Where Do They Go? Finding Places for the Severely -- and Dangerously -- Ill Patient

In the upcoming Mother Jones article "Schizophrenic.  Killer.  My Cousin,"  Mac McClelland talks about his third cousin who suffers from schizophrenia and ultimately kills his own father. 

McClelland talks about the difficulty in getting an ill person help, changes in how resources have been allocated which make this difficult, and fears about calling the police to bring a mentally ill patient to the hospital.  McClelland writes:

"You can call the police," the deputy director of Sonoma County's National Alliance on Mental Illness (NAMI), David France, said when I asked him what options are available to a parent whose adult child appears to be having a mental breakdown. "The police can activate resources," like an emergency psych bed in a regular hospital, or transport and admission to a psychiatric hospital in a county that, unlike Sonoma, has one. But only if the police decide your child is a danger to himself or others can they arrest him with the right to hold him for three days—what in California is called a 5150, after the relevant section of state law. Otherwise you can be turned away for lack of space even if your loved one is willing to be admitted, or be left no good options if they're not. Ninety-two percent of the patients in California's state psych hospitals got there via the criminal-justice system.

But Mark didn't want to call the police. For one, he didn't think Houston was dangerous, just upset, despairing. 

McClelland goes on to write about her aunt's devastating struggle with schizophrenia and the economics of decreasing mental health care dollars and beds.  

 Ah, California. No. 1 in the amount of mental-health funding cut from 2009 to 2011, No. 7 in cuts as a percentage. Home to one of the largest jail/psych facilities in the nation, the LA County Jail. Where visitors can't believe how many bat-shit-crazy homeless we've got. Where deinstitutionalization was pioneered under Gov. Ronald Reagan with the 1967 Lanterman-Petris-Short Act, which made it vastly more difficult to commit people, and where the rate of mentally ill in the criminal-justice system doubled just one year after it took effect. Where, often, the severely mentally ill live in jail for three to six months because they're waiting for a bed to open up in a psychiatric facility. California: where, says Torrey, the psychiatrist who warns about "predictable" violence like my cousin's, "they led the way in [deinstitutionalization], and they've led the way downhill. They're certainly leading the way in consequences

One psychiatrist we know called the article 'sensationalism not journalism,' and I'll leave that judgement to you.

ADHD or Just Plain Tired?

In Diagnosing the Wrong Deficit,  Dr. Vatsal G. Thakkar talks about the concept that the incidence of Attention Deficit Disorder has coincided with people getting less sleep as their days have gotten busier and longer.  He wonders if the symptoms that get attributed to ADD might be a result of too little sleep.  And if not too little, then maybe the wrong kind of sleep.  Dr. Thakkar goes on to talk about his own difficulties with focus and concentration and how he believes these symptoms were because his sleep architecture was disordered: too much dreaming, too little deep sleep -- a problem that was solved with a stimulant by day and a selective serotonin-norepinephrine uptake inhibitor (an SNRI such as Cymbalta or Effexor) by night.  He also mentions that clonidine, a alpha-2 adrenergic anti-hypertensive agent that is used by psychiatrists for -?- (sleep/ptsd/restless legs/whatever ails you)  might be useful to change sleep architecture and quality.

Thakkar writes:

We all get less sleep than we used to. The number of adults who reported sleeping fewer than seven hours each night went from some 2 percent in 1960 to more than 35 percent in 2011. Sleep is even more crucial for children, who need delta sleep — the deep, rejuvenating, slow-wave kind — for proper growth and development. Yet today’s youngsters sleep more than an hour less than they did a hundred years ago. And for all ages, contemporary daytime activities — marked by nonstop 14-hour schedules and inescapable melatonin-inhibiting iDevices — often impair sleep. It might just be a coincidence, but this sleep-restricting lifestyle began getting more extreme in the 1990s, the decade with the explosion in A.D.H.D. diagnoses. 

Interesting ideas and I'm wondering what others think of them.

Does more sleep get rid of the symptoms of ADD?  Since I'm not a big 'fan' of the controversial adult ADD diagnosis, it sounds good to me.   Is more sleep enough, or is changing how a patient sleeps with medications helpful?  And what about the use of clonidine?  I know child psychiatrists sometimes use it, and that it is used for the treatment of drug withdrawal, but I have never prescribed it.  Tell me what your experience with clonidine is.

Where Did the Self Go?

In tomorrow's New York Times Magazine, you can read an article by Linda Logan, 
"The Problem With How We Treat Bipolar Disorder."  Ms. Logan writes, in a tender and tragic way, about her own struggle with a severe, treatment-resistant mood disorder, and how her psychiatrists attended to her symptoms, but not to what she calls her loss of self.  

Ms. Logan writes:

How much insult to the self is done by the symptoms of the disorder and how much by the drugs used to treat it? Paradoxically, psychotropic drugs can induce anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of depersonalization, psychosis and suicidal thoughts, while being used to treat the same symptoms. Before getting to the hospital, my daily moods ranged from bad to worse, each state accompanied by a profound depth of feeling. The first drug I was given was amitriptyline (Elavil), which, in the process of reducing my despair, blunted all my other emotions. I no longer felt anything. It was like going from satellite TV to one lousy channel.

While some medications affected my mood, others — especially mood stabilizers — turned my formerly agile mind into mush, leaving me so stupefied that if my brain could have drooled, it would have. Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory and concentration had all left me. I was slowly fading away. 

I would try to talk to my doctors about my vanishing self, but they didn’t have much to say on the subject. Instead they focused on whether I could make eye contact or how much expression I showed in my face. They monitored my lithium and cortisol levels; they took an M.R.I. of my head. I received an EKG, was exposed to full-spectrum lighting and kept awake all night for sleep-deprivation therapy. Nurses jotted down their observations; my scribbled lines in art therapy were inspected. Everything was scrutinized — except the transformation of my self and my experience of its loss. 

She describes hospitalizations lasting for months, trials with many, many medications, psychotherapy, support groups, desperate episodes of mania and psychosis, and the toll this took on her as a person, as a mother, as a wife, and as a professional.  Even as a psychiatrist, I found her story tragic, though by the end, we do have the sense that she has gotten so much better and so much more functional.  And sadly, while Ms. Logan longs for a treatment paradigm that addresses not only the illness, but the loss of self, aside from acknowledging that both the illness and the treatment can strip you of who you are, and working towards getting yourself back is a worthwhile goal, I'm not sure I have much to add.  As always, I'd love to hear your thoughts.

Another CPT Coding Resource

 

 Dr. Michael Price writes:

 

Hello. I'm writing in response to your 11/2012 Clinical Psychiatry News
article re CPT coding, to let you and the other Shrink Rap people know
about a free web-based interactive teaching resource I developed for
helping people learn CPT coding for psychiatry, trying to get the word
out. I don't know if you'd actually want to link to it in a CPN note or
something, because it's not "official" from any organization, but I
think your members and others might want to know about it in some way or
other, and it's new enough (I finished it mid-February) and I'm small
enough (just a person, not some organization with a big site and high
traffic) that it doesn't really show up much in web searches about that
sort of thing. It hasn't gotten a lot of hits as yet,but I have had very
positive feedback from people who've used it.

Anyway, if you look at it and think it would be useful to people, please
do whatever seems best to make people aware of it as a resource - I
think it's one of the best ways to master coding quickly, and I don't
know why none of our organizations did something like this themselves to
let people get hands-on and see the nuts and bolts in action. Your
article noted, "Dr. Schmidt suggested I buy a manual on how to use E/M
codes and noted, “There probably is not a way to make learning this
easy.” The truth be told, I want a way for this to be easy." I think you
might actually agree that maybe now there is, or about as easy as it can
be (or if not, I'd like to know, since that was my goal, lol - looking
for something like this and not finding it (except a very crude
implementation on soapnotes.org) was what motivated me to create it)

The link to the page is here:
http://home.midmaine.com/~mtpmd/PsychCodeCoach.html

and it's most easily/directly found in searches by "psychiatric code coach".



Mandatory Testicle Removal

Back when I was concerned that Maryland might pass a law requiring mental health professionals to report dangerous patients to the FBI's database, I sent some robo-emails to legislators opposing House Bill 810.  Today, I got the following reply from a state senator (not mine):

Sent: Wednesday, February 27, 2013 9:45 AM
To: Jacobs, Nancy Senator
Subject: Opposing House Bill 810

Dear Senator Jacobs,
I am writing to let you know that I strongly oppose the passage of House Bill 810.

---
From: "Jacobs, Nancy Senator
 Sent: Tuesday, April 23, 2013 4:14 AM
Subject: RE: Opposing House Bill 810

Dear Ms. Dinah:
Thank you for writing Senator Jacobs requesting support for Senate Bill 820/House Bill 767 - Animal Welfare - Spay/Neuter Fund - Establishment.  Senator Jacobs was in support of this legislation and is happy to report that the bill passed both the Senate and the House.
Sincerely,
Cynthia 

Legislative Aide to Senator Nancy C. Jacobs

 --------------
So no mandatory reporting, but it seems that some poor dogs may have lost their reproductive organs because of me.  

What Every Mother --and Every Psychiatrist -- Fears Most

Let me ask you: when someone commits an act of terror -- whether it be a spree shooting or a planting a bomb -- whose fault is it?  Was it a flaw in their childhood?  Poor parenting?  The angry, violent child of angry, violent parents?  Should their parents have known and gotten them help?  What about their psychiatrist?  Should he have known and stopped the criminal?  When things go wrong, we all have theories and we all look for culprits.  
 
Today's blog post can be found over on Clinical Psychiatry News (no registration needed) in The Criminal's Keeper, where I wrote about the difficult roles of being a mother and a psychiatrist and feeling responsible for the behavior of others. 

Cake?

We had an impromptu get together to celebrate our blog's 7th anniversary.

If you like statistics: 1884 posts, 20,153 comments, and  2,065,618 pageviews

There's the My Three Shrinks podcast with 69 episodes, trying for more but our updated computers don't jive with our mixer anymore and there are some issues with the hosting site. 

We have collateral blogs on Clinical Psychiatry News and Psychology Today.

Follow us on Facebook at

 http://www.facebook.com/shrinkrapbook?ref=hl

And our twitterfeeds are ShrinkRapDinah, ClinkShink, and ShrinkRapRoy

Finally, do consider reading our Shrink Rap Book or any of Dinah's shrinky novels Here.

Thank you again for being in our lives, and I am so sorry to report that the cake is all gone.

Seven Years of Shrink Rap!

Seven is a lucky number.

Today, Shrink Rap is seven years old -- that's a happy thing, right?  I still love Shrink Rap, I still love having somewhere to chat with people about psychiatry, to vent about the paperwork things that annoy me, to share the aspects of my work I love.  I still love talking about ducks and psychiatry with ClinkShrink and Roy.

Thank you so much for being the best of readers and commenters, and thank you for sharing your ideas with us and enriching our lives!

It's Hard not to Worry

We all have things we worry about.  Sometimes the things we worry about seem perfectly reasonable, such as whether a biopsy will prove malignant, taxes will be owed,  or a guilty verdict will be rendered at a trial.  Other times, worries are more far-flung and statistically unlikely, such as the safety of flying on an airplane or riding the subway.  Professionally, we can worry about being sued, audited, fined, sanctioned, or even criminally sentenced in some regions.  It's not at all unusual for people to worry about their children and to do many things to keep them safe, including securing their car seats, having them vaccinated (or not), or buying certain foods they believe to be healthier.  We all have our "things" to worry about and we don't universally agree on how much time, expense, effort, and mental energy we should be expending on preventing bad consequences.  For one person, it seems perfectly reasonable to live a life without ever boarding an airplane, no matter how much that limits them; for another, that seems absurd.

Lately, our collective sense of what to worry about is facing challenges.  Is it safe to go to a movie? To listen to a politician talk at the local supermarket? To send a child to kindergarten?  To watch a race on a beautiful April day?  Certainty would be nice, but there is none, and while it probably doesn't help to worry about those things over which we have no control, such worries do seem to be built into our wiring, if not in one way, then perhaps in another.  Does worrying protect us?  Some people don't worry at all, and for others there is a superstitious quality, as if to announce that if one worries, then it won't happen.  Other people seem jinxed: their worries come true, proving they were right to be afraid.

When awful things happen, they damage us all.  They bring us just a little closer to our fears and  remind us that no worry is all that unreasonable. They blanket us in poison.  With time, most people heal; they move on and often emerge even stronger.  The journey can be both bumpy and senseless.

Our hearts go out to all those who were harmed by the events in Boston this week.   

Cognitive Behavioral Therapy (CBT) : Why Don't More Shrinks Do It?

First, I'd ask you to read Harriet Brown's article in the New York Times Well Section in "Looking for Evidence That Therapy Works." 

Ms. Brown talks about how there is little evidence-based data to support most psychotherapies, that psychotherapists tend to be wishy-washy about their approach and are vague with their ability to describe what they do, using the catch-all term "eclectic."  Furthermore, therapists over-estimate their success rates, and while there are proven psychotherapies such as cognitive behavioral psychotherapy (CBT), she notes that surprisingly few therapists use this treatment.  She suggests asking prospective therapists a variety of questions including "What manuals do you use."  

So I think this is a fair question.  If CBT works, why don't shrinks employ the techniques more?  I looked at the 365 comments on the article (anything for a blog post).  Most of them were theoretical discussions about therapy.  Many were from therapists.  There were a fair number of comments citing how screwed up therapists are.  There were 3 comments from patients saying CBT helped them.  There was 1 comment from someone saying a CBT book cured them without the therapist, after other psychotherapy had failed.  There were 3 patients who said CBT was helpful in combination with other therapies --so that awful eclectic approach. A number of people wrote in to say CBT harmed them -- unfortunately I read those comments before I got the idea to keep count, but I want to say there were ?3-4 people saying it injured them.  One person was finally helped by a form of energy therapy.

So let me ask you, especially those who have been in therapy:
 Does CBT work?  If you're a therapist, do you use it? Why or why not?  And since Ms. Brown's article questions so-called eclectic treatments, can I ask you to limit your comments to the manualized version of CBT which includes doing homework and is structured and specifically called CBT. 

No Mandatory Reporting in Maryland

The legislative session ended here at Midnight.   Maryland repealed the death penalty, added a gas tax, and has sweeping gun legislation that bans assault weapons & requires licensing with background checks & a gun safety course, and limits magazines capacity to 10 rounds. Medical marijuana is now legal but with the limitation that it be prescribed through an academic center and with a number of stipulations that include failure of conventional treatments.  Even I can live with that.

There were more mental health bills related to gun legislation than I care to discuss.  Most of them went quietly away. 

Mandatory reporting of patients who are "likely to be dangerous" did not get incorporated into our Firearms Act. 

If I'm right on the final version (and I may be back with an update here), the following people must be reported to the NICS database:

• Anyone civilly committed to a psychiatric hospital and found, by the administrative law judge, to be dangerous to others.  Please note this does not mean if you are committed from an ER-- you need to go to an actual hearing and this usually takes place several days after admission.  By this point, the patient often decides to sign in voluntarily, or the staff decides the patient isn't dangerous and they are permitted to sign out, so the people who make it to the hearing and then are held by the judge after the hearing are a select few.  And then it's only those who are deemed dangerous to others who go to the database.  I'm not commenting.

• Any patient hospitalized (voluntarily or not) for 30 consecutive days or more.  The psychiatric society fought this one, but apparently there is federal law requiring this and only the state hospitals had been reporting. 

To get your gun rights back, there are still a lot of hoops to jump through, including getting a psychiatrist to certify that you are safe with a firearm. I haven't checked the details on that one yet, I think it's toned down a little from the original and may not ask to have the future predicted, but I still think it may be a hard call to find a psychiatrist to say you're safe with a gun.  Guns are to shoot people with : is anyone safe with one?  Good luck finding a gun-certifying shrink, and please don't call my office with that request. 

It could have been a lot worse, especially when you look at what was proposed, including psychiatric assessments for gun ownership for every psychiatric inpatient immediately upon admission.  I'm glad I ranted everywhere I did in print,  and I'm glad I went to Annapolis twice. I'd like to believe it helped.  Our MPS legislative chairs, Dr. Brian Zimnitsky and Dr. Jennifer Palmer did an incredible job and spent countless uncompensated hours on this.  Brian was in Annapolis during the workday, late into the night, and on at least one weekend.  Our lobbyists, Lisa Harris Jones and Sean Malone and their intern-extraordinaire, Philip Cronin, were terrific, I hope they are off having a beer somewhere. 

I'll know more later, and I'll amend this post at the bottom if I was wrong about the final issues.
 

It's Okay to Get Help

Meg sent this to me.  It's nice that the psychiatrist in charge of Student Health can talk about his own struggles.

Cosmetic Psychopharmacology?

We read everywhere that psychotropics are over-prescribed.  The DSM guidelines have pathologized normal reactions and  DSM-V promises to make this even more so.  For example, over 11% of children are now diagnosed with Attention Deficit Disorder.  Our friend, Dr. Mojtabai, tells us that many patients who are given antidepressants by primary care doctors don't have a psychiatric diagnosis, our colleague, Dr. Frances (and many others) doesn't want normal symptoms of grief to be diagnosed as major depression after 2 weeks of symptoms, and our readers have written in saying that there are effective psychotherapeutic treatments for schizophrenia.

Why the push to give so many people a diagnosis, and then a pill?

I'll venture some guesses here.  These are only guesses:

~ Psychiatric disorders were previously under-diagnosed and with the broadening of diagnostic categories, and the promise of relief, more people go to the doctor seeking these diagnoses.  In order to get a diagnosis of ADD, you have to point out the symptoms to a doctor -- a doctor doesn't just know that you can't concentrate, focus, and lose things all the time (to name a few symptoms) and if you think this is normal, you won't tell the doctor your problem.  So greater public awareness and desire for diagnoses and treatment.
~A desire to blame problems on biology and therefore not have to own them.
~Treatments with fewer perceived side effects.  Many people have no side effects to the medications, and so the risk/benefit tradeoff is low.  I left it as "perceived side effects" because some of the treatments include risks that may not initially be felt as such by the patient, such as the risk of addiction or of metabolic problems which may not have obvious symptoms.  But some people truly get benefits from medicine with no untoward side effects.
~A push by the pharmaceutical agencies to sell their wares to doctors and consumers.  Funny, we have villainized physicians who let drug reps give them pens or feed them sandwiches or pay them thousands to peddle their product, but it's fine that drug companies now advertise direct-to-consumers in 30 second bytes.  I'll leave that one for another day.
~Sometimes these medicines work and provide tremendous relief and then they become their own advertisement.  My friend feels great on Drug X and I want some, too.
~Who doesn't like a quick fix?  I believe medications work best in combination with psychotherapy, and it's not an either-or proposition.  Some people get all the way better by simply popping a pill, others don't get better with all the drugs and all the psychotherapy there is in the world. 
~While a trial length for medications is clear, we don't have a definitive time frame for how long one needs to go to therapy.  Do you get better after 4 sessions or 4 years?

That's for background.  Now for today's blog post:

So with a push to accurately diagnose, and to reserve treatments for only those who meet diagnostic criteria, I'm going to ask a question: What's wrong with cosmetic psychopharmacology?  Why is a problem to give someone who doesn't meet criteria for a disorder a pill, provided the patient comes looking for help (I don't advocate sending psychiatrists to knock on doors), provided they are made aware that the medication has risks, provided the patient has some form of free will and can stop the medications at any time?  And given the fact that "meeting criteria" is about diagnoses that are decided by a committee and not based on something hard and fast and scientific, for example the presence of a large tumor.  The issue, of course, gets sticky when the treatment includes medication with the potential for addiction, but let me give you some examples, and you can comment as you will.  Keep in mind, I'm asking to be provocative, not to say it's fine.

~ A patient comes in with 4 weeks of  profound sadness, feeling hopeless and suicidal.  There are no neuro-vegetative symptoms (meaning no change in sleep/appetite/sex drive) and he's a couple of symptoms short of "meeting criteria" for Major Depression.  There are no clear precipitants to the episode, both parents and one sibling have had treatment for depression, and the patient is willing to come for therapy, but he's also requesting medication.
~ A patient requests a single tablet of Valium (or any of it's relatives) to take before a flight.  The patient has flown before and gets very anxious, but has no psychiatric diagnoses.  His flight is next week and he has neither the time, funds, or propensity to undergo desensitization training.
~ A college student comes in requesting a prescription for a stimulant.  He has been taking a friend's and finds it to be very helpful.  He only takes it before exams or to write papers and he feels it gives him an edge he wouldn't otherwise have.  He has no history of addiction, no blood pressure problems or arrhythmia, he is requesting a low dose and only wants a small supply.
~ A woman is a wreck 2 weeks after her mother dies.  She has every symptom of depression and wants medication.  She understands that her symptoms are from grief, but she wants to see if a medicine might help mitigate some of her misery.
~ A gentleman with a family history of Alzheimer's has noticed some age-related changes in his memory.  A neurologist has told him that he doesn't not have Alzheimer's disease.  He wants to start Aricept as a prophylactic medication in the hope that if he were to get Alzheimer's disease, this would slow it's progress.
~ A man took an SSRI for a single episode of depression and made a full recovery quite quickly.  During the episode of depression, he was seen weekly for psychotherapy, since then he has come in for monthly sessions.  After a year, his psychiatrist took him off the medication.  He has not had a relapse and is doing well, but is requesting to resume the medication because he just feels better on it, but can't articulate why other than to say he feels calmer and more resilient.   He has no side effects to the medication, and it does not make him complacent or unmotivated.
~ A patient has trouble sleeping and wants Ambien to take once in a while.  Then he wants Ambien to take every night. It helps him sleep and he has no side effects from it.
~ A patient has trouble sleeping and has a history of addiction.  The psychiatrist is worried about starting Ambien or a benzodiezepine.  The patient did not have a good response to trazodone or benedryl.  His insurance won't pay for Rozeram.  He found Seroquel to be helpful, his insurance will pay for this, and he understands that it might cause weight gain and metabolic issues, but he's young, healthy, slim, exercises regularly and willing to take the risk with monitoring of his weight and labs, but it's not indicated as a sleeping pill. 

Go for it.

The Irony of "Medical Necessity."

In the state of Maryland, regulations require that patients seen in community mental health centers must see a physician every 90 days for a review, unless they are not taking medications, in which case they must see a physician once every 6 months.  It seems reasonable to me to say that a patient with a chronic disorder on medications should be seen 4 times a year to have their status, medications, lab work, health issues, mental status exam, all reviewed and to make sure the medications are still working and indicated and not causing undo side effects.  At the psychiatrist's discretion, patients can be seen more often, and patients who are having a problem are seen sooner.  Every patient has an assigned therapist and it's not unusual for a therapist to schedule someone to come in sooner than the 90 day review if they aren't doing well.  When I see someone, I often start my note with "Here for 90 day review."  It's code to myself that it's a routine visit to assess the continued necessity of the medications, and it's a bit different than if I write "Seen for an emergency -- sister notes was walking naked on the golf course and the patient is complaining of auditory hallucinations."  

So today I received an email informing me that the clinic is auditing charts to be sure the documentation fits with the CPT codes that are billed.  It's a problem, we're told, if the note says that the patient is being seen for a 90 day review.  It implies that the visit is for paperwork, and that there is no medically necessary reason for the visit and I shouldn't do this.

So wait, the law requires that I see the patient every 90 days, but if I write that that's why the patient is here today, that's a problem, because it's legally required but doesn't make the bar for being "medically necessary"?    

Where are the Psychiatrists? Thoughts about Legislating Public Policy

Why is this young man playing my favorite boardwalk game?

Today's post is up over on Clinical Psychiatry News.  You don't need to register.

My Shrink Rap Life vs. My Real Psychiatry Life

Soon --April 21st to be precise-- Shrink Rap will celebrate it's 7th year as a blog.  No plans yet, but they are sure to include food.

Seven years later, and I want to say that Shrink Rap life remains distinctly different from my real life as a clinician.  Before Shrink Rap, the concept of anti-psychiatry was a foreign one to me.  The idea that there were people out there who saw psychiatry as bad, that psychiatric medications cause more harm than good and should be made illegal for all, that psychiatry was about power, that the patient and doctor were anything but on the same side, that diagnosis -- a word -- was inherently stigmatizing or life-destroying, this all was news to me.  Maybe I was in my own little bubble.

What I've learned on Shrink Rap has been illuminating.  At first, I thought it made me a better psychiatrist, more sensitive to a new realm of issues.  Then I wondered if it was making me a worse psychiatrist; here I was warning people of side effects that our readers had which I'd never seen in years of practice, assuming people were wary of psychiatric medications when they they weren't and their only experiences of them were good-- "made my brother so much better," and assuming people had qualms about treatment that they didn't actually have.  There are are literally days when readers are writing in about how medicines destroy lives and patients are sitting in my office saying, "Please don't ever let me stop this medicine again, I never want to go back to that place."  

In clinical practice, people come to me in distress and I work with them to help them get better.  If I have any sense that my goals for them are different than their goals for themselves, I verbalize my concerns and ask them to make sure that it's their goals that we strive for.   In general, I'm the one striving higher.  It's not all wonderful, some people don't get better and psychotherapy requires chemistry; I've no doubt that I'm not the best psychiatrist for everyone, but I think most patients who don't like what I have to offer just quietly go elsewhere.  And that's fine, too.  My real life world isn't about coercion or trying to get people to do things they don't want to do.  I listen, I try, I do my best, and I have my off days, too, because psychiatrists are human. 

Clinically, people come to get better and for the most part they do.  There aren't power struggles and there isn't a whole lot of clashing. Who would sign on for a career where everyday is full of emotionally charged confrontation? No one has ever expressed anger with a diagnosis.  To me, it's mostly a number that gets put on an insurance form so the patient can get reimbursed, not a stamp on anyone's forehead, and diagnosis has little, in my experience, to do with prognosis.  Most people come requesting medications, so we do that.  Some don't and if I think they might be helpful, I encourage them to at least try, but I've never said, "I won't work with you unless you'll take medications."  Much less a specific medication that is causing problems.  And I certainly can't imagine telling someone they had to stay on medications with intolerable side effects - the good/bad balance is the patient's decision.  People come in eager to see me, either because they want the relief of talking when they are in a bad place, or because they want to share their accomplishments when they are in a good place.   Sometimes people tell me they didn't want to come in, especially if they'd been doing well and had stopped treatment for a while, and I understand that as well.  Everyone is different, and that needs to be respected. 

To read the Shrink Rap comments, you'd think the therapeutic relationship was an adversarial war, and it's just not.  Seven years later, I continue to read the comments and be perplexed.  They don't reflect my personal experience of clinical psychiatry.