Monday, May 31, 2010

Our Readers' List of Best Shrinky Books

I asked for Shrinky Book recommendations, and I thought I'd compile the full list of recommendations. Thank you for your help, and here goes:

Aqua said...
Existential Psychotherapy , by Irvin Yalom. This book resonated so deeply with me. It has helped me get so much more out of therapy than I ever imagined possible.
Blogger Rach said...
Totally agree with Aqua. I'll add Kay Redfield Jamison's books books. And for the totally obvious one, the DSM-IV-TR . (I know it sounds counter-intuitive, but for some people, reading about what they "have" provides some semblance of relief. or comedy. or tragedy. or a combination.)

Mindful said...
My recommendations: Shoot the Damn Dog: A Memoir of Depression by Sally Brampton; Darkness Visible: A Memoir of Madness by William Styron; An Unquiet Mind by Kay Redfield Jamieson; and Man's Search for Meaning by Viktor Frankl.
Sarebear said...
Don't you hate it when it's on the tip of your tongue/fingers/brain but you can't quite come up with it? Flowers for Algernon has always been a fave, if that fits. Sad though. Kay's an Unquiet Mind never did much for me; alot of it was, well, her friends were all in the field, so she had a helluva support system. Nothing like the real world for most people. Not that that makes the book invalid for any "list"; just is why I don't like it. "In Session" by Deborah A. Lott The Dance of Anger by Harriet Lerner The Dance of Intimacy, Harriet Goldhor Lerner, Ph.D. The Search For the Real Self, James F. Masterson, M.D.

Anonymous said...
Second "In Session" by Deborah A. Lott. Also liked Harriet Goldhor Lerner's "The Dance of Intimacy". Yalom and Kramer's books are good. "The Anxiety & Phobia Workbook" by Edmund Bourne, Ph.D and "Self-Esteem" by Matthew McKay, Ph.D are useful resources for cognitive work. Liked Syd Baumel's "Dealing With Depression Naturally" for complementary and alternative therapies. And also liked "The Seven Principles for Making Marriage Work" by John Gottman, Ph.D and "Hold Me Tight" by Sue Johnson, Ph.D for couples/relationship issues.
Anonymous said...
Womens' Moods:What Every Women Must Know About Hormones, the Brain and Emotional Health - by Deborah Sichel and Jeanne Watson Driscoll. Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder - by Jim Phelps

Anonymous said...
The Sociopath Next Door - made such a difference in my life in both recognizing such people and realizing that I was not the problem.
Blogger Rach said...
I third In Session.
"In a House of Dreams and Glass" By Robert Klitzman, MD About his Psychiatric Residency-excellent! (He later wrote a book, i believe it's called "When Doctors-or Physicans-Become Patients", based on his own severe reactive depression when his sister was killed in the Twin Towers...) The classic, wonderful "Mount Misery", sequel to "House of God". "The Gift of Therapy" Irving Yalom, MD
Anonymous Anonymous said...
Marya Hornbacher wrote two books that describe her mental illnesses that are a very good first hand account of what it might be like to have them. Wasted (written in her early 20s) describes her childhood and teen years struggling with bulimia and anorexia. Madness (written in her later 20s or early 30s) describes her manic and depressive breakdowns which she had later, after writing wasted. When she wrote wasted she did not know she had bipolar disorder.
Anonymous merope3 said...
Best book about depression I ever read? "Crime and Punishment." I've never had a fictional character resonate so powerfully with me before.

Ally said...
Deborah Luepnitz's book on intimacy. Dan Gottlieb. And absolutely Jim Phelps and Kay Redfield Jamison!
Anonymous Paula said...

hmmm, shrinky books ... um, probably "Gas Smells Awful" by Helen Razer, covers some important issues in a non-conventional kind of humorous way.
Anonymous Anonymous said...
I wrote a long comment and my connection crashed! I am reading "MAD, BAD and SAD: A history of women and the mind doctors from 1800 to the present" by Lisa Appignanesi I would recommend this book to people who want a more longitudinal view of psychiatric medicine. It's not one for the here and now "what is therapy, how does it work". For anyone with an interest in the history of medicine and the background and major players in the field of psych, this book might be for you. Along the way there are vignettes, some familiar and others more obscure. I am reading it slowly, it's not a 'page turner'. All I can say is that I am glad I am alive in the era of prozac and bupropion. Paperdoll
Blogger tracy said...
Definately agree on Mayra Hornbacher!!! She's excellent! Also, "Gracefully Insane" the history of McLean Hospital. Some really sad and touching stories put it mildly.

Blogger dr. bob said...
Users of my web site have voted to highlight: In Session: The Bond Between Women and Their Therapists by Deborah A. Lott and Marie Cohen Feeling Good: The New Mood Therapy by David D. Burns The Road Less Traveled : A New Psychology of Love, Traditional Values and Spiritual Growth by M. Scott Peck
Kathy said...
Hi there - here are some books most of you won't have heard of... I had a black dog - Matthew Johnstone, 2005. A brilliant, illustrated insight into life with the black dog and how we might tame it. Living with a black dog - Matthew and Ainsley Johnstone, 2008. A must-have guide for the partners, family, friends and colleagues of people suffering depression. Broken Open - Craig Hamilton, 2004. A memoir of what it's like to go mad in public and survive to tell the tale. My brush with depression - The Greg Wilson Story - Aaron Cootes and Greg Wilson, 2005. A biographical story which shows how much others' support can help one overcome depression. Journeys with the black dog - Inspirational stories of bringing depression to heel, 2007. Edited by Tessa Wigney, Kerrie Eyers and Gordon Parker. Dying for a cure - Rebekah Beddoe, 2007. A memoir of antidepressants, misdiagnosis and marketing disguised as science. I suffer chronic major depression. These books have touched me in various ways and helped me in my journey. Sometimes hearing someone else describing circumstances similar to my own has been the only thing that helped me to keep part of myself grounded in reality. I think it is always helpful to know that you are not alone in what you are experiencing.
Anonymous said...
Oh and I forgot to mention, with my network crash and all.... I so love "Staying Alive: Unreal Poems for unreal times" Edited by Neil Astley 500 life-afirming poems, fired by belief in the human spirit. They connect our aspirations to humanity and have help me in deep dark moments. Was I a book reviewer in a former life? Any one who feels low, please read these poems. I hope they help comfort you in the grey dark moments and give you that comfy, all is well feeling with rain falling on a tin roof. Excerpt p 456 Late fragment: And did you get what you wanted from this life, even so? I did. And what did you want? To call myself beloved, to feel myself beloved on this earth Raymond Carver Paperdoll
Attachment Girl said...
I would highly recommend "A General Theory of Love" by Thomas Lewis, Fari Amini, and Richard Lannon. It discusses, very poetically actually, the relationship between attachment theory, neurobiology and how we actually heal in therapy. The insight it gave me into the process was a major turning point for me. Highly accessible for layman, but my therapist also loved it.
butterfly said...
Being Ourself, by therapist Ty Clement has been the most valuable book I've encountered in my existential journey to healing.
Katie said...
Every single one of Kay Redfield Jamison's books - including her textbook on Manic Depressive Illness: Bipolar Disorders and Recurrent Depression. Also, Narcissism and the Psychotherapist, by Sheila Rouslin Welt, William G. Herron Learning from the Patient by Casement was Very Psychoanalytic based, but interesting Hurry Down Sunshine (Michael Greenberg) was a beautiful book about mental illness, not shrinky, though I very strongly dislike most of Yalom's writings...I know they are quite popular but I find them to be lacking any substance, and his writing to be quite full of himself.
Dr X said...
Regarding Katie's comment on Yalom, I feel the same way. I don't understand Yalom's popularity. His work strikes me as shallow. I also agree with the endorsement of Casement's book. It's an excellent presentation of self-supervision, supervision by the patient and the unconscious, interactional dimensions of treatment.
Sherri said...
Undercurrents, by Martha Manning

nardilfan said...
I'd love to be able to sound all pretentious and say Madness and Civilization by Michel Foucault - but unfortunately, I've actually read it and it seems to be nothing more than a long, boring, over-complicated, deliberately unclear and factually incorrect exercise in making Michel Foucault look cleverer than he actually was. Reading that drivel made me appreciate the humour of the Postmodernism Generator (at ) - and of Alan Sokal's infamous parody paper, Transgressing the Boundaries: Towards a Transformative Hermeneutics of Quantum Gravity ( see ). There are quite a few fiction books which I think are worth mentioning, if they can be made relevant. One Flew Over the Cuckoo's Nest, for example, although it is fiction and set a fair distance in the past, still has a lot of relevance in terms of issues around compulsory treatment, the differences between a prison sentence and psychiatric incarceration, and lots of other fun stuff (and does it a lot more effectively and entertainingly than Foucault's effort). For instructional manuals, there's the hilarious (and irritating) "Mind Over Mood" - which is used in the NHS, seemingly as a way of relieving the staff who actually deliver CBT of much of their workload. It's supposed to be used in conjunction with the clinician's version, and you work through it together. Can I suggest that as well as a bibliography you include a list of helpful and/or interesting MH-related films? There are a LOT of very interesting films that deal with many different aspects of mental illness, treatments, social attitudes etc. .\
Anonymous said...
Irvin Yalom, Nassir Ghaemi & Paul McHugh are all psychiatrists whose writings I admire. I also enjoy reading books that offer a more critical view of therapy/ psychiatry/ psychology/ etc, because these books have really made me think and re-think some of my beliefs about therapy/ diagnosis/ etc. (I say this as a patient): -Manufacturing Depression by Gary Greenberg (I just read it, one of the best books I've read) -Therapy Culture by Frank Furedi (and I would love to be able to read through the entire bibliography for this book...) -Bright-Sided by Barbara Ehrenreich (esp because of her chapters on the positive psychology movement) -The Loss of Sadness by Alan Horwitz and Jerome Wakefield -From Morality to Mental Health by Mike Martin -The Antidepressant Era by David Healy
Anonymous said...
The 10 best ever anxiety management techniques by Margaret Wehrenberg What works, why it works, what to do when it doesn't work The gift of therapy by Irving Yalom Even though he is self promoting, he's still right Our Inner Conflicts by Karen Horney Understanding and making peace with resistence All together 3 different approaches that make sense

Alison Cummins said...
Don't know what a "shrink book" is, but this is one that was helpful to me"
DeleteSunny CA said...
My favorite shrink book is: "Should You Leave?" By Peter D. Kramer Delete

Sunny CA said...
"The Man Who Mistook His Wife For A Hat" by Oliver Sacks is another favorite shrink book.

d'Zhuoy said...
Noonday Demon -- yes, yes, yes! What an incredible book. Even better than William Styron's Darkness Visible (which you might consider). Then there's A. Alvarez's books Night (1996) and The Savage God: A Study of Suicide (date?). I'm sure you've already added these three by Kay Redfield Jamison: Night Falls Fast, Touched with Fire, and An Unquiet Mind. Emile Durkheim's classic On Suicide. In a more literary vein there's Ted Hughes's The Birthday Letters, poems on the suicide of his wife, Sylvia Plath. Fascinating look into the mind of one who was left behind. The Plath-Hughes marriage is a rich vein for primary and secondary texts, from Plath's correspondence to feminist psychiatric critiques. I would encourage you to include some books that offer critiques of psychiatry. I'm not talking about the silly antipsychiatry spoutings of Scientology and the like; I'm talking about reasonable, rational critics like Thomas Szasz. But maybe I'm way off base. Delete

d'Zhuoy said...
Oh, and also... your ducky reminded me of my favorite-ever episode of The Ze Frank Show: The best use of 3 minutes I can think of.
From Dinah: Thank you, everyone, for you help!

Monday, May 24, 2010

Glen Gabbard: You Cannot See the Self in a Brain Scan

Greetings from New Orleans and the APA! I'm still here with Roy. ClinkShrink has gone home, but I'm sure she'll be here soon to tell you about the rat on Bourbon Street. I did not scream as loudly as she'll say I did.

It's been a busy day. I started at a lecture by Glen Gabbard, and that's what this post will ultimately be about. I then went to lunch with a gentleman I met once for 15 minutes, 5 years ago when I was down here after Katrina. You'd think it would be a little strange to have lunch with someone I don't know, but it wasn't...more like like seeing an old friend, and I tried to persuade him to do a guest blog post, so he's thinking (and dreaming) about it. Lunch was punctuated by a stream of urgent text messages from Roy: he wanted me to come interview a beauty queen with him, and so we met with Dr. Gariane Gunter, the former Mrs. USA, who is also a psychiatrist, and a podcast with her will be out soon (right, Roy?). Yes, she's beautiful, and very personable and accommodating to meet with us. I then went to a symposium on the Neurobiology of Obesity where I learned that rats prefer sweets to IV cocaine. Off to dinner shortly, but first let me tell you about Dr. Gabbard's talk.

I've heard Glen Gabbard talk before. He has a gift for being able to so clearly articulate what it is we do in this strange practice of psychotherapy. He's the only psychoanalyst who speaks a language I understand. Roy asked what I was going to hear him talk about, and then stopped himself to say "I guess it doesn't matter." No, it doesn't matter, Dr. Gabbard could talk about how to take the garbage out and it would be inspiring.

The talk was part of a prestigious award presentation and was titled Why I Teach. His stories are wonderful, and he started by talking about how patients want to be remembered, and how touched he was when a medical patient told him, years ago when he was a student, that she'd always remember him. There was the story he told of the woman in Africa who cares for children dying of AIDS and how she holds their hands and tells them they will live on in her heart. "Our patients fear they will be forgotten."

Why else does he teach? To alleviate his existential dread, to altruistically have an impact, to teach, to learn, and to preserve a dying art (that would be psychodynamic psychotherapy). "Teaching forces you to clarify and articulate your thoughts."

Sometimes during lectures and professional meetings, I do what the kids do...I make my grocery list, I text my friends, I play games on my iTouch. But this was inspiring, my thoughts scrambled around, but not to the grocery list. I thought of people who I want to remember me, I vowed to at least try to resolve an unresolved relationship where I'm not happy with the memories, I thought about teaching a course on psychotherapy -- I'd be good at this -- should I go talk to my chairman about this? Should I ask someone to teach it with me? -- I identified a potential victim. I designed the course in my head and reminded myself that I'm trying to slow life down, not take on even more projects!

I went to the exhibit hall and bought Dr. Gabbard's book, and told him how I much I enjoyed the talk (along with everyone else....we all want to be remembered). I suppose the mark of a good lecture is that it moves you to think just a little differently.

Good quotes:
You cannot see the self in a brain scan.
Psychotherapy is not a popularity contest, we take people to places they don't want to go.
When in doubt, be human.

APA Annual Meeting in New Orleans 2010 #apanola2010

The American Psychiatric Association's Annual Meeting began on Saturday and goes through to Wednesday.  Lots of great talks here.  I'm trying to learn a lot more about TMS (Transcranial Magnetic Stimulation), for one.  There have been a number of talks on the use of social media, as well, including the use of blogs, facebook, and twitter.

I'll post more soon, but just wanted to give our readers a heads up on the meeting.  Also, you can follow the twitter stream on tweets from the meeting on TweetChat using the hashtag #APANOLA2010.  A stream of these tweets is in our sidebar for the rest of this week, and is also below in this post.

Friday, May 21, 2010

What's Your Favorite Shrinky Book?

We're going to start working on The Suggested Reading section for our book. We know what our favorite books are, but if you've read something that's been helpful, we might want to include that. Needs to be mental health related, doesn't need to be either by or for psychiatrists. We welcome your suggestions! And thanks to Alison who gave us The Noonday Demon.

Thursday, May 20, 2010

The Stressed Out Shrink Rapper

Yes, shrinks get stressed out, too. Can I tell you about it?

I hate paperwork, in case I never mentioned it. And I hate dumb things that are mandated by institutions and don't make sense. So I'm getting ready to go to APA this weekend ( see you there?) and I'm trying to tie things up. It's not going so well. Here's my list:

Remember I told you that I moved and tried to change my address with Medicare? Ah, 221 downloadable forms on the Medicare website, and not one of them is a change of address form. To change my address, I had to re-enroll. 27 pages. Then they wanted my office utility bills. But I don't have utility bills, they are included in my rent. I faxed my rent invoice--it has my address, and it says "office rent" on it. It's a very nice office. I figured I was done.
Two days ago, I got a letter from Medicare. I've been denied my application as a Doctor of Medicine. I can appeal. Why? I didn't send in three things: 1) Downloadable form 558 giving access to my bank account so they could pay me. Only I'm not an in-network doc. They don't pay me. Ever. 2) my participating agreement. I'm non par and wish to stay that way. 3) my utility bills as proof of address. Am I the only doctor who rents space with utilities included?
I called. Twice. If I won't give them my bank account numbers and routing information, I'm out. Which means I have to leave my clinic job where I've been for 12 years. I don't have to fill out a participating agreement. And they'll take another copy of my rent invoice. I have 30 days to appeal. From the date on the letter which came 2 days ago. The letter is dated in April (it's now May 20th). And I'm really not happy about giving them my bank account information---what happens when they pay me for patients I see at the clinic? I'm salaried there, I don't get paid by the patient, the clinic does. If I do nothing, I'm quickly opted out, and that's a good thing...unless you're my Medicare patient and you no longer can get reimbursement or you're the clinic that wants me there. Have other people had to give their bank account info to change their address? Never done this before. Time expended: who knows. Hours. If you're a non-par provider could you offer some words of wisdom here/?

Next problem:
Clinic says I need to be tested for TB along with all the other employees. So I get a ppd placed, no big deal. Only I work there one morning a week, and in the past, I've read it myself or had a dr. friend sign off on it, because it's a hassle to get to the hospital, park, and take off work for this. Now I'm told I can't read it myself or have another doctor read it, unless it's an internist, pediatrician, or pulmonologist. Okay, found a friend, still have to get the form faxed in. Time expended: 2 hours.

Next problem:
My cell phone blitzed last night. I called. They said I needed updates and they'd push them through. Whatever. The phone worked, I thanked them, and half an hour later, I was on my merry way. Only then the phone didn't work. And my kid's phone didn't work. I called back I held. I powered off, I powered on, I removed the sim cards, I read the numbers, I switched the sim cards, I powered on and off and ate the batteries and prayed for ducks to come. The phones aren't reading the sim cards. I need to get new ones. Okay. Hours. I got to work today. The phone works fine. I called AT&T. Can't be the sim card. Husband's phone works fine. Must be the degrading tower. What's a degrading tower? Does it crumble? Why does husband's phone work? Very strange, no explanation, but tonight, all the phones work. Time expended: 2.5 hours.

I suppose the last thing is the book. Time expended 4,237 hours. Our editor wants it in Mid May. I think that happened. It's almost there. We still need a little polish on the last few chapters and a table of contents and Suggested Reading . If you know a shrink book that's been helpful to you, please let us know in the comments===we'll try to stick it in.

Hanging on for:

Thank you for humoring me tonight, please send a bill

Monday, May 17, 2010

Name That Tune!

As you may remember (or might want to forget) we three Shrink Rappers are writing a book. Taken in bits from our blog, it's a more serious endeavor to describe what it is psychiatrists do and to explain and discuss our work. It's written for anyone who is interested in psychiatry--the lay public and students of the field, but not for psychiatrists.

It feels like we've been at this forever and a day. We put the proposal together, we searched for a publisher, there was the whole approval process, and finally a contract. The contract was an eighteen month project, so our drop dead date is in late June, and we're about ready to drop dead. Final draft here, and we are so grateful to our patient families, and our reviewers. It's nothing short of a miracle that I haven't killed Roy. Really. And vice versa, I'm sure.

So we've had an issue that we've been stuck on, and if you've been following us throughout this, you know that we can't figure out what to name the book! For a while, we were using Off the Couch...and I liked it and ClinkShrink liked it, but Roy didn't and our editor was blah on it, and then last week, another book was released on psychoanalysis called....Off the Couch! So much for that.

Tonight we got together with a mission: Name That Book. We came up with Four potential titles. I'm fine with all of them. And once again, I'm asking your opinion. Please, no Sex with Fish recommendations.

Details: more to follow, but the book, whatever its name might be, will be released in Spring of 2011 by Johns Hopkins University Press.

Please bear with us and vote once again on a possible title!

Thursday, May 13, 2010

I Don't Know What to Charge!

I got a letter today from a patient asking me to explain why I've billed him roughly $4.50 more than Medicare allows. He included a statement from...?Medicare or it's administrators saying that this lower amount is the Medicare-allowed amount and that if his doctor charged more, a refund is due.

Every year, in December, I try to figure out the Medicare fees. Mostly I call a shrink friend who is in the same jurisdiction who is also a non-participating Medicare provider, which is different then someone who "opts out." I have to charge the Medicare amount, but it's always this funny challenge to figure it out just how much that is. At one point, I couldn't even figure out where I practice---in Maryland there are two districts, 01 and 99, and my office appeared to be located in neither. So now I think I know where I am (no one else I asked was completely certain either). For the record, it's not easy to find the fees, they vary by district and by procedure and by whether you are a facility or non-facility, participating, or non-participating, and there is the limiting fee and caps, and it gets mailed to me as a CD that doesn't open, and it's not on a website that I can find and the psychiatric society doesn't always have any better luck, and some of my friends are "participating" and have different fees, and most have "opted out" and one just can't deal so he doesn't charge any Medicare patient any fee and he doesn't submit...easier to work for free.

Okay, so every year for the past couple of years, Medicare is cutting fees by 21% or 24%. But at some point, Congress changes their minds and undoes the cut, so I've taken to keeping my fees the same, with the idea that it will be easier to reimburse patients (or credit their accounts) then it will be to tell patients that I was wrong to drop my fees and they now owe me money. And every year, Congress votes, after a period of ranting and uncertainty, to undo the fee cut. This year, Congress seems to vote to delay the cut multiple times every few weeks. I called a friend, he got a similar letter from a patient. The tone of the letters imply that we are purposely overcharging or willfully committing Medicare fraud.

The executive director of our state medical society got pulled in. He sent out a newsletter from the Medicare folks. It states:

On April 15, 2010, President Obama signed into law
the “Continuing Extension Act of 2010.” This law
extends through May 31, 2010, the zero percent
update to the Medicare physician fee schedule
(MPFS) that was in effect for claims with dates of
service January 1, 2010 through March 31,
2010. The law is retroactive to April 1, 2010.
Consequently, effective immediately, claims with
dates of service April 1, 2010 and later, which were
being held by Medicare contractors, have been
released for processing and payment. Please keep in
mind that the statutory payment floors still apply and,
therefore, clean electronic claims cannot be paid
before 14 calendar days after the date they are
received by Medicare contractors (29 calendar days
for clean paper claims).

Given the uncertainty regarding MPFS claims with
dates of service June 1, 2010, and later, please
watch your listservs and your contractor‟s website for
more information.

So Medicare is saying there is no decrease, at least not for the next 2 weeks, at which point we can again try to figure out what to charge. But CMS is telling patients that the fees we are charging are illegally high. Whistle blowers and Medicare fraud publicity and fines, leave me wishing it was easy for everyone to simply know the correct fees.

Wednesday, May 12, 2010

Death and Mental Illness

Huffington Post

May 11, 2010

Lloyd I. Sederer, MD

Deadly Consequences: Why We Need to Integrate Health and Mental Health

Dr. Sederer talks about how people with severe mental illnesses die an average of 25 years younger than the general population--
He talks about lifestyles, the lack of a medical home, the contribution of medications to chronic illnesses, nicotine, and the role of prevention and early diagnosis.

Alarming evidence has emerged in recent years, from studies of people treated in the public mental health care system, that adults with serious mental illness die on average 25 years earlier than the general population. For a decade or two before their demise they suffer from early onset diabetes, high blood pressure, heart and lung disease and cancer. Why? Their habits place them at great risk for these conditions. They eat poorly, are sedentary and don't have a primary care doctor -- or if they do they don't go and get preventive and ongoing physical healthcare. They smoke heavily, with more than three out of four being nicotine dependent (see my previous blog on this issue here).

The psychiatric medications many receive for their mental illnesses increase the likelihood of weight gain, diabetes and cardiovascular disease. Mental health professionals have discovered what the Craig family painfully learned: physical disability and early death add to the burden of mental illness for those affected and their families. The burden does not stop there since our health care system, already groaning from the weight of the consequences of American habit disorders, shoulders the extraordinary health costs of this high need population.

What can be done? A lot.

Click here to read the whole article. Well worth reading.
Lloyd I. Sederer, MD

Tuesday, May 11, 2010

The Vicar of Towson or Another Shrink with a Blog

Roger Lewin is a psychiatrist/writer with a blog. He writes fiction and poetry and about psychiatry. I like people like this.

Roger's blog is so much simpler, quieter, and more elegant than Shrink Rap. His home page has a single word: Welcome. Nowhere on his website is there a picture of his feet.

I'll link to a really gentle, non-fiction piece called The Vicar of Towson, where Dr. Lewin talks about the vicarious life he lives listening to his patients:

Proust wrote that “the only real voyage of discovery consists not in seeing new landscapes, but in having new eyes, in seeing the universe with the eyes of another, of hundreds of others, in seeing the hundreds of universes that each of them sees.” Psychotherapy is an art of such listening that the other can world forth a world, this world being his world - and have it shared, not statically, but so that it can live and breath, declare itself and grow. Psychotherapy is a partnership in presence. A good psychotherapist is a gifted story listener.

He goes on:

Each patient is a dream. Every way of living is a way of dreaming. Part of what language makes possible is that this waking dreaming should be able to be made sociable. I listen to my patient talk about how hard his conscience makes life for him, finding fault with him wherever he goes. I see a lonely little boy, one who does not know what he can count on. I see myself as a lonely little boy.

Monday, May 10, 2010

Fishy Pedicure Ban

I was rummaging through the legal news lately when I came across a case that made me flash back to our old Cure for Fish Phobia post.

It appears that the state of Arizona has passed a law banning the use of tiny little fish for pedicures. Arizona wasn't the first either. New Hampshire decided that the fish were "beauty salon tools" that had to be cleaned in between use. Texas is concerned that the fish bowls aren't cleaned between use and could transmit disease.

Will pedicure fish now come with a black box warning? CAUTION: Fish, use only as directed. For external use only. Possible side effects may include drowsiness, dry mouth, blurred vision, constipation, the aftertaste of sushi, syncope, seizures, coma and death. Oh yeah, and scaly skin.

Unhinged-- The Trouble With Psychiatry by Daniel Carlat, my Review

Unhinged. The Trouble with Psychiatry--A Doctor's Revelations about a Profession in Crisis by Daniel Carlat.

Disclaimer: I wrote this book review while I was working on the final draft of our own book, so it's hard not to compare our book and style to those of Dr. Carlat. Ours is better (just so you know). This is not the result of a controlled study and there was no pharmaceutical agency support. It's simply my biased opinion.

So, I started out poised to hate this book. Dr. Carlat is a shrink/writer who has both a blog and an e-newsletter. He has a good reputation in the medical blogosphere, at least I think that's the case. So why was I poised to hate the book? I was offered a review copy by the publisher -- an inquiry email came with hype: "Carlat exposes deeply disturbing problems plaguing his profession." “The shocking truth is that psychiatry has yet to develop a convincing explanation for the pathophysiology of any illness at all.” "This has to stop—and it can. Throughout the book, Dr. Carlat provides empowering advice for prospective patients, describing the kinds of treatments that work, and those that should be avoided. In the final chapter, he provides a powerful prescription for how to get psychiatry back on track."

Yup, it's true, we don't know the actual pathophysiology of most of the psychiatric disorders. Is this shocking? Deeply disturbing? We've got a long way to go and we've got issues in our field. . Does it help to use language that sensationalizes these problems? It's kind of shocking that we haven't cured cancer, dementia, or obesity . I started reading. Carlat presents the fact that we don't know the actual causes of psychiatric disorders as though it's some big secret, something we purposefully withhold from our patients. He doesn't say that exactly, but he implies it with statements about how doctors don't like to admit what they don't know.

Okay, so the book is full of Carlat's epiphanies and revelations: he starts with the realization that it is limiting to see patients for a 50 minute evaluation, write a prescription, and then have the patient come back in a month for a 15-minute visit and refer them to a social worker or psychologist for therapy. Maybe this isn't the type of practice Dr. Carlat was meant to have! It's the way some psychiatrists practice, but it is not the way all psychiatrists practice. He writes as though this is the standard in the field and what we're "taught" to do. It's what some docs do and are comfortable with, but we aren't told that this is how you must practice, and no one packages this version of care as the best, highest standard of treatment. I personally don't like that he peddles the notion that a large volume/brief contact practice is the only thing psychiatrists do.

Later in the book, he talks about the use of therapy by psychiatrists, and discusses one psychiatrist who sees patients for psychotherapy -- she lives in a rural area and she makes half the income of the average US psychiatrist. She is the only psychiatrist he talks about who sees patients for psychotherapy--the others are a now-retired, lost generation of older docs who had it right. I know psychiatrists with psychotherapy practices who make reasonable livings. He doesn't even touch on this possibility, and in a single sentence he dismisses the idea of a fee-for-service, non-insurance based practice. It's not reasonable to present the field in the light that all psychiatrists do is write prescriptions....quickly and badly at that...and that there's no time for thoughtfulness. It got me thinking that -- at least among Shrink Rap readers -- and our informal, non-scientific polling reveals that 44% of readers who responded see their shrink for 45-60 minutes per session (the most frequent answer by far) and that less than 20% of readers see their psychiatrists for 15 minutes or less. Granted, we may have a skewed readership of those who are thinking a lot about their care and perhaps more apt to seek out something more fulfilling. A quarter of our readers see their psychiatrist weekly (also the most common answer but not by much), about the same number who see their psychiatrists every three months. At least among Shrink Rap readers, we can conclude that psychiatrists practice in a variety of ways and it's not uncommon for people to see psychiatrists for 50 minute sessions, or to see them weekly. I'm sure this varies depending on the region of the country, the availability of psychiatrists, the financial needs of those psychiatrists, the setting in which treatment takes place, and the role insurance has in determining care, and the age of the practice-- with the idea that patients may start out with weekly treatment and move to every one-to-three months after they get better. But Carlat glances over those issues. Dr. Carlat notes that fewer docs offer all their patients psychotherapy. One of the figures he quotes is that only 11% of psychiatrists offer psychotherapy to all patients at every visit. Hmm... All patients. Every visit. Some of this might depend on how we each define psychotherapy -- and there is no standard to that -- but if I was asked this same question, I'd say No. I work a half day a week in a clinic and there I see patients who also see a social worker/therapist. I see two patients an hour there, and sometimes they talk and I listen and sometimes it feels a lot like psychotherapy, and sometimes it doesn't feel anything like psychotherapy, but I would say that No, the therapy is done by the social workers and I don't "offer" psychotherapy to "every patient" I see in every capacity of my practice of psychiatry. And I would ask, "how exactly are you defining psychotherapy?" Read the Shrink Rap book (Spring, 2011) and we'll talk more about this. Interestingly, by the end of the book, Carlat talks about doing psychotherapy in 20 minute sessions.

Okay, so he says psychiatrists are taught to write prescriptions and aren't taught how to do therapy. Only he talks in some detail about his therapy supervisors, their thoughtful insights, how he was supervised in a psychodynamic style, and later he talks about how his training program educated residents in Cognitive Behavioral Therapy. Are we taught therapy or not? This all sounds quite reasonable-- what's he complaining about? For the record, I think I finished training at the same time Carlat started (so, 3 years earlier than he) at an institution with a strong biological focus, so I don't think our differences in opinion on how docs practice is about orientation or timing .At the end of the book, Carlat proposes some solutions: Psychiatrists should NOT go to medical school, it's a waste, and they should have more stream-lined training. All psychologists should be taught to prescribe medications. He had no problems with the DOD program in Louisiana, where 7 years of the program taught a total of 10 psychologists to prescribe. He says this type of program is safe and works well. He fails to note that it cost the military over $600,000 per psychologist (why? no idea?) and that's why they stopped it. Or that it did not decrease the mental health treatment shortage in Louisiana. I'll spare you my rants, you can read about
psychologist prescribing here, in a piece by Ron Pies and the article does reference Dr. Carlat. He talks about his own revelations that Cognitive Behavioral Therapy works well, that it's good to ask a patient with a recurrence of depression if anything is going on in their lives (funny how that works), and how he he now does a brand of therapy that he calls "therapy lite." I found the examples to be a bit condescending -- his description of therapy sounds a bit like common sense.

Carlat's book may make him enemies. I'm wondering who his audience is:

-- it might appeal to the anti-psychiatry audience, at least from the cover hype, only much of the book is a fairly reasonable discussion of our work, and so it's not really anti-psychiatry.

-- I don't think many psychiatrists will agree that medical school should be done away with for us, or that other professionals can do what we do as well and as safely.

-- The alarmist tone just didn't go over well with me.

-- Sometimes it felt like he quoted studies when they fit his agenda. There were several mentions of how psychiatrists feel inferior to other doctors, and I'm not sure what to make of that one. Is this a universal phenomena?

-- His bash on how pharmaceutical companies interface with psychiatry include some of our major psychiatrist players here. But if you want to hate the drug companies, this is the book to read.

So what was good about it, why did I read it to the end, and why would I ever put this review on Shrink Rap? After the beginning, Carlat presents a reasonable view of how the DSM is crafted, including the controversies about disclosure in the process of writing the new DSM-V. The most interesting part of the book, however, is his discussion of how the drug companies have influenced research, publications, and practice. Some of this I had read in the New York Times. Some was news to me. I've never seen this side of the pharmaceutical hard-sell -- it was interesting, a bit shocking, and definitely eye-opening. His insider's view of this world is revealing.

So is Daniel Carlat the emissary of truth and ethics while the rest of us remain busy trying to get the big bucks by seeing too many patients too quickly or by getting money unjustly from the pharmaceutical industry? Read the book and see what you think.