Thursday, December 08, 2011

The Secret Lives of Patients

In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing.  The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life. 

Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage.  It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me).  What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy.  He had a secret life.

There's not really much to do about this.  One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website.  Oh, and I am so glad.  

When it comes to hiding medications, or treatments, then perhaps that's different.  Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax?  If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't  prescribe to someone doing such things.  Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his psychiatrist?  We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.

So where is the line?  Is it okay to hide manic behaviors from a psychiatrist---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings!  Is the psychiatrist entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink?  That mom thinks he's getting sick again?  Every fantasy that pops into his head?  Is it okay to withhold your dreams from your psychoanalyst?

I won't go on.  You tell me where the exact line is.  I have no idea.


Taylo said...

I don't think there is a line. I think you should share everything. When I was seeing my therapist (I've since "graduated" yay) sometimes I thought about holding something back, but why? I wanted to feel better and I knew for her to help me I needed to divulge everything. Now did I need to tell her that I cut someone off yesterday? No, but I shared anything going on my life. Even if it was embarrassing, I didn't want to talk about it, or if I started talking to that person I said I was never going to talk to again. I read something once about going to see your regular doctor. You go in b/c your arm is hurting and you would tell them everything that related to that hurt arm, right? So why would you hold back with your therapist? I let her decide whether it was important or not. I ended up telling her something I had never told anyone, which turned out to be the biggest breakthrough in therapy and in my life. So my advice is to never hold back.

Notgoingtoheaven said...

Getting Xanax from more than one doctor at a time is double doctoring and is illegal where I live. That is a little different from some of your other examples.Most patients don't hide manic behavior because when they are manic they tend to be sure they are normal and everyone else is just very slow. Your example of the fellow who brought up a sexual issue shows that it often takes patients a long, long time to develop the level of trust needed to be able to talk about tough stuff. Did he have a secret life by choice or because he was too ashamed until he developed trust? I don't think it helps the cause of trust to be checking up on everything a patient does. There is no line. patients bring what they feel they can. It is not only about a doctor you can trust 100 per cent. I will never be able to do that, not 100 per cent. it is about finding someone who gives you the time to develop the trust.
i know it is a one way relationship but really, doctors are the ones with the secret lives. The doctor who sneaks smokes between patients who are admonished to quit smoking, the doctor who tells the patient to take better care of themselves and who does not practice any self care at all. That leaves out the doctors who have ultra secret lives until they are reported. They are in the minority but they do exist. So asking a patient to put all their trust in anyone is, uh, nuts.
I can see it now. Psych patients taking meds will have a special stamp on their forehead with the name and number of their doc so that the bartender can call to see if it is okay to serve them.

jesse said...

Agree with the above posts. On some issues patients may not consciously realize what is relevant, on others they may be too inhibited to speak of them. What is most important is to put the burden on the psychiatrist, where it belongs. The psychiatrist may practice in a way that makes it difficult for the patient to reveal certain things. That is in fact often the case. The patient picks up many cues from the psychiatrist.

As an example, if the psychiatrist pays too much attention to symptoms he may unwittingly be discouraging fantasies. If he is seen as judgmental he discourages revelations. If he does not give the patient sufficient time, or interjects too much, certain material will never emerge. The list is near endless.

Liz's Blog said...

i got a prescription for celexa at my first visit to my current psychiatrist a few weeks ago. while deciding whether or not i wanted to take it, i lost the prescription. i was doing okay (for the most part) so i decided this wasn't a big problem for me. i have another appointment coming up... will she know i never filled that scrip?

here's my take on the privacy issue: my treatment is my responsibility. i choose who i trust and how much i trust them, and i tell them what i want to tell them accordingly. while this can lead to issues and could potentially disrupt the effectiveness of my treatment, i feel that's my prerogative. it's my health, after all.

this DOES sort of piss me off. it seems like the rights of providers to information trumps the patient's right to control their own medical records.


rob lindeman said...

The line is where ever the client wants it to be. If they don't want to tell you stuff, it's their business. We ought to be careful to avoid allowing ourselves to believe we have to right to know what our clients don't want us to know. If a client reveals something to you that for any reason you feel they should have revealed earlier, and furthermore you feel that their withholding vitiates your therapeutic relationship, you can sever that relationship.

wv = scardice; Lesser-known Pacino film. Never got much box-office

jesse said...

Agree with Rob. The patient has a right to reveal only what he wants to, and the psychiatrist has no right to more. Whether consciously withholding pertinent information interferes with treatment is another matter altogether.

rob lindeman said...

And I agree with Jesse's previous comment, particularly the examples given in the second paragraph. Would that all therapists paid attention to these considerations!

wv = rebrin; Freeze-dried ocean. Just add water and serve!

Jane said...

Hiding a manic episode from the dermatologist? Well, that's not such a big deal. And I fully understand why someone would want to hide a bipolar diagnosis from doctors who are totally uninvolved with treating that disorder. It gets more complicated when meds are involved. Admitting to a Lithium prescription is kind of a giveaway, but it might be necessary in some instances. Information should be kept as private as possible from the people that it is not relevant to. Because people do have preconceived notions (LD is caused by mental illness, ADHD kids don't do well in school, etc).

When you enter a disabled students program at a college, your disability is kept totally private. Only the disability counselors know. None of your professors have ANY access to this information. They are notified by the office of what accommodations you are entitled to (if you request it), and that is it. If a professor asks the office what the disability is, they are told very politely that it is none of their business. I've never had a problem as an adult in a college setting receiving accommodations.

This is not the case where kids are involved. Kids have no choice. All of my teachers were notified of my emotional disturbance and defiance issues and were told this was the cause for my inability to learn in their classes. I received absolutely no extra help. Weirdly, I received more help in college than in public school, and I’ve heard it’s actually supposed to be the opposite. The accommodations are supposed to decrease as you head up the academic ladder.

When talking to a learning disabilities specialist in college, he did vent a little about what a problem this is. When a school labels a kid as "emotionally disturbed," not only did they just assign a terrible label to that kid, but they just told all of those teachers to NOT help that kid. What teacher wants to accommodate an emotionally/mentally messed up kid? Not too many. If you report an ADHD diagnosis to your kid’s school, and request accommodations, they notify his teachers of the diagnosis (as well as his accommodations). His teachers may or may not choose to help him, depending on whether the parents are pushy or not. And if he under performs and gets Fs...well, what did you expect? Of course he didn't learn! He can't pay attention long enough to learn! If you report a disability to a public school to get your kid help, you may have actually just made his situation worse. His condition will no longer be private, and this information will be in the hands of people who may or may not fully understand his diagnosis.

For the same reason that I think not everyone who works at your kid's public school needs to know if he has a certain condition, I also think that not all of your doctors need to know about some of your specific medical hangups.

Jane said...

Oh whoops. left something out. I was doing poorly in school as a kid, so I was tested for LD. I scored as LD. Special Ed. then diagnosed it as an emotional disturbance, and said that was the reason I scored as LD. So they threw out the scores, diagnosed an emotional disturbance, and told all my teachers I was intelligent enough to learn in their classes, but I was so mentally unstable that I couldn't perform. They then told my father that he would be guilty of child neglect if he did get me psychiatric help, which led to years of psych meds that either made me feel worse or didn't help at all.

And that is why information should be kept private. If Special Ed. had kept their info to themselves, and my emotional disturbance diagnosis kept private, maybe things might have been easier.

I'm sure a patient diagnosed with borderline personality disorder once upon a time, might not want that disclosed to everyone.

Anonymous said...

I cannot help but think that, yes, it is the patient's responsibility to be honest with the shrink, but it is also the responsibility of the shrink to be perceptive and ask appropriate questions in the pursuit of encouraging the patient to divulge critical and albeit painful truths.

For example, I was diagnosed with garden variety depression. I was put on a couple of antidepressants and some other pills for anxiety and insomnia. And then I felt better so I stopped going to the shrink. I mean really felt better. I met several men off of the internet and I do not remember their names. I was super productive. I bought lots of stuff. I was giddy.

And then I crashed. Whimpered back to the shrink. I was not asked, "What have you been doing these past few months?" I was placed back on the antidepressants and the bipolar diagnosis was delayed.

In this case, I think the onus is on the shrink and not the patient. This patient thought she was feeling good and having a good ol' time. I believe the shrink needs to be perceptive and know what questions to ask.

Nowadays, I am feeling well enough to know what information is imperative for my shrink to know so that she can help me remain healthy.

Unknown said...

This gets even muddier when treating adolescents and children, because sometimes people tell on them and expect us to respond to the new symptoms like the client is requesting help. More often that I would like to remember, I have psychiatrists, parents, and foster care folks wanting me to talk to my clients about their incontinence problems, relationship problems, or history of molestation the child never brought up and might not want to bring up. Because of the sticky relationships between the client and the person consenting to their treatment, I often feel placed in the position of embarrassing the client, or treading on their rights to feels so divisive, especially if I suspect I am actually being triangulated by nervous caregivers into having conversations they are unwilling to have but NEED to have with the minors in their care.

I liked Jesse's statement that:
"The patient has a right to reveal only what he wants to, and the psychiatrist has no right to more. Whether consciously withholding pertinent information interferes with treatment is another matter altogether."

I wish my clients were given this kind of privacy as minors, instead of being told on every time their behavior deviates from the mythical norm established in their caregiver's minds.

But I can't be too hard on the adults, either. They want the child to be safe, healthy, and happy. I'm just not sure we do our clients many favors by forcing topics they may not be ready for, especially for teens who are at such a vulnerable identity seeking stage anyway.

CatLover said...

I have never had a psychiatrist express any interest in anything going on in my life. They only have ever wanted me to rattle off a list of symptoms and if I am taking my pills or not. Anything else, I am supposed to talk to my therapist. I have had many psychiatrists thru the years, and it has always been this way.

As for my therapist, I am not secretive with her, but I think it is my OWN business what I share with her or don't share. I am paying for her to help me, and it's up to me to tell her what I think is needed so that she can help me. She is NOT a priest for me to confess to! You have to edit what you say anyway, due to time considerations

I think where the line is depends on the patient, very much.

I would avoid telling doctors I have bipolar, since I don't take meds (they were a disaster, as I've mentioned before). But I am on Medicare, under 65, and otherwise healthy, so I am stuck. I don't tell the dentist, to whom I pay cash. Going to the doctor for an infected cat bite or twisted knee and having them know I have bipolar is just more shaming, and I think it's part of why I can't seem to get out of depression. Then doctors who don't know me try to shame me into taking medications, and psychiatrists who DO know me wanted me to stop trying any more pills. It doesn't come up much because I don't have any serious physical health problems, but as I age, it will get to be a bigger problem, I think.

Sarebear said...

At least on the yeast issue, embarassing as it is, well I had cause to read a book last year on yeast health problems and it said anyway it can make you depressed and other stuff, but who knows, it's yeast? I'm not sure I bought everything the book said, it's an older book and sounded sort of FADdy.

So I don't know. But you never know what medical stuff might affect your mental health; heck, just having a variety of medical issues can be quite an impact on your mental health.

Also, I am just now learning due to finding out my MIL is getting her hip replaced, that all of a sudden intense, unknown to me but buried emotions, about my own knee replacements and all the physical, mental, and emotional struggle that went on, all the suffering, well it's all bubbling up, and I'm going to have to wade through it because I'm going to be her primary helper in the first week or two after surgery. My husband was unusually perceptive and especially characteristically kind when he said, "If it's too painful (emotionally) for you to help her, you don't have to." Of course, he lived with me through it all so maybe her perceived more than I thought . . .

But who'da thunk a stupid surger(ies) would have had such psychological impact? I was of course aware that I still haven't emotionally recovered from them, but this stuff that just bubbled up completely took me unawares.

So, as I wor up the courage to call a new shrink this week, will my surgeries get discussed beyond just answering on the form about any surgeries and whatnot? Yes, even though I wouldn't be seeing said shrink for therapy. It's very pertinent to my mental and emotional state (physical as well, can't forget all that pain I live with), so I feel it's important for my psychiatrist to know more than just that I had the surgeries.

Sometimes health issues impact other areas of your life (including impacting your mental health) in ways that can't always be predicted.

I'm of a mind that it's helpful for a psychiatrist to see the big picture; if you don't trust them with private, intimate things, then what DO you trust them with?

On the issue of secrets in general from your shrink, I read in the last 8 months somewhere (maybe here? lol) that it's not uncommon for the patient to hold some little something back from therapy, to have something that isn't getting poked and prodded, to have something that's theirs alone.

Funnily enough for me (and you shrink rappers, if you see the irony) mine was (I "told" him about 4-6 months ago I think? Is that I come to this blog and have for years and how I feel about it and stuff. I always felt it was a corner of my life that just . . . what is there to examine? And, well, it felt like it was mine, to hold close.

Of course we examined why I felt so private about it (irony since I am not so private here, sometimes) and stuff.

I wasn't consciously (most of the time) purposely keeping a "secret"; on the rare occasions it would occur to me that I hadn't discussed this blog with him, I thought, "I'll get to it eventually" and of course I'd forget.

I did however discuss a few things from the blog over the years, and mentioned "a blog" but not much about it, and that posts and/or comments/discussions had brought up things in me that I hadn't realized before and wanted to discuss in therapy.

Anyway. I'm kind of embarassed now . . . lol.

Liz said...

i have no idea, either.....but ultimately, isn't it the patient's right to reveal what he or she wants to reveal....with the understanding, of course, that hiding relevant information will end up compromising one's success in therapy....i.e. you are only cheating yourself if you withhold the truth.

Sideways Shrink said...

This is a great follow up subject which I really I appreciate. Taking a long time to reveal sensitive things to a psychotherapist is not unusual. It took me a year in full of 2-3 times a week psychoanalysis during my training to reveal to my analyst my frustrations with husband. After she thought about it, knowing the background of my parent's marital dynamic of alcoholic co dependence I'm sure she wasn't surprised that I was hiding his problems from her. But I could see in the moment this brief pause which betrayed her surprise (which is one of the things I really liked about this woman who was on the faculty of one of the preeminent psychoanalytic institutes in the country--thank God student health paid for a lot of the cost!!). It showed she was human and had not pretended to herself that she had me figured out. And, then, of course, came the uncomfortable questions about why I had not discussed these feelings before when they had been a problem since before I started seeing her. But that is what a good therapist will do: encourage you to explore something difficult, because this tells you about yourself that you know but perhaps haven't articulated to yourself. (My shrink referred us for marital counseling with this great social worker who helped us with our early marital issues and we are married 13 years now.)
The stigma about mental health treatment and taking psychiatric medications still exists in some people's tiny minds. However, whenever you, yes you whether you are a shrink patient or a patient or a pediatrician who really dislikes psychiatry (Hi, Rob! He, he!), withhold your full medication list from a prescriber of any kind in any context, primary care or an ER or shrink office, you are taking a risk that you just can't calculate because you don't know in advance what might be prescribed for you at that visit (or put into your IV) and so you can't research it in time to stop potential ill effects from happening to you. Take care of yourself. Try not to feel ashamed. Voluntarily getting care for your mental health problems, as every shrink knows, means your not big "C" crazy.
Otherwise, we are all basically little "c" crazy.... Otherwise, there would be no art, creativity, Nikolai Teslas, MacArthur Genus grant winners, astronauts, jazz musicians, etc. Rejoice!

whatevs said...

if I had to go see a new shrink, oh wait.. I do have to go see a new shrink, there is no way i would end up laying everything on the table off the bat. I get 50 minutes-barely enough time to give them a rough outline of my basic issues--diagnosis, living situation etc. Then, i have to assume that this person may not end up being someone I will stick with--am I comfortable with them? I won;t know for a good long while. it will take a lot of me putting bits and pieces out there and seeing how they respond. If they are not a good fit, better that I did not bare my soul. It will take a very long time to ever get to the point that I would really be able to break through the walls that keep me isolated from everyone in the world. if that happens, they will probably tell me that they are leaving on a cruise around the world for two years. Most people who get married do not get married a week after meeting someone. They wait and see how things unfold. I am not marrying a shrink but there are some parallel issues such as when to disclose what and not because I want to protect myself. i had a pretty good doc for a decent amount of time but even there, I would not bring up a yeast infection. No swinging going on, but I do have some shreds of dignity left. Not many, but I will guard them as best I can. About the person who is worth millions and getting a discounted rate-- that is about fraud and not about trust or fear unless the person is a secret stash cash under the mattress because the world is coming to an end, seriously believes they are poor sort. Nothing is simple except that I do not need to be spied on and when I am good and ready i will say what needs to be said.

Jen said...

completely agree with Jesse.

Also, a therapist is not automatically "entitled" to know everything that goes on in my life/thoughts/dreams. Quite frankly, a therapist "earns" a lot of that -- and earns it by being empathic, intelligent, astute, aware, etc...but also mostly by not being an idiot. Sadly, there is a reason why mental healthcare gets such a bad rap.

Anonymous said...

For once I agree with Rob in his first post.

As for omitting information in therapy/with the psychiatrist. I never, ever tell them of my financial woes when they ask if I have any other things going on that are causing severe stress. It is a HUGE source of stress and depression, and anxiety symptoms are exacerbated as a result. I grew up in a home where it was embarassing or looked down upon if you are struggling financially. You hid those facts and pretended that everything was just fine.

I am still terribly embarassed about this and can't bring myself to talk about money issues in therapy. Weird I know, but it is a big deal to me.

Sideways Shrink said...

I have had some obtuse therapists, however, I think the reason "mental health care" has a bad rap is the same reason the "mentally ill" (whatever that really means)has a bad rap--almost all cultures stigmatize mental illness because it terrifies every person that they, them selves might lose control of their minds. So who better to project this doubt on than overworked and underpaid mental health care providers? The public health infrastructure was defunded by the Reagan administration AFTER thousands of people were released from long term placements in psychiatric hospitals and put in less restrictive group homes. This is the actual advent of "homelessness".
You are free to distrust your psychiatrist and I hope you overcome that if you want to. I agree with Jesse as well, and I would like to elaborate on my earlier post: I only progressed in therapy when I was able to trust my therapist. She did not actually change at all. I did all the work and kept going--2-3 times a week--she checked her answering machine randomly for God's sake! I was the one who changed and trusted her. It is something to think about before your slander or blanketly disparage "mental health care" per se.
I hate to sound "directive" in psychotherapy terms, but I am offering food for thought based not on my experience as a shrink, but as a patient who has had insight into what it means to be a psychotherapy patient or as they say here on the west coast,from whence I hail, "client".

Taylo said...

I'm sorry, but it seem some of you need to move on from your therapists. Yes, it definitely takes time to build that relationship and trust, but if you have been seeing him/her for awhile and you can't share secrets with them, then maybe it's time to find a new therapist? Just as you aren't going to click with every person or significant other you meet, you're not going to click with every therapist you see. I saw three therapists before mine, and never told the others even a quarter of what I told my last one. If it isn't working it's important to find someone else.

Anonymous said...

I see a psychologist and a primary care doctor who work at two different clinics under the same healthcare organization. I was seeing my primary care doctor about my cholesterol levels and in the medical record he found notes from previous visits to the psychologist. That really surprised me. I don't mind if information about medications etc. are shared on a need-to-know basis (not every staff member on an inpatient unit needs to know you have high cholesterol!) but I think the content of a therapy session is something I should have total control of. I also think personality disorder diagnoses should be kept out of the record because of the bias it engenders. My primary care doctor is great- he doesn't pretend to treat my mental illness- but I am sure glad my psychologist keeps his notes to a minimum!

Sarebear said...

It isn't that I can't share these (or that) thing(s) with my therapist, it's just that there were generally other things to talk about (for example, I started blogging ab out 3 months into therapy, and Shrink Rap started within a month or three of that; by 6 months into therapy, therapy started shifting from getting to know all the ins and outs of my life (not that he could completely have gotten to know me by that time, but it was kind of an introductory period, getting to know the therapeutic relationship, etc.), to moving beyond the initial trust-building stage to more working on stuff (not that I didn't work on stuff from Day 1).

So yes, while the 3r'd or 4th time it may have ocurred to me, "I haven't told my therapist about this aspect of my life, oh well I'll get around to it sometime", I possibly should have marked it as curious enough for therapeutic exploration that I kept putting it off, it just didn't seem THAT important, really.

Sunny CA said...

Part 1
It took me a long time to tell my psychiatrist many things that have happened during my life and things I have done that embarrass me, but in the end I did tell him, and he is the only person who I have ever told most difficult and secret things to. I was going to post that I have told him and do tell him "everything", then realized there is one topic I have not discussed with him, and it is his fault, at least in part.

Here is my "secret life" story. I have been having a real issue with clutter and disorganization. It has not been a lifelong issue, but has been during the time I have been seeing my psychiatrist. I am not talking about having a few things out of place. I am talking about having a house in which the most heavily-used living areas are non-functional due to disorganization and the resulting clutter. I have brought up the issue with him several times and his response is generally the same. When I tell him that my environment is cluttered and disorganized and I can't stand it, he is certain that I am holding myself to neatness standards that are too high. I am not.

Sunny CA said...

Part 2
The first time I brought it up, he proceeded to tell me about a friend of his whose clutter is REALLY horrible. When my doc toured this friend's house, my doc asked to be shown the room with closed door and inside was a bedroom stacked with "stuff" to the ceilings. My psychiatrist then berated his friend for this and expressed disgust with his friend. While listening, I was certain his friend's house was better than mine because at least all the other rooms in this home were "normal". This caused me to back away from telling my psychiatrist more about this even though I had two rooms I could not get into due to accumulated clutter & disorganization and countless areas that were non-functional. It is not that I find it emotionally difficult to get rid of things or to organize, but that I have felt for several years that I have no energy and I don't seem to have the decision making capability to figure out how to deal with it. I have felt like I am in mud or underwater so I can hardly move at times. I can find it impossible to open the dishwasher to put in a dish or impossible to put a wrapper in the trash or impossible to put away something I used because of my level of lethargy and feeling like I am "trapped in mud" is so intense. Yet, at the same time, the clutter actually works against my ability to get things done and the clutter makes me feel more lethargic and beaten. At times during the last 5 years, my clutter makes it hard to cook because of mail and other paperwork stacked on the (flat ceramic top) stove. I find it difficult to shower in one of the bathrooms because of clothes hanging on the shower rack and clutter on the counter and floor in the bathroom. It really is an issue in my life. On the encouraging side, it does seem that this problem is going to "solve itself" without being directly addressed in psychotherapy. After finally getting a decent job, I have been feeling more energetic and happy in the last three months, and I have been able to clear and clean the kitchen counter tops, and have that area functional again. I got my dining table cleared of clutter and am able to eat at the dining table again. I sorted my closets and gave clothes I no longer need to charity. I went through my kitchen cupboards and filled boxes for charity, so I am starting to resurface. Still, I am not there yet, and I suspect it will take a year or more (because I work a demanding job and have lots of other things to do in addition to clean) of sorting, throwing out, organizing to get my house organized and back to full functionality and up to a level at which I could have guests visit, again. Perhaps my psychiatrist was right in that it was not productive to beat myself up about my disorganization. In general, I don't grant myself much slack. He has encouraged me to take time off to do pleasurable activities which I often have not done. He has worked to help me accept myself as I am. However, I would have rather had him encourage me to tell him more by asking more questions, and not show his bias against disorder and clutter. It is a strong personal bias of his. I know that his own home is a showplace that he puts a lot of time and money into. During the time I have known him he has gutted his bathrooms to the studs and redone both rooms, he had a color specialist design a palette of colors for all his rooms and rooms were painted to those coordinated colors. If he is done with something, it goes out. During that same time, I have been having to force myself to do something, anything, using a technique I devised of setting a timer for 10 minutes and trying to put away or throw away 10 things in those 10 minutes and finding that very, very hard to do. Yet, it that has been my secret. I have told him about my lethargy, lack of energy, inability to make decisions, etc, so have not withheld that.

Jane said...

Oh my goodness Sunny! You are not alone at all. I am the same way about clutter. I think for me it might be, at least in part, the ADHD brain I have. If indeed I even have that (no blood test, etc). I think cleaning and organizing is just so not stimulating that it actually makes me really tired and causes brain drain. I noticed when I was on strattera it was much easier for me to clean and reorganize. It's too bad the drug didn't work out :(

But I think some people are just really disorganized like the point that taking out the trash and doing dishes bores them to tears and they can't focus and it actually causes brain drain...and then the overwhelming clutter is a brain drain as well.

I could never be a maid.

CatLover said...

Sunny, I really feel for you. my problem is not clutter so much (but I have a tiny house so it is cluttered anyhow) but I had a run of years of depression, and have not been able to do anything but the barest minimum of house cleaning in that time. So now I have felt noticeably better for a couple months, and the kitchen cabinets are washed, I washed kitchen walls, behind things, pulling out furniture to vacuum, etc. I hadn't dusted for 2 years and I am just getting to that, and decluttering as I go. It's still awful, but I guess if I just put in an hour a day of basic cleaning, eventually it will be ok. Hopefully I can finish before the depression comes back and it will have to be ok for another couple of years. I'm hoping the years long depression was just an anomaly and won't be like that again. I dunno what to do about the shame. I never let anybody go upstairs (but I have made major progress there now). The house is really run down, too, and I probably will get the depression back again by the time good weather rolls around again.

mental health workers seriously underestimate how much of a toll it takes on a person to have a horrible home that they cannot invite anyone over, assuming they are even feeling sociable. And I do not feel that it is ok to take a break and do pleasurable activities when there is a big mess I should clean. But I only have enough energy to do that little bit, so I rarely do anything fun that require energy.

I am feeling so much better that my home is almost presentable now. Another month and it will be whipped into shape. My God, is that an achievement for me nowadays.

Dinah said...

Sunny CA: There are a lot of you out there and I hear about clutter all the time in therapy.

So secrets.... I don't think it's really expected that people reveal all their secrets in therapy. If it's a source of distress or something to work on, then certainly, and of course it may take time to feel comfortable with it. So embarrassing things are one type of secret.

Secrets that directly impact treatment seem different, or deceptive. So getting meds from multiple doctors, or hiding things that are clearly indicative of illness are good examples.

Swinging is actually a good example. If it's something done in the context of a relationship that everyone involved is happy with and not a sexual behavior that is causing any problems, and not something the patient wants fixed, it doesn't seem necessary to bring it up--- people often don't talk about their sexual lives, and if everyone is a consenting adult without jealousies... If it's something the patient does only in certain mood states, or something someone is angry about or feeling coerced into, then maybe it's worth talking about.

One can talk about issues without discussing them in depth. "I'm anxious about my finances, but I was brought up not to discuss these things, so I don't want to discuss them, but I want you to know that this stress is contributing to my anxiety." There isn't a pill that fixes that, so it's worth knowing & it might guide the doc towards seeing if meds need to be samples/or generics, and to think about the frequency of sessions. It is extremely common for people to be anxious about money issues.

Cleanskin said...

Thanks Dinah for another wonderful stimulating topic!
I withheld some facts from a previous psychiatrist (eg same sex attracted) because of his strong religious views.
My current psychiatrist is someone with whom I feel comfortable talking about anything. However I am somewhat restrained in what I say because if if I say (for example) that I don't feel I'm making progress, he takes it personally. He said he is very sensitive and its obvious that he is.
I think Jen got it right when she said that therapists have to earn it.
Sunny Ca and Catlover: I resonate completely with what you say!

Abby said...

btw, anyone who prescribes me medication or performs any treatment that might affect/be affected by medication I take is entitled to know about the other medication. that is a matter of simple health/safety and supersedes any embarrassment I feel (and you bet I am embarrassed telling a dermatologist which psych meds I take).

That said, my psychiatrist-of-five-years-who-I-trust-with-anything doesn't need to know if I get a yeast infection. If I start to feel suicidal after taking that pill, then yes, she needs to know, lest that be a potential cause. But guess what, I've never had any interaction between psych drugs and diflucan. So that means that my psychiatrist really doesn't need to know about my visit to the gynecologist. Just because I am in therapy - or even, just because I take psychiatric medications - does not mean that I no longer have either any pride, nor privacy. I am still human. I also still have some common sense. I like to think that my shrink trusts me enough to not leave out the stuff that if left out would be detrimental to the treatment.

Anonymous said...

Everyone talks about the wonders of electronic medical records (and as a physician, I am not at all sold on their "benefits", yet); however, few people are raising the issue that with EMR's, privacy is being thrown out the window with hardly a glance.

As an internist, I am a little shocked at what "elements" are being added under the guise of "meaningful use." I think the primary meaning is going to be for the payors who will harvest this information for their own ends.

Yes, working with an EMR has left me feeling quite haldol deficient, but it is a world that I don't trust with it's claimed efficiencies and accuracies. We play a dangerous game with this technology. We can write of patient privacy, but there will be no privacy in the world of EMR's.

Anonymous said...

I'm a nurse working in a hospital and now that we have EMRs, we are required by management to ask every patient what mental health problems they have (from a long list), if anyone in their family has committed suicide or had any mental health issue, who they see for therapy, if they have ever been jailed for hurting someone, and on and on. Since I'm also a mentally ill person I know I would refuse to answer any of those questions when I'm in to have my gallbladder out. Every nurse and doctor treating me during that hospitalization can see that information and none of them need to know it. It's all done in the name of wholistic care and assessing for risk of self injury... No one wants to hear that it isn't right, that it's actually harmful...

barolo said...

Holistic care messed with me big time. I had a physical ailment and since everyone at the hospital could see that i was being treated for a mental illness and had attempted suicide in the past, i was treated like a mental patient for the duration of my stay. I know that people on other wards lose their dignity but there is nothing quite like going in for a routine procedure and being treated like a crazy person. That is one reason that people hide their psych histories from other docs.

jesse said...

@two last anonymouses (anonymice?), it is not done for holistic care. It is done so that there will be no blame for having not asked that question. A legal reason. and the way confidentiality will be preserved is that the record will become basically useless. Recently a patient was hospitalized due to having lost consciousness at home and it was suspected she had made an overdose. I received the discharge summary. It said absolutely nothing. This is not the first such record I have seen. So that while everything may be asked there are times when nothing is transmitted.

Anonymous said...

Jesse is correct. "The patient has a right to reveal only what he wants to, and the psychiatrist has no right to more. Whether consciously withholding pertinent information interferes with treatment is another matter altogether."

I pick and choose when to share and when not to. I chose not to share with the dermatologist that I was on psych meds when I had a mole removed. I determined the risks for not disclosing were clinically insignificant, and that was my choice. As a patient, I am paying for advice and guidance on a particular matter. I am not paying to have them act as my parent or make decisions for me.

I would not tell a psychiatrist if I were being treated for a yeast infection because I don't think it's relevant, not because it's embarrassing. I also don't mention every time I apply OTC ointment to a mosquito bite.

There are actually many patients who are educated enough to understand things like half lives and drug interactions, etc. I am not a physician and respect their opinions. But, it's ultimately my decision what I disclose and when, and whether to take their advice or not. I can make an educated decision about when disclosing or not disclosing puts me at risk or not. Even, if I were not making educated decisions, still my right as a legally competent adult to make even stupid decisions.

As for scheduled drugs if someone is doctor shopping to get more drugs, they will eventually get caught and have to face legal consquences for that. I see that as a different issue.


Anonymous said...

To add to what the anon internist said,the people who create these EMR's have absolutely no idea of the impact of all this on patients. They're not up at the hospital at 4AM when the patient who has been in the ER for hours and finally has a room is subjected to a nurse who is required to ask 5,000 questions most of which the physician doesn't care about to enter into the admission database, including everything from "how many stairs do you have in your house," to food preferences and on and on and on. Most patients answer all of that because they are trying to be helpful, but understandably get upset because it goes on forever.

It helped to remind patients before all the 5,000 questions started that they could of course refuse any questions they didn't want to answer. You could almost see the relief on their faces that they were given an out. Obviously things like hx, meds, allergies, etc are needed, but it's not necessary that at 4 am (or any other time for that matter) that a patient who is already really sick is subjected to all that.

I was always a little amazed at the number of patients who answered all the questions. Most patients want to please the physician and staff, and I think many believe if they dont answer all those thousands of questions that they will be seen as difficult or bad patients, when that's not the case.

If I am admitted to the hospital, I would decline much of the admission questions. I would tell medical/surgical history (except for past psych hx), meds, allergies and that's pretty much it.


barolo said...

Jesse, I should have made it clearer that I was being sarcastic in the use of the term "holistic care". It is tough to convey the eye rolls in a blog comment. there was nothing holistic about my treatment other than the fact that every cell of my being was treated as mentally ill. Farewell to my mentally ill appendix.

Dinah said...

Anon the nurse wrote regarding EMRs:
"Every nurse and doctor treating me during that hospitalization can see that information and none of them need to know it."

In the hospital where I work, it's not just "during that hospitalization" every health care provider who sees you forevermore can access that information.

In our hospital, any health care provider in the system can access the full EMR on anyone in the system. This means I have full access to the records of anyone who has been treated in the hospital (inpt or outpatient) and I know that many of my friends, colleagues, neighbors, former mentors, and my own doctors get care there, as well as some celebrities, so in theory, I can access this. Conversely, I don't get care at my own hospital because I know that many of my friends, colleagues, neighbors, and some of my patients, can access my medical records in this system. HIPAA protects privacy? Hs! The only protection is the threat that if you get caught, you get fired. But you have to get caught, and I simply don't believe that every doctor/nurse/social worker/etc lives by the highest degrees of integrity. FYI, it's not that hard to catch someone, there is an easily accessible record of who has looked at the EMR. I can't help but wonder if one hospital employee dating another might check out the notes to see if the other has been treated for STDs, or HIV, or the like, or to see if they really did have that vasectomy...

Psych records are limited in the current system, a record of appointments and hospitalizations, and a list of meds. The internal medicine folks may list the diagnosis and "treated by" but so far, no progress notes. In patient notes are on a separate system. This will all change soon with the next implementation of EMR to include psych.

Anon5 said...

Dinah, I find your post ironic. I find it ironic, as I seem to recall a few weeks ago, you were making light of other people's - specifically psych patients - concerns about their privacy with online records. Yet here you are stating that you do not use your hospital because everyone there could theoretically have access to your information. Do you not see the irony here? Do you really not find it bizarre that you, as a provider, are allowed to have issues with privacy of your info, but your patients are not entitled those same concerns?

I'm troubled by this attitude/perspective.

Jane said...

Looking through these comments, there is something fishy about EMRs and everyone getting access to medical records. Especially Dinah's last comment about your records forevermore being part of hospital record for everyone to see. Dang.I would think they would verify who is checking out the record. Like you would have to be "cleared" first to check out the person's record. Or regular checks would be made to make sure no one accessed a record illegally. Maybe it's just too expensive to do that?

CatLover said...

I also worry about my social worker type persons - they have my stuff on their laptop computers, and we all know people leave the laptop in the car and it gets stolen, or lost in some other way. So sorry to bring up your horrible memories, Dinah. I have heard that insurance companies have had to pay off criminals who stole private medical info, which those criminals threatened to put it on the internet. And there have been a couple of VA incidents, also. Someday soon, anyone will be able to google me and find out I am a mental patient. Given how more than a few people think mental patients are axe murders, I think this will be a terrible thing to happen to many of us with serious mental illness, or other health problems full of stigma.

I don't think mental health records should ever have gone electronic.

Anonymous said...

Anon, the internist.
The problem with EMR's is that it can't travel both sides of the street. The efficiency is wedded in multiple practitioners having access to the record to avoid the cost of redundancy. However, that far flung access throws privacy out the window, but no one seems to talk about that.

Yes, access to the record can and is followed. In my hospital, I frequently see a screen that says "your name is not associated with this record. Are you certain you want to continue?" I click "yes" because I may be seeing a patient for consult for the first time (and my association with the record has not yet been duly noted by the ward clerk), or I'm covering for my partner or the accuracy of the system has somehow failed to register that I am the attending of record and it IS my patient from the start.

I know those hits on that screen are recorded and what gets people in trouble is when everyone is looking at a record (in the case of a celebrity) or it is obvious there is not association (a 2nd floor nurse is perusing 6th floor patients). However, there is a lot of room for random gawking that I am confident isn't addressed.

If you say psych records shouldn't go electronic, then there will also be people that say they don't want their STD to be recorded or their rash or ..... it's just not going to work that way. The payers won't allow it.

I have wondered if the Facebook generation has less problem with this this than I do.....I was brought up believing that there are many topics that just should not be aired in public.

Dinah said...

Anon the internist,
Sounds like your EMR is at least more threatening than the one I use.
I'm told these protections are in place (but I wasn't told this officially, just through the grapevine).

I have, however, with the patient's permission, checked labs, medical information on my private patients on the hospital computer. Because I see them privately, and not in the clinic where I work, there is no record that they have an association with me. So far, I've never been hunted down or asked why I was looking at these records.

CatLover, the thing is that many many people are psych meds. When the records are out there, it will be so obvious that wonderful, successful, brilliant, generous, kind people whom we all like and respect sometimes need help or take some meds along the way, that you won't be lumped in with the psychotic killers, unless of course you are one.

Anonymous said...

I remember reading about a physician who left a flash drive stuck in a computer some place containing all kinds of patient info. So much for patient privacy. I wonder how many med students have patient info on a flash drive hanging off their key chains. What are they doing with their flash drives and laptops when they upgrade to a new one? Frightening.

jesse said...

What worries me so much about the EMRs is that patients are under so much pressure to release their records, and they cannot earmark certain portions for special access. So whatever safeguards are put in place will be circumvented.

What happens, though, is that psychiatrists are caught between two poles: record the diagnosis that is most accurate or record that which will create the least harm to the patient. This has already been going on for some time because of the need to give a diagnosis for insurance.

CatLover said...

If I was just taking prozac, I wouldn't care, but I have taken many antipsychotics, had ECT, and been inpatient numerous times. I don't want people knowing stuff like that. I am so very sorry I ever got psychiatric treatment. It was a big mistake, but I did not foresee that eventually, everyone will know, or that the treatments would fail to help. Lost flash drive, stolen laptop, curious neighbor who works at the hospital, hacker, I'm screwed.

twang said...

@CatLover: I don't want anyone looking in my record either. At the same time, if you have children, a spouse or ex spouse, colleagues who have born witness to a manic episode gone very, very bad, chances are that people are going to know. Lots and lots of people.
of course, we cannot forget the fact that many doctors do talk about patients outside the office/hospital. I know this as a fact . While most docs don't, many do.
That ranges from dermatologists, to psychiatrists. Other professionals bound to keep confidentiality also have frequent lapses. Yes, stuff gets brought home on USB keys and sometimes the kid borrows that for a school project. You get the picture. It is something everyone worries about. Who knows what exactly it is that Dinah worries about when she chooses not to go to her own hospital. Everyone has something they want to keep private and should be entitled to whether that is a history of ECT, psych hospitalizations, an abortion, a pattern or showing up in ER after a spouse beats you to a pulp, a recurring yeast infection. Yet it is also the case that most medical records are profoundly boring. I would be surprised if anyone wanted to read my mine. If they really want to hear about all that, a bunch of people have written memoirs describing the inner workings of the psych ward, ECT, etc..

Anonymous said...

Good lord, I do not think you all have the "right" to know anything a client does not choose to tell you. I see two therapists who do not know about each other, I consult all the doctors and other specialists I want, and I do not think I am being deceitful or dishonest. It is my life, not the health care professional's and I only go to get their knowledge (and sometimes antibiotics for sinus infections). I would never go to a psychiatrist, but if I did, would not tell them everything, only about the reason I went to see them in the first place.

Anonymous said...

I didn't tell my pdoc for 14 years that I'm sometimes telepathic with some people and completely, mutually telepathic with a few people I know of, on this planet. I've shown no signs of psychosis in 14 years. Guess what? He thinks I'm delusional now. So yeah, there's just no point in mentioning some things at all. It just leads to a lot of unnecessary aggravation.

Anonymous said...

I've never told my pdoc that I've been seeing for 10 years that I have herpes and that I never tell anyone else either, including the people I sleep with. It's really better to just pretend it isn't so. It's worked for me so far anyway.

Anonymous said...

Hi I have an issue with my non-psychiatric doctors knowing what psychiatric medications I am on. Why? because I feel judged.
Once I was not feeling well and before changing my meds I wanted to make sure my thryoid was ok (I take synthroid). I should mention, that once I accepted that I had/have depression, I am very in tune with how I am feeling and how different psychiatric meds effect me.
As soon as the internist found out what meds I was on the whole conversation changed - ugh.
The same thing happened at my annual gynecologist appointment.
We are on psychiatric meds - our aches, pains etc. must be in our heads!
Bad enough we are stereotyped by people in general. I would expect more from physicians.
Also, I can't tell you how many doctors don't know that many meds "typically" prescribed for one type of mental disorder are often also used for another type of mental disorder. "Adjuvent", "Off-label" - they are formiliar with these terms? yes?