Wednesday, April 27, 2011

Hate A Shrink: They Ask For It, After All

Okay, KevinMD today was the final straw. I am so sick Shrink-bashing. We're insensitive, drug-pushers who don't talk to our patients, don't listen to our patients, don't care about our patients. We're in it for the quick buck and "Tell-me-about-your-mother" has been replaced by "Here's your script, NEXT!"

First there was the NY Times article about how shrinks now see 40 patients a day, and the story was about a shrink who tells his patients it's inappropriate for them to tell him their problems. Oy. Shrink Rap commentary HERE.

Next there's MovieDoc who calls shrinks of my ilk who see patients for meds and therapy "sporkiatrists." Jacks of all trades, masters of none, as if one person can't possibly do two things well. You know, I walk and chew gum at the very same time (oy, I'm snarky today).

Oh, and there's the commenter on our Psychology Today blog, Shrink Rap Today, who writes:

'Shrink''Antipsychotics' ('neuroleptics') have been proven to SHRINK the human brain... the frontal cortex, for instance... by about 1 percent loss of brain matter per year... There is horrific fallout from these drugs -So, 'SHRINK' is certainly appropriate.'Rap'Psychiatry, along with its partner in crime, Pharma has a RAP sheet a mile long, particulary in the areas of clinical research, done by psychiatrists... the "off-label" marketing of psychiatric drugs to children, Medicaid fraud... the 'RAP' sheet is quite long.

Thanks for stopping by. Do come again.

And so now KevinMD has a post by a psychiatrist, no less, who writes about how to get heard by your psychiatrist and suggests doing homework and bringing notebooks to those 15 minute med checks. Good we have pointers here because of course we'd assume that no psychiatrist would listen. Dr. Raina writes:

  • Many psychiatrists diagnose a patient’s illness after a 45-50 minute interview, without doing any tests to rule out potential medical causes of psychiatric symptoms and without obtaining history from corroborating sources, as recommended by diagnostic experts.
  • They see patients in follow up for 15 minutes or less.
  • In those 15 minutes all they care about is that the patient says he is better. Once again, they don’t use rating scales or obtain corroborating history to confirm the degree of improvement.
  • In general, patients who take still unfortunately difficult step of seeing a psychiatrist want to believe that they are getting better even when they are not.
  • For a patient, telling a psychiatrist they are not feeling heard might feel too risky – the psychiatrist might get upset at them and might not like them as a patient any more.
  • You could just change psychiatrists. But it’s not easy. You have to reveal the workings of your mind to yet another stranger.
Please, give me a break. What is it with this 15 minute visit stuff? We polled the shrinks in our state. A few see a lot of patients. The most common answer for how many patients do you see on your busiest day of the week? 8-11. Very few see more than 20 patients a day (and these may be 12 hour days?). Many see 1-2 patients/hour. Yes, it's very hard to find a psychiatrist to see you for weekly psychotherapy in-network---insurance just doesn't want to pay for this service. But there is the out-of-network option. On some insurances, it pays 80%. On others, it pays for your parking for the hour.

But we're not all callous jerks waiting to ream patients out if they say they don't feel heard. And what's this bit about how patients want to believe they are better --presumably they are too stupid to know?-- and that's all the doc wants to hear? From a psychiatrist, no less! Dr. Raina, I know a wonderful psychiatrist in Chicago you might like to meet, and I'm sure he'd love to listen to you.

So Clink works in corrections, she sees a lot of patients/inmates, as many as 3 an hour. And her focus is on med management, as is the case in most clinics and institutional settings. Do we think she's callous and uncaring? Ah, I know Clink--she's not. She's brilliant and mild-mannered and while we disagree about some things (about which I'm right), she has principals and she's a devoted and caring advocate for her patients.

I'm tired of being dissed. Thank you for listening.


Alexis said...

To be fair, insurance doesn't quite pay 80% on out of network. They will pay a maximum of 80% of UCR, which is nowhere near 80% of what an out of network psychiatrist will charge. I'm told that Maryland has unusually tough restrictions on balance billing, but most states don't. My plan pays 70% of UCR for out of network. If I see an out of network psychiatrist at $300 an hour, and Blue Shield says it's worth $180, pays $126, I'm left with paying $174--58%. That's not feasible for most people. I can afford to do it for an occasional consultation, but not on any regular basis.

That's assuming they will pay anything at all--I've known people whose insurers cut them off.

Dinah said...

Insurance companies occasionally send the checks to me by mistake (they are supposed to go to the patient). Some pay 80% of my actual fee.
I don't charge $300 an hour
Blue/Cross doesn't deem me worth anywhere near $180/hour (maybe for an evaluation, which I spend 2 hours on, but not for a therapy session).

I don't think this is fair either, but I don't want to provide time-intensive, thoughtful care for what most insurance companies want to pay for it, and just in case I might consider it, the paperwork requirements and hoops to jump through to get reimbursed for in-network care are more than I can deal with. I know psychiatrists who treat patients for free (yes, probably only a few) because the effort of submitting/haggling/arguing is more than they can tolerate.

Sarebear said...

Not one of my shrinks has ever asked me to have a thyroid test. On my own, I happened to have one done as I was getting another test at the time as well, and I took the result to my psychiatrist, who accepted it.

That first psychiatrist was very arrogant, and didn't listen to me, and we had many discussions about our problems communicating and he kept insisting it was my own psychological problems getting in the way.

My current and third psychiatrist I also have communication problems with. When I told her I was afraid of her, she went off the handle at me. I was so beaten down when she asked, am I scary (referring to that particular session) I said No, not even consciously doing it to please her, it just came out automatically. Later I realized, of course, that this appt. made me even more scared of her than before, and alot less likely to bring up issues between us.

Are my experiences a comprehensive study on how well psychiatrists relate to their patiens, and whether or not they consider ruling out physical causes for symptoms?

Sarebear said...

No. However, two out of three on negative relating, and three out of three on not checking for other causes, leads me to have my own murky opinion about psychiatrists.

Then there are you three, who give me hope that there ARE great psychiatrists out there (I can't speak to how great you actually treat patients and consider these issues since I haven't been your patient but after so many years reading the blog you seem really awesome).

This is another reason I keep coming back to this blog, because you give me hope that not all are like I've experienced, and maybe I'll eventually find a better psychiatrist.

Sarebear said...
This comment has been removed by the author.
Battle Weary said...

I have to agree with you on the shrink's seriously out of hand and out of line!

I saw my shrink for med management and a psychologist for therapy. First off, my "med checks" were always 30 minute visits. We spent a lot of time talking about how school was going, how I was managing anxiety, how I was eating, and what my exercise looked like. I've slowly been weened from psych meds, to the point that I am now only taking wellbutrin and klonopin prn for anxiety related sleep issues...I'm actually taking 1/2 a pill about 2 x a week now. Hardly a pill pushing shrink. Also, when my therapist traveled out of the country and became seriously ill, my shrink took over weekly therapy visits for two months so that I would not suddenly be without a therapist. Would she have been my first choice as a therapist? Probably not, but as a person I already had a relationship with, she was a great stand-in.

Nearly a year after she left my area, I am still sad that she is no longer my shrink.

Another thing that is out of hand lately is the bashing of people with anxiety by ER staff! Care to comment on that issue?

SteveBMD said...

Regarding the commenter on your Psychology Today blog: So how exactly is he or she wrong?

You have to admit, a lot of what we do (disclaimer: I'm a psychiatrist too) has the potential to harm patients, and some of our "leaders" have been less than ethical in the directions they have pushed and pulled our field. And don't even get me started on pharma.

Is there hope? Only if we rise above the brouhaha and demonstrate how we can truly help patients. (For starters, listening to what patients actually want and working with them to reach their goals, instead of preaching to them to achieve ours; often they know a lot more than I do.)

The longer we point fingers at each other and gripe about our field and those who hate us, the more irrelevant we become.

Anonymous said...

It's sad that there are so many patients who feel misunderstood or somehow overlooked by their psychiatrists. I genuinely believe that the mental health profession helps more than it hurts, and that a solid mental health professional is priceless. To insult the entire profession because of some isolated experiences is more damaging than anything.

Dinah said...

Sarebear: The standard is to check TFTs if the first episode of major depression occurs in a woman over 40 or a man over 30. (at least that is what it once was)'s not routine for everyone. And we think you are awesome, too!

BattleWeary: Not sure what you mean by anxiety and the ER. Roy does ER work, maybe you could inspire him?

SteveMB: The tone is hostile and accusatory. Yes, the medications we give have the potential to harm, but a) that is not the intent and often we don't know this until we've been prescribing it for some time-- years even. And b)the implication is that we should not prescribe these medications. What do you do when someone walks in the door who is distraught and suffering? Say "I'm sorry, there are medicines that might help you but they could have side effects or adverse effects (and I do say that) or they may shrink your brain so you can't have them? These medicines help people, at least in the moment, and for now, they are what we have. And some aspects of their use we can monitor.

It's not about pointing fingers at those who criticize us, it's about asking that it be done in a tone that opens, rather than closes, dialogue, and requesting that we not be lumped together as one entity (namely that of uncaring, indifferent, script-writing machines). I actually know a few psychiatrists who care about their patients and are nice people.

Rach said...

Wow, Dinah - what a post.

Things like this (co-pays, insurance battles and the like) makes me glad that I'm Canadian, and that my Canadian shrink likes what he does and is willing to spend the time with me that I need. But I think that that's not the trend so much in psychiatry anymore, even here.

... I'm still here, reading away...


Alison Cummins said...

Dinah, this is what you quote from the Kevin MD post:.

"For a patient, telling a psychiatrist they are not feeling heard might feel too risky – the psychiatrist might get upset at them and might not like them as a patient any more."

It says that patients might not feel heard and might be afraid of speaking up. It doesn't say anything at all about psychiatrists, only about some patients' feelings.

This is your reply:

But we're not all callous jerks waiting to ream patients out if they say they don't feel heard.

What I am hearing is... You aren't hearing. You appear to be moving from feeling attacked because you are attacked to perceiving attack where there is none. That's not careful, accurate listening.

Sunny CA said...

Your strong reaction causes me to wish to point out to you that the psychiatrist-bashers are not "all wrong". My first psychiatrist was worse than the guy in the NYTimes because he looked at the floor or at his pad of paper instead of at me and jumped to a 5-minute or less conclusion about my diagnosis by putting words in my mouth in addition to having less than 15 minute sessions. His FIRST session was under 20 minutes. I would think it likely he sees more than 8-11 a day because so few would want to see him if they had a choice.

I was on antipsychotics which severely impacted my intellect and memory at the time of taking them in addition to taking away my feelings which made it seem to me that I had become a rather dumb robot. My husband used to joke about my finally being lowered to "average intelligence" (now you know how it feels to be dumb) when I was on Abilify and Zyprexa (and others all at the same time). I seem to have recovered my mental ability along with my feelings after being off the drugs for about 6-12 months.

Anything MovieDoc says, you might consider the source. He is the only one who seems to agree with what he says, so don't take his comments too seriously. He is extremely rude and insulting, along with being wrong in my opinion when he gets into his "sporkiatrist" routine.

The fact that insurance companies and big pharma are corrupt has the possibility of affecting perception of psychiatrists, but how psychiatrists are actually perceived is in their own hands. Why don't you write a rebuttal article to the article about the 40-patient-a-day doc and submit it to the New York Times? Many psychiatrists would thank you. Psychiatrists need to fight back in productive and constructive ways to change their image.

HappyOrganist said...

HI Dinah.
I didn't care for the one psychiatrist I saw as a patient. But I enjoy this blog b/c you remind us that you are real people like the rest of anyone else. Quirks, perks, etc. =)

jesse said...

Dr. Raina actually notes quite a few useful and perceptive things in his article, but unfortunately writes it as though there is just one way to be a patient, as he presumes there is just one way to be a good psychiatrist. It is not a defect in the field that there are different models of treatment as well as different styles of individual practitioners.

The overall context of the bullet points read as a catalogue of uncaring psychiatrists. Dr. Raina states them as facts, not as the feelings of their patients. "All they care about..." is in the third bullet point. That is why, I think, that Dinah read the second part of the sentence "For a patient, telling a psychiatrist they are not feeling heard might feel too risky – the psychiatrist might get upset at them and might not like them as a patient any more" as yet another comment by Dr. Raina on psychiatrists rather than as a continuation of "not feeling heard" in the first part.

Both readings are valid. And there are many more ways to be a good psychiatrist than there are ways to parse that sentence.

Sarebear said...

Exalya, it seems to me you are saying, "Even though you've had negative experiences with psychiatrists, only let the positive things they can do shape your opinion, because airing your negative experiences is damaging and insulting to the profession."

If I've interpreted you correctly, I'm insulted. Of COURSE the experiences I have with my psychiatrists will shape my opinion of psychiatrists in general, because I have nothing other than experience on which to base my opinions. Including my experiences interacting with the Shrink Rappers on their blog, which is definitely not negative.

I do agree that a solid mental health professional is priceless. Sadly, I don't believe any of my psychiatrists would qualify. The second was a bit incompetent and in at least one drug company's pocket, the latter based on conversations I heard between him and the drug rep for, I think Pfizer makes Effexor. Also based on him pushing Pristiq at me over and over right when we were stopping Effexor for it having stopped working for years; they're so close to the same thing as to make not much difference. I refused the Pristiq until he eventually got the message.

You already know some of what I think of my other two from my previous comment.

Dinah, Thanks! And that information is good to know and helps me form a more informed opinion.

Anonymous said...

AMEN! I am tired of shrinks getting dissed to, as well as psychiatry in general... I think it is coming from people that don't believe in the process and have never suffered from a Hellish mood disorder, a psychotic break, or schizophrenia, to name just a few. But then again,I am a psych patient.

So glad you wrote this post.

Milo said...

Dinah, I am grateful for my shrink

merope said...

To be honest, the KevinMD article described fairly closely my own experiences as a psychiatric patient. I didn't really see the article as "shrink bashing" but more as a description of what many patients MAY experience and some ways to help the patient work with the psychiatrist to more engage them in treatment.

It always amazes me how much the mentally unwell have to go through in order to find a doctor they mesh with. It has been my experience that at every step in this complicated, tiring, and sometimes very discouraging process, it is not unusual to find psychiatrists, psychologists, nurses, social workers, etc. who discount everything I say because, you know, I'm crazy.

moviedoc said...

I agree with Dinah that we should stop or at least expose the flaws in the bashing. Even my sporkiatrist animation was intended to demonstrate through satire that combining psychotherapy with med management has its flaws too and other approaches are OK. SteveB pointed out in a comment on my series on The Good Med Check that the clinic -- not always the psychiatrist -- may impose the 15' limit. Doesn't make it OK to see a patient in 15' who needed 30', but don't blame the psychiatrist. As in any profession there are rotten apples, but most of don't deserve the blaming and attacks.

Daedra said...

Sarebear: I was not actually directing my comments at you, but rather in general. You have had bad experiences, but you are not making the claim that the existence of bad psychiatrists means that the entire profession is worthless. There are others who like to take their personal experiences and apply them to every psychiatrist ever; I feel that such statements (not made by you) are all too common and even dangerous for those seeking help.

I'm the first to admit that there are way too many poor psychiatrists out there. I've met some good psychiatrists as a medical student, but when I was a patient talking to private practice psychiatrists, I never met one that was any good. They wouldn't talk to me for more than 15 minutes, and one of them wouldn't even look me in the eye when I was speaking. The only reason I am able to have faith in mental healthcare is because of one brilliant psychologist who was able to help me. Trust me... I know it can be bad out there. >.<

Anonymous said...

Dinah, I think you take this way too personally. Internet trolls who insult anyone and anything just for the fun of it. I'm not sure if that can really be rationalized. Then there are people who have legitimate complaints about what they've experienced. Generally these experiences come at very bad times. Since happy, well adjusted people aren't generally looking for psychiatrists, the experience of seeing a really bad one sticks.

You've probably already heard all of the complaints against psychiatry, so do you mind if I commute the subject to a different profession for the sake of clarity?

I had a great fourth-grade teacher.
Every other elementary school teacher I had, however, I look back on with loathing. When I picture most of my elementary school teachers, it's a mental image of an obnoxious, nasty woman standing in front of the class, red-faced and screaming about how horrible we were. Then there's my second grade teacher, who I remember mainly for marking a correct answer on a test as wrong, and then accusing me of having changed it after having gotten it back.
Especially when talking to parents who are having particular trouble with awful elementary school teachers, I end up engaging in a bit of elementary school teacher bashing.
None of that means I hate all elementary school teachers. If I went looking for an elementary school teaching blog, I'd probably be impressed by the fact that that person cared enough to write about their experiences. And I certainly don't believe that the existence of bad elementary school teachers makes elementary education in general a bad thing! The fact that most of my elementary school teachers were awful doesn't mean that elementary school education is wrong and should be abolished. It means that elementary education needs to be taken more seriously and not relegated to people who haven't moved beyond the elementary level themselves. It needs to be seen not as the most primitive, "easy" education but as the foundation for everything else, and we need to realize that that foundation has to be solid if the educational system is going to work at all. It means that good elementary school teachers are desperately needed. And it means that the ones that are good stand out even more.

Duane Sherry, M.S. said...

Dr. Miller,

I'm glad I stopped by the Psychology Today blog...

I'm not alone.
Many people are waking up to the scam of pscyhiatric "treatments"... a number of professionals are growing tired of the harm!

Duane Sherry

Duane Sherry, M.S. said...


As a psychiatrist, you wrote:

You have to admit, a lot of what we do (disclaimer: I'm a psychiatrist too) has the potential to harm patients, and some of our "leaders" have been less than ethical in the directions they have pushed and pulled our field. And don't even get me started on pharma.

Is there hope? Only if we rise above the brouhaha and demonstrate how we can truly help patients. (For starters, listening to what patients actually want and working with them to reach their goals, instead of preaching to them to achieve ours; often they know a lot more than I do.)

I would like to say, "Thank-you."

You're right... a lot of psychiatric patients know a lot more than many psychiatrists...

History will get the last call...

In my opinion, history will not be kind. History will not need to "bash" psychiatry... It will only need to explain the injury and harm that has been caused by psychiatry.

IMO, the days of conventional psychiatry are numbered... The American public will soon realize that psychiatry was behind its own death... by ignoring the tenets of its oath, "Fist, do no harm."

Duane Sherry, M.S.

Anonymous said...

I almost forgot the third group-- people selling their own brand of mental health "recovery." Some are of the group with legitimate grievances over the treatment they received, but others can only be defined as competitors.

You still do have to remember that no matter how low the percentage of psychiatrists that do a 5-minute evaluation, jump to conclusions, and write prescriptions, that is what insurance generally covers. Just because that's not most psychiatrist doesn't mean that's not what most patients will encounter when first looking for a psychiatrist. If someone starts with the list of doctors their insurance company gives them, and then makes an appointment with the one that's taking new patients, that doctor may not be representative of what the majority of psychiatrists do, but it is fairly representative of what the majority of patients encounter when first seeking treatment. And when you're at the end of your rope, finally deciding you need help, seeing someone really bad leaves a mark. It's such a feeling of hopelessness to finally admit that you can't do this alone, and then discover that the psychiatrist your insurance company sent you to isn't going to be of help. A healthy rational person might not have trouble getting past that and looking for other options, but someone who is already wondering if their situation is hopeless is more vulnerable.

Dinah said...

Last Anon Commenter re insurance companies and the 5 min. eval:
May I quote your comments for a post?

Eidolon said...

Believe it or not, some of my medication management patients actually resent it when I spend too much time with them. I think it is all a matter of goodness-of-fit - a patient stays with a doctor who they feel comfortable with.

Anonymous said...

Of course.

Duane Sherry said...

Psychiatry is not the answer...

There are safer and more effective treatments available... Ones that lead to wellness and recovery -

Duane Sherry, M.S.

Meb said...

What a great site! I appreciate this venue and the diversity and thoughtfulness of perspectives. As both the child of a psychiatrist and a current and former patient of several psychiatrists and psychologists over the years, I can appreciate the range of perspectives about this issue. Only now in my 30s, I’ve spent the bulk of my adult life and more than $30k trying to find effective treatment for my depression. The difficulty in finding effective care was sometimes as simple as incompatibility in style, but more often due to structural limitations – in particular, limited diagnostic work, 15-minute follow up med visits, and insurance limitations. Only now have I found a gifted psychiatrist who does skilled psychotherapy and extensive diagnostic work – which has, for the first time in my life, provided me with a clear understanding of the interplay of my conditions. As good as my health insurance is for the rest of my medical needs, however, it has not covered sufficient care. Despite parity efforts, one’s insurance/employer still has extensive power in determining what kind of services one receives. In addition, now that I no longer live in New York (apparently the great psychiatric homeland!), finding sufficiently skilled psychiatrists/therapists is quite challenging. While “bashing” may be understandable in some cases, it seems more important to take a step back and to consider the challenge of mental health care from the 30,000 foot socioeconomic level – what do we value in society, and how are we paying the price in the availability of quality care? To what extent are we supporting systems (such as big pharmacy and insurance companies) that drive medical decision making despite the best efforts of the best doctors? (How) are we encouraging bright and compassionate doctors to enter psychiatry? I appreciate “anonymous’” reference to education in this regard. As an educator, I see a clear analogy; we hold responsible teachers and principals for all the failings of students, yet we don’t consider the complex dynamics of racism and poverty that constrain our ability to support systemic school improvement for all students.

Dinah said...

Mr. Sherry,
So you've said. A number of times, in fact.

Unknown said...


You're right.

I should let you and your colleagues continue to talk about insurance re-imbursements.



Duane Sherry, M.S. said...


In a comment to SteveBMD, you wrote:

"The tone is hostile and accusatory. Yes, the medications we give have the potential to harm, but a) that is not the intent and often we don't know this until we've been prescribing it for some time-- years even. And b)the implication is that we should not prescribe these medications. What do you do when someone walks in the door who is distraught and suffering? Say "I'm sorry, there are medicines that might help you but they could have side effects or adverse effects (and I do say that) or they may shrink your brain so you can't have them?"

I have two questions?

a) Are you kidding me? !!!
B) Do you mind if I quote you in a post?

... And you have the arrogance to wonder why people are down on your "profession?"

... I call you out, and I cite specific examples of how conventional psychiatry harms its patients, and rather than respond to the facts, you chose instead to appeal to your readers... who came by the droves to give you comfort... ignoring the issue at hand, ignoring the injury your profession continues to cause -

Let me take a moment to remind you of the Hippocratic Oath, "FIRST, DO NO HARM!"

Duane Sherry, M.S.

Yti said...

In my experience, the comments you heard are correct. Not just that, but there must be some agenda as well. Confronting a psychiatrist or therapist really doesn't work either. They will deny everything, even if it's documented. From my personal experience, a judgment has been made before you came in, based on demographics and their personal agenda. After that, they see you, deciding a diagnosis on their first impression, and decide on how harsh the treatment should be based on whether or not they like your tone of voice, and key words taken completely out of context.

I've seen horrible things written about me. Ugly, nasty things, and they look as if there is just simply another person they are talking about. They just make it up to fill out a comment sheet is my guess.

Look; if you don't want these things written about your profession, than weed these people out! Be careful to listen to the answers the patient is telling you, rather than key words and your own feeling on the colour of their shoes. Track this and the progress... actually TRACK it, rather than goof of and ask "how are you today?" and actually develop and execute a battle plan with your patients. It's not hard. Just use your brain a little and focus.

You might feel unjustly condemned, but think about how we feel when we come in saying, say, we feel like we're the bad guy for failing, and you write that we rape kittens with our skinhead buddies and throw Abilify at us, with no follow up for what we failed at. You might be surprised that you can actually HELP a patient if you just demonstrate you are listening in your notes. Did you ever consider that?

And lay off meds until after therapy. What's the harm in figuring out the problem first? This "Gosh and by golly" nonsense in the mental health field just needs to be gotten under control.