Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Wednesday, January 20, 2010
I'm working on a chapter for our book. I still like either Off the Couch or Beyond the Couch for a title. Roy wants to name it Set the Couch on Fire. And he's not kidding. What do you think?
Okay, so the current chapter is on real life intrusions-- things that impact care, for better or for worse, in ways we may or may not really understand. So stuff external to the actual treatment. Some examples are--- Money/fees/ not showing up for appointments/ Violence (how does it impact care if you have a suicide attempt? If you threaten or assault your shrink?/ assumptions people make about their patients or shrinks/ drug company influences/ and the media portrayal of psychiatry. A lot of the chapter is about money and insurance companies and fees.
Are we missing anything? The chapter is short---still waiting for Clink to write about violence, still waiting for Roy to chip in. And really, this isn't a real entity in psychiatry, it's something to draw together some unrelated stuff we wanted to talk about and make it cohesive. So is there something you want to know about that might intrude on care?
Posted by Dinah on Wednesday, January 20, 2010
Labels: MTS: The Book
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I happen to think that "Set the Couch on Fire" is a hilarious title, but I'm not sure that it would work in practice, unless there is anything within the book that it could be taken to refer to.
I think "Behind the Couch" is more catchy. But that would probably mislead..
How about the client's previous therapy experiences (either good or bad!)? Oh and I vote for "beyond the couch"
You know, I kind of like Behind the Couch....it conjures up all sorts of images. We've got the analyst sitting behind the patient on the couch. And the dust bunnies. And Clink's puppy might be back there. And the word "behind" has the connotation of "behind the scene" and implies a deeper look, so I like it.
Crystal: Perfect! I had not thought of this, excellent thing to incorporate.
Keep talking, you're doing great.
Another vote for 'behind the couch' because of the layers of meaning that it has.
Intrusions...barriers to starting and/or staying in treatment -
past experiences, both your own and those of people close to you
travel hassle, parking,
what types of folks you have contact with in hall, restroom, elevator, etc. (current MD is a good fit, but her office is in a building on the campus of a world famous psychiatric hospital. Sharing an elevator with a client who is being admitted to a locked unit, seeing the sign in the hall about not giving matches or sharp objects to people, etc, is definitely a stressor . In this setting i am VERY aware of being a psych patient, in a way I have not had when seeing a psych MD with an office in a generic building.
degree of insurance hassle - esp. when getting started, the whole insurance runaround can put you off if you are ambivalent or feel so down that you can't imagine ever feeling better, etc. clients who don't have a significant person in their lives who is supportive of meds/talk therapy, etc may not ever get started, or may drop out too soon.
cultural bias - for we of the irishcatholicalcoholic group, the prevailing belief is that if you have to see a counselor of any kind or take 'nerve pills' you have a serious character defect and/or are really CRAZY (schizophrenic type out of touch with reality sick)
difficulty scheduling appts - esp at the start, when not really convinced that treatment will help much, anyway.
are you planning to address the issue of transference/counter transference - sorta where does the patient's shit end and the shrink's shit begin?
I agree with Crystal about previous experience...
What about issues relating to:
- people who travel frequently for business/family and continuity in the therapy process
- optimizing time
- What about discussing how the internet can be useful in therapy (ie: for research, blogging, etc)?
That's off the top of my head... I'm sure I'll come up with more.
A minor point on intrusions: address what it does to patients to see drug company reps in the waiting room when they are nervously or suicidally or furiously sitting there waiting for their (late) doctor. Like instantly diminish the credibility of the doctor. Humiliate a shy patient who thought they would be alone in the waiting room. Convince them that their doctor will prescribe whatever s/he is getting the most incentives to prescribe. I know, I know... the rationalization a shrink friend from church has: "I let them in so they give me free samples I can give to patients who can't afford meds."
Other ones? Consider the fact that since mental illness and personality problems are largely genetic, the patient in therapy likely has others in their immediate family who need varying degrees of treatment themselves. When a shrink is negotiating with one patient over a fee, or wondering what it "means" to the patient, they should learn to think in terms of family systems also. It isn't all about the transference, but sometimes just limited family finances. In my extended clan, families often have to do triage, and decide which family member gets the therapy, which one gets the expensive meds, and the other ones don't.
I may have posted a comment on this here before, but think of maintenance meds in a family with several members in remission. $400 a month just on copays (after deductible) on a good health care plan for their mix of meds. Interestingly, with the multiple new drugs many people take for certain conditions, it may be cheaper now for a person with no insurance to be in therapy regularly than rely solely on meds.
Another intrusion? Insurance companies' changing criteria for what they will and won't reimburse for. A major factor in changing patterns of diagnosis (chasing the most likely to reimburse? this already happens in school districts where parents are warned by advocates to refuse certain labels and insist on others, which it has been demonstrated that the district will offer supports for.)
btw, dinah et al,
I think you should include the post where you compared meds costs via pharmacy, or something to that extent.
I think you wrote about that... last year?
I have been a fan of Off the Couch ever since the book was first mooted and it still has my vote.
Other issues affecting care: previous experience with meds especially if side effects have been severe; degree of patient's responsibility in following a treatment plan; patient's motivation in wanting to get well: attitude and support of workplace eg ability to take time off for medical appointments; patient's access to a support network - family, friends etc; stigma - will I ssek treatment for fear of being stignmatised; influence of media and how mental illness is portrayed.
I vote for "Behind The Couch" (due to the dust bunnies, of course.
Insurance is a hassle to the doctor/patient process, but what about patients who decide to do self-pay because they don't want a paper trail showing they're getting mental health treatment? (HIPAA aside) Or doctors who decide they are not going to accept insurance, which is fine, but then they argue with you when you don't bring exact change. One psychiatrist argued with me over $5.00. I thought, "Buddy, you may be a good doctor, but you are really stupid to comment about $5.00, letting me know that you're angry because you told me the price and I brought the wrong amount." I had $20 too much and $5too little and no one could make change. He is never going to live that down, no matter what good things come of our relationship.
If you make it Behind the Couch, you definitely need to have an illustration at the top of the chapter with the dust bunnies, etc..
Is it an intrusion to therapy if the only reason I don't commit suicide is because I don't want to let my therapist down?
Writing by focus group, are we?
I want to throw another vote in there for "travel." It is a struggle for me to maintain any sort of regular schedule with my therapist (less difficult with the psychiatrist, as those visits are less frequent) because I travel for work. I'm lucky, in that my therapist works with me now, but the last one I saw wanted me to come in the same time, the same day of the week, and it just took too much effort. Unfortunately, I also have to travel out of the US for work quite often, usually to countries that don't believe in psychotherapy. So, I would add "cultural expectations" as an intrusion, especially for people who are 1st, 2nd or 3rd generation Americans.
I don't know if this is what you mean by "intrusions" or maybe these things are closer to the heart of what is going on with the patient but what about:
patient losing his/her job or his/her business going down the tubes
severe downturn in the economy affecting client finances
natural disaster(s) in the patient's area affecting the patient
"From The Other End* of the Couch" ?
* or "Side"
Don't, at all, like "Set the Couch on Fire" - sounds more like the biog. of a middle-aged rock band.....not quite brave enough to completely trash the hotel room but still wanting to do something "outrageous"!
"Set the Couch on Fire" caught my eye as the biggest intrusion into my therapy was a fireman pounding on the door ... barging in to evacuate us as there was a "potential" fire on the roof. Awkward, doesn't even cover it. Funny in reflection.
Impaired physicians. I've heard the % are higher in psychiatry. Not sure if that's true or not.
Definitely transference and countertransference can be intrusions. But, not sure how you could adequately address that topic in one chapter.
Set the Couch on Fire makes me think of an arsonist therapist.
I don't like Set the Couch on Fire, but I do like "Couch on Fire". If I saw that in a book store, it would make me stop to see what the book was about.
I kind of like "Set the Couch on Fire." It reminds me of a session with my therapist when a car alarm kept going off just outside the door. When it started, I stopped talking and asked, "is that your car?" He looked weary when he shook his head and told me it's been happening all day...
a long, long time ago i was taught that fee negotiation does not stand apart but is in fact part of the treatment in that it helps define one aspect of the boundaries in the relationship. In that way, i would not see it as an intrusion.
Suicide attempts--I think any clinician has dealt with a number of those. Like anything else, how they are dealt with will either get in the way of or help propel the treatment forward.
None of these things sound like intrusions. They are part of life and therefore part of treatment.
A long time ago, I had mentioned once, before he moved his office down the hall, that I had considered, if I ever felt trapped or a building urge or feeling of some kind of having to do something right NOW that I had considered breaking the glass fireplace "screen" in front of the fireplace in his office and using that on my wrists or somehow on self.
After I revealed that I wondered for some time into the future how or if that bothered him, or if he'd be prepared to stop me if I tried. Or if he thought that my saying something like that was more of a . . . let's see if he'll stop me if I try kind of a thing.
It was more of a, at least at the time I thought it was more of a, if I was feeling desperate, and he had a call he absolutely had to had to take that required privacy and had to step out of the office, and I was in a bad way, and circumstances lined up just right, then it was something that potentially could happen that I could do to myself, but it never did.
One that hits close to home - knowing personal things about your therapist (by way of Google), that they haven't told you. Cyber-snooping. Will he freak out that I know where he lives/goes to church/has as a hobby? Should I even tell him?
@Anonymous Re: cybersnooping via Google. I am sure that the your therapist knows where he lives, goes to church and what his hobbies are. No need to tell him.
(edited for typos)
Things for your book to address:
Race, class, gender and their interactions with psychiatry. Such as blacks are more likely to get dx with sz and women seem to be more likely to be dx with something, anything than men are.
Are most psychiatrists still male?
Stalking. Patients who stalk "providers".
how about intense sexual attraction, and/or profound cultural differences
Oh ya... BEYOND THE COUCH! that's great
Hope it's not too late to add to this. What about family crises, etc, especially where the patient's family is dysfunctional and the dysfunction contributes to (or caused) the patient's problems.
Internet support groups can be an intrusion, I suppose. That said, it's important to get fuller information since you may only hear about it when it's a problem.
The consumerist movement in healthcare.
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