Monday, December 31, 2007

Top 25 Shrink Rap Posts for 2007

Happy New Year!!

Last year at this time, we gave you a Top 25 Posts of 2006 list, so we give you this year's countdown list now. (Yes, I will also do a Roy's Favorite Search Phrases of 2007, like I did last year.)

Last year, our main blog page had 27,809 page views, with 9991 "absolute unique visitors" (we started in April 2006, so last year was not a full year). In 2007, the main page had 70,166 views (173,444 page views for the entire site) and 67,867 absolute unique visitors. Thank you for your interest in Shrink Rap!

Last year our #1 post was Stopping the Scourge of P.E. (my post, as DrivingMissMolly pointed out). This year it is again one of mine, so I am challenging my co-bloggers to out-post me in 2008 (if you

Blog Post
25579The Well-Worried Well
24583Who Wants to be a Psychiatrist?
23586Roy's Top 10 Search Phrases of 2006
22586Personality Disorder?: Chloe O'Brian from "24"
21598The Co$t of Being Depressed
20619Transference To The Blog [a 2006 post]
19673Depakote & Ammonia
18689How This Shrink Picks A Sleep Medication
17694My Three Shrinks Podcast 1
16696Walk Like A Psychiatrist
15713FDA Drugs: February 2007
14725Put Down the Duckie: A Psychotherapeutic Study
13733What To Get Your Psychiatrist For Christmas, Hanukkah, or Kwanzaa
12733FDA Drugs: November 2006
11736True Confessions [a 2006 post]
10951What's Your Favorite SSRI?
9968Sex With Fish [a 2006 post]
81179How A Shrink Picks An Anti-Depressant
71184SSRI Antidepressants & Violence
61377What People Talk About In Therapy [a 2006 post]
51451Ritalin or Abilify for I.V. Amphetamine Dependence
41901Roy: Psych Notes for Smilies [a 2006 post]
32303Why I Still Prescribe Seroquel
22391Grand Rounds at Shrink Rap!
15987Why Docs Don't Like Xanax (some of us)

Sunday, December 30, 2007

Friends, Coffee, and of course, The New York Times Magazine

Happy New Year, everyone! As 2008 approaches, Roy, ClinkShrink and I will be meeting today (with the new & improved sound equipment) to record a podcast, and then I'm off to sip champagne on a warm and sunny beach. My friends, I trust, will hold the blog fort up.

So the other day, one of my kids asked me if I'd drive a bit and pick up one of their camp friends to spend the night. This child lives a fair distance and I've met only once, at a mall, when the two kids wanted to spend a little time together. This request was for me to pick the kid up, bring her home, and have her spend the night. A stranger to me, but a fellow camper to my child.

Some of my kids' friends see therapists and psychiatrists and take psychotropic medications. Some aren't so quiet it about it, I can be driving in a car and someone will pop out with "That's the building where my psychiatrist works!" Okay. But if they take medications while they're sleeping over my house, then I guess they do so quietly, no one's ever asked my assistance with any medication before. And a few, well, as they're jumping off my furniture in back flips, I just Know they must be taking Ritalin or something like it to get through the school day.

So I pick up the unknown camp kid and her mother hands me a bag of medications. I don't know mom, and I don't know the kid, and I don't imagine they know I'm a psychiatrist. "The instructions are on the bottles." Okay, I can do this.

The visit was uneventful, the child is lovely, patient with my kid who enlisted her help on an hours-long school project from Hell (don't ask, but if you're handy with a drill and have nothing better to do this afternoon, we could use your help here). As I handed the visitor her third mood stabilizer, I asked, "Do you feel differently if you don't take this?" "Not right away," she said.
And from today's Sunday New York Times Magazine and the recap of this year's The Lives They Lived Issue and some thoughts on mental illness:

Thomas F. Eagleton: The Running Mate Who Wasn't. Once his history of mental illness was revealed, his vice-presidential bid was over.
Marian Radke-Yarrow: The Anthropological Psychologist who studied the long-term effects of maternal unipolar and bipolar depression on the children of the afflicted.

and finally,
Allen Wheelis: A Neurotic's Neurotic a psychoanalyst writer who explored both his work and his own psyche. I'll give Dr. Wheelis, pictured above, the Shrink Rap quote of the day:

"I have not found in psychoanalysis the meaning I sought. I function as a guide to the lost, but do not myself know the way."

Thursday, December 27, 2007

The Patient Who Wouldn't Pay

I posted the latest poll on the sidebar and I thought there would be hands-down winner, that everyone would agree, the hardest thing to talk about in therapy is MONEY. Payment. Fees.

Maybe it's just from the therapist's side, but I HATE TALKING ABOUT MONEY. I really hate it. How much do I hate it? A lot.

On the phone before I meet someone, I'm very clear about a bunch of money things-- I hate this, it turns me off, but people have the right to know what they're getting into and if it isn't clear there are a lot of misunderstandings. So I don't participate with insurance companies, the patient needs to pay up front and then submit the bill so the insurance company will reimburse him directly. He needs to call the insurance company before he even comes in-- it's called "preauthorization" and if you don't jump through this hoop, some companies will refuse to reimburse at all. Many companies have a separate managed care component for mental health and ask for a treatment plan. The patient needs to find out how many visits he has before a treatment plan needs to be submitted (it may be 1, it may be 8, it may be 11, it may be never) and he has to to tell me Where to send the treatment plan to. Then he has to count the appointments so I know when the next treatment plan is due (--oh, actually I have a system for doing this, but it doesn't hurt to have a back up reminder). I tell the patient the cost of the evaluation and the cost of a regular 50 minute session. I tell them to expect to pay at the time of the visit-- that's the most comfortable way I've found to say it. A lot of people say "no thanks, I'll find someone in my network," and that's fine. I say a few other things too, like how to find my office and what to expect, and that it's fine to bring someone if that will be helpful, and definitely bring your medications.

I hate talking about money (did I mention that?). What I don't do is ask for payment during the session, it feels tacky. Most people write a check at the end---they were told this is the policy on the phone. If they don't, I send a bill at the end of the month, with all the other bills. The majority of people mail or bring a check, and it's just not a problem. Here and there, someone just doesn't pay. I hate asking. Eventually, I ask. Usually I don't, and eventually the patient pays, but I've been stiffed by a few people.

There was once a woman who'd seen me for years, payed at every session, and then had an unexpected financial crisis and now was really struggling. I didn't ask her to pay for the full session, instead, I nagged her to submit to her insurance company and at least pay the portion they would pay. Should I mention that the reason for her unexpected crisis was that she outspent her excessive standard of living? I've had this happen a few times, and I tell people to catch up at they rate that they can. In the case of people who have had true crises (lost jobs with few assets any way), I will slide their fee. But I'm not so comfortable doing that when the patient drives a late model luxury car or owns a vacation home. I'm sympathetic to their sudden financial plight, but I need to make a living, too. My hardest is the patient who struggles and struggles just to make a living, sleeps on the couches of friends, every purchase is a hardship, and I would say "forget it," I'll see you for free, but for that little drug habit--- if you can swing upwards of $50/week on your habit, another $50 for your cigarettes, a few bottles of wine, then maybe it's good to make a minimal payment on your shrink bill to that shrink who calls around to get you free samples.

Do you want to hear about the surgeon who came twice and never paid the bill? Or the patient who moans about every dime of the bill and the struggles to get reimbursed, but spends in a way most people wouldn't dream of spending on luxury trips, 5-star restaurants, homes so big the utility bills are bigger than his medical bills? Or the few patients I've seen who simply didn't pay at all--even after being asked, uncomfortably, repeatedly, just said "next time," or "I'll send a check" or "I did send a check." The odd thing is these aren't people who are talking about their financial hardships, they're people who are talking about their vacations and boats. The reality is they make a profit by not paying, because they get reimbursed by their insurance companies (often these same patients will ask to have the statements regenerated two or three times), but they never pass along the fee. This is called fraud, I believe.

Uncomfortably, I've been left to say on a few occasions, "Why don't you catch up and then call to schedule the next appointment." I hate talking about money.

I'm sorry, I sound bitter and this is an issue with so very few people. Most people, if they fall behind, they say something and I'm happy to have them catch up at their own pace, and they do. Nothing specific set me off tonight, I just was surprised that more people have trouble talking about sex than money. Maybe I'm feeling a little Grinchy. You can guess which I'd rather talk about.

Monday, December 24, 2007

My Recycled Post, Back Again After Technical Difficulties

Don't ask, this is recycled from last year. It was gone, now it's back, unfortunately the three new comments were lost.

Please vote on our sidebar poll if you haven't already...

Wishing you all the best....

What To Get Your Psychiatrist For Christmas, Hanukkah, or Kwanzaa

One commenter (was it Sarebear?) mentioned some time ago that she didn't know what to get her psychiatrist for the holidays. I thought about this and decided the answer is easy:
Give your psychiatrist a holiday card and write something meaningful and kind in it. Say, "Thanks for helping me." Or "I'm glad you're in my life." "You're the best psychiatrist in the world" works nicely, too. If you hate your psychiatrist and for inexplicable reasons feel compelled to get them something anyway, then skip the note and just give a generic Seasons Greetings card.

Don't get your psychiatrist an expensive gift. And don't, not even as a joke, give your psychiatrist money or make comments about a holiday "tip."

So gifts and shrinks are often an unsettling combination. As psychiatrists, we're taught that treatment is offered for a fee. End of discussion and anything more represents a violation of boundaries. Psychiatrists in training are told not to accept gifts, and psychotherapists as a whole are taught to try to understand behaviors that skim the usual boundaries. So, theoretically, the psychiatrist should refuse the gift and explore with the patient what meaning the gift, the refusal, the whole exchange, has to the patient.

When residents ask me what to do when patients want to give them gifts, I say "Tell them the program has rules that say you're not allowed to accept gifts." This is the truth and the resident risks getting in trouble if they do accept gifts. If you can't take a pen from a drug rep anymore, why should you be allowed to take a timeshare from a patient? (Okay, I made that up, I've never heard of a patient gifting a resident with a timeshare, but we can all have fantasies, right?)

I'm in private practice, there's no program director, I make the rules. When a patient gives me a gift, I accept it and say, "Thank you." Why? Because it seems intentionally hurtful to do otherwise-- I assume it has meaning to the patient, that their feelings will be hurt if I refuse the gift, that the patient has taken the time, effort, and money to pick out a gift and this represents something meaningful to him and that it might be painful to have this refused. While the act of giving a gift might have a multitude of meanings, depending on the gift, depending on the patient's illness, depending on the circumstances, I just can't find a way to say No that would feel anything other than rejecting. So I accept the gift and thank the patient, and if the gift is edible, I eat it. This is the thing though: while I've decided that this is the way to go, at least so far for me within the realm of my own practice, I always feel like I'm doing something wrong by accepting a gift, training issues remain in the back of my head, and I'd really rather just have a card that says I'm the best psychiatrist in the world.

Disclaimer in honor of Dr. A, Fat Doctor, Flea, Midwife with a Knife and other non-shrink physicians: Doctors in other specialties have no such concerns with accepting gifts. They probably don't want anything that taxes your budget. Food is usually good, a bottle of wine, a plant, candles, all will do nicely. Fat Doctor, I hear, is in need of some good toe nail polish remover.


Sarebear said...

It was someone else, actually, but I'm tickled to be mentioned in a Shrink Rap post! I commented under that person about wondering about holiday cards and such.

Oh, another thing I thought of, is there is a website, where you can pick which program you want to donate to, and do it in someone's name even.

The programs are various ones like getting geese for people to raise (in third world countries) to make some income for them, and many other things that provide purpose and opportunity and other helpful things for people in difficult times in countries like that. I think you can even just buy one chick towards the program for someone . . . Anyway, doing that in someone's name, say, $10 towards improving someone's life in another country, and then put that on a certificate inside a card you give your mental health professional, I thought would be a way to give a gift to your ologist, iatrist, what have you, and yet it's a , well, it's a gift that's non-refuseable, and I don't think, inappropriate under these or most any other circumstances, either.

Plus, it feels good. I'll haveta look up that site and post it here, and you can put it in your post if you look into it and like it and find it a useful solution to the gift problem.

I must say, as a patient, being so grateful for the help my ologist gives me, that there's just times where I wish I could mark say the anniversary of starting therapy, or something, in a meaningful way that I can share with him (aside from working on myself, which I know is what he would like the most). So a small donation to that sort of thing I thought would be copacetic. (I hope I used that word right, lol).

Oh, and is that sareBARE a Freudian slip on your part? Hee hee.

Roy said...


Sarebear, this is just the best thing. I've heard of these "microloans", where you loan someone money to buy a goat, they turn it into a cheese- & milk-selling business in their village, and pay back the money over time, plus a small amount of interest. There are others that just give the money away.

But combining these idea with that of a gift to someone else is great. Especially if one can somehow track the individual's success (how cool is that to check out your goat-guy's site 2 years later to see that he now owns 50 goats and employs 12 villagers).

I haven't completely checked these out, but here are a few sites which appear to do something like this...

Universal Giving
Village Banking

ClinkShrink said...

When I was a resident I had a psychotic inpatient who wanted a pass to leave the unit. The nurses were really busy and the policy said that patients had to be escorted whenever they left the unit. I was going stir crazy, so I volunteered to escort him. We went across the street to the drug store where he bought cigarettes (yes, he heard about that from me) then on the way back we stopped at the hospital library so he could return a book. (The librarian recognized him and called him by name, which I thought was a good sign.) When we got back to the unit he pulled a playing card out of his pocket (the eight of clubs) and handed to me, thanking him for the time off the unit.

To this day I don't know for sure what that playing card represented. I had a vague sense then that it served some protective function, but for all I know he could have meant "you are cursed and will turn into a duck within three days". I'm not sure if I accepted a gift or not.

Regardless, periodically since then when I've been in risky or uncomfortable situations I sometimes think to myself, "It's OK, I've got my eight of clubs." The magic may have worn off by now, but at least I haven't turned into a duck.

Roy said...

According to this site, the eight of clubs signifies "INSTABILITY - Internal strife; the foundations within are crumbling.".

Perhaps he was trying to tell you something?

(Okay, maybe not the most reliable site...'s interpretation seems less ominous.)

Dinah said...

Sarebear: oops! I fixed your name.

Wow! What an idea. Can I feed someone in a third world country a dinner of duck in cherry sauce and give this as a gift to Clink? I can hear her asking why I didn't feed her....

And Roy, should I donate Macs and IPODs to someone in third world countries in you name?

So I started thinking, can I make a donation in honor of my patients? Then I realized I can't use their names.

For those who want to stay closer to home, there are Foodbanks to feed the hungry locals, in Baltimore there is HealthCare for the Homeless.

Clink, hang on to that card, you never know.

ClinkShrink said...

Eight? Did I say eight? I meant six. The six of clubs is much better:

Naivete; failure to attempt to understand the world around one."

Yeah, that's it. Much better than instability.

Dinah you always feed me great. As long as you don't feed me to the homeless I'll never complain.

Anonymous said...

I gave mine a rechargeable flashlight with a note that expressed my thanks for his help in illuminating a difficult path I was walking. Corny, but less than $10, and my appreciation was real.

Sarebear said...

Glad you like the idea!

Feeling more secure, and less drafty in here in my sarebearishness. Hee hee.

Dreaming again said...

My therapists birthday was in October. She'd recently moved offices I gave her a gift for her office. A decorative candle.

I have been wondering about the holidays and my psychiatrist this year. Last year, Thanksgiving time, I mailed him a letter, first time, rather intense, about some childhood memories that I'd realized carried more significance than I'd given them credit for.

He'd gotten the letter, and because it came Thanksgiving week, just figured it was a Thanksgiving letter (he'd gotten several Thanksgiving cards). When I had an appointment the next week and had to have him read the letter in front of me ...I realized NEVER send through the mail an emergency letter at holiday time!!!!

Maybe this year, I'll just give him an autographed copy of my book when it comes out ...hmmmm

Midwife with a Knife said...

Hm... you know, a card that says, "You're the best obstetrician in the world" would go a long way. My favorite "gift" hass always been baby pictures, even if by email, of babies I've delivered.

Even though I'm still in training, and with student loans and all am kind of "poor", now my patients are much poorer than I am, and recieving a gift from someone who couldn't really afford it would just make me feel weird.

Pictures of moms and/or babies who are alive and doing well, however, is something I can save and look at when I've had a hard day (like a maternal or fetal/neonatal death) to remind myself that sometimes moms and/or babies are alive and well, mabe even because of my involvement in a case. I think that giving someone a goat is great (especially
under the circumstances sarebear detailed), but if you're looking to give me something that I will get maximum enjoyment, peace of mind, courage, and...well... courage and peace, just give me some baby pictures. :)

I don't really know what the psychiatric equivalent of baby pictures is, really... unless it actually is a card that says, "You're the best psychiatrist in the world!"; you know, something that you can look at when you've had a day where everything seems really bad, and feel like you're OK.

I think that people don't appreciate what a precious gift those baby pictures can be sometimes. So, everybody, give your OB those cute baby pictures, even if you think they might be annoying, they're not. Your obstetrician probably looks at them in the middle of the night while delivering a stillborn child and thinks that maybe they can come and do this job another day.

healthpsych said...

When I was on internship, one of my patients gave me a framed photograph she'd taken herself. It was great, I loved it and really appreciated the thought behind it but I was very uncomfortable. It didn't seem appropriate to take it because of the boundaries reasons yet I also felt that it was offered with good intentions and would be potentially hurtful to refuse. I knew the no gift rule but my supervisor said it really was dependent on the nature of the gift. A box of chocolates - not so bad - something more personal like this, trickier. In the end, she advised me to accept it. After that, I think they elaborated on the 'no gifts' policy in their intake information - that would definitely make it easier to explain away refusal and reduce the likelihood of offence.

One of the other interns got given some sexy lingerie by one of her famle patients...I'm glad I didn't have that particular dilemma!

jw said...

Well, you give a Canadian psych timmies! (Tim Horton's Coffee, Canada's national food).

Anonymous said...

As a BPD masochist, my psychiatrist dropped me from his practice in October 2005. For Christmas last year I gave him a $50 gift certificate to a cool Indian restaurant near his office.

I would have liked a thank you--even if it was scrawled on a PostIt note.

DrivingMissMolly said...

I'm glad to see this addressed here. Before I gave my last psychiatrist a gift, I researched gift appropriateness on the Internet. There are some strong admonishments for not accepting, but there are strong reasons to accept as well, especially those involving rejection causing hurt to a patient.

After much deliberation I decided it would be alright to bring him a gift at our last session (he was a resident), since it was a termination gift and of modest value.

I ordered two moleskine notebooks for him because I liked the symbolism of blank notebooks for a resident/baby psychoanalyst.

I wrapped them in black organza ribbon and sewed gold tassels to the ribbon ends. I expressed my gratitude and my best wishes for a happy career and personal life in a blank card I attached behind the notebooks. I then shoved it all into a paper bag.

At the end of our last session I pulled the bag out and said; "I got you something." He turned red. I handed it to him and said something brief. Then I got up and fled as quickly as I could because I was afraid he would reject it and I wanted the card to speak for itself.

I heard him call my name as I got on the elevator but I kept going...

This holiday I have a new shrink. I know he is Jewish. I don't know what, if anything I'll get him. He is so new to me. I was thinking of a charitable donation in his name accompanied by my usual UNICEF card.

Last year I got therapist a huge poinsettia for the office. I think items for the office aren't as personal feeling so they may be more acceptable to patient and therapist or psychiatrist.

Thanks for the post, Dinah.

Thanks Dr. R

NeoNurseChic said...

I like the poinsettia thing... My current doctor's office is so barren - he seriously needs a picture on the wall or SOMEthing! Not that I will do anything - but that would be nice. His old office had a picture on the wall and he had a nice comfy couch in there. Must've been a permanent office fixture because now his office has your standard teacher's desk, a desk chair, another standard desk chair for patients to sit in, a computer, and 2 shelves that he's filled with books. That's it. Of course, in his last office, he had no window - and now he has a really nice big window - that looks over a parking lot but still. Perfect window for people watching I guess!

I've always known about the receiving gifts thing because honestly they hammer nurses about it (and anyone who works in a hospital) quite a bit, too. I can see where it is a bigger issue in psychiatry than in other specialties because if you accept or refuse the gift, it means different things and both could be good or bad...and that's completely discounting what the gift even is.

Guess that's certainly a different way of accepting a gift, whether it be something physical or something that I might say about our work together.

Just an interesting insight to me!

Dinah said...

Actually, I would like to suggest that giving a photo of a baby you gave birth to, or a CD of yourself performing, isn't really a "gift" in that it's not something you've gone to the store and purchased of monetary value to give someone for only their benefit, but that as sweet and touching as it is, it is really more a gift of sharing yourself, and that even the pickiest of psychiatrists would be hard pressed to refuse or be anything but honored by such a gift.

I'm not sure what to say about office gifts. I have a book in my waiting room that a patient gave me for it, I think she wanted to share this with others in distress (it's called The Blue Day Book) and I've had many comments about the book, all positive, and I've told her that people have liked it. I'm not sure what I would do if a patient gave me something I didn't like, but I would probably feel obligated to display it if that's what the patient wanted.

Still, the card saying I'm the best psychiatrist in the world would make my day, if anyone wants (I've never gotten one). A charity contribution (I like HealthCare for the Homeless) would be great, and I'd be pleased to be honored with financing someone's goat in a developing country. I may get this for Roy for the holidays. Clink gets a used playing card, maybe the ace of spades.

Sarebear said...

The Blue Day book . . . is that one of those ones w/funny animal pics and great captions to go with them?

Someone mailed me this book, years ago, and it's the beginnings of my "rainy day" kit, for when I'm having a really bad day.

Course, I don't know where I put the basket I was starting to put stuff in, like Sense and Sensibility, The Blue Day book, and a few other things.

If that's the book I'm thinking of, the same guy has done other ones, that I wish my family and friends would give me to cheer me up. They really give me a giggle.

If I was waiting in a psychiatrist's waiting area and saw that book, I'd instantly know, or rather, think I know, that they had a sense of fun and humor.

NeoNurseChic said...

But I still bought the cds I used to record my recitals on...and paid $200 and $150 respectively to have them professionally recorded. Come to think of it, I should be charging people for copies of it, no? LOL

Just kidding around here...

I do like the Blue Day book. My mom gave it to me when I was a student at Penn State - during one of my times when I wasn't doing so hot. I saw another one by the same author recently and really wanted to purchase it, but I haven't yet! I even have the blue day journal - my blue day journal is filled with quotes and song lyrics that I like. Then I started writing about my headaches in it at one point - just personal thoughts I'd had... I also have a list of friends and phone numbers in the back of it - whenever I made that list, it was a list of people I knew I could call and count on when I needed a friend. :)

Fat Doctor said...

Dinah: My silence was unintentional. I check in here daily but for some reason must have missed the day you posted this.

As for the toenail polish, I took a reader's advice and bought some pure acetone. Worked like a charm!

By the way, I want to thank you for picking up on some identifying information in one of my posts and alerting me to it. I fixed the post, as you can see, and didn't post your comment. I figured you'd understand. Sincere thanks!

guinness girl said...

Oh, yay! I give my therapist a nice card every year at Christmas, thanking her for helping me to enrich, improve, and understand my life. Glad I wasn't supposed to include a sweater or a gift card or, oh, say, a timeshare, too. :)

I'm new to Shrink Rap, but I came over from Fat Doctor's site. Any friend of hers is a friend of mine. :)

DrivingMissMolly said...

HEIFER INTERNATIONAL! That's the name of the place I used to get a catalog from that sells the animals! You can give bees, a water buffalo, a knitting basket, and many other things.

I wouldn't feel comfortable sending a "Your the best psychiarist in the world" card because well, as a borderline patient, I will hate him the next day anyway....Haahhahhaha. Sorry.

I noticed that my therapist has three "stick ups" on his bookshelf. I have wanted to tease him about them, but I am pretty reserved in RL. A good office gift would be a candle and warmer. Yankee Candle Company makes nice little holiday sets in various holiday-ish scents such as cinammon and balsam that might be enjoyable.

DrivingMissMolly said...

Dinah, Clink and Roy, Heifer International will allow you, for $20 to purchase a flock of ducks!!


jcat said...

I'm in South Africa, and I think we're a bit more relaxed about doctors accepting gifts from patients, as long as they aren't too costly.
I've been seeing my current psychiatrist for 18 months now. Didn't get him anything last xmas, cos I didn't feel like I knew him well enough. We have a kind of standing joke about his ultimate bribe being a Porsche Turbo Convertible, so for the anniversary of seeing him this year, I went to the Porshe dealer, and asked for the cheapest, identifiably Porsche Turbo part that they had - turned out to be a thing for the centre of the wheel, and cost very little, and gave that to him with a card that said that the best thing about a really horrid year had been seeing him.
For christmas this year, I bought a feng shui frog, that I really liked, and wrote a soppy card. I would be really hurt if he wouldn't accept something - it doesn't matter to me whether he displays it or not, but it means a lot to me to be able to acknowledge his help and caring, with a gift of something that I have put thought into.

Been seeing my psychologist for 3 years now, and our relationship is a lot less formal, especially seeing as she practices from home. So I know her pets, have met her fiance in passing - I buy birthday and christmas gifts for her, and we're both comfortable with that. Sometimes I'll take dog treats with me, or fresh biscuits - just small things to thank her for being there for me. She's gone out of her way to help me at times, like visiting me in hospital, and bringing things that she knew I needed. So it goes both ways.
I don't think that shrinks should have too much of a moral crisis over accepting presents - as long as they aren't way too personal (the underwear!!) or expensive. And as long as they are given without expectation, just to say thanks for caring.

Friday, December 21, 2007

Christmas Prize

Okay, you know that Max and I have coffee every morning with our favorite judge in hair curlers. I may have neglected to mention that we are often joined by Carol and her dog, Prize, and sometimes even Maria and her dog, Nelly. From 8 to 8:30 am, I host a dog party, a big dog party, a little dog party, good dogs, bad dogs, happy dogs, sad dogs.

This morning, in honor of the holiday season, Prize arrived all decked out. I kid you not. Max would never tolerate such a costume, but Prize didn't mind and Carol came bearing gifts, so all the more fun.

I'm not sure Shrink Rap or My Three Shrinks will look like over the next few days. Hoping to be off somewhere warm sometime soon, and Clink has gone skiing. Roy, perhaps can be counted on to put up the last of our podcasts (not the last ever, just the last one we did), a new & improved one with the new mics and firewire mixer.

I feel like we need a new sidebar poll, and I'm tired of meds, so I'll try something else. The question is for you, whether you're a shrink, a patient, or anyone else.

From all of the Shrink Rappers:
Happy Holidays!

Wednesday, December 19, 2007

Shiny Happy Person Hosts Grand Rounds Haikus

Hey, you've gotta get over and see SHP's Grand Rounds for this week.  She has done a great job of introducing each post with an haiku.  
Example (NeoNurseChic will like this one):

For pain sufferers
Some things may work better than
A blow on the head

Also, if you have a Medscape account (they are free) then you can read Nick Genes' interview with SHP, talking about how her bipolar disorder affects her writing and also about the NHS problem in Great Britain.

Monday, December 17, 2007

Poll Results: What's Your Favorite Anti-Psychotic Medication

Seroquel wins, by a lot.

Answer TextVotes%








Decanoate forms of Haldol or Prolixin (injection)64%


Clozaril (clozapine)21%

Other older neuroleptic (trilafon/navane/stelazine/moban/thorazine21%


Paliperidone0 0%


Please Scroll Down to see the "Other" write-in votes. I had technical difficulties importing the results from PollDaddy.


Other Votes

Here is a list of the 'other' votes that people have entered.

226895 Geritol

226131 none

225558 Achhhhhhhhhhhhhhhhhhhh!

220651 scotch

219200 gin

218589 ativan

217571 never mind, my some of the above is not listed

217569 alcohol plus some of the above and hope i die in my sleep.

212915 I say no to drugs

212159 Largacgactil


201494 Solian or Amisulphride

200957 None. They all turned me into an apathetic zombie

200956 I prefer the take-down

200347 old ones over the atypicals for sure.

Sunday, December 16, 2007

Shooter Psychology

It appears that I'm destined to blog about this. Every time a shooting spree hits the news and several people get killed, I get a note from somewhere asking if I heard about the story and my thoughts about it.

I have to say up front that I'm reluctant to blog about spree killers. I didn't blog about Cho and the Virginia Tech shootings or about the Amish school shootings or about the shootings at the Omaha shopping mall. And now we have the shootings in Colorado. These high profile media blitzes just strike me as disrespectful and hurtful to the victims and the victims' loved ones. I don't want to be another mental health talking head discussing the pop psychology of criminals. It makes the criminal take on an almost fictional quality, like a character in a television series, and turns a real human being into nothing more than a profile:

"He was drunk, he was high, he was poor, he was desparate, he was abandoned by his wife or girlfriend, fired from his job, facing jail time, always a loser, always a loner, he was quiet or cantankerous or paranoid and litiginous. He listened to heavy metal, listened to rap music, wore dark clothes, wore a trench coat, never spoke, he said hi to the neighbors, seemed like a nice guy, never thought he would do something like this."

For me, these stories aren't theoretical. They are my patients. I've known more than one spree killer and several hostage-takers, and I can tell you that there is no single monolithic answer to the question of why someone pulls the trigger. For me the most concerning reason was reflected in the suicide note left by the Omaha shooter. It said: "I want to be famous." And now, thanks to the New York Times, he is.

This leads me to the final reason I don't want to blog about spree shooters. Because somewhere out there, right now, there is a sad, angry, desperate person who also wants to be famous. I want that person to know that he will not be, at least not here on Shrink Rap.

Friday, December 14, 2007

Preconceived Notions

Roy referred a patient to me the other day. Thanks, Roy!

The patient made a point of telling me both on the phone and when we met that Dr. Roy had given her a list of psychiatrists, but he'd circled my name. Of the docs on the list, I was the one most highly recommended, or so the patient says.

When I was a new-be psychiatrist and someone came to me saying, "So-and-so says you're really good," I felt a bit uncomfortable, worried I'd disappoint. Sometimes patients came after 3 other shrinks didn't fix them, and I was fresh out of residency: it was a bit intimidating.

I've not done any research on this-- it's more anecdote and if I had real data, I assure you it would be useless---but now I like it when people walk in with the idea that I'm an extra-special shrink. A lot of treatment, especially the beginning of treatment, is about hope, and if people believe they're seeing someone good, someone better than the rest, they walk in hopeful and it seems to me that they're more likely to both connect with me easily and to get better.

There are lots of good psychiatrists in Baltimore, I'm nothing special. But if the patient comes expecting to be helped, chances are better that I'll succeed than disappoint.

Thursday, December 13, 2007

Glow in the Dark Cats

Apparently, the South Koreans have cloned Glow-In-The-Dark Cats
! Wow!
Max and I want one. My family has never owned a cat, but just think how cool it would be to be the first on the block to have one of these? Hopefully they'll be easier to get than that Nintendo
Wii thing was.

Wednesday, December 12, 2007

Where Do Tests Come From?

I'm writing this post in followup to my previous post "How This Psychiatrist Thinks About Psychological Tests". In that post I wrote about the different types of psychological tests and why psychiatrists and psychologists use them. In this post I'm going to talk about how psychological tests get invented.

It's always something I thought would be a great gig to have: invent a psychological test, get a copyright, make sure it's good for something, then set up nationwide seminars to train and certify people to use it and sell the test to them. Talk about a self-made entrepreneur!

But there's a reason why everybody isn't doing this. It's because inventing a test---I mean one that is actually meaningful and useful---is actually quite hard to do. Drug companies spend loads of money inventing new drugs only to have them go down in flames during the clinical trials; the same thing happens with psychological tests.

To illustrate the process, let's imagine that we are going to invent a test that would be useful to the blog. We want a tool that will measure the degree to which a post (or blogger, or podcast guest) will entertain a reader or listener. Let's call it the Shrink Rap Silliness Inventory (SRSI).

The first thing you do is scour the literature looking for existing tests that are supposed to do what you want. In our case, there is nothing out there already in use that measures silliness. If we found such a test we'd look at the research behind the test to see what we presently know about the silliness measuring business. This literature review might tell us that there are various characteristics that are indicators of silliness: a tendency to wear big floppy shoes, to talk in a funny voice, to be a Monty Python fan, or to be named Roy (sorry Roy, couldn't resist). We'd use this information to put together the items used in the SRSI. The items might be questions that the subject/patient has to answer (eg. "Is your name Roy?") or observations that the test administrator makes (eg. "On a scale of 1 to 7, how big and floppy are this subject's shoes?"). Once you have a series of experimental test items put together, you're ready to start taking your SRSI for a test run (pardon the pun) to see how well it works.

The first thing you have to figure out is whether or not the test actually measures what you want it to measure---this is known as validity. We want the SRSI to measure silliness when it's present and to rule out subjects who aren't silly. In order to do this you have to give your test to groups of people known to be silly and others who aren't, and compare their scores. If SRSI scores are high for known silly folks (say, students at the local clown college or improv group) and low for non-silly folks (maybe your local newscasters) then this suggests your test is valid because it can distinguish between groups. This is analogous to using a medical laboratory test to distinguish between diseased and healthy people. There are other ways of proving test validity, but this is the usual starting point.

The second thing you have to prove is test reliability. In other words, that you can trust the test to measure things stably over time. We want the SRSI to work every time, like a car that will start in cold weather. You check for this by giving the test repeatedly to the same person or group of people over time and comparing their scores. Since we know silliness is always consistent, we want SRSI scores to be stable too---this is known as test-retest reliability. We also want lots of people to be able to use the test and have it work well for all of them. So we give the SRSI to a lot of people and have them each rate the same subject. If the SRSI scores all turn out the same we know our test has good inter-rater reliability.

Finally, you want to know how likely it is that your test score is going to be wrong. There are two ways a test score could be wrong: if a silly person gets a low SRSI score that would be an error known as a false negative test; if a non-silly person gets a high score that's a false positive test. We would have to look at our test data and figure out the percentage of times the SRSI gets a wrong score, either false positive or false negative.

This is just a portion of the research that has to go into inventing a good psychological or medical test. If we manage to jump through all these hurdles then you'd go on to do research to see if the test actually gives us useful information----if podcast guests with high SRSI scores give us better iTunes ratings and downloads, or higher visitor counts on days when they guest blog. We could even have SRSI scores for each of us Shrink Rappers! But I guess that comes back to my original issue with psychological tests---I don't need a test to tell me that Roy would be silliest.


(Alright, you have to admit that inkblot looks like a pelvis. I can't be the only one seeing body parts here.)

Tuesday, December 11, 2007

Previews of Coming Events

Don't forget to listen to the latest Podcast, #37, out of order with the old equipment, sort of like a check that got cashed late! Roy will be posting the newest one soon. Our podcast schedule can be found at My Three Shrinks or by clicking on the three feet logo on the sidebar.

I will soon be posting the results of our Anti-Psychotics poll, if you haven't voted, please do. You can have a favorite even if you don't prescribe or take them. We're not picky. Seroquel remains in first place.

ClinkShrink tells me has some posts ready to go. I'm waiting patiently.

I've got a post brewing in my head about how a patient's expectations effect treatment before they even walk in the door-- this idea with thanks to Roy.

And I think Rach asked about how it effects a psychiatrist if they have their own mental illness. A while back, I wrote a post that sort of addressed this. See what you think.

Sunday, December 09, 2007

My Three Shrinks Podcast 37: Poop-Out

[36] . . . [37] . . . [38] . . . [All]

Sorry for the delay in getting podcasts out, folks. This one may be a bit confusing, as we recorded it prior to the new sound equipment, so it is not "new and improved". This is actually #37. So, the next one to come out will be #39 (later this week... really! :-).

December 9, 2007: #37 Poop-Out

Topics include:

Find show notes with links at: The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.

Friday, December 07, 2007

How This Psychiatrist Thinks About Psychological Tests

First a big thank you to Gerbil for giving me the idea for this post. In a comment on my post "What Good Are Psychologists?" she mentioned psychiatrists who refer patients for diagnostic psychological testing. It got me thinking---this is a good thing---about why I do (or don't do) what I do.

I have to say I hardly ever request psychological tests. Even before I started working in prison, it just wasn't something I routinely did with my patients. When I was in residency we had lectures from psychologists about the different types of tests and what they're indicated for and a few things about interpretation, and later psychologists I've worked with have told me that I have a better understanding of testing than the average psychiatrist, but I'm not sure what that means.

For the lay readers among us, there are some general categories of psychological tests. There are personality tests that measures different character traits. There are intelligence tests that measure IQ. There are projective tests that are used to get an understanding of the person's interpersonal dynamics and style of thinking. There are neuropsychological tests that measure a person's cognitive capacity---ability to learn and remember, use language, coordinate eye-hand movements and so forth.

In general, when thinking about tests you have to consider what it is you're trying to figure out. If you have a patient who is failing in school you might want to order IQ or other achievement tests to see if the personal has a developmental disability or learning disability. If the patient has had a head injury or you think he or she might be getting demented you'd order neuropsychological testing. If you have a patient in therapy and you want material that might be useful to help the patient understand his own inner workings, you'd request projective testing and/or personality testing. Some tests are used as tools to predict certain things: whether or not someone would perform well on a certain job or whether or not they will re-offend as criminals.

It's important for tests to be used as part of an overall patient assessment. Test results fit into a whole database of information that a psychiatrist considers when making a diagnosis or putting together a treatment plan, in addition to a good patient history and a review of available treatment records.

It's also important to know whether or not the given test has been validated for your particular patient because 'normal' test results can be different for different groups of people. A test is only as good as the patients it's been based upon. For example, normal results for the original Minnesota Multiphasic Personality Inventory (MMPI, a test used to diagnose psychiatric disorders) was originally based upon only 500 people living in Minnesota. Much as I would like to think that Minnesota should be the gold standard for normalcy, this just isn't realistic. I mean really---Baltimoreans would end up looking pretty depressed compared to them. This is where a big limitation comes into play for me working in prison---many psychological tests have not been validated for use in prisoners.

Similarly, predictive tests only give group predictions and aren't necessarily reliable for the individual. A certain score on the Hare Psychopathy Checklist might give you a result that the patient has a 15% chance of re-offending, but that just means that out of 100 people with an identical score 85 will not re-offend and 15 will. The score doesn't tell you which of the two groups your patient will actually be in. The other trick with using tests to predict things is that many tests used for prediction have never been proven to have predictive value---there is no test to predict 'good parenthood', for example, yet psychological tests are used constantly in custody evaluations. It's important to know the limits of the test.

So...which tests do I actually use?

In prison the most common test I use is the Mini-Mental State Examination (MMSE). It was invented by two psychiatrists as a quick bedside test of cognitive functioning. You can give it in about ten minutes and it's a great way of measuring how brain impairment changes over time. You use it to check to see if someone's delirium is resolving, or as a screening tool for problems that should be investigated further.

In free society the most common tests I used, besides the MMSE, were general symptom inventories. For example, the Beck Depression Inventory (BDI) is a nice tool for measuring the severity of depressive symptoms. It's used to screen people for depression and also to monitor reponse to treatment.

I never use projective testing, mainly because I've never found it particularly useful for anything---maybe I would if I had a psychotherapy practice but even then I don't know too many psychiatrists who use them. I'd probably use neuropsychological tests if I could, but these are very specialized tests that have to be administered by a neuropsychologist (a subspecialty of psychology) and I don't know of any prisons who have one of those.

So that's my take on psychological tests. Thanks, Gerbil.