven't given away any patient details, and it doesn't seem that you have, you have given away a great deal of what you really think. Some of that comes out less in posts than in some of the comments to commenters as well as in the Podcasts.Or,in what you might have thought was a casual little line that you have long forgotten but that resonates with the readers, some anyway.And, you really do not know who your readers are, even with your little widgets.
It is all very interesting, but at the same time distressing. Yes distressing. I know, no one has to read it,but it is like the mountain that is there.
One of you once wrote about transference to the blog. It is strange how after reading something that riles me, I really don't want to show up to appointments. At other times, it makes me realize that i am lucky to have a doc who is not making jokes about drugs, being snarky or over the top goofy in a look at me , look at me kind of way. It almost feels like you are dying for attention after all the time put in listening to others.For other readers, it seems that some view you as an amalgam of their ideal shrink and that too is funny.
Po' Po' pitiful you, you want to write about resilience but you also want to bitch about filling out forms.

Anonymous said...

The three of us have had a great time with our blog/podcast. While I began with the idea that I'd like to have exchanges with psychiatrists, I believe we've all enjoyed, learned from, and even grown from the interactions we've had here and none of us are troubled by the fact that our readers/commenters include patients and bystanders and not just psychiatrists. We'll do this as long as it's fun, and no one talks about closing up shop because our readers aren't all shrinks. If we know who reads us, we cater our posts a bit, speak in more "plain english" and are thrilled that people want to read what we have to say. Maybe a chance to speak after a day of listening, and I will reserve the right to bitch about forms, it has nothing to do with with my feelings about my career or my patients.

Anonymous bloggers get themselves in trouble. No one here has said anything they'd be ashamed to own.

Our intent has never been to be disrespectful or disparaging. If anything has come off as snarky, thorny, or in any way mocking, this was not how it was meant to come from our hearts or be heard by anyone's ears.

I got an email recently from a local psychiatrist who said he'd emailed 120 of his patients a link to the My Three Shrinks podcast. What an honor and a compliment! I hope we don't disappoint him or his patients.

If Shrink Rap is unsettling, I'm not sure I understand why one would to read. The last comment felt like a plea to have us shut down.

Anonymous said...

It wasn't a plea, and as to why one would read if it distresses, that is very complicated. Some of us are into S.I. to begin with and another reason may be that one reads to confirm long held notions that people are not what they seem.Congratulations on your tremendous growth. Wouldn't mama be proud?

Midwife with a Knife said...

I, personally, enjoy it when y'all stir things up!

Alison Cummins said...

Part of the problem is strictly technical. Dinah, if you blog about a confabulated patient, nobody will recognise her. She could be anyone.

I cannot blog about a confabulated shrink except in a very limited way. I have a talk therapist and I have a psychiatrist, so I suppose that half the time I talk about my shrink I could pretend it was my talk therapist. Anyone who knows me who wanted to know the names of my shrinks, I would tell. (Don't you tell your friends the name of your dentist?)

What you are suggesting is that you can occasionally choose to blog about your feelings about your relationship with an unrecognisable or confabulated patient, but that you are asking me to never blog about my relationships with my treating professionals. Because they might be uncomfortable. Because for technical reasons I cannot sufficiently disguise their identities.

Or rather, that I may say nice things about them but that if I think they are being irresponsible (for instance if I say that I hate the fact that my talk therapist is counselling me to get off meds because it would make talk therapy more engaging, and if I explain all the reasons that this advice is so inappropriate and distressing) it would be impolite to say so. First because it's clear that I'm talking about my talk therapist and not my psychiatrist, and second because it's not complimentary and my talk therapist might feel uncomfortable knowing that other people know she says this kind of thing.

Just because I say something on my blog or in a comment doesn't mean I don't bring it up in therapy. (In both instances where the talk therapists made the above completely irresponsible suggestion, I did bring it up.) But is it so impolite to share this information with other psych patients that I should vow never to speak out? Does the fact that we have a limited number of health care providers and cannot sufficiently protect their anonymity mean that you are asking us to all suffer alone, not to share with one another what it is like to be on the receiving end of therapy - good or bad?

(Roy, this is empowerment?)

Dinah, I may have completely misunderstood, but I can't be the only one. If you are wondering why the strong reaction - this is why. Maybe I shouldn't have misunderstood, but I did. (And I'm pretty sure I am continuing to misunderstand, because your first post didn't upset me - I thought it was insufficiently thought through, but that's ok because it would be filled out by comments, and it was. Great. All as it should be. Your second post... seems defensive. Which is disappointing. When someone steps on my toe and I say Ow! You stepped on my toe! I expect them to absorb the new information I am providing and to remove their foot. If they instead become angry and say they didn't mean to, they missed the point. And I am disappointed in them and think less of them. Not for stepping on my toe, but for not being open to new information.

As a feminist, I am very aware of what women are asked to shut up about in the name of being polite, or considerate of other people's feelings, or protecting community institutions. As therapists, I would expect all of you to be similarly aware. (Though perhaps this isn't the first concern with Clinshrink's clientele.)

In general, I try not to make statements that put other people in a position of having to decide who is telling the truth, or to take sides. I think that's rude. I'll tell the truth as I experience it: that the mental health care I get is imperfect, dispensed as it is by fallible humans and with a limited budget; that in my own experience it has been imperfect in particular, predictable ways; that the problems I have encountered over years of trying to get appropriate mental health care are life-threatening; that I do not know what to do about it. That this lack of input to my own life-and-death issues is distressing to me.

I don't discuss previous therapists with my current therapist except in the most general terms. She knows some personally and I conceal that fact from her. Because I don't want to appear to be asking her to take sides. (If she knew who I was talking about by name, she would be in a position to weigh her credibility against mine, which I don't want to ask her to do.) Because I think that would cloud the professional relationship I wish to have with her as a particular person.

If I don't vent about previous therapists to my current therapist, who am I supposed to vent to exactly?

Where am I supposed to seek validation from someone with a similar experience except on the internet?

Yes, I'm upset. You brought up a topic of discussion and people who occupy the position of patient were upset. We talked about power imbalances.

But the discussion you brought up has been cut off. 1) There are no power imbalances. We won't talk about that because there is no need to. They don't exist. 2) Even if there are, if you don't like them it's not polite to say so on the internet because your therapist would rather you discussed them with her. It's not nice to air your dirty laundry in public, even if your life is at stake. (Especially if your life is at stake because saying so might be uncomplimentary to your therapist.)

I'm sorry, I'm disappointed. Not that the discussion was brought up, because it was timely (Black Wednesday was not that long ago) and generative, but because of the three shrinks' apparent reluctance to engage in the discussion they brought up, or to acknowledge that issues other than therapist comfort might be relevant to the discussion.

Like power.

(Oh, and if you want to take a peek at my own blog, it's

Gerbil said...

From my perspective on both sides of the proverbial couch, I found these posts and the discussions they generated really, really interesting--in a really, really complex way.

When I have my provider hat on, I'm restricted by law in what I can say about my clients. When I have my client hat on, I'm really only restricted by my own conscience.

This, too, is a power imbalance. It's just more subtle than the one we usually think of--the one in which the doctor has all of the power and the patient has none.

One final thought--if you're annoyed with your provider and blog about him/her by full name, are you in some way trying to discredit him/her? (And is this a micro version of cyber-bullying?)

For the record--I've never blogged about my clients or my own providers.

Anonymous said...

Alison has hit the nail on the head. The defensiveness, the outright denial of the doctor's power, and the suggestion that someone has "misunderstood". That is the tone and nature of the response from your end. All three ends. And that is the nature of the shrinky mind games that evoke strong reactions. Bidirectional. Like a shrink having a strong negative reaction to a strong negative reaction from a patient--the patient must have misunderstood, shift the conversation. Say something about how many of your patients adore you, you must be great, say that the patient has all the power in that they are free to leave treatment at any time and the doc won't go running after them to come back. Say that they may need to up their meds because they are being hypersensitive and that must be a symptom. Send them downstairs to Rite Aid and call in a heavy duty precription for some AP. Ask them why they keep coming if they have so many "issues". Then, refer them and send a letter to the new guy about what a difficult pt this one is.

Alison Cummins said...

I've been talking about the need to be heard, and I'm trying to find a way to hear Dinah.

An obstacle to communication here might be that we don't all share the same understanding of what "blogging about your doctor" means.

Does it mean me mentioning on my blog that I have a shrink or two? I'm identifiable and I have a blog, but I don't have a file on my providers that can be accessed by hospital staff that would allow anyone to identify my providers. Someone would either have to know me well enough to ask me for a reference to the shrink I love so much, or stalk me for months until I physically lead them to my provider. So I get a bit snifffy at the suggestion that I need to observe HIPAA-type restrictions to protect the confidentiality of my providers. (For instance, do not mention the shrink at all if the province they practice in can be deduced. Well, they live in the same province as me, so with this guideline I wouldn't even be able to mention the fact that I have any health-care providers. Not realistic.) I hope you understand my sniffiness with regards to this interpretation.

Does "blogging about your doctor" mean me creating a blog called and ranting about their incompetence and maliciousness every day?

Does it mean me posting angry rants on doctor-rating sites? (Regarding the side-thread on the credibility of mental health patients, I would never choose a mental health care provider based on posts by anonymous mentally ill people, whether they were positive or negative. Once I had chosen a provider and decided for myself that I was pleased/ambivalent/dissatisfied I might look them up to see how other people perceived them. But that's it. And I haven't yet.)

For the last two examples, I understand that being the target of either would be upsetting. I even know enough about the human condition to know that it would be more upsetting that I can imagine. (Kind of like malpractice suits - most members of the public don't think a malpractice suit would drive a doctor to suicide, but they apparently do. Regularly.) But from my perspective, you really just have to take it. You offer a public service to a paying clientele. People who offer commercial services or who sell consumer products also feel terrible about being attacked on blogs or in Consumer Reports or wherever, and they may feel horribly misunderstood, but they just have to suck it up.

I understand ranting about it. I understand foofoo and clinkshrink talking about the impact of public ranting by antisocial patients. (I think that's interesting. I think the discussions of the social context are limited, but if that's what we're talking about I don't feel sniffy at all.)

But I think the possibility of being the subject of public complaints is an integral part of the position you hold, just as a feeling of powerlessness is typically an integral part of the experience of being a patient. Ranting isn't going to do anything about it. You just need to find ways to cope anyway.

Does this help?

Gerbil said...

Alison--I agree about the definitional problem! Also, I suspect that we're all getting het up over whether it's okay to blog negatively about a provider. Because (except for those with extreme difficulty accepting positive feedback) very few people complain about being praised :)

Alison Cummins said...

Blogging about patients according to HIPAA:

"The following information must be removed:
- Names
- All geographic subdivisions smaller than a State including street address, city, county, precinct, zip code, and their equivalent geocodes
- All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older
- Full face photographic images and any comparable images
- Any other unique identifying number, characteristic, or code"

We know that you guys are in Baltimore, which is smaller than a state. According to these guidelines, you shouldn't be able to refer to anything other than a strictly imaginary patient because "Baltimore" is identifiable. As far as I know, none of you has violated it. Except perhaps Dinah talking about her criminal patient.

If you are asking me to observe the same guidelines, I would not be able to mention anyone other than a strictly hypothetical health care provider because I am known to live in Montreal. I certainly cannot refer to any experience I may have had myself. This is completely antithetical to... um... everything.

While the reasonableness of HIPAA restrictions on medical professionals is up for debate - and is in fact hotly debated - HIPAA does not apply to patients. Which I actually think is a good thing.

This is why we need some clarity here. What exactly is being asked of patient-bloggers?

Anonymous said...

No Dinah, you are not scolding. You are yelling through a blowhorn.
You blog, people respond. How would that give you the right to consider scolding?

Anonymous said...

there is so much more potential for abuse with the personal information that the doc has about the patient, than with the information that the patient has about the doc.
also, when it comes to thinking that the patient shouldn't write inflammatory statements about a doc, using his/her name in an identifying manner (i forget what all was said and this thing doesn't let me look at the post i'm commenting to as i'm writing the comment)... it's interesting to look at seeing a psychiatrist, therapist, phychologist, etc as paying for and receiving a service. personally, i have written about a past psychiatrist on
there are many health care professionals on there, right next to the lawyers, mechanics, babysitters, etc.
i'm not sure where i'm going with this... just thinking.

Roy said...

Seem to have hit a nerve here, and I'm trying to figure out what the hubbub's about.

To sum up, Dinah posts a message which essentially says "Docs can't post about their patients but their patients can post about them." [yes, that's true, deal with it, end of discussion]

Then, Clink posts about the correctional side, and suggests that people should not blog negatively about their therapists. [frankly, I don't see a problem with that other than I think that it is a good personal policy to be respectful of others --in general-- when talking to or about them, online or in Real Life, even when you disagree, whether patient, doctor, lawyer or candlestick maker -- yes, even when speaking "anonymously". ]

Finally, Dinah makes herself "perfectly clear", but clarity remains elusive. "What exactly is being asked of patient-bloggers?" I'm not asking anything, other than mutual respect. [Myself, I would handle disrespect (and by 'disrespect', I don't mean disagreement or dissatisfaction, but outright rudeness, which is starting to creep in here today) here in the same manner that I would in RL... by either pointing out that this is not fruitful or by disengaging from the individual until the rudeness ends.]

And that's about all I have on this topic.

All snarkiness aside, I'm gonna go get Podcast #29 ready, so that my mama will be proud.

redfawn said...

A Comment and A Question

I am a patient of a clinical psychologist and I have been looking for blogs other patients write between therapy, and I am considering writing my own. Can you recommend any good ones that you have seen where the person has been working with someone for a while and has developed a good amount of insight?

Because this is a blog for psychiatrists, I've just perused it. I feel a desire to respect your intention for the blog AND I also have a desire to maintain the veil so to speak for the sake of my own therapy relationship. It's kind of cool that your post stimulated the chance to really ask myself if I wanted to keep looking.

Also from the bit that I have read, I think the quality of questions you're asking is great. Plus in the days when I was submitting forms for health insurance for my therapy I sure could have used an outlet for my frustration! So I sympathize.

Sarebear said...

Before I read Roy's post, I was going to say, "I think alot is being read into Dinah that was . . . taken as meaning, by adding up posts (from different people, same blog, different people) that would not mean near what any of them alone, or attributed to their authors, mean, or has, by being read in series, on the same blog, and regarding a highly charged issue, been magnified in some aspects from what my perception of the original intents were/was."

After reading Roy's comment, I still say that. Just wanted to let you know it was on my mind before I read his.

I enjoy a lively discussion, but there are journeys beyond "lively".

Allison, it's my interpretation from my own point of view, of everything that's been posted and commented by the three shrinks on this, that it's more the kind of thing I've done, once or twice, on my blog, where I post negatively about my first psychiatrist and included his name.

While perhaps they wouldn't agree with or appreciate my occasional though much more rare negative blogging about my first psychiatrist (whom I referred to as 'ole Dorkface, or some such, in the comments on one of these posts; I mention that to show a little of what they might be talking about, not to throw it in their faces or anything), I think what might be almost incredulously, perhaps, in my guesstimation of intent and emotion and thoughts (yeah, yeah, mind-reading) be part of what is being objected to when they editorialize on this subject, is the TYPE of what I describe above in my paragraph that begins with Allison's name.

I'm not egocentric enough to think that any of these posts were posted BECAUSE of me, but it's my interpretation that what I've done may have been in their mind a bit, for SOME of the posts, after they started writing maybe, ESPECIALLY after my Dr. Dorkface comment. A small remembrance perhaps, if anything, brought perhaps more to the front by my . . . colorfully-put label of the . . . individual.

I understand that I may be partially or completely wrong.

Sarebear said...

I meant "my unnamed, occasional though much more . . ." etc. etc. etc.

While perhaps they wouldn't agree with or appreciate my occasional though much more rare negative blogging about my first psychiatrist

Anonymous said...

I think that this has been an unexpected emotional issue for everyone.

I get confidentiality.
I worked in an abortion clinic.
We were HIPAA decades before HIPPA

If we breeched confidential information, someone could die (I am not even going to acknowledge a debate on abortion)

There were times in which it pained me very much to keep patient records confidential.
I have had detectives investigating sexual crimes against children, and I told them they needed to have a court issued document to release info.

My point:

It can be very emotionally exhausting to a doctor to always have to bottled up their feelings inside. Many people find it theuraputic to "unload" the accumilated emotional junk at the end of the day. Doctors cannot vent to their spouses. This just sucks.

And for the patients reading this: doctors as a group are more likely to commit suicide than the population as a whole. So remember doctors are patients too)

Alison Cummins said...

Sigh. I had been intending to disengage - I was trying really hard not to be rude, but I think I'm just not getting it, so I'm being rude anyway, which I don't mean to - so I was just going to walk away.

But then I completely coincidentally saw this, which is too relevant to ignore.

"Most Recent Draft [of the Code of Ethics]

Clear representation of perspective - readers must understand the training and overall perspective of the author of a blog. Certainly bloggers can have opinions on subjects outside of their training, and these opinions may be true, but readers must have a place to look on a blog to get an idea of where this author is coming from. This also encompasses the idea of the distinction between advertisement and content. This does not preclude anonymous blogging, but it asks that even anonymous bloggers share the professional perspective from which they are blogging.

Confidentiality - Medical bloggers must respect the nature of the relationship between patient and medical professionals and the clear need for confidentiality. All discussions of patients must be done in a way in which patients' identity cannot be inferred.

Commercial Disclosure - the presence or absence of commercial ties of the author must be made clear for the readers. If the author is using their blog to pitch a product, it must be clear that they are doing that. Any ties to device manufacturer and/or pharmaceutical company ties must be clearly stated.

Reliability of Information - citing sources when appropriate and changing inaccuracies when they are pointed out

Courtesy - Bloggers should not engage in personal attacks, nor should they allow their commenters to do so. Debate and discussion of ideas is one of the major purposes of blogging. While the ideas people hold should be criticized and even confronted, the overall purpose is a discussion of ideas, not those who hold ideas.

DrivingMissMolly said...


I love you. I think you are warm, caring and smart.

I am really glad for this post.

I'm especially glad you clarified your tone. It was hard for me to imagine you as a psychiatrist (I confess that I HATE the word "shrink"). You always seemed too "soft" to me.

I like to imagine each of you as my psychiatrist sometimes and I always felt that I would just eat you for lunch if I were your patient. Now I see you hold your own.


DrivingMissMolly said...

If you self injure and something is a trigger for you, avoid it.

These guys aren't responsible for that. I read one book on SI with no problems, but when I got another from the library to read, it was very, very gory, and I felt, tempted.

That's probably the only book that was not only NOT returned late, but EARLY!


ania said...

Good morning,

I've read all (I think) of your posts since near the start of this venture.

I guess I'm surprised that anyone views ([any one/a couple/all] of) the three of you as disclosing information about your own self that might make them uncomfortable as a patient.

I find most personal things that you share to be mild, and generally just amusing or clarifying bits of information.

What blog is everyone else reading?

Take care.

ania said...

"venture" = blog. Not specifically the topic at hand.

Your Mother said...

Gosh, I think this and the related posts are really interesting, and I'm not a psychiatrist or a patient, just a self-conscious blogger.

jcat said...

Hey - I'm a patient, and I'd be flattered if my p-doc or t-doc thought about me enough out of a session to actually blog something about me.
I do - about them - but then I only have one of each, not a full case-load.
And I trust them both enough that if they were going to say something unkind, it would be something that they had brought up with me already.
Perhaps we should get bumper stickers made up saying 'Doctors are people too!'

ania said...

There was a very interesting Diane Rehm Show on yesterday (Tuesday July 24, 2007).

"Joshua Coleman: "When Parents Hurt" (Collins)
A clinical psychologist offers advice to parents who have difficult relationships with their adult children.

This is the link, Diane Rehm Show
Click on the program's title ("Joshua Coleman: "When Parents Hurt") on the left hand side of the page.

Take care.

Anonymous said...

Thanks for the supportive comments!
And Ania, thanks for the link, I passed it along...