Thursday, January 29, 2009

Response to the Comments on the Last Post

So I wrote about the 12 ways to drive ME crazy...and it got a few comments. I've nothing better to post about, so I thought I'd address those comments here. My co-bloggers seem to have gone dark with posting. I hope it's okay if I reference the random commenters.

One commenter wrote in an additional idea:
13. Spend the treatment session being totally non-compliant and then tell everyone how useless your therapist is.

Fortunately, if my patients are feeling I'm useless, they aren't telling me. Many are non-compliant, and that just goes with the turf of being a shrink. I've been at it too long to take it personally or to be driven crazy by it.

Return of Saturn (what a great blog name!) is worried about returning to care after a few no shows and a few years. Personally, I'm always flattered when people return to treatment. I'm sorry they are feeling badly, but I like that they feel comfortable enough coming back. And No Shows are a pretty common thing, they aren't something that gets held in long term shrink memory. They do generally get charged for, however.

For everyone who commented on Calling Between Sessions: it's only necessary if a shrink specifically asks to be called. No one is waiting on unrequested calls. If a shrink requests a check in, then ends up chasing the patient down repeatedly, gets to be plain inconsiderate. Often, however, we work on the No News Is Good News theory and lost sleep is the exception, not the rule.

Mindful wants to know what personal intrusive questions I get and the worst of them isn't going on the blog. Try This for a post on Questions for the Doctor.

Anonymous wants to know why I like Seroquel better than Xanax and says it's more toxic. I like Seroquel better than Xanax because you can give someone a very low dose to take as an emergency medication (yes, off label, and yes I explain this) and it's not addictive and doesn't cause physical dependency, so they can take it or not take it, while Xanax gets you committed fairly fast. Given all we now know about the metabolic issues with Seroquel and the atypical antipsychotics, I'm a lot more hesitant about giving these medications and it's fairly rare that I use them off label. At this point, this is really an emergency measure for someone feeling pretty desperate or on the verge of hospitalization. And Xanax isn't much of an issue any more because so few shrinks prescribe it on a standing basis that it's been a very long time since a new patient has come to see me already on Xanax.

The same Anon is also concerned that I don't want patients to come off meds when they aren't having side effects, or don't realize that they are until they come off meds.
I have to say that I have very few contentious discussions with patients regarding medications. Most people are on medications because they feel better on them, and I'm more often saying it's time to at least consider coming off (many people don't want to risk a relapse and I respect that). I'm with Roy here, who commented that it's really about working with someone and the risk/benefit ratio. My Drive ME crazy list referred to the quite rare case where someone has repeatedly come off meds only to relapse and either the relapse has resulted in hospitalizations, violence, or the patient's misery being so tangible that it felt like my own (and months of very distressed phone calls). Many patients stop their meds: I tell them what I think they should do, what I think the risk of relapse is, and from there, it's not my decision. And I don't stop treating anyone who says they feel better without meds and is willing to risk the unknown. I don't know what to say about side effects: if someone says they aren't having them, I don't argue. And often it's hard to tell the difference between a symptom of illness and a side effect of meds. I do a lot of my thinking out loud and try to share my thought processes with my patients. It's the best I can do.

To Spotsy and Mind Mechanic: thanks for the support.

And to Roy: mostly you got the list of what you do that drives me crazy right. The podcast, however, was your baby, and so it doesn't bother me that you don't post them after we make them. I love your company for it's own sake, so I don't lose sleep over unposted podcasts. ClinkShrink, however, may feel differently. Please please please don' t post what I do that drives you crazy. I don't want to know.


Anonymous said...

Could you pretend that Roy's failure to post the podcasts drives you crazy? At least a little?

'Cause those of us who do love the podcasts have been considering off-label uses of our iPod earbuds for months now.

Anonymous said...

It's odd based on what you have written, but MY psychiatrist told me that I OUGHT to ask him more personal questions. I don't generally. I don't understand exactly why he would say I should. Perhaps I am too formal; too reserved; too intimidated? Or it may be because of the "elephant in the room". I have strong clues that he's gay and have been wanting to ask, but it seems intrusive to me. Maybe he wants me to ask. I don't know. It's not really any of my business, though.

***Fortunately, if my patients are feeling I'm useless, they aren't telling me.***
If they are coming back they probably see you as useful.

Anonymous said...

I'm glad you said that about coming back...that was hard for me too, after a few years.

Battle Weary said...

From a patient standpoint...I too like seroquel off-label better than xanax. I have extreme anxiety around sleep...childhood based trauma nightmares are the culprit. I either fight to stay awake in order to avoid the nightmares, or I do actually sleep but wake up multiple times near panic due to the nightmares. Xanax made me sleepy, but I still woke up near panic. When I tried it during the day, it wore off suddenly, with anxiety still very high. Seroquel in a very low dose (25 mgs) makes me very sleepy, and if I wake up, I am able to go right back to sleep because the anxiety is not high. The only side effect I have noticed is my legs are "jumpy" if I don't go to bed when it's time. If I go to bed, no "jumpy" legs. The only problem is that I can't take seroquel for anxiety during the I have a very low dose of ativan for that (doesn't make me sleepy). However, I haven't taken any ativan in about 3 months now, possibly because the seroquel is still in my system?

Curtis and Shae said...

So...uh...I am not by any means new here. I've read your blog for a some time now. And I guess I just have a question really. If it isn't cool that I ask it, well...let me know. So, I've gone to therapy for a while now. I've lived a pretty dysfunctional life and about 2 years ago I just needed some help. So I went. I go to school at a pretty major university where counseling is offered for free...and all you are expected to do is show up. And it is awesome, since that doesn't really happen in real life. So I went faithfully for 2 years. I never missed a session...ever. And I saw the same guy. We got to be really good friends and I came to consider him as someone I could trust and let help me. Then I went on a year and a half sabbatical. I am now home, and very recently my life has all but fallen apart. Completely. Everything that could go wrong has, and I've felt more and more like I am losing my mind...and more and more alone. So I decide to call up the Doc and see what he can do. So I go into see him once. I feel guilty about going, because I think I should have my life in order and not have to go and have him help me. So I make an appointment for the next week, in which I completely flake. I knew I had an appointment and I chose not to go. I didn't call, I didn't email him...I just didn't show up. So then more crap hits the ceiling...and my life falls apart even more...and I drop him an email, pretty much freaking out...and he actually made time for me to come in...and we talk. And during the session towards the end, I fly off the handle. I all but tell him to screw off...

First of all...why? Why did I act so irrationally? Does this happen? I mean, what the crap?

Second of he going to hate me? Before I left he asked me when I would like to come back. I basically told him that maybe I didn't want to come back. He asked again and I said..."Sign me up for whatever, I don't care." So he made a spot for me to come in next week, which wasn't there before.

I feel like I should apologize or something. Or maybe I should just call it good and never show up again. I don't know...what do you think?? P.S. You can respond here if you'd rather...or not at all, whatever you like.

Return Of Saturn said...

Dinah, thanks for your response to my comments. I kept repeating what you wrote during the drive and on the way to the office. I was nervous, and I felt dumb, but I did it. And he didn't beat me for being inconsiderate and bailing before... Phew!