Monday, April 01, 2013

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.


Liz said...

a couple of notes-- you work in private practice with clients who choose to see YOU, right? my issues have mainly been with hospital psychiatrists. i have had an issue or two with community psychiatrists, but i just chose to never go to see them again. it makes sense your experience would be different. also, most people who feel like me about psychiatric medicines would avoid seeing a psychiatrist professionally ever again.

baxter said...

It doesn't have to be an "adversarial war" in order to accept and acknowledge the very real power differential in the room. Patients do have the power to choose not to come or to go elsewhere. Doctors hold enormous power even if they do not see it or feel it. A diagnosis might be helpful and it is usually needed for insurance reimbursement but once you have written that diagnosis down, it can be used in ways that disempower the patient. The diagnosis may mean the individual will not be accepted as a candidate for life insurance or for a pilot's license when another person, suffering the same symptoms but holding no diagnosis can make it through the screening. Two people presenting to a hospital ER with physical complaints will often have very different experiences especially if one has a psych dx and the other does not. A parent going through a messy divorce with custody issues can be seen as experiencing normal anxiety, grief, anger and sadness if they do not have a dx but one with psych dx expressing the same emotions will often be seen as ill and labelled as unfit even when the dx is just a note in a file and the individual takes meds and goes to therapy and has never done anything out of the range of what would be considered normal for a person with no dx.
If one has a history of needing more intensive psych treatment in a hospital, the shrink is the person in whom you confide but who has the power to hospitalize. Some people are helped and some find it re-traumatizing.You have blogged on that before. I like my doctor and would like to feel I can say anything but there are times I do not say how I really am feeling because he will have no choice but to hospitalize me or write in the notes that patient is expressing suicidal thoughts, advised to go to ER.That way, the doctor is covered but I end up with more reason for someone to say oh so and so is not fit for this or that.
The doctor also has the power to tell me what is going on with me and if I do not agree, they have the final word unless I do a good enough job of convincing otherwise. For example, the doctor does not worry about natural disasters. I do. If I stock up on supplies the doctor can say I might be getting a but spinny because he does not see it as a normal thing to do. He might write in a note that I have a tendency to catastrophize when I see it as preparedness. The doctor is sometimes blind to the fact that our values may be different and my patient status allows him to pass judgement, usually in a gentle manner and tone but it is still a judgement and not one grounded in anything to do with psychiatry. Doctors who are attuned to the fact that a power imbalance exists are less likely to get caught up in that kind of thinking. I find it odd that the doctor can cancel an appointment because of a sick family member and while I can too, if I do, I am questioned as to whether I am avoiding something since surely another person could have helped me out so I would not have to miss my session.
My doctor has at times appeared disheveled and stressed but always says he is fine. I make sure to dress decently and comb my hair because I cannot afford to be seen as disheveled as it could be seen as a sign that I cannot take care of myself.
I am not anti psch. I am not totally anti meds. I agree that sometimes a psych ward can keep a person from suicide but am not sure it is the best option for many people. I do think that just as many doctors think they are invincible, they also think there is no power imbalance. Too many doctors are in denial. They are human. Dinah, I am not writing about you; I do not know you. I have known my share of doctors.

Steven Reidbord MD said...

I continue to appreciate and resonate with your posts, which often mirror my own experience. I've been conscious of the antipsychiatry perspective since my undergrad ethics courses, where patient autonomy was defended against the paternalism of "doctor knows best." Also, I've been online since well before the WWW, and learned long ago that one can hardly discuss psychiatry or mental health in any open forum without being subject to long angry diatribes by disaffected former or current patients.

As you said, none of this feels related to my office practice, where patients come and go freely, and where my job consists of being sensitive as possible to the slightest anger, frustration, or dissatisfaction of my patient, even when it isn't yet conscious. I only use diagnoses when the patient requests one for insurance reimbursement, and even then tend to undercode, with the patient's permission, to maximize confidentiality.

Perhaps the missing point is that we're self-selected. Knowing what I did about the politics (and my own feelings) regarding involuntary treatment and the behavioral control of wildly agitated patients, I chose a practice that hardly ever includes any of that. (On very rare occasions an acutely suicidal patient in the office makes a 3-day hold a real possibility; even then I almost always avoid that outcome, which I think is necessary but overused.) My colleagues who work in ERs or on inpatient units do not sadistically enjoy trampling on patients' rights and forcing injections, but they don't seem to mind an adversarial stance, or wielding that power, as much as I would. In an ideal world we wouldn't need psychiatric facilities with restraint beds. But this world is far from ideal. Even though I choose not to work in such a setting and often criticize its excesses, I'm still glad they exist and are staffed by professionals, most of whom do a hard job well.

Nathan said...

I wonder if some of the folks you guys assume just move on quietly and are getting what they need elsewhere are really actually feeling quite harmed and afraid to engage further.
Maybe the folks who have experienced a lot of hurt just aren't coming to outpatient practices anymore.

catlover said...

I wonder if it's a good or a stupid idea for me to write a letter to my past psychiatrists who told me for years that all the new behavioral and cognitive problems I was having in my 30's and 40's were due to my mental disorder worsening, when all along it was the prescribed medications making me so much worse. The only doctor that knows this is my current one. I doubt that they would remember me or really care, and it feels like a boundary violation sort of - is this a stupid idea? Maybe they would just write me off as attention-seeking (if they remembered me, I doubt that, though). I think the reason docs don't know about patients who don't take drugs anymore is because they drop out of treatment, therefore, they get no feedback.

I think the doctors here don't know about patients like me or others commenting here, because those patients usually drop out of treatment.

I come here for the same reason that Jesse does, and also began coming here to learn how to protect myself from involuntary commitment, which was a serious risk at one time. Now that I'm off the drugs, I'm behaving so normally that's extremely unlikely to every happen. The past few months, off and on, are the first in more than 10 years that I wasn't desperately suicidal. The drugs did that to me, turning an intermittent problem chronic. I seem to be gradually returning to classic bipolar, like I was before taking drugs, instead of terribly mentally ill nearly 100% of the time. I had 2 months last year where I wasn't depressed at all, and it was the most amazing thing not to cry every morning because I didn't die in my sleep. I do think those doctors were all trying to help me, while their drugs caused grave harm, and therefore, I have conflicted feelings about the whole thing. Which leads me to another purpose - to make sure doctors THINK - if their patients are getting worse, could the drugs be the problem? Doctors say that they do that, but in my experience, not once did doctors ever tell me they thought drug treatment was a mistake, until the end when I was going to give up anyhow, because there were no more serious treatment options left.

Simple Citizen said...

Thanks for the insight. As a psychiatry resident it's nice to read your posts and the comments. I know what you mean - sometimes I fell like I'm defending psychiatry or medications when the patients have no qualms about them whatseover.

Thank you for this post and Happy 7th Anniversary!

My blog is offically 5 years old, but I've only been writing regularly for 2 years. I've often used your blog as an example and template for what I can do with mine. Thanks.

L said...

Basically, every time you write a post like this I think again that you must see a very self-selecting portion of people. I also think that the people you see are likely mild to moderately mentally ill, and that you just don't have the experience (no, a few years early on many years ago just don't count) to know anything beyond that self selecting, mildly afflicted group.
Not that there's anything at all wrong with that. Just that it gets old real fast when you try to use that perspective to deal with real issues that your commentators do face.
(THis post, yet again, was frankly insulting because you, yet again, delegitimitized your readers experiences. You never learn.)

Anonymous said...

L - boy, you just can't win on this blog! Dinah listens to her clients, doesn't shove meds at them or dx and sounds like she is accessible. Isn't this what everyone who complained wanted in a pdoc. She said most got better, that's not all, and I would guess many struggle; they just aren't disgruntled. When a dx is explained and medication is explained and discussed and a doc is there for an emergency there is a lot less anger and a lot more hope. Just an opposing opinion to think about. Ps I don't think Dinah is alone in practicing in this way.

Dinah said...

I'm glad the psychiatrist find Shrink Rap helpful, it's a huge compliment.

I'm not sure what the people who feel they've been wronged by psychiatry want from me. Of course, people could be leaving my practice feeling harmed, but I do know it's not the majority, and I don't know how I could be all things to all patients. I am the person/shrink I am, if I'm intimidating people without realizing it, I wouldn't know where to get a new personality or a new style of practicing. And if I somehow magically could to cater to the unexpressed concerns of those who are reportedly feeling injured by my way of practicing, then wouldn't I risk that my new style might injure someone else? Docs are human, really.

My intention is not to discount anyone's experience. I am a sensitive soul myself, and I have felt very discounted/annoyed by things doctors have said/done/not done as well. I am telling you what my experience is, and no matter what I've said over the years, people who have not known me or my patients have responded by telling me that I'm blind to my patient's concerns. If I sense that someone is upset, I ask about it. I don't know what more I could do.

I think that people looking for validation in the awful ways of psychiatry should get together on their own blogs. We Shrink Rappers enjoy our work, even if we can't please every patient or reader. If you could do better, you should become a psychiatrist and fix the system! I absolutely believe that there are awful, insensitive shrinks out there, but I've heard people sing the praises of docs I've thought are awful. To each his own. But if you're feeling injured here, you'd be better off going to a blog where you feel safer and validated.

HIGurl said...


I think it's great that you can distinguish the difference between your Shrink Rap Life and your Real Psychiatry Life. Demographics play a huge part in what you see and don't see.

Your Real Psychiatry Life is confined to local residents (maybe a few out-of-towners) - and so yes, you'll get a mix bag of personalities. However, your Shrink Rap Life has no boundaries; it's open to the entire world. Mixed cultures = mixed results. And as you know from the biopsychosocial model, responses will vary from the typical norms to the not-so-typical norms.

All in all, it's great to have the open-ended discussion with this blog. You'll have responses that will amaze you, that will disappoint you, and that will challenge you. Isn't that the great thing about psychiatry?

I'm very grateful to be able to follow this blog. Thank you for sharing a piece of your life with us. You're doing a great job!

jesse said...

Thank you to the last Anon and to Jessa, baxter, and HIGurl. Many of the posts by people who have had negative experiences are quite thoughtful and show a wish to have a dialogue, as these do. Catlover, your thought of writing to your previous psychiatrists is a good one. They may well appreciate hearing from you and it could be therapeutic for you, too, to let them know what has happened.

What I fail to understand are the posters who are not only repeatedly negative and grant no other experience or point of view, but are also extremely rude. "Pretend you are sitting in our living room" is the basic ground rule here.

There is certainly self-selection but it is not what some of these posts suggest. The self selection is not in regard to our patients but in regard to those who see nothing good in psychiatry. Who never acknowledge that there might be many people who have been helped.

These are posters who simply wait for something to attack. Since most are anonymous, and it is easy to have several aliases, it appears that there really are not so many out there as it might appear. They post on other blogs, and exactly the same thing. HIGurl correctly points out that they may span the globe. Anonymity makes it easier to be rude. As Dr. Reidbord pointed out the negative transference can flourish easily.

It is like the fort garrisoned by the Foreign Legion in Wren's novel Beau Geste. It appears that there are many when there are actually very few.

My own experience is like Dinah's. I enjoy working with my patients and try my best to be of help. So Happy Birthday, Shrink Rap! You add a lot to our lives.

jesse said...

@Liz, please don'tthink the critical part of my note above referred to you. It did not.

vla said...

I'm a typical Dinah patient, I think. I've found some medicines helpful in the past and am open to trying them again. I'm also open to trying different therapies -- definitely don't want just meds. But I'm aware that the way I'm thinking/behaving/feeling is causing me and those around me considerable pain, and I accept psychiatry is the field of medicine that addresses this. I've been hospitalized, but always signed myself in. (I've noticed psychiatrists really vary in how heavy-handed/threatening they are when they hear about suicidal ideation, btw. Some really will toss you into the hospital for virtually nothing.)

My friend is quite different. When her life circumstances got more complicated, she started having trouble making decisions, then saw her life collapsing around her. She had reasons for everything: can't use the toilet because the pipes are clogged; can't drive because the insurance is unpaid; can't eat because that'll make her need to use the toilet; calls friends at all hours screaming that the bills are unpaid and she's about to be thrown onto the streets; won't believe any evidence her bank account isn't empty, or any evidence that the pipes are ok, etc.

I'm no fan of involuntary commitment, but what, in the anti-psychiatry world, should I do? I'd love to be able to whisk her away to some nice spa -- but she'd just think it was costing her money. There is no intervention she would have approved of -- psychiatric or not.

Unfortunately, she was forced into a hospital as "gravely disabled" and then a board and care. She takes meds and goes to an outpatient program, but feels these are things she has been forced to do by her doctor. She does not see her thoughts/behavior then or now as disturbed or causing her and her loved ones any pain.

I can imagine she might be quite disgruntled about psychiatry -- I can see so many ways in which her trip through the system was unsatisfactory -- but I honestly don't know what the alternatives might be.

Anonymous said...

Bravo, Via!!!!
Via had said what no Shrink Rap writer or reader has ever wanted to say (Finally)... that some of the people who may have been wronged by involuntary incarceration might possibly lack any insight into the fact that they were perhaps just a weeeeee bit paranoid, an actual danger to themselves or others --not just misunderstood by an evil power-monger shrink a-lying in wait wanting nothing more than to slam dunK them into an institution to be abused.

What kind of civilized society are we that we leave crazy dirty people eating from the garbage and sleeping in the street while they talk to their halluciantions and die with their rights on.

Anonymous said...

I think a big part of it has to do with what Roy said a long time ago and that's a lot of people dealing with transference. Others have mentioned it as well. I don't think that everyone who is anti-psychiatry is destined to stay that way, though. I think there is hope for some to change their minds.

My first psychiatrist committed malpractice which kind of scrambled up my brains for some time. The Medical Board held him accountable, but I didn't get what I wanted which was for him to actually feel some remorse for the harms he caused me and other people. I've had my moments over the years of overreacting on blogs, but hopefully never crossed over into abusive territory. I'm not sure I even considered the transference thing until Roy mentioned it one time. (It's always so much easier to see behavior in other people I don't see in myself).

I think when something goes really wrong in psychiatry, whether it's as extreme as malpractice or the practitioner is just clueless or a jerk, it may hit people harder than in other areas of medicine because it's not just dealing with the physical, it's trust, it may be vulnerability when at our lowest, not to mention still being left with the issues the person turned to a psychiatrist for in the first place. Not an excuse for overreacting or taking it out on the wrong people, but maybe part of what goes on.

To those who have been hurt and have given up on the whole field, I would say to give it another chance. The psychiatrist I have now is ethical, and he's a good doctor. He has helped me a lot. I wish I hadn't waited so long to try again.

Joel Hassman, MD said...

Dr Dinah, I think it is fairly obvious what is behind a good portion of the antipsychiatry lobby, and other blog authors who have been willing to offer their perspective of what some people bring to threads have reinforced my interpretation having some legitimacy. I can't say it directly at a thread like this for risk of nuclear implosion, if not just censored away.

Frankly, I can't imagine any mental health care blog NOT having comment moderation these days. And it is not to solely make a site partisan supported solely, but to let people know they can't just shout down the authors and claim posters' perspectives alone are correct. And having been to several sites over the past 3 plus years, I have read a lot that is both enlightening and completely venomous beyond reproach.

Personally, I have come to learn you can't medicate Non Axis 1 disruptions, in fact, it may be a paradoxical risk to do so.

The internet has truly been a double edged effect on our culture. You can learn a lot, but also be at risk for a lot too. Finding that happy medium, always seems to be a work in progress.

It is the antisocial element that worries me the most these days that seem to proliferate with the help of anonymity, not directed in the use as aliases in commenters, but instead by setting up access to nefarious agendas for the general public and not having to answer for outward disruptions once tracked back to internet sources.

Oh, catch the NBC report that ADD diagnosing is up 50% in the past 7 or more years? Not a favorable report for psychiatry in my opinion. child and Adolescent psychiatry is not a positive poster child for our profession, and I say that with respect for our colleagues who do practice with caution and adherence to the treatment process.

Your post was well said.

B said...

This thread makes me sad because it seems to highlight the us vs them mentality that is held by both patients and shrinks a lot of the time. I think Jesse gets it.

Nathan said...


When I wrote a letter to a past psychiatrist way after treatment ended, where I carefully tried to explain how treatment became a deeply negative force in my life and why it was important for me to stop, it was taken as like a boundary violation and later I found out that just sending the letter led to additional diagnoses on my record (which i am not afraid to ask for more information about or engage about in fear of even more serious notes being written). So while it may be therapeutic for you to write the letter, I would be hesitant to send it. Though perhaps your past physicians were different than mine.

Nathan said...

And I guess similar to what Baxter wrote, whether or not psychiatrists feel a lot of power, they do have it. Certainly most psychiatrists are ethical and kind and want to support their clients, but structurally, they have the same power as those who folks trusted that were part of a very negative experience. It is hard to put trust again into a similar kind of relationship with a much fuller understanding of the pitfalls of that power differential.

Susan Inman said...

When I read the comments to these interesting blogs, I do see them dominated by anti-medication people. But my daughter and her friends who live with psychotic illnesses are grateful for the anti-psychotic medications that saved them from the hell of psychosis. Fortunately, because of early psychosis intervention programs, they have had good education about their illnesses; this includes information about the lack of insight that frequently accompanies psychosis. These programs help people accept and manage their disorders.

I appreciate these blogs and appreciate that some psychiatrists want to communicate with the public; this is really important and needs to occur to a much greater degree. Neither Canada (where I live) or the US have adequate public education campaigns about psychotic disorders. People don't understand what is known about these disorders which is why bewildered parents don't recognize the early signs of psychosis and don't locate the best treatment. Sociology courses still teach that mental illness (or so-called 'mental illness' as they would say) is socially constructed.

I hope you'll begin to address the issues confronting families who support relatives living with psychotic disorders. I discuss many of these problems in my Huffington Post Canada articles:

jesse said...

@Jessa, your blog is very thoughtful, and I will look at it more carefuly soon. In the meantime, it reminds me a lot of a blog I followed put up by a depressed artist named Allie Brosh. It is called Hyperbole and a Half. Have you seen it? Allie stopped posting some time ago and there are a lot of people out there worried about her.

And Nathan, while some doctors might not like getting a letter from a former patient, I think most would. Particularly if it is thoughtful, and not purely excoriating. So I would encourage you to write. but most importantly try to put yourself in the doctor's shoes so you can hear how the letter would sound. Sometimes the loudest voice is that which is quiet and kind.

Dinah said...

I love the conversational quality to Shrink Rap. Where else can you have a conversation like this one where everyone chimes in on a level playing field? Our readers are thoughtful, intelligent, and articulate, and this has been extremely enlightening -- I hope for everyone.

I'm not sure the 7 year barrage of "how psychiatry has hurt me" has been that useful, however. I did not hurt you (no particular "you" here), and I don't have any way to undo the hurt that someone else may have inflicted. I hope all those who tell us about the evils/power plays/ ways they've been injured, at least feel some relief from venting, but from this side, it feels like a personal attack on something I can do nothing about. And the relentless nature of it feels like an attempt to get us to understand that we personally are bad people for doing what we do, which is actually quite rewarding.

We have gone back and forth about comment moderation, and mostly we agree that we are against it, except at times when we feel overly assaulted or when readers start inflicting invectives on each other. I've thought about turning it on recently, but I don't want to stifle discussion, and I don't want to give the sense that we only hear those who agree with us.

Joel Hassman, MD said...

Comment moderation does not stifle healthy debate, because it is about the author of the post having to take time to review comments. So, is it about quality, or, quantity?

I think when you introduce advertising dollars into a site, it runs the risk of perversing the integrity of a blog that is trying to educate and inform, versus, make a buck.

Hey, I could be flagrantly wrong in this interpretation. Or, maybe I do introduce a legitimate observation to what people are trying to accomplish here on the net.

You control it, as you have erased comments to now without "moderation". I see it as a venue to allow people to have the opportunity to bash before caught. But, you do as you wish.

I did link this post to my own blog, but you won't like why I did so. Not about you, Dr D, but about your commenters.

jesse said...

Jessa told us she has a blog so I visited it and read her college paper which is intriguingly titled "The Parallel Universes of Mental Health Care Professionals and Patients." There is a lot in it and it reminded me of papers on the difficulties in doing psychotherapy and how therapists can unwittingly harm patients.

One of many points she makes is to draw attention to how professionals can hurt patients by not answering honestly and by not validating, or even worse denying, correct observations from the patients.

This might be an excellent subject for future blogs on Shrink Rap.

Anonymous said...

Jesse is a good egg.

Anonymous said...

I wanted to caution people to not lump everyone who speaks out against psychiatry as crazy anti psychiatry zealots just like we are cautioned not to label psychiatry as totally evil.

I personally have experienced psychiatry as adversarial even though it was subtle. When I tapered off of psych meds, I felt like my psychiatrist was waiting for me to fail and did not feel supported by him. As a result, I learned pretty quickly to be careful as to what I said and eventually reduced my visits to practically nothing near the end of my taper.

Still, I don't hate psychiatry as there are some very thoughtful ones such as Sandra Steingard, who blog on the Mad In America website.

I am also not anti medication as recently, due to horrific insomnia, I tried ambien which unfortunately, was a bleeping disaster. It didn't help that the doctor who prescribed it rushed me through a 15 minute appointment and just threw it at me without any thought. So yes, Dr. Hassman, a perfect example of non psychiatrists doing a horrible job of prescribing meds.

My concern is that many people who take meds have not been given fully informed disclosure and that is criminal. But as long as that is occurring, then that is fine.

Jessa, I read your paper and it is excellent. You nailed the crux of the issues and maybe if folks who railed against "crazy anti psychiatry" nuts read your paper before they wrote their post, they might have a different perspective.

I so related to the section in which you wrote about people being forced to socialize no matter what. It made me think about people with autism who had been hospitalized who felt brutally assaulted when they had to deal with those conditions.

For those of you not familiar with autism, many of the folks with the condition (not all) get overloaded very easily sensory wise. That is why being forced to socialize all day would feel like an assault.

By the way Jesse, kudos to you for reading the paper and being willing to look at the issues that Jessa raises.


Minneapolis psychiatrist said...

Dinah, I do not have a high-profile blog like yours, so I can't relate to the "shrink rap life," but I definitely relate to your real psychiatry life. Our profession is one of helping, listening, trying things out, and working with people, not against them. I know that some psychiatrists are real wolves - but isn't that true in every profession? I sympathize greatly with people who have experienced bad psychiatry. But I'm often surprised to read the comments on your blog as well referencing coercive therapists who ruined their lives. I would never ever think to coerce a client. Thank you for sharing your insights here.

catlover said...

I'm going to clarify that I have no interest in writing former doctors as a therapeutic exercise. My reason for doing so is to help other people not go thru what I did. I'm going to take Nathan's experience under advisement. I'll see what my current doc and therapist think. My therapist will probably say it would be therapeutic, LOL, isn't that what therapists say? Ha ha, I can imagine the conversation already.

I won't post here anymore. I have no interest in stressing someone out. My main purpose was to have doctors think carefully when patients are getting worse in treatment. I've given that message, and because of various topics that came up, I also communicated about the trauma of forced treatment, and what I did in my local area to improve that a little bit. I wrote about rural life, and how guns are an intrinsic part of that, and that I would drop out of treatment rather than be put on a government list. I think I was heard. Time to move on. I'm rapidly losing interest in a lot of this stuff anyway now that I am getting my "normal" life back again. Now I can do stuff, instead of just write about my life as a mental patient.

It's a great blog, and I've loved the rubber duckies.

Dinah said...

You are always welcome. You express yourself in a way that is effective, and I have tremendous admiration for the fact that you don't just complain on blogs, you actually go out an enact having your concerns heard by the people who can make changes.

The delivery is crucial. Relentless delivery of the same message is tiresome and does nothing to further any effort.

We have heard that there are people out there who feel wronged by psychiatry. We right our stuff to express ourselves, to enjoy reasonable dialogue, to learn and educate. There is not any question that we believe that people have been treated disrespectfully, wronged, given medicines that make them worse. I'm just not sure what that does in the big picture of things. I think we're all on the same side, we want patients to be treated respectfully and to get better.

"I didn't like what happened to me." is fine. All psychiatrists are evil is not. We help many people, and telling people that medicines are bad as a blanket statement and that diagnoses are bad diminishes those who feel helped by them, or those who felt comforted by having an explanation for their problems. It also diminishes a free society to suggest that no one should take medicines because some people don't like them: we believe people with psychiatric disorders should have the choice of taking medications that may help them or seeking treatment with those who offer help.

There's a difference between saying "I had this bad experience with a psychiatrist/medicine/institution and I'm not going that route again" and saying "psychiatry is evil and you shouldn't try it."

I do think that part of the reason that those who are helped by psychiatry don't hang out on blogs posting relentlessly is because they've gotten better and they are busy with work/friends/projects/family and those who feel injured hang on to it.

So Catlover, I like having you here, do come visit, but if you have better things to do than write about life as a mental patient, go in peace, visit when you feel so inspired, and keep on being a positive force in the world!

In friendship,

jesse said...

@Nathan and Catlover, writing to former psychiatrists about treatment , positive or negative, is not a boundary violation. If you do it it may be useful to the doctor and the feedback may also be useful to you. Both you and they would hopefully learn something.

And Catlover, I hope you decide to stick with Shrink Rap.

Nathan said...


Thanks for the info. I wish I never set my letter, as it made an already bad situation much more entrenched. My goal was to with more clarity than I could when in treatment detail why I found treatment unhelpful. I did this primarily for myself, as verbalizing it in treatment was difficult and I failed to effectively do so before I left. Taking the time to think it through was helpful to bring clarity to me, and I wanted for my sake to express myself with more clarity and freedom than I felt in treatment. My letter also included gratitude and appreciation for components that were helpful. While the letter I got in response was kind, when I accessed my health record later, it told a very different story. I won't get into it here, but I will say it only exasperated feelings of mistrust. So whether or not sending a letter is a boundary violation, I will say that at least one provider considered it a part of treatment and took it as evidence for new diagnoses that were never shared with me directly (only in my notes).

I do want to thank you and Dinah for engaging commentators. I know you work hard to understand your patients and the people you engage with online. While I am often critical of your perspectives, that you publish them and actively are thoughtful about responses to them is admirable.

jesse said...

@Nathan, what you describe is exactly what Jessa talked about in her paper. Good treatment is an honest dialogue. If any of my patients ever saw my notes they would not be surprised by anything I wrote, or, if they were, it would be that the notes were much softer than anything I had said. There should be no surprises in notes, as the patient is in the room with the doctor and both have heard the same thing.

It is very appropriate to write to a doctor to comment on treatment.

Anonymous said...


I too wanted to thank you and Dinah for engaging with commentators. Totally agree with everything that Nathan said.

Your post about there not being any surprise regarding notes made me recall a situation with my psychiatrist in which the issue of a med side effect came up. He stated that I had said a few things that absolutely stunned me as I recalled saying something completely different. Of course, no one is perfect but for various reasons that are too long to get into, i found this very troubling.

And speaking of communicating about treatment, near the end of my sessions, I did express some negative comments. I did try very hard to be respectful but all that resulted was the guy starting to ask about my mood which of course, completely stopped me from saying anything else and made me very careful in anything else I said.

I felt this was a perfect example of many of your colleagues using complaints by patients as evidence that they had a disorder when there was nothing of the kind. Nathan's situation in which he got additional diagnosis' is a perfect example of this.

On a different note, after watching the Dr. Oz show on the dangers of antidepressants yesterday, I am beginning to think there should be anti primary care doctor movement. Of course, I am being facetious but I am just as outraged they are over prescribing these drugs as I feel psychiatry is. And in some ways, I feel it is more outrageous because I am greatly concerned that many physical diagnosis' may be misdiagnosed as psych issues just because the doctor can't take the time to figure out what is wrong. And I am sorry, blaming the insurance companies is a cop out reason.

Finally, I am curious as how you, Dinah, and other psychiatrists who post on this blog would deal with a situation where someone who has schizophrenia or bipolar disorder wanted to go off their meds due to experiencing horrific side effects. Perhaps this could be a future blog entry if you didn't want to currently address the question.

Joel Hassman, MD said...

There are several dynamics that have forced psychiatry into the inappropriate role it has morphed into now, but the one I see as the largest and most pervasive really can be summed up as "hear the lie enough and it becomes the truth".

It is concerning, disruptive, and annoying when patients come in and basically demand meds as intervention number 1, and too often not interested in interventions 2 or more, but, when you hear providers/clinicians just echo this false notion of meds only, meds first, more meds, and "oh, you have a biochemical imbalance", what has done this to providers? The lie. And when few if none in our profession refuse to speak out to argue otherwise, well, you know the adage about silence too.

As an aside, anonymous above writes about "horrific side effects", that is too general for me to comment on. Horrific to me means dystonias, acute liver or renal failure, Neuroleptic Malignant syndrome, entrenched GI upset or emesis, pancreatitis, exacerbated polycystic ovarian syndrome, acute withdrawal with high dose benzos.

Weight gain, fatigue, headaches, sedation, troubles with cognition, are all unpleasant and need addressed, but are not horrific side effects as usually presented.

If you are interested in my perspective, please give examples of what is "horrific".

Anonymous said...

Dr Hassman, this is in response to this exert from your post, "Weight gain, fatigue, headaches, sedation, troubles with cognition, are all unpleasant and need addressed, but are not horrific side effects as usually presented."

Well, I think it all depends on perspective. True, something like acute liver failure sounds worse than trouble with cognition. But as someone who was already cognitively compromised before starting psych meds for various reasons, experiencing that side effect made life h-ll for me.

I guess since I feel it is the patient who should decided what is horrific for them, maybe I should restate my point to ask, what would you do if that person wanted to get off of meds? Maybe he/she isn't experiencing any side effects but is simply concerned about being on them long term. Or they are experiencing problems you don't think are a big deal but they have a different perspective.

By the way, thank you for being willing to discuss this issue.


Joel Hassman, MD said...

I can only speak for myself, but if a patient is having a side effect that causes disruption or impairment in function that rivals the symptoms that got the patient on the medication in the first place, then the patient has to speak up and consider other options.

Different medication, begin therapy if not already in it, take stock in lifestyle and choices and then reframe and change, and be invested in care.

It is a multifactorial process to illness and treatment. Any doctor who would not consider a change if the medication was causing problems, well, there better be a good reason that trumps patient comfort and continued compliance.

I hope that gives some perspective to one physician's opinion.

By the by, perhaps unrelated to the post and thread, but the issue with patients not being treated at outpatient sites with chemotherapy for cancer, well, once the partisan rhetoric and shill special interest media reporting has subsided, if the truth is that sequester cuts are a primary cause, you all better think again if you think that Abomination Care, ie PPACA, is good for America.

Because if the politicians can get away with chipping away with the elderly who are terminally ill, you really think mental health care populations are safe?

Again, not cynical, but hardened reality and ugly history as guide!

mctps said...

As an informed patient, the only ways in which psychiatry may affect me personally are forced medication and forced hospitalisation. I won't rehash these topics here now.

As a thinker, I'm more alarmed by the philosophical frivolity of current psychiatry. Psychiatrists wish to replace priests as exorcists, but their ways are neither more nor less effective, comforting, or scientific than those of the healers of the past ages. On the contrary, since we live in the age of scientists, scientists have tested the alleged effectiveness of particular established treatments, and found them seriously lacking, so that certain modern treatments could be said to be obviously unscientific in a way that past treatments were not known to be until recently.

Also, in a distinctly unscientific fashion, psychiatry makes grand ontological claims about issues its practitioners know very little about. It depends, for its validity, on vague concepts that can be expanded to accommodate any data — its ethos, its Core Theory, can't be falsified even in principle.

For instance, I can't say that if the intrusive voice in my head told me something I couldn't possibly know or guess then that would disprove the idea it is somehow part of me. A properly trained psychiatrist would simply respond that if I seemed to experience such an impossible thing, this would just be further evidence I'm suffering from delusions. Similarly, if I perceive that my emotions are being controlled, that means I'm suffering from delusions of control. If I said I've experienced my body being controlled like a puppet, that's just a delusion as well, never mind that I was the person who experienced it, not my psychiatrist, so I'm supposed to be the one who knows what he is talking about on that issue. But no, in psychiatry, experience becomes meaningless and theoretical notions whose limits no one understands reign supreme.

Or if the psychiatrist doesn't expand the vague concept of delusion to accommodate that sort of thing, he will expand the vague concept of the unconscious mind to accommodate it instead: so it was just my unconscious mind that made me walk around like a rag doll, never mind this sort of thing is supposed to be impossible.

At no point, would I have the opportunity to object with "wait, did your theory of the unconscious mind predict (i.e. allow for) that sort of thing, and on what basis other than circular reasoning?" or "hey, wait a second, if anything can be delusion or hallucination, then what priviliges the conventional worldview above all others?"

The three concepts, delusion, the unconscious mind, hallucination, can, in the wrong hands, be used to account for absolutely everything that can be imagined to happen or that will happen even if no one can imagine it. It doesn't matter what really happens in the real world. Regardless of actual facts, those three concepts can be expanded to explain away anything at all.

Nasty people call that sort of thing pseudo-science, because any hypothesis which is unfalsifiable in principle cannot be scientific. Modern psychiatry is no different from Dark Age Christianity, with its ad hoc "God did it" explanation for every strange phenomenon. Both have their holy trinity which explains all conceivable phenomena in this world inasmuch as it falls beyond the confines of traditional science. If you object, you are either possessed by a demon or "lack insight".

Anonymous said...

Dr. Hassman, thank you for your response. I greatly appreciate the fact that you understand the issues in keeping people on meds when they find the side effects intolerable.

Sorry I wasn't clear in my previous post but I am also interested in how you and your colleagues would do if one of your patients with schizophrenia or bipolar disorder wanted to go off of their meds. Here is the reason I am asking this question.

I understand what Dinah is saying about making sure her goals are the patients' goals. But in my opinion, the story changes when it comes to patients who have schizophrenia and bipolar disorder. By the way, I am stating that in general terms as this not directed anyone specifically. Again, if you chose not to answer, that is fine.

Joel Hassman, MD said...

As part of the problem with some examples in treatment noncompliance, I have never been a fan of conditional care demands, that meaning court ordered care. Which seems to involve more often schizophrenia or bipolar as diagnoses. Treatment has to be framed as voluntary as outpatient services go, even if the patient is not 100% invested, at least a core 50% is hoped.

Outpatient care is more convoluted these days per the role of courts, employer mandates, and even family somewhat coercive with demanding people be in care. Unfortunately, insight and judgment can't be medicated into place, and people sometimes just don't want to admit to a problem/disorder.

Also unfortunately there are more side effect profile issues with antipsychotics and antimanics (note I don't call them mood stabilizers because as far as I am concerned, there is no drug that stabilizes bipolar disorder, just either mania or depression). So, with the history of the older established drugs like Lithium, Tegretol, Depakote, and the antipsychotics like Haldol, thorazine, Mellaril, Navane et al, I was trained to be cautious prescribing because of the added risks. Why colleagues mistakenly just assumed new meds in the same class of drugs would be easier and need less monitoring was at least foolish to assume, if not reckless.

And, I still believe to this day that antipsychotics prescribed for NON psychotic illnesses should NOT be assumed needed for indefinite periods of time. At least not at the higher dosages first prescribed when the patient presented with acute symptoms. I cringe to hear colleagues tell patients "you need to be on this the rest of your life" and never try to lower dosages when patients are stable and making non pharmacological efforts to maintain stability while being compliant with med use.

Also, Bipolar Disorder is overdiagnosed to this day. I again cringe to see what DSM 5 has the audacity to claim are further presentations to label Bipolar.

Unfortunately, there are not medications for immaturity, low frustration tolerance, and just poor interpersonal skills. But, docs don't get reimbursed for diagnoses that aren't simple 296 codes, true, colleagues?

So, hope the comment is of value to AA/anonymous. My final comment to offer in this thread is this to patients: do you also come to your PCP/somatic providers and demand full negotiation with care interventions for non psychiatric treatment? Not saying you can't in some instances, but, I get the sense that some who write here think that patients call all the shots in care interventions, but, as a collaborative, it is finding middle ground if there is disagreement in the treatment process.

just my opinion. Have a nice weekend.

jesse said...

@Anon above and AA, I agree with much of what Dr. Hassman wrote. Bipolar is diagnosed a lot, and in addition it is the favorite lay diagnosis, especially of kids ("He is SO bipolar..."). Curiously, when I was in training, the popular diagnosis was neurotic. "He's SO neurotic." You don't hear that anymore and almost no one even knows what it means.

My own practice is completely voluntary. If a patient wants to go off his medications, or not follow my recommendations, that is his choice. I have never stopped working with a patient who wanted to continue to see me, and certainly would not make taking my medication suggestions as reason for terminating treatment.

I always try to suggest what I think is in my patients' best interests. I often suggest consultation with others.

I very much agree with what Dr. Hassman picked up and responded to in regard to "horrific" side effects. Often there are side effects, but going crazy and doing very destructive things to one's self or others also has consequences, frequently vastly worse than the side effects that led to it.

For instance, it is not uncommon for a student to go off his medication and set off a depression/mania that has him out of school for a year or more. And this occurs when in fact there were no side effects.

One "medication" that it is often hard to get a patient to give up is alcohol. The terrible effects of alcoholic drinking combined with mood disorders is well known.

I hope this answers your questions. I think most of the psychiatrists I know would say the same thing.

Anonymous said...

Dr. H.
Just curious...perceptual distortions, brains zaps, Crashing depression as ssri side effects. Horrific or annoying? Guess we needed a middle category bc it's not renal failure, but it's pretty darn serious. I agree, weight gain, forgetting words, weird taste...annoying but usually benefit outweighs. Baz-

L said...

Dinah, the biggest problem with you is that you don't listen and you deligitimize readers. You assume , or at least act/write as if, your opinion is more valid then those of us who have experienced these things. And then you don't listen when we tell you about that. To my mind, that is the single worst characterstistic a shrink could ever have. Clink and Roy don't do this, so you don't see these sorts of posts on their posts. It's that simple.

Maggie said...

Personally, I think that "neurotic" needs to come back. I dislike the quick jumps to specific diagnosis; it seems to me that it would be more accurate to use "neurotic disorder NOS" or "psychotic disorder NOS" as a starting point. The need to quickly arrive at a specific diagnosis seems like it usually ends up rushing the process and making conclusions without enough information. I think it ends up clinging too tightly to the original conclusion-- arrive at a diagnosis, and then interpret future information based on that diagnosis, rather than taking in the new information. (Obviously that's not universal, but once you've come to a conclusion, it's too easy to use it as a frame or reference, even if you know you didn't have enough time or information initially.)
Yes, I'm neurotic. Going beyond that, you end up with a laundry list that adds up to something that ends up sounding nonsensical. I feel like the attempts to name everything that seems like it might be descriptive ends up just making a blurry mess. "Neurotic" is technically less descriptive, but I still think it's more accurate.

jesse said...

Hi Maggie, welcome back to Shrink Rap! Here is a part of Wiki's article on neurosis:

"As an illness, neurosis represents a variety of mental disorders in which emotional distress or unconscious conflict is expressed through various physical, physiological, and mental disturbances, which may include physical symptoms (e.g., hysteria). The definitive symptom is anxieties. Neurotic tendencies are common and may manifest themselves as depression, acute or chronic anxiety, obsessive–compulsive tendencies, specific phobias, such as social phobia, arachnophobia or any number of other phobias, and some personality disorders: paranoid, schizotypal, borderline, histrionic, avoidant, dependent and obsessive–compulsive. It has perhaps been most simply defined as a "poor ability to adapt to one's environment, an inability to change one's life patterns, and the inability to develop a richer, more complex, more satisfying personality."[7] Neurosis should not be mistaken for psychosis, which refers to loss of touch with reality, or neuroticism, a fundamental personality trait according to psychological theory.

"According to psychoanalytic theory, neuroses may be rooted in ego defense mechanisms, but the two concepts are not synonymous. Defense mechanisms are a normal way of developing and maintaining a consistent sense of self (i.e., an ego), while only those thoughts and behavior patterns that produce difficulties in living should be termed "neuroses"."

Psycritic said...

Dinah and the other Shrink Rappers,

Congratulations on the blog reaching its 7th birthday! It's certainly an interesting challenge, blogging on the Internet and being exposed to all sorts of points of view. I've written a bit about this on a blog that I'm starting, and I'd be interested in your thoughts.

- Psycritic

Maggie said...

I'm sorry Jesse, re-reading my last comment it does look like I was saying that I thought that neurosis and psychosis were the same thing, but I was trying to say the opposite.
My personal experience has been with difficult-to-pin-down neurotic disorders. I find it extremely unlikely that I actually have a half-dozen separate neurotic disorders rather than some more cohesive explanation.

There seem to be many people who have similar diagnostic problems with psychotic disorders. There are pretty rampant stories of schizophrenia being diagnosed in any psychotic episode, even without enough information, or with inaccurate information.

I think that the neurosis vs. psychosis dichotomy should have been retained for initial diagnosis, and more specific diagnosis should wait for a broader picture, rather than being rushed into an immediate classification.

Dinah, I see your point about the difference between your "real" life and your Shrink Rap life. However, while I've got some pretty significant bones to pick with psychiatry in general, if you asked my psychiatrist, I doubt that's something that would even come to mind. Besides medication, the biggest thing I need is a quiet, predictable environment in which I can remain engrossed in finicky details of my latest sewing or 3D modeling project. I've had to reassure her several times that when I describe my current state as "boring," I really do mean that as a good thing.
Having found a psychiatrist I'm happy with, my problems with psychiatry are now limited to more generic issues (and terror at the idea that I may someday move out of the area and have to go through the same hell of finding a decent psychiatrist all over again.)

jesse said...

Actually, Maggie, what you wrote about jumping too quickly to diagnoses is exactly the point Dr. Allen Frances was making a few posts ago. Neurosis does deserve to make a comeback, too, but psychiatry has moved away from trying to understand inner conflict, which is a real loss. What often happens is that an excellent explanation is used to eplain increasingly more of everything, until a backlash sets in.

And again, welcome back to Shrink Rap.

jcat said...

Hey Dinah,
visiting after a couple of years away from all blogging- related activities ....

The first thing that has struck me, reading through the Shrink Rap archives, is that "wow! There are some amazingly rude people out there!", and I have to question why they insist on hanging around if they hate you and everything you stand for so much.

As far as this post goes, I guess I fall into the same group of people that you generally see in your practice. That is, I choose to see a psychiatrist, and I can choose which one I see. My issues are the kind that impact on me, not on society in general, so I'm not in line for the involuntary kind of stuff. Which means my relationships with psychiatrists might be skewed positively - I want help with the whole bipolar depression bit, and I believe that a psychiatrist is on my side in that. From many of the comments on this post, as well as others from the last couple of years, it seems that many other patients (or at least the ones online) view psychiatrists as the enemy. And I have to question whether that attitude isn't a big part of the problems that those people might have. If you view a psychiatrist as someone who is there primarily to force bad drugs on you, to engage in power struggles, and to otherwise infringe on your "rights", I'd think that you are going to influence your treatment negatively. Kind of a self-fulfilling prophesy....if you act like an asshole, you should expect to be treated like one....