Wednesday, December 29, 2010

Scratch, Sniff, Prescribe

I was surfing around the net one day and I found this article about scientists who are creating a machine that will detect acetone in someone's breath. Acetone can be a sign that someone suffers from diabetes, so in theory this machine could use scent to diagnose this disease.

That story brought to mind other stories I've heard about people using dogs to sniff out cancer in people. According to this article:

"The results of the study showed that dogs can detect breast and lung cancer with sensitivity and specificity between 88% and 97%. The high accuracy persisted even after results were adjusted to take into account whether the lung cancer patients were currently smokers. Moreover, the study also confirmed that the trained dogs could even detect the early stages of lung cancer, as well as early breast cancer."

People have even tried "smelling" schizophrenia.

But what if there were a pheromone for violence? About a year ago, someone approached my hospital and wanted to bring in dogs to do a study on violence. They wanted to see if canine scent detection could be used to predict which patient would be aggressive. The idea seemed pretty bizarre to me at the time, and in fact there is nothing in PubMed to suggest that it would work.

While googling around on the topic of scent detection I also found this novel, The Nadjik Pheromone. The plot is based on the idea that somebody discovers a pheromone that gets emitted when someone lies. It's an interesting idea. The author came up with the idea when he heard about people using fMRI for lie detection.

I don't really have a conclusion for this post, I just thought I'd throw out some ideas. Maybe someday people will be giving "truth perfume" for Christmas.

Monday, December 27, 2010

Most Popular Shrink Rap Posts of 2010

This is Roy's job, but he's otherwise occupied. He'd do a better job, I promise. Here's my quick and dirty list of our most popular posts this year:

What's a Psychiatric Emergency? 2/8/10

Prescribing Psychotherapy 12/13/10

ObamaMama it's Health Care Reform 3/27/10

Is it Malpractice to Lie? 3/17/10

Are In-Network Shrinks Better Shrinks? 2/14/10

What's Your Favorite Shrink Book? 5/21/10

What Makes Mental Illness Bad? 10/13/10

Shopping Spree 4/8/10

Unhinged: The Trouble With Psychiatry: Book Review 5/10/10

Saving Normal 3/3/10

Unrelated to the New Year, but the all-time most popular Shrink Rap post:

The Angry Birds

You always think it can't happen to you. Addiction is something that happens to other people, other families.

Let me first talk about anger, because it's an emotion we commonly address in psychotherapy. Anger is a normal human emotion, but it's gotten a bad rap, and the inappropriate expression of anger can make life very difficult. When anger is recognized and used wisely, it can help us to solve problems, to stand up for what we believe in, and to change the world. It's never a terribly comfortable emotion, and often people strive to decrease their comfort by discharging anger.

So tonight I downloaded the Angry Birds app to my iTouch. Oh, I'm not so sure about this. I've catapulting these little animated critters at piggys in pens all night. I spent over an hour on level twelve. I can't stop. I posted on my Facebook about it, and an old high school friend--who's now a physicist at Stanford-- told me not to do it..."It's like crack." It's late and I want to go to bed. But what about the piggys in the stone pens on Level 15? Doesn't some angry bird need to smash them? If you know any shortcuts, please do share. Not sure I'll ever blog again....

Saturday, December 25, 2010

Merry Christmas!!

For all our readers and listeners, the Shrink Rappers wish you a Merry Christmas and the best of the season!

Monday, December 13, 2010

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins

Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-psychiatrist-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage psychiatrists to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that psychiatrists are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and psychiatrist-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a psychiatrist or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of psychiatrists during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a psychiatrist who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different psychiatrists, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that psychiatrists "should" practice a certain uniform way. "Should" every psychiatrist have to do psychotherapy even if they hate listening to the same patients? "Should" every psychiatrist see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a psychiatrist can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped
by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
Really good Grand Rounds.

Related Post: The Psychiatrist as Therapist

Sunday, December 12, 2010

Diagnostic Errors and The Shrink

Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry.
The author writes: Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: my tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule). At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: what else could this be? relevant possibilities. Patients often present with a constellation of symptoms that don’t entirely fit the diagnosis they actually have. Often the discrepancies between these presentations and the textbook descriptions are unimportant—but sometimes those discrepancies exist not because the patient’s body hasn’t read the textbook, but because the diagnosis the doctor makes is the wrong one. Such misdiagnoses are occasionally unavoidable: the symptoms with which the patient presents are simply too far afield from the way the medical literature says the disease

It’s the same with us all. We all come to early closure all the time, forming opinions about the behavior of others without sufficient consideration of all relevant facts. We become attached to the explanations that make the most sense from the perspective of our own experience and our own point of view.

Do we do this in psychiatry? Of course. It's not at all uncommon for a psychiatrist to diagnosis a patient with Major Depression when, in fact, the patient has Bipolar Disorder. Why? Sometimes there has been no episode of mania (yet) and a diagnosis can't be made. Other times the symptoms have been explained away as something else: an exuberant personality, anxiety, a reaction to events. And finally, sometimes the doctor simply forgets to ask about such episodes or the patient/family don't report them as they've drawn their own conclusions.

What else? Psychiatrists may attribute mood instability to personality disorders. This is the case less and less, as we've found that when people's mood stabilizes, so does their behavior. Or a psychiatrist may see a patient who is very distraught after an upsetting life event and attribute the mood changes to an adjustment disorder, when in fact the patient has developed depression. Hopefully, we re-think our diagnosis if the symptoms persist or don't follow the usual course.

Wednesday, December 08, 2010

ClinkShrink and Roy, It's Safe to Come Out Now.

In Treatment is over for the year.
We will be resuming our regularly scheduled psychiatry blog.
Thank you for staying tuned, we hope you've enjoyed the show.

In Treatment: Adele, Week 7

Paul starts with the usual: he blames Adele for giving him bum advice and says she is responsible for Sunil's deportation. Ho hum.

Adele is in his face with how stuck his life is--- hmmm, didn't this guy just get divorced, move to Brooklyn, have his kid, leave his kid? I guess those don't count. Paul announces he's decided on the spot to stop practicing psychotherapy. Independently wealthy, I presume. And yesterday he broke off with his girlfriend and felt nothing. And then, in a rare moment of insight, Paul tells Adele he is stopping therapy, that it is just a repetition of the same patterns and he can't continue with this painstaking examination of transferential feelings. Adele implores him to stay; these people seem to feel that therapy is essential to life and that no change is possible without it. Paul says no, he must go. It seems like his first true insight in years. And then he announces he is no longer her patient and so it's fine if she tells him if she ever thought the two of them could be together. Some things never change? Until next year?

Tuesday, December 07, 2010

In Treatment: Jesse, Week 7

Jesse went to prison for hopping a train to Providence without paying. Another episode for ClinkShrink!

He's back in Paul's office with his dad, and dad doesn't have much use for shrinks. He tells Paul he should have been a plumber. And now that he and Jesse are cool, Jesse doesn't need to come.

Paul talks to Jesse alone. He implores Jesse to stay in treatment, and he puts it in terms of how he cares for Jesse and how Jesse will lose the gains he made. To watch Paul, leaving therapy is a catastrophic event, one that warrants blowing a few cerebral blood vessels. It's a do or die deal.

For once, could Paul just say, "I'm glad this has been helpful to you. I think there are still issues to address and it could continue to be helpful to you. If you need me, please do call."

Monday, December 06, 2010

In Treatment: Sunil, Week 7

ClinkShrink's dream has come true! A session in the jail. Sunil was locked up and soon he'll be deported back to India, and we learn that this was part of a grand plan, his only way to get home to India. He faked the whole creepy/dangerous scenario, aware that if the police came and he refused to show his papers, he'd get arrested and deported. Couldn't he just have shoplifted an apple?

Paul is angry. What was real? Was it all farce on his therapy? Sunil points out his assorted boundary transgressions as he created a therapist/friend scenario, and Sunil says that Paul got something out of the sessions as well in their shared loneliness. And to ease Paul's anger (oy, he curses at the patient, my idea of a no-no), he lets him in on a new twist to the stories, once again drawing Paul in: his wrong-caste girlfriend who committed suicide was pregnant with his baby.

Sunil sings to Paul as the guard escorts him off.

In Treatment: Frances, Week 7

Sunil doesn't come for his scheduled session. Instead, we get Frances.

Frances continues to struggle with her relationships with her teenage daughter, Izzy, and her terminally ill sister, Patricia. She now has to balance Izzy's wish to prolong Patricia's life with Patricia's wish to die peacefully at home. Should she "pull the plug?" She tells Paul how special it was when Patricia said she loved her, and how she feels like she'll be left alone with no one. Does Paul know how that feels. Indeed, he does.

The session bounces back to how sister Patricia was Paul's patient years ago. As she leaves, Frances asks, "Were you in love with her?" Please, Paul, just say no, she was a patient, her sister is now a patient, why would you have been in love with her and if you were, why would you have ever agreed to treat her sister, much less admit you had such feelings. Therapists don't owe their patients the right to every inner thought. Paul doesn't really answer, he just says that he cared about her a lot, an acceptable feeling to have for a patient.

Sunday, December 05, 2010

News Flash: Preauthorization Impacts Care

Thanks to Kery for heads up.
Illustration by J.C. Duffy / copyright © 2010 by the American College of Physicians

The American Medical Association had a press release on November 22nd and announced findings from their survey on the impact of insurance company preauthorization policies. Surprisingly, they discovered that these policies use physician time and delay treatment. It's funny, because preauthorization policies were designed to
save money. And I imagine they do, for the insurer, but they cost money for everyone else.

I'm pasting the AMA findings here, taken directly from their website:
New AMA Survey Finds Insurer Preauthorization Policies Impact Patient Care

For immediate release:
Nov. 22, 2010

Chicago – Policies that require physicians to ask permission from a patient's insurance company before performing a treatment negatively impact patient care, according to a new survey released today by the American Medical Association (AMA). This is the first national physician survey by the AMA to quantify the burden of insurers' preauthorization requirements for a growing list of routine tests, procedures and drugs.

"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," said AMA Immediate Past President J. James Rohack, M.D. "According to the AMA survey, 78 percent of physicians believe insurers use preauthorization requirements for an unreasonable list of tests, procedures and drugs."

The AMA survey of approximately 2,400 physicians indicates that health insurer requirements to preauthorize care has delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions. Highlights from the AMA survey include:

  • More than one-third (37%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.
  • Nearly half (46%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.
  • Nearly two-thirds (63%) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13%) wait more than a week. More than two-thirds (69%) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten (10%) wait more than a week.
  • Nearly two-thirds (64%) of physicians report it is difficult to determine which test and procedures require preauthorization by insurers. More than two-thirds (67%) of physicians report it is difficult to determine which drugs require preauthorization by insurers.

Preauthorization policies deliver costly bureaucratic hassles that take time from patient care. Physicians spend 20 hours per week on average just dealing with preauthorizations. Studies show that navigating the managed care maze costs physicians $23.2 to $31 billion a year.

"Nearly all physicians surveyed said that streamlining the preauthorization process is important and 75 percent believe an automated process would increase efficiency," said Dr. Rohack. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."

Thursday, December 02, 2010

And Now For Something Completely Different...

I'm going to briefly interrupt In Treatment to post a link to a recent U.S. Supreme Court case. In California, the U.S. district court has ordered that tens of thousands of prisoners be released to reduce overcrowding. The case, Schwarzenegger v. Plata, was argued this past Tuesday and the transcript is up online here. This is relevant to a psychiatry blog because one of the arguments used in support of the releases is the contention that overcrowded facilities reduce access to mental health and medical services and that overcrowding causes mental deterioration and breakdown. The APA filed an amicus brief in the case, but the brief isn't available online yet. (Keep an eye out for it here.)

The challenge with this case is that there is no (or extremely little) actual research to support the link between overcrowding and psychological problems. Correctional systems have spent a lot of time litigating issues---and experts make a fair amount of money working on these cases---without actual data. For example, for decades people have just accepted the notion that solitary confinement causes mental deterioration in spite of the fact that there were no controlled trials to investigate this. The Colorado DOC recently published a landmark case looking at the effects of disciplinary segregation using two control groups, and found that the condition of mentally ill prisoners actually improves in segregation. (The study is entitled "One Year Longitudinal Study of the Psychological Effects of Administrative Segregation" and I can't find it online yet, although I do have a pdf of the report for distribution.)

I think it's a good thing to reduce overcrowded facilities, but justification should be based on what you know, not what you think you know.

Addendum: I'm wading through the transcript now. I had to laugh when I reached page 18 and Justice Ginsburg's comment, "The class (prisoners) wants to have clinics. They want to have personnel who function someplace outside of a broom closet."

I immediately remembered FooFoo5's comment on one of my first posts, "Knowledge is Obligation": "The one time I volunteered to assess women preparing to parole, I sat in a supply closet on an overturned 5-gallon bucket because there was only one chair and I left it for the patients." FooFoo worked in California's prison system. I haven't heard from him for a while and I hope he's doing well.

Wednesday, December 01, 2010

In Treatment: Adele, Week 6

Adele and Paul spent the episode sparring. It's reminds me of some of his sessions with Gina, only not as good. Adele's manner feels forced, like she's reading her lines, and they all have the same inflection. Paul calls her 'remote,' and 'a Freudian ice goddess," that is when he's not cursing at her, saying she's a narcissist, or accusing her of purposely humiliating him by letting him express fantasies about having a relationship with her when, in fact, she's pregnant. She does inspire him to call Sunil's daughter-in-law and to see Sunil as a more imminent threat.

Watching a half hour on TV is draining enough. Glad my days aren't so filled with conflict, anger, angst, and interpersonal confrontation.

Tuesday, November 30, 2010

In Treatment: Jesse, Week 6

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

 Happy Birthday, Jesse! He's 17 and in all the glory of adolescent angst. Jesse is a black hole of need. To make 17 all the harder, Jesse continues to deal with issues of identity and belonging. It's probably not the easiest age to be gay or to be discovering birth parents.

Jesse's relationship with Paul has gotten much better, much warmer. I liked when Paul told him he would gain strength from his struggle. Finally, he has something positive and encouraging to say to a patient. And he's tender with Jesse as the parallels continue with his own angsty relationship with his son, Max.

In Treatment: Frances, Week 6 and a Few Words on Narcissism

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

 Frances spends the session grappling with her relationship with her dying sister and her angry teenage daughter. She wants Paul to feed her--she's hungry and he must have food, after all he lives here--but he refuses.

She leaves the stage to be with her sister after months of estrangement. They have a nice moment after Frances rescues the sister, bathes her, and puts her to bed. But it's short lived--the sister wakes up confused and needs to go to the hospital.

Frances has a tendency to look at all of her interactions as centering on herself. Her sister's warm declarations become meaningless when replaced by febrile mumblings. Paul's look is skeptical. She feels constantly judged and she looks for repeated approval and reassurance. Her daughter hates her, and it can't just be that the daughter is a teenager who is struggling with her aunt's terminal illness, her parent's divorce, and the tumultuous world of teenagers, it has to be about Frances. Ah, the teenager says Frances is a narcissist and that's untreatable. Is this true?

From my point of view, I don't believe that people change their personalities much. But therapy does seem to help people re-frame things, recognize their patterns, say "oh, I'm doing
that again" and question what is going on. If I don't think I can "fix" something, I work on reframing it in a positive way. Most traits can be both good and bad, and the choice of words makes all the difference in the world. A shrink might tell Frances that it seems to be true that she likes being the center of attention, most actresses do, and it's a pretty helpful characteristic to have if you're going to be the star of the show. But maybe the sister's death isn't about Frances, and maybe she shouldn't take everyone else's distress too personally.

Ah, and here's a link to an editorial in the NY Times about the fate of Narcissistic Personality Disorder in the New DSM.

Monday, November 29, 2010

In Treatment: Sunil, Week 6

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

 Julia comes in first. She was injured when Sunil pushed her and she says that he is worse. Treatment is not helping and she is no longer going to pay for it. Her husband will need to prescribe stronger medications for his father (or perhaps the houseplant).

Sunil continues to evade the questions. He sings in Bengali for Paul, a farewell song. When he says words in Bengali, Paul cuts him off, rather rudely, and tells him to speak English. Sunil asks Paul to keep an old cricket bat he's found; he might be tempted to use it to murder or maim or do something bad to Julia.

Paul is rather worked up during this session and he implores Julia to allow Sunil to continue in treatment. He further implores Sunil to keep coming. He offers to see Sunil
pro bono, or to meet him outside the office for tea.

This episode requires that the viewer suspend disbelief in the realities of psychiatric treatment. It's a world with no psychiatrists, no hospitals, no rationale use of medications, no duty to prevent harm, and no sense that violence can come from a illness that one can't be talked out of. There is faith that treatment will ultimately lead to betterment, even when things are getting worse and the characters may not live through the day.

Sunday, November 28, 2010

The Ethicist On Whether Shrinks Should Lie to Keep Their Clients

I hope everyone had a wonderful holiday! We've been busy brining, basting, baking, eating, and visiting with family. Sad to go back to the daily routine.

In today's NY Times Magazine the ethicist entertains the question of whether it's okay for a psychiatrist to lie to keep his clientele. (!)

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?


If you want the ethicist's answer, check out the column here.

I think that most of us would agree that it's not okay to lie with the intention of keeping business. What if a patient asks how long you've been practicing, and your sense is that the patient wants an experienced psychiatrist-- would it be okay to say 10 years, rather than 1 year? Clearly not.

Personal questions can be awkward, however. In traditional psychodynamic therapy, the therapist doesn't answer personal questions---the "blank screen" is necessary for the treatment, and the meaning behind the question is explored. This can be very off-putting to some patients, and for myself, I find that it feels disingenuous, and I prefer to simply answer questions. It helps that I don't get many questions: Do you have children is the most common, I've been asked my religion a couple of times, if I have a dog (Yes, two, would you like one?). Here and there, I've been asked rather unusual questions (Do I have a cook? Who has a cook? No, but I'd like one!)

It seems to me that if something like this is essential to the patient's comfort level, then they should ask this on the phone before the first session. Does it all matter? Who knows---they make good therapists in all shapes and sizes and the interpersonal fit often is found in the least expected place. And my guess is that the ability to accurately diagnose and treat a mental illness has relatively little to do with any of these matters. Probably people are more picky about the personal lives of their shrinks than their brain surgeons, but maybe they shouldn't be.

Related Posts:

Self Disclosure and Being Genuine

A Shrink Like Me

Wednesday, November 24, 2010

Podcast 54: Tell Me! Information and Technology

Welcome to Podcast Number 54: Tell Me! Information and Technology

Here's what we talk about:

Roy talks about the Maryland Health Information Exchange (HIE) called CRISP, which stands for Chesapeake Regional Information System for our Patients. Note that your health information is accessible to participating health care providers unless you opt out. You can read more at We ramble about the downside of sharing health information electronically. We also complain about how difficult it can be to get medical information now, so there are pros and cons.

Roy talks about career satisfaction of psychiatrists based on a survey done by Epocrates. Roy talks about the increasing job satisfaction of primary care docs -- it's going up! In psychiatry it's also going up, based on data now compared to 3 years ago. Happy shrinks are up to 83% from 70%. Roy encourages med students to join us. Dinah extols the wonders of the diversity of psychiatry. Read the article about the survey Here.

Dinah brings up the age old dilemma of how to write about clinical information in psychiatry without compromising patient confidentially. We talk about how we deal with this problem in
Shrink Rap: Three Psychiatrists Explain Their Work. Ah, but it's not just printed matter, but blogging and tweeting and podcasting.

Finally, Roy talks about healthcare providers and social media, referencing an earlier blog post on What To Do When Your Patient Friends You On Facebook.

Once again, thank you for listening and please do write a review on iTunes.


This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from
Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Tuesday, November 23, 2010

In Treatment: Adele, Week 5, revised

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

Could someone please be warm and fuzzy?

Roy thinks this was a mistake, that I didn't finish the post, but this was all I had to say. It was a contentious and uncomfortable session and by the end, I wanted to go home. Ah, I was at home! These people are not nice, and who would want to pay for this kind of confrontation, unleashed emotion, and discomfort. Paul is a handful, and now we hear his fantasies about a life together with Adele, and that he's watching her building (for an hour after the last session!) and knows she doesn't have any patients after him, so at 6 o'clock at night, she should be happy to extend his session. It's like Jesse, only at least we can excuse Jesse's immaturity as adolescence. And why is everyone in this show a stalker? I did not think that Adele did as a good a job as before: she openly sneared at Paul in the beginning, and she angrily confronted him with his refusal to look at the important things and his rigidity.

Just a hint: name calling makes people defensive. They are more likely to consider your thoughts if you couch them in kind terms or universal phenomena that make them easier to swallow: "it's difficult to look at your own weaknesses"..."there are parts of your style that serve you very well..."

Ok, Roy won, I wrote more.

In Treatment: Jesse, Week 5

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

High drama here on HBO. And Paul chases yet another patient out of his office.

Paul is making pancakes for dinner with his son, Max, and trying all-too-hard to connect with the quiet pre-teen. A knock at the door and it's patient Jesse, in distress. He needs an emergency session and Paul leaves Max to go to Jesse.

Jesse went to see his birth parents. He showed up early and there were kids in the yard. He left and returned at the appointed time, stoned. The kids were gone, without a trace, and one was in a wheelchair. Maybe the birth parents had searched for Jesse because they want his organs for the sick kid. Oh, and they asked Jesse to leave, perhaps because he asked them for money.

Paul confronts Jesse with his habit of testing people and using their failure as proof that Jesse is no good. It's a pattern, he's done it tonight by showing up at Paul's apartment. Injured, Jesse runs out with Paul yelling at him not to leave. We call this therapy? Paul follows Jesse and they sit on the steps more calmly. Until, the smoke detector goes off and Paul has to choose between Jesse and saving his son from the burning building (or rather, the burning pancakes). Everyone here needs a hug.

So what about the boundaries of the home office? And why doesn't Paul recognize that his timing sucks: when someone is in a state of distress, they need a little empathy, warmth, and kindness, not an interpretation of all their faults as a human being. I'd kind of like to take his batteries out about now.

In Treatment: Frances, Week 5

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

Frances continues to be flirtatious and provocative. She insists that Paul open and read her cancer gene results, just as she tried to get him to run play lines with her, but this time he bites. The results are negative. They are both relieved, but the sparring continues.

Frances remains jealous that her daughter wants to be with her dying sister, Patricia (Paul's former patient of 20 years ago).

Last night, Frances had sex for the first time since her husband left her, with a man 20 years her junior. She seems to enjoy giving Paul the details.

And what happened between you and my sister, Frances asks Paul. She says you were in love with her. Were you? If Paul's not provoked by this, maybe he can see it through.

Frances isn't going to see her dying sister. Paul tries to explore this and he finally tells her, point blank, that she needs to go see her sister before she dies or she will regret it forever. This as he chases her to the door.

Why are Paul's patients always storming off with him on their tail?
The chinchilla is for Jesse.

Monday, November 22, 2010

In Treatment: Sunil, Week 5

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Week 6: Sunil - Frances - Jesse

ClinkShrink, where are you when we need you?

The buildup continues as Paul worries that Sunil might be homicidal.

He feels like a prisoner in Brooklyn, while back home the monsoons are causing devastating floods. Paul believes that his problems could be fixed by better communication. Tell your son you want to move. Sunil is frustrated in his attempts to get Paul to understand his life. He can't leave, can't go home, and must stay put in his son's residence. Paul thinks Sunil could get a job and move into his own apartment. To make matters worse, Paul insists on talking about Sunil's dream, and Sunil gets outraged when Paul concludes that a character in the dream is the former girlfriend, despite Sunil's protests. So what else is new?

Sunil is convinced that his daughter-in-law is having and affair, and that she is mocking him-- something he finds humiliating. He is enraged and wants to smother her, or perhaps her laughter. He tries her bedroom door, and thinks of calling Paul in the middle of the night.

Paul is clearly worried, and he says so. He doesn't ever ask outright if Sunil is thinking of killing Julia. He talks to Sunil about what stress he is under, and just as I think he's going to suggest that Sunil go into the hospital, he recommends he come twice a week for therapy. It's certainly understandable that Paul would want to keep closer tabs on Sunil, but is digging deeper a good idea? The patient seems to be unraveling, and Paul tends to find the strands then pull and pull.

Friday, November 19, 2010

Prison Poetry

Recently there was a little problem in one of our local facilities. Nobody died, but the incident caused the officers in my facility to reminisce about fights they've had to break up in the past. I overheard some of the conversation and the result is this poem, direct from the officers' mouths:

Two of You and the Gate is Locked

200 guys in the yard, two of you and the gate is locked
You had two fights over here, three fights over there, it was like May Day...
It wasn't against us, it was BGF but we still had to stop it
It was over something small, one guy had a beef
That's when the weapons came out
The officer opened the gate to let him out
"I couldn't stand there and see the guy stabbed up"
They kicked the gate open
That's how the fight got to the compound
You gotta contain it
The gates lock you ain't going no where
They hit the doors, you contain it
You ain't going no where
You in there

Thursday, November 18, 2010

In Treatment: Adele, Week 4

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Grand Rounds in the medical blogosphere will be on Gratitude this week. Roy wants me to write a post on gratitude. ClinkShrink wants me to write a book about In Treatment. I am grateful I have friends to help me figure out how to spend my time and keep me off the streets. Does this count? Perhaps the Grand Rounds folks would like to read about In Treatment?
Great line, Adele to Paul: "At a certain point, you have to move past the stories you've assigned to your life."

Paul says he lacks passion, something that everyone else has. Adele, he says, has passion for this,
this being her work. At first it seems a bit narcissistic....Paul is assuming she loves her work, because her work, after all, is talking to him, and no one wants to think that their therapist hates coming to work. But then we learn that Paul has Googled Adele, and part of why he assumes she loves her work is because she's written a lot-- she must have passion.

Adele is a bit stiff for my taste. I like animated people. But she's a good therapist for a fictional character--she's attentive and able to distill patterns, and she has good insights. So just as I'm thinking that Adele is such a much better example of a therapist than Paul is because she doesn't get in his face and say confrontational, contentious things, she blows it. Paul talks about how caring for his sick mother stifled his childhood, and Adele proposes that he may have used this as an excuse to hide. He says no, this doesn't feel right, but Adele insists it is. I hate it when they do that.

Finally, Paul was distracted during sex this afternoon. You knew he was thinking about Adele, that he has become attracted to her, and in this episode her eyes have become so much more flirtatious. New makeup or camera angles, I suppose? And at the end of the session, he tells her she's right when she says he holds back, and he tells her he's been thinking about her (during sex with his girlfriend). Textbook transference, he says, as though being a therapist himself should make him above all that. It's a compelling session, and we're left to wonder if Adele can hold her boundaries (we think so) and what will happen next week.

I'm grateful that someone somewhere might be interested in my thoughts on a TV show. Thank you for reading!

Shrink Rap: A Doctor Who Grand Rounds at Emergiblog

While reading Kim's excellent Doctor Who edition of the weekly Grand Rounds on Emergiblog, add to the ambience by listening to My Three Shrink's Dr Phil prank, which has a mashup of KLM's Doctorin' the Tardis song starting about 10 minutes into the 19 minute segment [4MB] (complete with Anne's maniacal laughing).

Wednesday, November 17, 2010

In Treatment: Jesse, Week 4

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

It's thundering outside, an extra component to this week's stormy session with Jesse.

Jesse is struggling as he copes with communications from both his birth parents. His adoptive parents were angry--- a sign that they want him. "I have ADD and I'm a slut. Who would want me? Would you?" Paul says "Yes." It was a nice thing to say, I'm not so sure I believe him. And he answers this charged question, but won't answer when Jesse asks if Paul likes the letter Jesse crafted to his birth parents. Both of Jesse's moms are depressed, it seems. Marissa hasn't gotten out of bed for a week-- not since her visit to Jesse's psychotherapy session, and Karen always gets depressed around his birthday, presumably out of grief that she gave her baby away.

Jesse is still cursing, but overall, he's become more insightful, less ready to charge, and less provocative. My satellite blitzed for the last few seconds of the show, so fill me in. Jesse leaves and Paul still has all the letters to and from Jesse's birth dad. And what's with the show opener where he's sniffing spices? Still trying to figure out if he has Parkinson's Disease? I guess it's the season-long personal life of the therapist theme.

Tuesday, November 16, 2010

In Treatment: Frances, Week 4

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele
Paul rejects Frances yet again. He wouldn't run lines with her last week, and this week he won't accept tickets to her play. He suggests she bring her sick sister or her estranged daughter, but Frances isn't biting.

She talks about how her dying mother came to see her in play; they celebrated with champagne. But the trip was hard on her mother and she feels guilty for having had her mother come at all. She was no good when mom was sick-- "inept" and vomited in the hospital sink. Her sister's illness has revived all these issue around death.

Who is Frances? She puts herself down and she can't accept a compliment. Fame and accolades and she goes home to a dark apartment and soup from a can. She checks her makeup in the mirror before she leaves the session and worries about who might be in the waiting room. She feels like a empty receptacle that can never be filled.