Tuesday, July 18, 2017

Swiping for Therapists

Over in The New York Times, Melissa Miller has an article titled "How to Find the Right Therapist."

Miller compares it to dating, and she makes the very valid point that good chemistry helps, it's really nice to like and respect your psychotherapist, and to feel a sense of rapport.  In psychotherapy, the talking is an integral part of the treatment and the relationship itself can be healing.  So it is important in therapy that the patient be comfortable confiding in the therapist, be open and honest, and feel safe saying things that can make one feel vulnerable.

Miller compares it to dating, and talks about the pleasure of comparing wedding plans with her finally-found perfect therapist.  She then offers advise on how you, too, can find a good therapist.  

Her advise is awful.  Really.  It's not that some of her points aren't valid, but she starts by giving a quick summary of what type of professional you should see:

Determine the type of professional you need.

If you’re suffering from ailments like panic attacks, depression, post-traumatic stress disorder or obsessive-compulsive disorder, look for a clinical psychologist or social worker rather than a psychiatrist, said Dr. David D. Burns, adjunct clinical professor emeritus at the department of psychiatry and behavioral sciences at Stanford University School of Medicine.
If the issue is something more like bipolar disorder, major depressive disorder, sociopathy, borderline personality disorder or schizophrenia, it’s best to see a psychiatrist or a psychologist with considerable experience in that specialty

I don't know Dr. Burns, whom Miller quotes, but really?  Don't see a psychiatrist for panic attacks, depression, PTSD, or OCD?  But, hey, we apparently do a great job curing sociopathy!  I don't get the division, and I'd suggest that all of those conditions are well-treated by psychiatrists (which may or may not include medications in the treatment).   

Miller advises readers to check therapist reviews on-line.  She doesn't point out that anyone can review anything and there is no way of knowing that good or bad reviews are not verified to be from patients and may be from best friends, ex-lovers, or even the therapist himself.  I'd go for personal recommendations from doctors or known patients myself. And Miller proudly touts that she ghosts her eating disorder counselor and 'broke up' with her therapist by text.  Hmmm.....

Do some research, she suggests, and it seems reasonable to check to make sure the therapist has reasonable credentials and hasn't been sanctioned by a licensing board for something egregious.  A quick telephone discussion is also reasonable, but the author suggests asking the therapist what they like most about being a counselor.   Again, really?  Maybe stick to 'Do you have experience treating my problem.' I'm not sure it's best to start a relationship with a therapist by inquiring about their personal motives for going to work each day; much as I love my work, being asked what I like best about my work by a stranger looking for treatment might make me feel like a college student being asked that wonderful question of "where do you see yourself in 10 years."  

She goes on to address issues of insurance participation and finances.  She suggests that if it's too expensive that the patient should switch the sessions to once a month (not necessarily a bad idea, but shouldn't the therapist be consulted?) or use Skype or email for sessions -- and why would Skype be cheaper?  And how would email work?  She goes on to quote Michelle Katz, a nurse/health advocate:

“They become family to you, so you can ask them to work on a payment plan,” Ms. Katz said.

“Anything is negotiable, and if a therapist is not willing to negotiate with you, especially after you’ve been with them for a while, it’s probably not a good match for you,” Ms. Katz said.

 Finally, Miller talks about timelines for treatment and quotes Dr. Burns again:
“If my son or daughter were depressed, I’d want them to go to a therapist who can get them dramatic improvements in just a few sessions, not just have them pondering their life for months or years without change,” he said.

Rapport is important; feeling cared about, feeling comfortable-- these are all good.  Competency is also important, and Miller doesn't address this beyond a minimal level.  She talks about looking for a therapist like looking for a date, and she assumes the date has no needs of his own: that every patient's a great catch who every therapist would be thrilled to have.  But mental health care is often limited by huge demand, and therapists might not negotiate rates because they have mortgages, student loans, childcare, and food costs.  It's a give and take -- skype and email sessions might not be in the patient's best interest or convenient for the therapist.  And if you call my office, before you even know me, please don't quiz me on what I love best about my job.  Just sayin'.  

So finally, if you want my thoughts on how to find a psychiatrist, I'm going to link you back to an old Shrink Rap post: 

Saturday, July 08, 2017

The Interesting Thing About Reviews of Committed.....

Hello!  It's been a month since the last Shrink Rap post, and it's now summer.  I love the long days and the slower pace.  There have been many times when I have read something and have thought, 'I want to write a blog post about that....' but then time gets the best of me and I end up tweeting it instead. I do believe my brain has reduced itself to 140 character thoughts.  Please do follow me on Twitter at https://twitter.com/shrinkrapdinah

As you may know, ClinkShrink and I are the authors of Committed: The Battle Over Involuntary Psychiatric Care, released by Johns Hopkins University Press on November 1st.  The last few reviews of the book have reminded me how divisive the topic can be.  While all the reviewers have talked about the book as being readable and dressed in the stories of people, the reviewers themselves have opinions on the topic and let them be known.  Let me tell you more.

In Committed, we talk about the anti-psychiatry groups, and we give a voice to those who feel psychotropic medications are ineffective, harmful, or even the cause of psychiatric symptoms.  Reviewers from these groups have invariable noted that, as psychiatrists, we go on to write about the different aspects of forced care with the supposition that psychiatric treatments work, and we don't do a comprehensive challenge of their efficacy.  These reviewers are right: our combined 50+ years of experience is that our treatments are helpful to many people, and we limited our perspective to that of involuntary care. We were not interested in writing a book that questions the efficacy of the treatments -- that's been done by others, and the idea that psychotropic medications don't help everyone or cause some people to have intolerable side effects, is something we discussed in our first book, Shrink Rap: Three Psychiatrists Explain Their Work

On the Mad in America website, Dr. Sandra Steingard starts her review with: 

Dinah Miller and Annette Hanson are two of the three psychiatrists who blog at Shrink Rap. After I started blogging, I began to search out other blogging psychiatrists and I found them. They also have articles published in Clinical Psychiatry News. My impression is that they are decent, well-meaning, and thoughtful psychiatrists (not unlike most of the psychiatrists I know) who want to demystify our profession. Their writing is clear, straightforward, and accessible. Like me, they are all practicing psychiatrists and they deal with the pragmatic challenges we face in our daily work. They offer critical views but they overall seem proud of their profession and their careers. While I respect their work, in that area we seem to differ; they do not seem to be burdened by the professional existential angst that besets me.

On one topic we agree — the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry. To their great credit, they have directed an enormous amount of attention and effort to this subject in their latest book, Committed: The Battle Over Involuntary Psychiatric Care. 

I found it interesting that later in her review, Steingard talks about the concoction of medications that Eleanor (the patient against involuntary treatment) was placed on in the hospital -- she calls it a 'shocking cocktail" and talks about our 'unexamined confidence.'  Ah, Dr. Steingard wasn't there for our behind-the-scenes discussion, or for the article that came out of this particular discussion-- Questioning Psychiatry's Assumptions About Lifelong Antipsychotics-- it was far from unexamined.  I was astounded by the cocktail of medicines-- in the Clinical Psychiatry News article, I refer to it as 'enough medication to drop a Clydesdale-- but in criticizing it for Committed, Clink felt we were throwing the treating psychiatrist under the bus.  We decided to report the cocktail and leave it to any reader in the know to be shocked (as we were), and suffice it to say, this was not a combination of medications we could imagine prescribing.  Does that make it wrong?  Eleanor, as the chapter notes, had many side effects, but she also got better.  While I don't advocate this particular cocktail, we decided it wasn't fair to comment on another doctor's prescribing when we weren't there and the patient ultimately got better --though not with her own share of distress and trauma from the admission.  The Monday morning quarterback always play the game better.

On the other side of the debate, Dr. Lloyd Sederer has posted his review of Committed on the Psychology Today website. Sederer starts by talking about the topic in broad terms:

Americans act as if they have a covenant that demands of them considerable liberty and privacy. These warranties have, at times and in my opinion, exceeded other warranties such as public safety and the public’s health – sometimes even common sense.
Sederer's perspective, as you might imagine, feels to be more pro-involuntary treatment, although he goes on to say that the pendulum needed to swing away from a doctor-knows-best stance, then he asks if it has swung too far. He goes on to write:

This is the important question and challenge that Drs. Miller and Hanson have undertaken in what is an exceptionally intelligent, clear, readable and well researched manner. They do have a POV (point of view), which they express early on and weave into the book’s narrative: they call for “…the judicious and limited use of involuntary and humane psychiatric care, as a last resort, after every attempt has been made to thoughtfully engage patients in accessible, kind and comprehensive services on a voluntary basis.”  

Their book first describes the “for” and the “against” arguments for involuntary treatments. They have tapped the nation’s authorities on these subjects so we gain access to the clearest and most informed of sources. Then comes a section on “Civil Rights”, where we learn about the history and processes of commitment laws. The authors then turn their attention to hospitals (general, public and private hospitals), and their delivery of emergency room, inpatient, crisis and outpatient care. They handle this (in fact, all material) in a story-based manner with abundant actual clinical examples, using pseudonyms to protect privacy. It is like we are there to share the dilemmas that patients, families and clinicians face in profound and uncertain ways.

We have been pleased: the reviews of Committed: The Battle Over Involuntary Psychiatric Care have been uniformly positive from both sides of the battle field.  It is, as we knew, a book that everyone might hate: for the pro-involuntary care side, we don't take a strong enough view; for the anti-forced care side, we are not critical enough of our field.  Again, thank you to all the reviewers, and to all of our blog readers who contributed to the book, and to those who inspired us to write it!

Are there messages I'd like to get across?  Yes:
  • Be kind to the patients.
  • Patients may be traumatized by involuntary care, so it should not be undertaken lightly.
  • Forcing treatment won't cure society's problems, but there are times when it may well help the individual involved.
  • It's kind of crazy that we put so much emphasis on debating forced care when there are so many people who want the treatments we have to offer but can not access them voluntarily. 
  • Our mental health system is a mess and forced care is a very complex topic.  
If you want to learn more about Committed, do visit our website at CommittedBook.com

Finally, I am going to change the topic and send you over to Pete Earley's blog.  I recently wrote about the  NAMI elections and how they were really about involuntary treatment.  Since then, the elections have happened, and Pete writes about the results in NAMI Elects New Board Members But Not Without Controversy