For The Sake Of Argument

[Subtitle: Clink Takes The Bait]

But first, Good News for those following the HBO In Treatment Sub-Blog: Post on Sophie below this: Click Here.

If I were a trout I'd be three feet out of the water by now. Dinah's post "When A Shrink Picks A Benzodiazepine" is like a bright colorful feathered fly with a tantalizing spin. I tried resisting, but I just had to leap for it.

In my clinic today two patients had benzodiazepine issues. Patient One had been taking his mother's Xanax. Patient Two had his parole violated for a dirty urine. He said he had been getting his psychiatric care through a local program, but that they had only prescribed Xanax "to help me with my marijuana problem". I asked him what they were giving him for his bipolar disorder, and he said, "Oh nothing. Between the marijuana and the Xanax I was alright." Right.

I'd like to think the outpatient doctors for both Patient One and Patient Two were both as careful as Dinah. Hopefully they both took good substance abuse histories and knew their patients well. I'm sure they were well-intentioned. Right. The problem with the approach Dinah suggests is that people with active addictions aren't going to tell you about them. They're going to conceal their substance abuse histories and lie about the pharmacies they go to. Taking a history isn't going to help too much.

So for the sake of argument (and we do like to argue here at Shrink Rap!) let's say Patient One's mother has, as Dinah suggests, a fear of flying that necessitates occasional benzodiazepine use. So nervous flying mom also has a pot-smoking son who also drinks a bit (but is smart enough to hide the empties), a son who also snorts his Ritalin. Patient One's doctor takes a history and learns nervous flying mom has never abused alcohol or been dependent on drugs. He doesn't find out about snorting, pot-smoking son because nervous flying mom is clueless. He writes a prescription for a benzodiazepine and now pot-smoking son mentally blesses him whenever he opens his mom's medicine cabinet. And I have a new parole-violating patient. And mom's doctor never has a clue this is going on.

So when I hear about free society docs who never have a problem with patients on benzodiazepines, I can't help but wonder if the problems are truly that rare or if they just never find out about them. The patients disappear when the med gets tapered (or they get arrested) and the doc never hears the end of the story.

And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail. Thus, addicts from low socioeconomic classes are pretty much stuck buying their stuff off the street.

So I agree with Dinah that prescribing involves a risk-benefit assessment. I just don't get the part where the risk of temporary nervousness while flying outweighs the risk of diversion, misuse, abuse and dependence. I'm still working on that part.

(Dinah and I could keep this up until people beg for more In Treatment posts. I'll try to contain myself.)

HBO In Treatment: Sophie is Bullied Out of Her Suicidality

Sophie comes to a session with her mom after overdosing on her shrink's sleeping pills. She is non-stop hostile to mom, insulting, rude, angry. Paul gets to decide if she can go back to the gym and Olympic gymnast training (with the coach she's slept with), and Mom is not happy when Paul says she can go back. Mom storms off, leaving Paul to follow a distraught and angry Sophie around his office and to sit down on the couch next to her. He tells her that her suicide attempt was her way of "testing" him to see if he really loved her, and he barely passed the test-- he talks about how he has to find something he loves in every patient. Sophie is uneasy with this, and she talks about her dad, the only person in the world who really loves her, and she lies to Paul saying her dad visited her in the hospital. This we learn when a tearful mom pops back in to say Sophie can't go back to the gym, and Sophie insists that if she can't train, she'll kill herself. Paul tells her he can't treat her with the threat of suicide hanging over, that she can never come back to therapy if...if what? he doesn't say, I guess if she's suicidal, and Sophie promises not to kill herself while she's in therapy.

So the only reasonable person here is the tearful, dramatic, "surgically enhanced" mother.

We're left to wonder what issues has with his daughter Rosie (the one who sleeps with drug addicts, per stalker patient Alex) and how he's playing them out with Sophie.

The list of what Paul's done "wrong:"

--1) He hasn't reported the pedophile gymnastics coach, though he has thought about it.
--2) He's gotten Sophie out of the hospital immediately after a suicide attempt, rather then leave her there where she can be kept safe and carefully evaluated for a mood disorder. And he's painted the hospital as a bad place to be rescued from for someone who may well need to be there at some point.
--3) He's allowed himself to be the decision maker about sending someone back to gymnastics. At least he should fully hear the mom's reasons for not wanting to send her.
--4) He's telling a sexually abused 16 year old that he 'loves' her as he follows her way too closely around his office. And he tells her he trusts her after she's overdosed in his bathroom--- now why would he trust her? And she lies about her father visiting her in the hospital, why believe she's truthful about anything else?
--5) The kid's now on her 3rd serious suicide attempt in a short period of time (2 car accidents, one overdose) and he's just shut down the option for her to tell him when she's suicidal. "You can't come back to therapy, ever" --I could see telling someone this if they perhaps have another Attempt (and definitely, no therapy ever if you succeed at killing yourself!), but he says he can't operate under the threat of suicide. In other words, if you're thinking about it, keep it to yourself. It just doesn't cut it for psychiatric care.
--6) Paul tells Sophie why she tried to commit suicide in his office-- a theory he's now committed to (much the way Gina comes up with theories about his behavior), without even asking Sophie "why?" He's made a lot of assumptions and closed his eyes to other possibilities for her behavior.
--7) Paul is too invested in being liked by his patients and this blinds him from acting in their best interest.

Somebody remind me that it's just a TV show.

When A Shrink Picks A Benzodiazepine

I'm still talking about our not-so-favorite shrink medications, those calming, addictive benzodiazepines: valium, librium, ativan, klonopin, and everyone's favorite: Xanax.

If you listened to our podcast The Benzo Wars, you know this is a heated topic among the three Shrink Rappers, and then ClinkShrink had to go post again in Sober Thoughts. Okay, it finally happened, I finally agreed with something Clink said about benzos. She writes:

Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to.

ClinkShrink is right here: some patients take a medicine and it gathers a life of it's own, an addiction forms. And there's not a way of knowing if that post-operative Percocet will start an addiction or make the patient vomit or simply relieve the pain. Clink has made the point that it's never worth the risk in the case of benzodiazepines: take them and your life could dissolve and you could end up being her inmate.

While she's right about the unknown risk, I'll make the point that life is full of uncertainties. With her thinking, one should never try a drink-- it could (oh, and it often does) lead to alcoholism. I don't know when I prescribe any medication who will get diabetes from it, who will have a bad side effect, whose kidneys and thyroid will be compromised, who will become suicidal from that SSRI, or who will have a horrible time with withdrawal symptoms when they decide to stop it. I don't know who will become addicted, I do my best to take a guess.

I do prescribe benzodiazepines for short-term use for acute anxiety. I don't see a problem with giving someone a tablet of Ativan for an MRI or a few to deal with post-9/11 flying anxiety. And if someone is having panic attacks, they are a good temporary measure until a prophylactic agent kicks in. I've seen plenty of patients on benzodiazepines (yes, even Xanax) where I tell them to stop the medicine, and they do so without arguing, bargaining, complaining, or insisting it's the only thing that helps. I only prescribe them in my private practice where I follow the patients very closely and know them well. In the clinics where I've worked, very few doctors have used these medications, and it is very rare that I'll start them in that setting.

So what helps me feel a little more comfortable prescribing a benzodiazepine?

1) If a patient has been on them in the past and stopped them without difficulty. I don't hesitate to check with old docs and pharmacies.
2) If the patient has never had a problem with alcohol-- benzodiazepines bind to the same receptors and there is cross-tolerance.
3) If there is no personal history of substance abuse or addiction
4) If there is no family history of substance abuse or addiction
5) If the patient understands that it's a short-term solution, not a permanent thing.
6) And yes, I've had patients come to me already on these medications where I just can't get them to taper off and I can't really pinpoint how exactly the medication is hurting them. I will continue such a patient on a low dose. It's been just a handful of people over the years, most people don't seem to need or want chronic benzodiazepines.

Funny, but ClinkShink writes:

I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary.

My experience-- and I have no data to support this, it's just my "gut"-- is that when I tell patients that the medication can be addictive, the people who express concern are the ones I worry least about-- you're supposed to worry about getting addicted, you're supposed to watch out for a craving for the drug. It's the people who immediately say, "Oh, I won't get addicted," that I worry about the most.

Life is full of risks-- I'll give you a list if you'd like, but they'll include the heart attack you can have when you get on the treadmill and the concussion you can get when you fly off your bicycle.

At this point, I feel a little anxious when I write a new prescription for almost any medication.

HBO In Treatment: : Laura Says Goodbye, Alex Gets Espresso Dumped on Him

So Laura starts by announcing it's her final session. "How Do You Feel?" from both parties. Laura goes on to discuss how a 15 year-old nearly died during a simple surgery --apparently, Laura's an anesthesia resident....the attending was out of the room and Laura had never taken a patient to Recovery alone before and she didn't know what to do (Huh??). This brings us back to when Laura was a tender 15 year-old. her mother died and she talks about a relationship with a couple she stayed with that summer in California. We thought she never saw them again; oh, but now she says the husband stayed at her house or at the Hay Adams hotel in DC, for 2 months while he while he had a trial going on, and Laura had sex with him every day. When she'd previously told Paul that her "first" was a kid in high school, that had been a lie. Hard to know what's true here. Paul gets angry that the 40 year-old man who'd slept with her had a moral obligation to say No. It seems he's talking to himself. Laura needs a drink, something other than water (all these characters do is drink and go to the bathroom) and they linger over the espresso maker that Paul's patient Alex, who is also Laura's lover, has given him. And oh, the 15-year-old girl on the operating table almost died because Laura made a mistake because she was thinking about Paul. Good-bye and a lingering hug that leaves us wondering, but finally Laura exits. Good riddance. I have nothing to add.

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Okay, it's Alex's turn now. He's obnoxious, aggressive and hostile. He picks at Paul, constantly asking how he feels, asking if he's slept with Laura, insisting that therapy is reciprocal and "Don't you see how you twist things?" Paul wants Alex to talk about his father, and this does not go well. Alex has done his research--we'll call this Stalking-- he knows Paul's wife was in Italy having an affair, that his daughter is sleeping with drug addicts, and when he refers to patient Laura as a "slut," well that's when Paul loses it and physically assaults Alex. He throws his coffee and calls him a prick. End of session.

This is drama, it's not psychotherapy. Nothing even close to this ever goes on in my office. And I'm starting to wish I was more like Roy-- there are some things started that should not be finished. The whole thing stunk and as I watched, I peeled and de-veined shrimp for dinner.

Hollywood, Schizophrenia

I'm watching the Academy Awards. I'm betting on Atonement. You heard it hear first. I also loved Juno. We were going to do a podcast today, but Clink went to the opera. Roy and I and our beloved non-shrink proles went to see Vantage Point. Not shrinky, I leave it to Roy to find a way to blog about it.

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You can read about a new Schizophrenia medication in development in the New York Times business section: "Daring to Think Differently About Schizophrenia." LY2140023 works on glutamate receptors, a new approach but the article mentions that preliminary testing shows it to be slightly less effective than Zyprexa.

HBO In Treatment....Once A Patient, Always A Patient

Paul meets with Gina for supervision or debate team or personal torture or whatever you want to call it. He down plays his role in Sophie's overdose on his meds in his office, right after her meaningful "breakthrough." (I prefer patients not breakthrough quite like this, I wouldn't even like the back-flips off my couch). He told the psychiatrist at the hospital not to hospitalize her because she would feel he's abandoning her. OMG (to quote my 13 year old)--- her second serious suicide attempt in a couple of months and she's still seeing her coach who's slept with her-- and he PREVENTS her from going to a safer place for stabilization. Oh give me a break.

Gina and Paul talk in diffuse ways about diffuse things and who knows what it's all about. He's mad that she once wrote he was compromised by his wanting to please his patients, even though everything else in her letter was glowing. He carried the letter around for months in his pocket, it kept him from being the head of the Institute. They talk about Doris and the Institute. I don't know who Doris is and I don't care about the Institute. Paul tells Gina she's cold and has no empathy.

Finally, Paul engages Gina in one of those conversations about Why Can't I Have a Relationship With Laura, ....the personality disordered patient who is 20 years younger than he is.

Prole husband says: he wants permission to have an affair, and yet he goes to the person who he knows would never give it to him.

Dinah says: This show started off strong, Paul was a good and likable therapist the first week and lots of stuff was happening. Now, he's a creep, his own therapy/supervision sessions give insight into him not as a thoughtful therapist, but as a damaged man who can't negotiate his own family life and who has no sense of reasonable boundaries. His treatment of his supervisor is completely unrealistic--- he behaves like a narcissistic, entitled, and insensitive idiot. Who goes to a supervisor they have so much baggage with, and why do these two people sit in a room together pretending it's just fine that he's disrespectful and treading the line of abusive. And why do they both like it?

Hoping it's over soon. I've committed myself to blogging about it, I sort of like writing the blog, but I no longer like the TV show. Roy tells me our hits are way up since I started this, and last week we had over 5,000 page views. Unlike Roy, I tend to finish what I start. If you click the link, check out Roy's number 19.

Guest Blogger Eric Kuhn from CBS News on Easing the Pain

Hey, so we got an email from Eric at CBS. He wanted to tell us about a series CBS is doing on pain-- too late to watch, but I'll put up his synopsis and links. Cool stuff. And Eric, remember us when the Shrink Rappers get the book together!

Eric writes:

I have been reading your blog and think it is great. I thought you might be interested in a story that we are doing this week about pain.

EASING THE PAIN
February 19 – 21

Tuesday: NERVE STIMULATORS
Dr. Jon LaPook reported on a new kind of nerve stimulator in the final stage of FDA trials to treat pain. It's a headset that pulses electric currents to the back of the head and users say it works miracles to stop the throbbing. We follow a man with excruciating knee pain for a week of treatment to see firsthand what a difference it makes. It works because electrical currents somehow change the brain's perception of pain. Check it out the story that aired here - http://www.cbsnews.com/stories/2008/02/19/eveningnews/main3849876.shtml

Wednesday: ABUSE PROOF DRUGS
Dr. Jon LaPook examined the newest aspect of pain management, which are drugs that are called "Abuse Deterrent Opiates". These drugs can help prevent people from getting physically dependent on opiates, because they don't work if they're crushed and taken improperly. Doctors face a huge dilemma when trying to balance treatment and risk of addiction at the bedside. We'll meet people you'd never expect to become addicts, but who wound up getting hooked. We'll meet others for whom this new drug relieves the pain without risking addiction. Check it out here - http://www.cbsnews.com/stories/2008/02/20/eveningnews/main3854165.shtml

Thursday: BABIES' PAIN
CNN's Dr. Sanja Gupta reports on how there is no gold standard for measuring pain and discomfort in babies, especially newborns…however there is a clinical trial of a facial recognition technology to identify pain in infants. The initial research used photographs of infant faces but now there is research using video images. Catch this TONIGHT on the CBS Evening News with Katie Couric at 6:30 PM EST.

In Treatment: ....the sub-blog

I've fallen behind and life has gotten in the way, so I'm going to do a combination post as I catch up on this mostly snow day.

Therapist Paul and Patient Alex have a Pissing Contest.

At least this episode didn't hurt to watch. Alex shows up early, Paul lets him in (no waiting room). Alex insists on paying for the extra few minutes of time, and he throws the pro-rated fee in dollars and coins down on the table. Paul says he is demeaning him and showing his contempt. What a way to talk to a patient.

Alex wants to discuss his sexual encounter with other-patient Laura, but first he needs to know if Paul has sexual fantasies about his patients. Paul says he does. Can I go home now?

We hear again about the unsatisfactory sexual encounter, Paul points out some interesting dynamic interpretations to Alex as he makes himself espresso, and it seems Paul is having a difficult time treating patient man who slept with the patient he fantasizes sleeping with.

Suicidal Sophie

Sophie arrives all decked out-- up all night, full of tequila, status post bland sex. She talks about her mother, the shopping trip that led to the red striped shoes she's perched upon, her life after cast removal and her return to the gym. She does cartwheels and a backflip on Paul's couch, and she talks about how her accident was indeed a suicide attempt while Paul rubs her back. Sophie goes to the bathroom in her state of distress and once again, Dr. Paul is at the door asking "Are you okay." She opens the medicine cabinet, where Paul has conveniently left some pills--- freeze frame and I think they are a narcotic combo pill. Proll husband picks up that the bottle says "Baltimore" though the 301 area code sits better with my thought that it's the DC 'burbs. She pours the pills into her hands, we are left to assume she's taken them (oh, honey, not with all that tequila on board!!) and moments later, she passes out as she tries to exit the office.

What can I say? Husband gives his input: It's about therapy stirring the patient up and what kind of psychologist would leave drugs in the medicine cabinet for his patients?

Jake and Amy Bicker

Jake and Amy bicker. Not much else happens and I'm not sure what the point of the episode is. Too much "In Treatment" at once.

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"

That's exactly why we're blogging and podcasting about this. Thank you.

Shrinking the Shrink

Roy asked me to comment on Dr. Richard A. Friedman's article in yesterdays New York Times, "Have You Ever Been in Psychotherapy, Doctor?"

Dr. Friedman talks about a psychiatry resident-in-training who becomes uncomfortable when asked by a patient if he's ever been in therapy. He moves from the patient's question to the broader, much-discussed issue of whether it's necessary for a therapist to have been in therapy. Friedman reviews the issues that every psychiatry resident has heard and discussed--You don't need to have had brain surgery to be a neurosurgeon. Psychotherapy, it's said, is different. "One way to think about it is that a therapist should not start exploring a patient’s mind without really knowing what is in his own." He talks about understanding one's own feelings and being aware of counter-transference.

But even as we have been swept off our feet by sexy neuroscience, my field
is in danger of losing touch with the rich psychological life of patients, something that is reflected in the waning popularity of therapy during residency training.

All true, but we are far from understanding the ultimate cause of most psychiatric disorders, despite the promise of brain science. We can effectively relieve symptoms and increase functioning, but we still have to help our patients live with illness.

Psychiatrists who have had the humbling experience of therapy themselves know something of what it feels like to be a patient — the sense of frustration, anxiety and dependence it entails. As such, they can better understand the emotional reactions patients have to their illness — and to their doctors.

So do I think a psychiatrist needs to have had his/her own psychotherapy to be a good psychiatrist? Do I think the "humbling" experience of psychotherapy, or any other version of patient-hood, is necessary to create a good therapist?

Honestly, I have no idea. I'm not aware that anyone has every asked this question in a useful way. We'd have to survey patients and survey their shrinks, find measures to calculate good versus bad versus adequate docs and then we'd have to ask how much therapy, how often and by whom for it to "count." The psychoanalysts have made it a given, every psychoanalyst-in-training has to have completed a full psychoanalysis with a designated, experienced, "training" analyst. I'm not sure there's any reliability to who spends 4 years on the couch and who spends 10, but they've all been there. And are psychoanalysts "better" psychotherapists? I don't know.

I went to medical school in New York City when and where psychotherapy, and especially psychoanalysis, was still considered necessary for would-be psychiatrists. Part of "The unexamined life is not worth living," (thank you, Socrates) theory, I suppose. Still, when I started to see a psychiatry resident for my own therapy, I told no one and I worried about who would see me in the halls and what they might think. I was a medical student and I knew I'd be applying to that same department for residency ), so I worried about which supervisors talked about me with my resident doctor.

I only went for a little while, and this is what I can say about that particular psychotherapy experience: It was absolutely, and without a doubt, the most valuable experience I had in learning to become a psychotherapist.

Now, let me tell you about the psychiatry resident I saw. He was horrible. He wasn't a mean person in any way, but he wasn't a good therapist. No matter what I said, he'd say, "How would that make you feel?" Before I'd go to a session, I'd think about what I was going to say, and I'd think about how it would make me feel, and so I thought I had the bases covered. He'd still ask, "How would that make you feel?" I'd already told him! It was exasperating. I felt like he was a puppet of his supervisors, that he was wasn't thinking for himself. Years later, a classmate who was also going to be a psychiatrist and who was also in therapy with a resident in training, told me what safeguards were in place for student treatment, how the records were segregated and locked, and exactly who had access. Why hadn't my resident shrink just told me this? When I told him I worried about running into my advisor in the hall (who could have cared less that I was in therapy, I'm sure) why did he repeatedly ask "How Would that Make you Feel?" Why didn't he just tell me that my advisor didn't have access to my file?

I learned a lot about being frustrated as a patient. I learned an awful lot about what not to do, about how it leaves a patient feeling like you're not there with them.

Therapy is a kind of secretive mission-- perhaps why we enjoy the voyeuristic aspects of In Treatment and Jennifer Melfi's therapy with Tony Soprano. You can watch cardiac surgery. You can do it with a more experienced cardiac surgeon in the room. And Mirror Supervision for therapists is invaluable but often hard to arrange for. Mostly, we just try our best to report what happened to a supervisor, read books, try our best. What Dr. Friedman didn't mention is that being a psychotherapy patient is one of the very few ways that a therapist ever gets to see what goes on behind closed doors.

P.S. The resident who treated me for that brief period of time later went to work for a drug company. I'm sure he did a great job.

In Treatment....Episode? Lovely Laura

I'm a day behind and Roy wants me to write about a NY Times article on therapists in therapy. I'll get there.

So yesterday, Laura comes to talk about her sexual experiences with Paul's patient Alex. Way too much information. She is goading him, if I can't have you, then I'll sleep with Alex. Alex might as well be a dirty dish cloth. She returns to her feelings for Paul and pushes him: "Yes or No, Is this an intimate relationship." Paul says yes. She talks about hating herself, and this is where everything turns-- Paul talks about hating himself when he didn't do a good enough job caring for his ill mother when he was a child. They linger a little too closely as they say goodbye. And, oh, she owes him for the appointment.

So I didn't have a problem with Paul saying it was an intimate relationship, only this wasn't really the question. The question was "is this a special relationship?" He could have told her it was an intimate relationship, but that therapy is by it's nature intimate, instead the idea was transmitted that he also loves her.

Sometimes therapists decide it's useful to reveal personal information to patients. Sometimes it's comforting to know your doc has "been there." Here, however, Paul opens up his vulnerabilities to Laura at a time when he should be setting boundaries. He's let her know that he also lost his mother at a young age, he's "been there" but, like he told Gina, it feels like he knows where to press to get what he wants, and what he wants isn't what either of them should have....

Mid-life Suicide Rate Increases

The New York Times has a story today about the increasing rate of suicides in the 45-64 age set. It's worth reading to I thought I'd post it here for readers to surf to. Thanks to Patricia Cohen, who wrote the story.

It refers to a recent CDC report, which I could not find on the cdc.gov site (if someone finds it, please put a link in the comments). Here is a link to a .pdf CDC Fact Sheet on suicide.

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[Edit... added 2/20/2008, from additional info in comments]

Kudos to Bee! Thank you for finding the link to the Dec 14 2007 MMWR article.

Table 2 makes the point quite clearly.
From 1999 to 2004, the rate of identified suicides per 100,000 population in the 20-29 age group went from 12.3 to 12.4, a 1% increase.

The rate in the 45-54 age group went from 13.9 to 16.6, a 19% increase.

From the article: Among persons aged 45--54 years, the total injury mortality rate increased 24.5%, including an 87.0% increase in the mortality rate from unintentional poisoning (most commonly drug poisoning) and a 48.0% increase in suicide by hanging/suffocation...

[For the entire US population, i]ncreases in poisoning mortality accounted for 61.9% of the increase in unintentional injury, 28.0% of the increase in suicide, 81.2% of the increase in deaths from injury of undetermined intent, and 55.7% of the increase in total injury mortality.

The authors suggest that the increase in poisoning is mostly due to an increase in substance abuse. 6% of the poisonings were due to "psychoterapeutic drugs", while 47% were due to narcotics and hallucinogens [Table 2].

I note that Maryland is one of the 4 states that actually recorded a decrease in overall population poisoning deaths for this time period (hmm, despite Baltimore being the Heroin Capital?).

Grand Rounds is Up at Daily Interview

Hey, Grand Rounds is hosted this week at Daily Interview. While you're there, check out some of the interviews done so far. An impressive endeavor, to post an interview each day with someone, whether celebrity or not-yet.

My Three Shrinks Podcast 42: The Benzo Wars (or, Xanax Reloaded)

[41] . . . [42] . . . [43] . . . [All]

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Dinah, Clink and I get into a podcast brawl about the use of benzodiazepines (such as Xanax/alprazolam, Ativan/lorazepam, and Valium/diazepam) in the practice of psychiatry. See how many rounds we go, and who is left standing at the end.

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February 16, 2008: #42 The Benzo Wars

Topics include:

• Round 1: Why Docs Don't Like Xanax (or, Xanax Reloaded). This is what started it. Then there was Xanax Blues in Podcast 19. Also, this one from Oct 10.
  
  
• Round 2: Dose Dependence. Our blog commenters dissent.
  
  
• Round 3: Just Say No! Clink offers sage advise to fellow prescribers.
  
  
• Round 4: The Trouble with Tapering. How slow can you go? See Perchance to Dream.
  
  
• Round 5: Need It Versus Want It. Is there a difference?
  
  
• Final Round: Last Shrink Standing. What are the situations where you feel very uncomfortable prescribing benzodiazepines? Roy wraps things up by quoting from his Jan 12 comments from Dose Dependent.
  

[Ed: I forgot that I had transcribed a few comments from the podcast when I was on a plane recently. I've added them below, including the time in the podcast where they occur]

15:06 Dinah: "So, shut up a minute!"

17:20 Roy: "Benzo's modulate GABA receptors... You've got glutamate, which is an excitatory amino acid, and you've got GABA, which is an inhibitory amino acid. So, they kinda balance each other. If you have too much glutamate, that's bad, you can have ... seizures... If you have too much GABA, that's bad because then your brain is s-o s-l-o-w-e-d d-o-w-n that you can't do anything."
17:45 Dinah: "What's his point?"
18:00 Roy: "So, benzo's effectively increase the role that GABA plays in the brain. So does alcohol. In fact, for the most part, your brain can't tell the difference between alcohol and a benzo."

20:20 Roy: "You can be dependent but not addicted."
21:00 Clink: "Why is it that this [coming off Xanax] is so bothersome to you?"
21:22 Clink: "When you start hearing that 'this is the only thing that works', then the red flags should go up."
22:20 Clink: "I see the addictions that are started by physicians, and we need to address this as a reality."
24:00 Dinah: "We have this dilemma... is this a medicine that this person needs versus is this somebody who's addicted?"

24:20 Dinah: "There are circumstances where I encourage people to take benzos, and I'll tell you what they are..."
24:27 Roy: "Like now!"

Feel free to add your favorite quotes in the comments.

The background music is from the mash-up I made for podcast #24, Dr. Phil on Skype.

---

Find show notes with links at: http://mythreeshrinks.com/. 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 mythreeshrinks.com. Thank you for listening.

In Treatment: Episode ?....Paul Continues In Supervision With Gina, Sort Of

For those of you tired of In Treatment, there's a "real" post below. And Roy promises me he's putting up our heated to-benzo-or-not-to-benzo post today [20:31 ET: I'm working on it now. -R]. The end of this post talks about the differences between psychotherapy and clinical supervision.

So Paul returns to Gina for supervision. Every word out of her mouth, he jumps on. Why is he going? He blames her for encouraging him to terminate with Laura, the patient who wants to sleep with him, and he finally admits what we all knew: that he does, indeed, fantasize about Laura.

Every exchange between Paul and Gina is charged, aggressive, angry. These people want to be in a room together why?? They call it "supervision" and Paul talks about his fears that his urologist will think he has small genitalia. It all seems more like psychotherapy to me, not supervision. Angry psychotherapy without a clear agenda and purpose, at that. Paul is as defensive a supervisee as one could imagine any patient being. It's not fun to have this session on my TV screen, I personally, wouldn't want this guy in my office. Did I once say he, as an actor, is hot? I take it back. He started the series as a warm and likable therapist. Most of what happens on this show, no longer feels like anything that happens in my office. For this, I'm grateful.

One of our readers asked the difference between psychotherapy and supervision. Psychotherapy...well that's hard enough to define, but let's just say it's talk therapy to address a problem. We've been there in lots of posts before. It's all about the patient.

In supervision, a psychotherapists consults with another psychotherapist, usually someone older & wiser, about the treatment of patients. "Supervision" implies to me an ongoing process, while "consultation" can be a one-shot deal. The topic of discussion is generally limited to the patient and the interactions between the two of them. Certainly, the supervisee might bring up issues in his own life that feel relevant, but that's not main focus, and discussions of intimate personal matters aren't generally part of the discussion--- if the therapist needs that, a formal psychotherapy is more appropriate. Supervision isn't, by definition, cold or impersonal-- I always ask people I work with about their personal lives in some form-- how they are, if they have families, where they went for vacation, and they often ask the same of me. If a supervisee has been ill, they may chat about that, but it's generally determined by how much we 'click' and polite conversation.

Paul and Gina, the TV characters, can't decide what they're doing or even why they're doing it.

Co-Blogger Battle of the N=1 Post

OMG, I'm gonna kill her. Clink complained that I posted over her post, the one she put up to break up my monotonous In Treatment posts. So I re-posted her N=1 post with my intellectually stimulating comments at the beginning and the end in an effort to renew interest in this stimulating topic. This was at 1 AM after the 3 Shrink Rappers had been screaming at each other for 4 hours over a project unrelated to the blog. I got up this morning to see that at 6 AM (when do you sleep, girlfriend???) Clink removed my comments, remade them into another post, placed under the original post, given a similar name. Even I don't know what's flying here.

Some people are never happy.

[Note: This is Dinah's response to my N=1 post. They were originally put in my post, at the beginning and end, but I took them out and moved them here so it would be clear who was saying what. ---ClinkShrink]

We're getting mixed reviews on In Treatment. I'm sometimes enjoying the show, I think it brings up some real-life therapy issues, and I've been trying to talk more about those and less plot synopsis. ClinkShrink hates it, Roy is oblivious, and some of our readers say they miss the old Shrink Rap. It's not the old Shrink Rap, we've got a lot of Life Gets in The Way issues going on, one is that Clink's internet is on the fritz, and we're all involved in some other projects. I've given Roy a "To Do" list which includes posting the last podcast we did-- and we're not even married. We spent the whole podcast screaming about when, who, or even IF, benzodiazepines have a place in clinical practice, so if you've like the Xanax controversies on Shrink Rap, stay tuned and maybe put on your armor.

Okay, and ClinkShrink put up this post the other day to stimulate conversation about the role of doctors and patients in keeping down healthcare costs. It's not about the TV show. Ah, but I posted over it, so if you didn't read it, by all means.... and maybe Comcast will let Clink respond some day.....

So I read this and thought, wait, you don't think people should prescribe benzos for anxiety--they get people addicted, and you don't think people should take expensive meds like Seroquel, off-label for anxiety.....what do you want them to do?

Ah, but Clink says that's not the point of the post, the point is that we all have a role in helping keep down costs. I'm not sure what to do with that, when I have a patient in my office who is suffering-- I think best not cheapest. What's it worth dollarwise for a good night's sleep, or to stop those delusions, or to prevent an episode of mania, or to stop feeling suicidal? To make it so a patient only triple checks the locks? And what constitutes suffering??--Seroquel is perhaps okay if you're hearing voices but not if you're in the midst of an awful panic attack? Or people use it for insomnia, and isn't this an expensive treatment for insomnia, but what if it's the only thing that works or that isn't contraindicated. So we have these medicines, or expensive diagnostic procedures, we're left to ask how to ration them. Easy to blame the insurance companies for not forking over the bucks, or the docs for not being more diligent about cost-containment. But when I'm with a patient, I try to figure out what best helps the patient. Cost is in my head only if there are cheaper options that don't compromise care, have higher risks, or lower efficacy. Might be a little easier not to blame the insurance companies if we weren't reading articles like this from Boston.com:

November 19, 2007

RE "BLUE Cross gave chairman $16.4m in retirement pay: Van Faasen still on salary at insurer" (Business, Nov. 16): At a time when the cost of health insurance and the numbers of uninsured are rising, all sectors of the healthcare community must exercise prudent management of every healthcare dollar. This responsibility cannot be borne solely by the provider sector while the insurance industry passes expenses on to subscribers and employers.

Blue Cross and Blue Shield of Massachusetts voted its CEO a total of $19.4 million in salary and benefits while retaining him as chairman. Because Blue Cross-Blue Shield is a not-for-profit entity, Massachusetts considers it a public charity. As such, the insurer, its board of directors, and the state officials charged with the oversight of public charities should be held accountable by the citizens of the state for better guardianship of the public trust.

Dr. GERALD B. HEALY
Chicago

The N = 1 Trial

[Clink Note: First I put up this post, then Dinah posted over it, then she reposted it at the top of the blog with bookend comments. I've taken out her bookend comments and put them immediately after this post, so please do scroll down to read them or click here. Oy. My Comcast access has been really spotty or non-existant this week so I have to act fast while it's up.]

In the January edition of American Psychiatry News Dr. Glenn Treisman writes a critique of the "fail-first" policies of managed care organizations entitled Promoting The Concept Of The Individual Trial (free registration required to read the article). He begins with a brief case presentation of a patient who was successfully treated as an inpatient with a drug that was nonformulary according to his new insurance company. The patient was discharged and his outpatient doctor, who didn't have access to his previous treatment records, switched him to a different formulary medication which he had previously failed. The patient relapsed and required rehospitalization.

He begins with a critique of the idea of therapeutic equivalence. Therapeutic equivalence refers to the idea that different medications can be shown to be equally effective in treating a given medical condition. Dr. Treisman rightly points out that this evidence is based on treatment response of large groups of patients and may not be predictive for a given individual. For example, SSRI's as a whole may be equally effective in treating depression but a specific patient may find Zoloft more effective than Paxil. There may also be specific individual issues such as co-existing medical conditions that may influence a clinician's choice of medication. (See also Dinah and Roy's posts on How To Choose An Antidepressant, Part 1 and Part 2).

He goes on to attack what he refers to as a perversion of the term "evidence-based medicine". This term originally meant that doctors should base their treatment decisions upon current research, using the best information that is available at the time. He alleges that insurance companies use evidence-based practices as an excuse to deny care and save money:

"At times, evidence-based medicine has come to be used as an excuse to change the equation of medical treatment entirely. The new equation is to start with the premise that treatment should not be used unless it has been 'proven' to work."

The misuse of therapeutic equivalence and evidence-based medicine, according to Treisman, has caused patients to become disillusioned and suspicious of traditional medical care and turn to alternative and homeopathic treatments. And for doctors he feels the nonformulary approval process "wastes the time of busy physicians" and injures patients.

So that's my recap of the article. My reaction to the article is that I agree wholeheartedly with Dr. Treisman that it's good to remember the limitations of large clinical trials when you're treating the individual patient. It's also good to remember that therapeutic equivalence is a regulatory concept not necessarily a clinical truth.

Here's where I disagree:

The nonformulary process and the emphasis upon adherence to treatment guidelines is not solely the fault of the "evil" greedy insurance companies. I think we as physicians need to accept our role in driving these policies.

Health care cost containment is everyone's responsibility. It's easy for doctors to feel bothered by paperwork, to feel threatened by challenges to clinical autonomy, or to be offended by suggestions that one's practice is not up to modern clinical standards. But the fact of the matter is that in psychiatry there are a lot of free-wheeling physicians out there. Indiscriminate use of expensive medications for vague clinical indications (Seroquel for anxiety, anyone?) drives up the cost of health care for everyone. And practice guidelines were not developed by insurance companies. They were created by professional organizations to enhance the overall standard of care and quality of care given by their physician members. The professionals themselves recognized that there were issues with wide variation in patient care, or suboptimal care, long before insurance companies got ahold of these guidelines.

It's a facile sleight-of-hand trick to point to the evil greedy insurance companies for the policies that now nag us. I'd remind folks that we have only ourselves to blame.

In Treatment, Episode Whatever...the sub-blog...Couple From Hell

Last night's episode of In Treatment was the final blow to my long day. Here's why I don't do couples' therapy.

Amy comes alone, apparently Jake has quit. She feels great, happy as a clam to have miscarried, but disturbed that she lacks the appropriate grief she should be feeling. She comes on to Paul, flirts with him, insults him (he might be handsome on a deserted island). She's great at pushing Paul's buttons and he looks unkempt and ruffled-- she describes her imagined scene of him trying to get her blood off the couch so well that one might wonder if she (like all the others) is stalking him. I wonder if she's manic between her repeated references to her mood elation and her hypersexuality. Jake shows up, angry and knows she'd made a pass at Paul. A repeated pattern of seducing authority figures, apparently. She calls him Paranoid. These people are annoying. They leave in a huff.

So Kate the wife of shrink walks in to announce she's going out yet again. She's decked out, and by the way, in a play-out of the couple's session that just ended, she'll be going to Rome next week with her lover. Paul can use the time to connect with his children.

Is there anything to say? Happy Valentine's Day.

Mandatory Reporting...more thoughts on Sophie

Okay, I'm still talking about this TV show, the blog post is a response to comments on yesterday's In Treatment episode on Sophie. Please, remember it's fiction.

In Maryland, the law is that mental health professionals must report any child abuse issues. It doesn't matter if it happened 40 years ago, if it happened in another state, if the perpetrator is dead, this is either the law, or the attorney general's interpretation of it, and it's how mental health professionals operate. Okay, it can be silly, I'm not a detective, I'm just telling you law. And on the information sheet I give patients, it has a line that says that there are laws regarding confidentiality and issues of child abuse.

The Sophie issue is more clearcut-- this is recent sexual activity of an adult with a child and the adult continues to have contact with her and with other children. No issue legally. I won't comment on the therapeutic ramifications about trust, because, well, there's no legal ambivalence here. For those who aren't watching the show: Sophie lived with her gymnastics coach for a while, for months his wife was out of state, she cared for their child, had a relationship with coach, slept with him (mentioned that before they had sex, everyone assumed they were), and after the session, Paul calls her mother to ask her to come in.

Throughout the session, Sophie looks childlike and younger than her stated age. I believe the TV folks did this on purpose.

Here are my thoughts:
--Paul should have told Sophie that he's obligated to report this. Yup, given that she loves the coach, this probably would have ended the therapeutic relationship, but preserving the therapeutic relationship is not the most important thing in the world. Remember, this is the coach who picked her up from her last therapy session.
--Paul should not have called Mom without discussing it with Sophie.
--Do we believe this? Kid lives with coach, her parents allow this, his wife is away for 6 months, everyone thinks they've been having sex, which they do, and coach the pedophile-criminal transport kid to therapy where she may snitch on him and get him locked up for years?
It would be interesting to see what Sophie said when Paul told her he had to report it.
Next week, perhaps?

And I have wondered if the show is taking place in the DC suburbs.

I'm still thinking about my response to ClinkShrink's last post.

In Treatment: Episode 13....Sophie

ClinkShrink has asked me to reiterate that this is a "Painfully Silly" show.

Sophie kicks her backpack towards Paul. She has brought him a model boat, he is delighted.

"It must really suck having to listen to other people's problems all day." Oh, I hear some version of that a lot. I remind people that I chose to be a shrink, I actually kind of like it.

Sophie and Paul change seats and she plays Shrink for a while. He treats Sophie with a gentleness and fondness that he doesn't have for his adult patients. It's as though this is the one patient we meet who isn't laden with noise for Paul, he looks younger while he sees Sophie. They talk about "what if I'm a therapy patient" and Paul does a nice role induction. Sophie tells Paul angrily about her parents and how they split and how they told her.

Sophie talks about her relationship with her Coach, Cy, and we aren't surprised to hear they've had a sexual relationship while Sophie was staying there, caring for their daughter, while his wife was away for months. It's all a pretty sad story and Sophie feels responsible for Cy's marital problems. She left their house and had her near-fatal accident.

Sophie goes to the bathroom. We will she kill herself in there? Something shatters. She broke some picture frames, she's worried she'll hurt their relationship. She demands that he determine if her accident was a suicide attempt. She screams and curses at Paul.

These people are worried about the insurance company and whether something that happened weeks ago was a suicide attempt....they don't even mention that she was sleeping with her adult coach-- ummm....she calls him a 'gentleman,' a really good guy. Paul never counters this. Sophie talks about how she messes everything up. They say good bye at the door. He calls Sophie's mother and asks to meet with her. Shouldn't someone be more concerned about this kid's imminent safety and arresting the coach?

In Treatment: Episode 12....the sub-blog

[Posted by Clink (thank you!) Commentary by dinah]

I think I may have reached a new low in blogging. I am posting a blank post.

Dinah called me when I was on my way home from work to ask me to put up a blank "In Treatment" post so that people would have some place to comment on the show until she could get to the blog.

_____________

Okay, so this episode, Alex returns to see Paul with a top-of-the-line Italian espresso maker gift gotten off EBay, well, I found myself dozing.

Alex brings the gift, a dig at Paul's awful coffee from the week before, he walks in, moves a model ship, a family photo, sets it up, starts brewing. Paul clearly feels invaded and uncomfortable, they agree it will stay for the duration of Alex's treatment.

Alex talks about his family: his friendless geek son whom he finally realized is happy with himself, his successful wife, his virtuoso mother, his philandering father. Oh, and he left his wife Michaela. Paul draws parallels between Alex and his father, we see the anxiety this brings out in Paul who is dealing with his own lovelorn marriage.

Guess what? Alex met Laura outside and they went out. Alex figures shrinks don't like that, that there are ethical issues for the shrink (huh?).

So I don't know what this episode was really about, it was pretty boring. Power, I guess, the two men struggle with every aspect of their relationship-- will Paul accept the espresso maker, will Alex date his patient, will Alex accept Paul's interpretations of his family dynamics?

Lacking is substance, is that what ClinkShrink said?? Actually I think the show is a pretty good springboard for discussion. I do hear that some folks are tired of it....we'll try to mix it up. Roy? Roy? What's going on down there.....

The Meeting I Didn't Get To

Tonight I learned that King George died when my friend Bruce was in kindergarten. Bruce and I learned lots of other things about each other as well. He was geeky kid, eats more than anyone he knows, and still has trouble sitting still. I wondered why someone who can't sit still would become a psychiatrist.

So once a year the shrinks sponsor an event to schmooze with the state legislators-- just a way to get acquainted, and we'd like our representatives to deal with relevant proposed legislation in a manner that helps mental health causes. It's a political action kind of thing, cocktails, appetizers, not much more. Last year I didn't go because of the lousy weather.

Last year I was a little smarter. This year, I set out in a car with Bruce, my friend, my driver for the night, and we had already called one doc who'd been sitting in traffic for hours. Still, we went. Election Day. The roads are a mess. We set out at 5:20....without traffic or ice, it's a 50 minute drive. We sat. We talked. We changed routes. We never got out of traffic. This was the perhaps the longest worst traffic of my life? It's midnight, and since 9 this morning I've been in a n outfit that constricts my breathing.

Okay, at 9:10 pm, we surrendered to gridlock, sitting with the engine off, the bump from behind of the car that slid into us, the calls to check in with other shrinks in gridlock. The first sight of food and we texted our Surrender, then pulled into Paul's Cafe. They'd stopped seating 10 minutes ago.

So here's my plug for Paul's Cafe-- they listened to my quick whine about 3 and a half hours in traffic (I tried hard to look pathetic), offered us any table, great service, delicious stuffed shrimp, a fine glass of wine. A Five-Star Shrink Rap review and we two shrinks even talked about the blog and podcast, even if Bruce is not a blogger, or even a wannabe blogger.

I didn't make the reception. I didn't make it to the meeting that followed. I did learn that the death of King George impacted a kindergarten child in the Bronx.

It could have been a lot worse.

In Treatment: Episode 11....the sub-blog

Mike Huckabee was on Meet The Press discussing how he cooked squirrel in a popcorn popper in his college dorm. That is so weird.

Okay, back to our show here:
Paul is sleeping on the couch in his office, fully dressed, rudely awakened by the alarm. His idea or Kate's?

Laura is 25 minutes late, she asks for water (also a common theme on this show, no wonder they all have to go to the bathroom). She's come in a cab and she watched a dog get hit by cars, repeatedly. "I had to get him to a vet. You would have pulled over?" Paul responds, "I wouldn't have pulled over, I'd have assumed he was dead and there was nothing I could do."

He points out that she would have been late, dead dog or not, "I would have appreciated a call." She accuses him of being "anti-me."

"What do you think your being late is trying to say to me? Maybe you think I'm not doing my job?" "Are you angry with me? Maybe we need to talk about what good this therapy is doing you." She talks about her distress at the end of the last session. "You're trying to make me angry. I can't win here." She curses him out. "You don't have to love me in return."

"Now I see why they laugh at shrinks and their ridiculous interpretation." She talks about her helplessness as the patient, about having an idiotic theory thrust on her.

"Maybe I'm not helping you at all," Paul says.

They talk about Laura's upcoming marriage, how she hasn't told her father, though her husband-to-be has blasted his whole e-addressbook. He returns her to the issue of her being late.

"You want to kick me out of therapy." He says absolutely not, but then says they should think about winding down. "You don't want me to treat you as a psychologist (he really garbles this, did he say ologist or iatrist?)....I'm the one who says No, who humiliates you. Therapy should not be a source of constant humiliation for you."

"Am I the first patient to be in love with you, Paul? Maybe you can't treat me because you're in love with me Paul?" She's breached the boundaries. He ends the session despite her pleas for more time and Laura storms off while Paul tries to hand her the bill. Laura bumps into Alex, who has arrived for his session a day early. They flirt on the street and they drive off together.

Oh my, so we've got early patients, late patients, popping squirrels and dead dogs. Patients in love with shrinks ramming unwelcome theories at them, and an uncomfortable doc who wants the patient to leave.

Okay, so I still don't know What Paul is. Laura made a reference to med school, so I thought a psychiatrist, but there's never any mention of meds. Of course, with all that water, one might think everyone has dry mouth from their medications. One of our commenters has said he's a psychoanalyst, but I don't think so, his patients come weekly, not daily, and he doesn't have an analytic set up with a chair behind an analytic couch (these are rather specific couches).
Paul and Laura have a discussion that epitomizes the type of power struggle our commenters often worry about. Another episode where no one feels heard. You know, the whole point of psychotherapy (or at least one major point of psychotherapy) is to feel heard. These people are getting it all wrong, and I don't blame Laura for feeling cornered. Seems like Paul takes turns with his patients being painted against the wall.

Why can't Paul be honest? It's hard to have a patient declare that they're in love with you, the boundaries are a mess, he's feeling uncomfortable and he CAN'T have a relationship with her, it's simply unethical and he would lose his license. So he went to see an old supervisor, to get another opinion of how to handle a situation that's uncomfortable for him and that is obviously uncomfortable and painful for her. The supervisor wondered if they shouldn't consider transferring her care and he feels that now that that option's been brought up, they should look at it. Laura would be mad, she'd feel betrayed, but at least it's honest, it gives the sense of consultation and propriety, and instead he's pushing Laura away, treating her unfairly, being unnecessarily cold.

And a final thought here-- Sarebear asked if anyone here worries about being sued (I think it was Sarebear)--between making tea and having one's wife dress one's patient in their daughter's dry clothes. Really, there's nothing to be sued for here--- there are only a few boundaries that are set in stone (don't sleep with your patient and don't kill them, for starters). A patient could lodge a complaint that her therapist made her tea, but why? And since he makes tea for everyone, and the question is milk or sugar, not Red or White, there isn't a boundary violation. And giving an injured wet and cold young patient dry clothes, well, it's hard to find harm here. The boundary issues become salient if a patient ends feeling injured, and then the doctor's behavior gets scrutinized. If Laura feels jilted, and she sues Paul, then things like whether he extended the time of the sessions, what he gave her to drink, whether they'd ever met outside of the office, then and only then is it an act that has relevance. Even if a patient and a therapist were to go out for a meal, yes this is a boundary violation, but in the absence of something more, a patient can't sue a doctor simply for going out to eat a meal. It's just a suspect thing to do, and becomes a part of the case against the doctor, if the patient then alleges they had sex.
ClinkShrink, I hear, shares her squirrels with her inmates.

My Assorted Thoughts on Tara Parker-Pope's Wellness Blog Today

I feel this funny kinship with The New York Times Wellness blogger, Tara Parker-Pope. I don't know her, probably never will, and I'm jealous that her blog is so much more widely read than mine. Why hasn't The New York Times hired me?? Maybe it's because she's a blogger, I think she's a mom, and "Tara" is the name of my college roommate who has journeyed around the country collecting advanced degrees and remains a beach-ball of energy (there's something 'round' about my Tara, I don't know why, she's petite, slim and runs miles a day, but she's energetic and hard to grab on to, nonetheless). More simply, though, Tara Parker-Pope often writes about things we like to address on Shrink Rap, and for the second time recently, we've "known" in some sideline way, the same people. Not long ago she wrote about headaches and referenced my neighbor, the Johns Hopkins migraine king-- a man with beautiful gardens, a lovely wife, who run circles around our neighborhood for exercise, but my conversation with him has been limited to mutual nods.

So the Wellness Blog of 2/8 came to my attention this morning because it's on When Doctors Become Patients. That was ClinkShrink's post!! There Tara Parker-Pope goes, stealing from Shrink Rap again. We got to do something about this!

So I click over and there's a photo of Bob. Who's Bob? you say. Well Robert Klitzman certainly wouldn't remember me, but he pops up in the media now and then so I remember him. When I was a third year medical student doing my much-anticipated psychiatry rotation (for Bob's sake, I won't say where), Bob was one of the four PGY-2 residents on the fourth floor unit I was assigned to. Only I wasn't assigned to work with him, I worked with Beth. Beth was great, the thing I remember most about Beth was she told me she didn't like to go to the movies on a first date; she wanted a chance to meet a guy, get to know him a little, so she could dump him right away (she eventually married a musician, don't know what happened to the marriage, but my feeling towards Beth remain fond).

Bob wrote a book about his residency training experience: In a House of Glass and Dreams. I stumbled upon it in a bookstore. I knew the author so I bought it, and while he never named the program, I knew all the details. I remembered the lock that stuck outside the hallway to my supervisors office. He talks about his first day going to therapy, and I remembered being in a conference and a bunch of the residents saying "Where's Bob?" and someone replied "Bob went to therapy!" "Bob went to therapy???" I didn't really know Bob but I assumed that wasn't expected. This was in an institution where the chief resident posted on a black board what times he'd be psychoanalysis, don't beep me then. At some point, many years ago, I chatted with Bob briefly when I accidentally ended up at the wrong reception at APA, and I told him how much I liked his book. I think he was flattered. The book, which I read well after completing my own residency at an institution where one certainly didn't announce that they were going to psychoanalysis, resonated with me and and left me feeling understood-- it was during a time in my life where I was having a hard time feeling like anyone understood. I'd had enough wine to be at the wrong reception, so who really knows what we talked about, maybe 15 years ago.

At some point, and I'm not sure why, I learned that Bob's sister had died in the September 11th attacks. My heart went out to a man I hadn't ever really known, and the Wellness blog is about Bob's experience of being a psychiatrist with depression in the aftermath of his sister's death, and how his own journey has made him a better, more considerate doc. I don't doubt it.

I guess the other thing I wanted to comment on, since this NYTimes post hit on so much for me, is that Bob initially experienced his depression as physical symptoms and didn't recognize them as a mental illness. This is not uncommon. I've had patients lose tremendous amounts of weight (50 pounds anyone?), have severe pain (usually GI) and have extensive cancer workups. One tells me frequently "No one ever told me this could be depression." Another is only now getting to be a little better after his zillion-dollar work up. When I heard of the case, as he was being referred, I said to the internist, "Hmmm, sounds like cancer." He agreed, said they were continuing to look for the elusive tumor. One look at the patient and I rethought, "Looks like depression." Patients, unfortunately hear this as "Your Pain Is All in Your Head." I' rephrase this as "Sometimes depression is expressed as pain. It doesn't mean the pain isn't real." I want it to not be insulting, but the reality is that the prognosis for pain as a symptom of depression is a whole lot better than the prognosis of pain as a symptom of lots of other things that people are wishing will be found.

In Treatment: Episode 10....the sub-blog

I'm posting after the fact, but I did watch the Paul-returns-to-Gina episode last night.

Can I give this episode a few sub-titles:
1) Why I don't have a home office.
2) Why don't these people listen to each other?

So Paul returns to tell Gina that Kate really is having an affair: an insurance agent/an employment guy/ a supermarket manager. I guess he wasn't listening. He talks about his disconnection from his childrens' lives and how Kate blames him for his neglect. While Paul has mentioned once last week that a patient says she's in love with him, that "erotic transference" thing, he hasn't said much about it, and Gina repeatedly and insistently-- as if by crystal ball-- comes back to the feelings Paul must have towards Laura as the source of his marital woes, and therefore, we can assume, in having some role in Kate's need for another relationship outside the marriage. He does eventually confess that Laura's beautiful and he 'enjoys' the flattery and the feelings. But well before this, Gina was probing him-- Laura could have been the ugliest, most unavailable woman in the world-- but Gina was insisting. I hate it when therapists do that--sure, patients repress things or don't see the obvious, but in real life, you're just testing theories, and if a patient backs away from an idea, you figure that either you (the therapist) were wrong, or that the patient needs more time or a new way to see this, and you back off. You don't ram your theories down their throats. Or I don't. It was interesting that Paul was eventually hammered into looking at the connection between Laura and his feelings, but it could have just as easily turned into a repeat of last week's screaming sessions, and unlike any of my patients, Paul has the benefit of a professional script writer to compose his lines for him.

Paul talks about Kate's jealousy of his home office, of her feeling excluded and not important to him. He mentions that she was in it after the miscarrying couple left (he didn't mention that she was there because he barked an order for her to come help with the damn spot), and he mocks Kate saying "What Happens In this Office?" Nothing in their real life compares to what goes on here and she never feels like his top priority. I ask my husband if he ever feels that my work comes first, and he says "never" (1 point for Dinah, zip for Paul). I hate to offend anyone, but much of what goes on in a therapist's office is mundane, while neat things happen, or there are frequent I-wish-I-could-write-about-this-on-my-blog moments, it's not that magical.

I think about our real life house-- it was built generations ago by a doctor and some form of doctor has always owned it (--we are the first family in which that doctor is the wife, not the husband). There is a separate entrance, and until the owners before us, the first floor was divided into a physician's office. I don't really know what the layout was, but as we
doing the final walk-through, the former owner (a hospitalist who didn't have his practice at home) pointed out that a radiology tank used to be where our TV now is, the bathroom had been relocated, essentially, our "playroom", family room, laundry area, were all somehow a separate physician's suite. It wouldn't be so hard to reconfigure this into a shrink's office, with the separate walkway and door already there, and people have asked why I don't have an office in my house. So if you watched In Treatment the last few days, you know that spending a few bucks on office rent, especially if you have a family and all those bathroom issues Paul seems to have, isn't such a bad idea.

So we move on to learn that Gina's husband David died just a year ago. And here's a fun subplot: Paul had referred his good friend Charlie to Gina for treatment. Charlie fell in love with Gina and he told Paul that Gina was in love with him. We see from her face this is true. Charlie, like David, is now conveniently dead so we can talk about all this with no hope of fixing it. Paul is angry that Gina's response to her feelings for her patient/his friend was to run away to England on sabbatical with her husband. Huh, Charlie was her only patient? No college tuitions or morgates to pay, I suppose. Paul writes her script that THIS was the reason why? There's no room here for other possibilities--- requirement of David's work, once-in-a-lifetime opportunity, nope, without asking, he's told her that she dropped her practice, picked up her hubby, and moved across the big pond to escape Charlie. Gina flinches so we figure it's true, but a little more convincing with the script writing, huh? Why don't these people Ask, try out their theories, consider other options. Paul mentions there sessions are like debate teams where everyone goes in ready to plug for their side without hearing the other's side. Yup. This isn't therapy and it isn't supervision, and it's only by virtue of television that they haven't thrown those pretty water glasses at each other.

Just for the record, Paul says if he transferred every patient he was attracted to, he wouldn't have a practice. Interesting. I don't believe that's the usual.