Psychotherapy: the Down Side

In my review of Lou Breger's book Psychotherapy: Lives Intersecting, several readers commented that they felt injured by psychotherapy.  It's a favorite topic of ClinkShrink who wrote the section for our Shrink Rap about how therapy can be harmful, and likes to note that any treatment with the potential to heal also has the potential to harm. 


So I got to thinking Why Would Psychotherapy be harmful?
There's bad therapy, like those mentioned by ClinkShrink and by Dr. Breger, where the therapist has their own belief system and thrusts it upon the patient, whether or not the patient feels the interpretations resonate.  We've talked before about what makes a good therapist.  Maybe we should talk about what makes a bad therapist?
I'll give you my list, please write in and add to it.
A bad therapist:

• Falls asleep during the sessions
• Forgets to show up for the sessions (repeatedly, we all have emergencies or calendar/technological failures).
• Does not return phone calls (or other communications) or is generally not responsive.
• Over-emphasizes money issues with patients who have traditionally paid.
• Makes interpretations that don't feel relevant to the patient and insists they are true even when this repeatedly upsets the patient.
• Takes non-urgent phone calls during sessions routinely.
• Is generally disrespectful of the patient (curses at him, eats pizza during the session, berates or belittles him).

• Is preoccupied and not attentive on a regular basis.

These were my thoughts off-the-top of my head, certainly not a comprehensive list, but this list is more inclusive and includes a list of more obvious red flags like licensing issues, the therapist initiating a physical relationship, revealing the identities of other patients, etc.  
 
 I want to say that there are always exceptions, and so these "bad therapist" ideas need to be general.  If the therapist just found out his wife has cancer, he may be less sensitive than usual or preoccupied, it doesn't mean he's a bad shrink.  And therapists have their own bills, and their own individual financial issues which may or may not permit them to be flexible or reduce fees, but some ways of talking about fees are more sensitive than others. 

 Finally, there is no perfect therapist: Someone who does everything wrong and has an awful reputation may be seen in a totally different light by a patient who feels very helped by his/her style, and the most wonderful of shrinks will still see patients who don't like them--- there's an element of chemistry that can't be ordered off the menu.



So tell me your list of bad shrinky things to do.
 
 
 

Does Mental Illness Make People Better Leaders?

We've talked before about whether people with mental illnesses can be politicians (or pilots, or doctors).  Today, on Midday with Dan Rodricks on WYPR, psychiatrist Nassir Ghaemi, author of A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness makes the case that in good times, we need sane and stable leaders, but that in difficult times, "insanity produces good results" and that in hard times those with mental illness are better leaders.  He talks about how mood disorders lead people to be more realistic, empathetic, resilient, and creative.  Want to hear more?  Click HERE to listen.


Kind of nice to hear a positive take on psychiatric disorders for a change.  Tell me what you think.

When A Thick Skin Helps

I had to follow up on Dinah's post "What Makes A Good Therapist." (Note to Dinah: I put the punctuation inside the quotation mark. I'm getting better!)

While I agree that empathy is important, it strikes me that so many times psychiatrists are also called upon to be able to tolerate a lot of negative stuff: anger, resentment, bitterness and the general nastiness that can come along with helping people sort out the awful historical relationships in their lives. Once upon a time there was a fantastic psychiatrist blogger by the name of Shiny Happy Person who suggested that in order to become a psychiatrist people should have to pass the "F-You Test." In other words, you have to be able to handle people screaming and cursing at you. Somebody is going to suggest that only happens with my patients because I treat criminals, but I know this happens with non-criminal patients too.

How do you balance empathy with a thick skin? It gets tricky. If you genuinely care about your patients and want them to get better then it would be nice if they weren't nasty to you in return. But if nastiness does happen, it's your job as a psychiatrist to not let it bother you or interfere in treatment. This is particularly true in forensic work when patients can regularly place blame on others (or on you!) for what goes on in their lives. And when a correctional patient makes demands or threats in order to get something inappropriate from you, a thick skin must be replaced with Kevlar. For the patient's own good, you have to have the toughness to do the right thing to avoid harm. (Eg. "I know you'd really like to have some Elavil for sleep, but since you're over 40 and have coronary artery disease and hepatitis C and have attempted suicide by pill overdose twice and have no recent EKG or liver function test results in your record, I really can't give that to you.")

Prisoner advocates criticize correctional health care providers for being cold or unempathic, but I think they are misinterpreting a necessary and appropriate line that a good correctional clinician has to walk. I just thought I'd bring it up because this is also sometimes necessary for non-forensic psychiatrists as well.

What Makes A Good Therapist?

This is for Dr. D.

We were having lunch when Dr. D mentioned she wanted to write a book aimed at teaching residents how to do psychotherapy. It would start with a section on What Makes a Good Therapist? What does she thinks makes a good therapist? Real life experiences which impart an ability to empathize. Do we grow from our own difficulties? More specifically, do we grow in to better therapists? I asked another shrink this, and he said that people like to believe there is some meaning to their suffering, and perhaps it's nice to believe that if you've been stuck suffering, then it makes you a better therapist, but he wasn't so convinced it was true. Me? I don't know, maybe. Or maybe not. Personally, I'm fine with the idea of not suffering, at all, ever again, so long as I live.

In residency, I was taught that warmth and empathy are important to being a good therapist. Empathy would speak to Dr. D's theory. These are hard things to teach--- I don't know how you make someone feel what they don't feel and empathy is there or it isn't. I do think people can learn responses that get perceived as empathic, and that this is important. When a patient talks about sadness around an issue and the shrink does not feel empathy, it's still important to have a modulated response that acknowledges the patient's feelings-- this sounds terribly difficult....tell me more about how you are feeling...or kind, gentle, silence, but not, "Yeah, yeah, well I'm glad your old hag of a cousin died, she was never nice to you anyway."

So what do I think makes a good therapist? The ability to listen and hear what the patient is saying, even if the shrink doesn't agree. A non-judgmental stance, and this can be harder than it appears. It seems obvious, but it can be hard when a patient talks about hard-to-hear things, such as a pro-racism viewpoint, or disliking people of the doctor's religion or political party, or feeling happy that another person is person is suffering.

Non-dismissive is even better. No one wants to hear that their feelings are stupid or unjustified.

Kind. That's important.
Probing in a way that brings up new information and insights.

Mostly, I think therapy is about pointing out to people their patterns of behaving and responding in a way that is not so painful that the patient becomes defensive, and lets the patient choose to make changes in these patterns. Some patterns are harder to break than others, and the really entrenched one are often components of one's personality.

I'm not doing so well here. I Googled What Makes A Good Therapist, so you can check out these links:
http://www.therapist4me.com/what_makes_a_good_therapist.htm
http://www.therapists411.com/therapist-information/what-makes-a-good-therapist.html
http://askdrrobert.dr-robert.com/goodtherapist.html
http://www.goodtherapy.org/what-is-good-therapy.html

From here, I'll leave it to you. What makes a good therapist?

Like Looking in a Mirror

Sometimes, I treat people who have the same problems I have in my personal life. It's hard. Oh, it's really hard. If I'm really distraught about something and a patient calls seeking treatment with a similar life circumstance, I will sometimes turn them away and recommend another shrink. But I don't always screen so carefully on the phone, and often "I'd like to make an appointment," will simply get a time and date.

The feelings get really complicated here.

If I feel I've had a role in creating my circumstances, then I wonder as my patients seek my counsel, Who am I to be making any suggestions, much less giving advice? Why are you looking to me, I've screwed up the same situations. Oh, you say, Dr. Jeff said on KevinMD that Psychiatrist's Shouldn't Give Advice, but you know, some of us do, and even when we don't, our feelings are often relayed through the questions we ask or the comments we make or don't make, or perhaps by the expressions on our faces, even if we don't say "You should do X." I told a friend once that I feel uneasy, guilty even, in these situations, and he replied, "How do you think I feel?" Did I mention he does family work and was in the midst of a stressful divorce? And I have yet to ask a colleague who also does family work how he managed during the years his own children wouldn't speak to him. Oy, life can be tough, for shrinks just like everyone else.

So perhaps I listen to someone talking about his most personal feelings about a situation, and you know, if I've been there before, perhaps it's good that I can empathize. If I'm in the middle of it, sometimes I listen and the patient's words seem so unreasonable, so unjustified, and yet I recognize them as being exactly my own--it's like having my own anxieties bounced off a wall only to ricochet straight back into my face.

Do I tell the patient that I've been in the same place before? Generally, no. Therapy is about his problems, not mine, and I think in these situations my empathy is clear. I say things that are more poignant and resonant than I might in circumstances where I feel removed. And patients never ask if I've been in the exact same place. On some of the harder things-- things that have no precise quick and easy answer-- I've taken to saying, "Not only don't I know what will fix this, I don't know anyone else who does have the answer." This I can say because I've done my own searching.

I hope I'm reassuring and comforting to people who find themselves in the same places I dwell. Certainly, tripping over a few stones on the path makes one walk a little more gingerly and judge a little less harshly those who walk more slowly. Mostly, though, I worry that I'm a little bit of a fraud just for being in the room.

Self Disclosure and Being Genuine

In the comment section to the post below on Sally Satel and Stigma, mysadalterego writes:

I am rotating through psychiatry now (family practice traning) and really enjoying it, yet I feel terribly inauthentic treating bipolar patients ("I know what you mean, it is hard to give up the highs...") while being so secretive myself.

My first thought was, well, if in a given situation it seems like it would feel more genuine to the doctor and might be helpful to the patient, then why not? It got me thinking about the reasons a physician might self-disclose a personal diagnosis to a patient, or not.

Pros:
-- It really is destigmatizing when successful people 'come out' and let people know they've been treated for an illness. On a person-by-person basis, this is not any individual's obligation, but I believe it does help when public figures discuss their mental disorders and treatment with the press.
--In illnesses where the prognosis is in question, it offers hope. So yes, I think it's helpful to a patient if a doctor says, "I had the exact same type of cancer and I got treated and I'm doing great." and I think it may well be helpful if a doctor says, "I have bipolar disorder and I've been able to manage it and I'm able to function well."
--The patient may feel better able to be helped by someone who has had similar struggles.
Do note that having the same illness does not always make for the best mix: the clinician may think "I didn't think/feel/behave that way when I was sick, so you shouldn't" and the clinician's views of treatment may be narrowed if some treatments were helpful or harmful to him.
--In substance abuse treatment, clinicians are often people who've had problems and often they are quite open about their own struggles.

Cons:
--There is no right to confidentiality on the part of the physician, so the doctor must be willing to forgo his privacy if he reveals personal things to a patient.
--There is the risk that the doctor's issues/stories will become a prominent focus of the treatment if the patient uses this as a door to ask questions and compare and contrast symptoms/treatment responses. This can detract from the patient's treatment, and the physician may have trouble setting boundaries with regard to his own privacy (but may be not?)
--The patient's response is not predictable. The patient may feel comforted by the like diagnosis, or the patient may feel angry: "How come your illness is under control and you get to be a doctor while I keep going in and out of the hospital!"
--Revealing personal information to patients can be considered a boundary violation. In and of itself, a single revelation like this is simply a single revelation. But if the doctor is ever in legal/disciplinary proceedings over a boundary violation (for example, if a patient alleges sexual improprieties), the fact that he revealed highly personal information may well be used as further evidence of poor boundaries.
--It's important to keep in mind that the goal is to help the patient as much as possible. Being completely 'genuine' isn't necessary and isn't always desirable.

Any thoughts? Are there mental health professionals out there who've told patients their own psychiatric diagnoses? And what's it like from the patient's point of view?

[Edit 7/18/2011: See also Self-Disclosure: To Patients Versus to the World]

Shrunken Shrinks?

Midwife with a Knife writes:

"Hm... so I'm not sure it's fair to make psychiatry residents have psychotherapy. After all, nobody made me have a gyn exam or give birth as part of my ob-gyn residency!"

It's been a common theme in our comments, this idea that one needs to walk in the shoes of the patient to truly empathize. One commenter even wanted all med students to have a couple of electroconvulsive therapy (ECT) treatments!

So let me talk for a moment about the whole concept of psychiatric residents having their own personal psychotherapies. It started as part of psychoanalytic training (and remains a requirement in order to become a psychoanalyst). The idea isn't to empathize, or to experience what the patient feels, the idea is that the analyst must understand and work through his own unconscious conflicts in order to effectively work with the patients. He must be able to recognize his own counter-transference, know which issues are his so he isn't projecting them on to the patients, and be aware of his own unconscious motivations and conflicts. It sounds good, I have no idea if it works. I'm also not a psychoanalyst and I've never been in psychoanalysis, so my knowledge is limited, and this whole last paragraph may be a bit off or misstated.

Some residency training programs encourage residents to have their own therapeutic experiences. Where I went to medical school, residents would openly post that they were off to therapy or analysis, and it was both expected and encouraged, and trainees would leave the hospital four and five times a week to lie on the couch. Where I trained as a resident, I was aware that some residents were in therapy, but it was never openly announced in public-- it was something that was either done quietly or on the residents' time-- I believe if a resident working on an inpatient unit announced they had to leave for therapy, it would have been frowned upon during working hours. The residents were expected to be doctoring and leaving th for the hospital for treatment in the middle of the work day was not encouraged.

It's hard to learn therapy. It's a process over time and there's not a great mechanism to watch it unwind. Having it oneself probably provides at least one example, and that can't be bad. Most supervision occurs based on notes or the resident's report and so it is skewed, the supervisor can't always be sure the reporting is accurate or necessarily get a great feel for an unseen patient. Yes, there is "mirror" supervision (where the supervisor watches the resident with a live patient), and this is a terrific learning experience, but there isn't really a way for a trainee to be a fly on the wall of an older, more experience psychotherapist over time. Being your own experiment may help with the learning curve, but I'm not aware of any programs that require it. Is therapy required (as opposed to encouraged) to become a social worker or a psychologist? If so, does the program pay for it, does health insurance, are there discounted ways of getting treatment, or does the trainee pay for it? And for how long and how often?

Does one need to have therapy to be a sympathetic human being? Absolutely not. In fact, one can have years of therapy and still be a creep, while another person can be a wonderful therapist even without having been a patient. Nor does one need to have chemotherapy to understand that cancer sucks, or have AIDS to treat it with kindness. As MWAK has pointed out, many child-free people have delivered wonderful healthy babies and rendered terrific care to their pregnant and delivering mothers without ever having had the experience themselves. And if one has never psychotic, can one truly appreciate the pain it causes: I doubt it. Is it necessary to feel that pain in order to render good care? Of course not.

Sometimes it brings people comfort to know their doc has been there. Substance abuse counselors are often open about their own past histories with drugs. A friend with cancer is now seeing a therapist who is a survivor, and she feels very comfortable with this. I have always been comforted by the idea that my children's pediatrician is himself a father.

But you don't have to have panic disorder to treat it. You don't have to have suffered with depression or schizophrenia or obsessive compulsive disorder to treat it or to appreciate that someone else is suffering.

Should psychiatrists undergo their own psychotherapy?
Oh, everyone knows what I'll say: yes, if they want to.
I believe that most people who are drawn to being psychotherapists have a somewhat analytic nature. They like to look at patterns and relationships (maybe they even like to blog about them). They are curious about what makes humans act the way they do, and by extension, they are probably interested in what makes their own psyches tick. Furthermore, people who practice psychotherapy tend to believe in it's power, they feel there is value in articulating emotional life and in examining the internal world. Given this, a personal therapy may have some appeal, with or without the presence of a psychiatric disorder. (I'm not going to even touch the question of who should pay for it if the psychiatrist doesn't actually have an illness...). If the psychiatry resident wants to have a personal psychotherapy, he should. If he has a psychiatric illness, he should get treatment. But a psychiatry resident who is not ill, who is not suffering emotionally, and who is able to work and to love and who doesn't want to have psychotherapy should not feel compelled to do so for it's own sake. And, by the way, if he later decides it might be helpful, there's no time limit on when, it's not just for trainees.

Are there studies? I don't know of any that randomly divide shrinks who've been shrunken from shrinks who are unshrunken and then looked at their treatment successes with patients....

True Emotions

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It was years ago.  I was a resident on an inpatient unit and the patient was floridly manic.  I don't remember the details, what I do remember was that she was running on empty, high as a kite, going 99 revolutions per minute, you name the cliche.  There was a reason why she was on an inpatient unit and not being seen by an out patient doc.  She wasn't getting better and, as is often the case with people suffering from mania, she had no insight that she was ill, she was feeling good-- really good-- and oh so energetic, and even louder than that, and so what's the problem here? Let me outta this joint!  We're talking, I'm trying to reason with her, and finally, she screams at me in a way that stays clear long after her name and the details of her life have oozed from my memory,  "You're problem is you're not Italian!  You don't understand TRUE EMOTION!!"  She had a point.

I'm not Italian, by the way.  And who defines what emotional response is true, what is valid, what is right to have?  

So once patients get the label of Bipolar Disorder, they come under an added scrutiny that makes them, and those who know they suffer from this disorder, subject to both added analysis of their reactions.  It often leaves them feeling invalidated, or questioning themselves in a way that adds an entirely new dimension, if not burden, to life.  I can have a feeling--- it's just my feeling.  I may question if it's valid for me to have that feeling-- come on, we all check out our feelings.  How often do you ask Was it Him or Me?  Or comment that everyone thinks he's a jerk, just to be sure you're not the one being overly sensitive.  People with Bipolar Disorder take this a bit farther.  If they're angry, irritable, have a great idea, in a good mood, in a bad mood, have trouble sleeping...and the list goes on....then they're ill.  No bad hair days for the labeled labile.  They, and everyone around them, are constantly questioning their sanity.  

There are other labels, though, and they aren't all about mental illness.  Perhaps you're a worrier, you want people to be considerate of the fact that you care about them, but they don't like to check in (--this particular example is for us moms).  Maybe they check in so you won't worry, or maybe they label you Neurotic, or Over-protective, or something that lets them blame you for your concern, that frees them from responsibility.  Or maybe you're very sensitive-- a trait that can be a very positive thing, especially if you're sensitive to the needs of others.  But once you're labeled as such, then the someone who says something that upsets you isn't held so accountable.  No biggie that I made Georgie cry, he's too sensitive, you know.

Emotions are a funny thing.  Sometimes I wish they could just be what they are and taken for face value.  And even if I'm not Italian, let it be known on the record that I'll eat pasta and gelato with glee and enthusiasm.

Fill In The Blanks

This is kind of a How-To post, if that's okay. It's about "How To" start off a therapeutic relationship in such a way that the patient's ability to feel hopeful is optimized, and the patient feels confident about the Shrink's skills. We've talked about people getting to Shrink Rap when they Google "how to manipulate your psychiatrist." This post is going to have a tinge of "how to manipulate your patient." Sort of, not really. This technique works well for psychiatric evaluations and the beginning of psychotherapeutic relationships, but it works just fine for other medical specialties, and probably in any field where a client comes to a professional seeking help solving a problem. There's no science here, just my own observations of patients, and my own feelings when I've seen a doc.

I'll call the technique Fill in the Blanks, but I'm not sure that's quite right. It could also be You're the Type of Person Who....

Quite simply, people feel a degree of confidence in a doctor who understands them, who helps them rephrase their feelings with new words that resonate, who knows things about them before being told. If the doctor can predict the future, well that's helpful, too.

So I'm struggling a little to really explain this and I don't have a great example. Often it boils down to saying to people, "You're the type of person who...." Here's an easy one that I often resort to: I can usually get a quick handle on whether someone is an introvert or an extrovert, and from there it's easy to make some quick assumptions about them. To an extrovert: You live in the moment, you sometimes forget that things will get better soon. To an introvert: Sunday nights are hard for you, you tend to get anxious about the upcoming week.

There are some basic Fill-in-the-Blank rules:

• In the course of telling a stranger about themselves, it's important to eat your words quickly if the patient tells you it's not true. If the patient says "actually I'm not that kind of person at all," the doc should ask, "What kind of person are you?" No one wants the blanks filled in wrong (even if the doc is right!), it leaves the patient feeling unheard, misunderstood, and rapport and confidence are killed. If someone is a touchy type of person who is easily offended, they may read too much into such statements and Fill-in-the-Blanks is risky.

• It's good to Fill in the Blanks with positive things about people. "You're the type of person who would sell your children as sex slaves to get your next drug fix" doesn't work. "You're the type of person who does a great job taking care of other people but doesn't always take the best care of yourself" is a better risk-- it paints the patient as selfless. ClinkShrink is the type of person who is always polite to everyone. Roy is the type of person who is always up for a new challenge. Dinah is the type of person who is always happy to eat a good meal with a friend.

• Perception is more important than fact. If the patient feels understood, it doesn't matter if the interpretation is perfect. "You have a strong moral code and sometimes this causes you to be angry at people who cheat the system." If it works for the patient, don't worry about the fact that they plagiarized a term paper or shoplifted a few times.

• Watch their face: expression says it all. People nod and light up when they feel understood. Some people are compliant and will say "Yes, doc" to everything. If they get grit their teeth and eye the vase to throw it at you, you've got it wrong. If you're fumbling, just say so. "I have the sense I've got you pegged wrong. Can you help me here?"

• It's okay to lie a little, but not a lot. Well, not really lie, but I tend to be reassuring in a way that may be more powerful than I can know for absolute sure. From your story, you've had a few episodes of depression before and they've always resolved, this one will resolve too." People feel buoyed by hopefulness, they don't tend to come back and say "You promised I'd get better and I didn't." So far (should I even say this?) no one has demanded a refund. But don't lie a lot-- if the patient has two weeks to live, it's poor form to assure them that their terminal condition will resolve.

--------------
Coming soon: a series on benzodiazepine use.

When Hummingbirds Bonk

In cycling and running there's a phenomenon known as "bonking". Bonking is when you just suddenly get overcome by exhaustion and you collapse. To be scientific about it, you 'deplete glycogen stores' and can't go on. A friend of mine tells me that this happens to hummingbirds. They can be found collapsed on the ground, exhausted, which isn't too surprising for a creature whose heart beats up to a thousand times a minute. Fortunately they can be revived with a little sugar water.

There are days when I can really identify with those little guys. On days when I see twenty-plus patients, when everyone is in crisis, when I just can't seem to find a chart (or the medication nurse can't find my order), at some point you hit the wall and bonk. It's that moment when I think to myself that I will just walk out of the facility and never come back.

Unfortunately, sugar water just doesn't do it for me.

This is what to do to revive a correctional psychiatrist in case you ever find one lying on the ground, exhausted, with a heart rate somewhat lower than a thousand beats a minute:

Administer coffee immediately, followed by judicious amounts of dark Belgian chocolate. Don't worry about checking for consciousness first, just hit the Starbucks.

If this doesn't work consider depositing a large, warm, furry and loudly purring cat on the psychiatrist's stomach. This is also a test for consciousness since those tiny sharp kneading claws are bound to get a reaction.

Once revived, deposit the psychiatrist in the middle of a large quiet forest with miles of hiking trails (trail map included). Allow time for staring up at tree branches, listening to the wind whistle, admiring large fungi and searching the stream for minnows.

Repeat, ad infinitum, until smiles return.

I suspect every psychiatrist has their own particular favorite ways to recover from the hummingbird bonk. Dinah is relaxing in a warm, sunny place and Roy seems to find comfort in buying new very large computer monitors (I'm jealous). Regardless of the recovery method, we will all find our way back to Shrink Rap eventually.

The Shrink Next Door

This is our 600th Post!
Lately my neighbors have been apologizing to me, which feels a little bit weird. We'll have brief (OK, sometimes not so brief) conversations and they end them by saying something to the effect of, "I'm sorry to chew your ear off," or "I know you're off duty, so I'm sorry about that," or words to that effect. They know I'm a psychiatrist so I guess they think they're burdening me when they do the normal problem-sharing thing that goes along with being a friendly neighbor. Now, it's possible that I get more than the usual share of mental-health related problem sharing because they know what I do for a living. And it's true I know lots of stuff about who in the neighborhood is on which medication, or who would never in their life take that particular medication, or who is looking for a psych referral (I give them names but they rarely follow through), just because of what I do for a living. But it doesn't feel like they're burdening me. I like my neighbors. I've never had a bad one, and that's pretty unusual considering how long I've lived here.

That being said, I can't say that I've ever gone to my mechanic neighbor for car advice or to my hair stylist neighbor for coloring advice (although Dinah probably thinks I should) but that's not because I don't think they'd help me if I asked for it. It just never occurs to me to ask. It is nice to know though that any one of those folks who apologized to me for "problem dumping" would be just as quick to listen to me if the tables were turned. That's just being a good neighbor.

Continuing with that thought....

I started to write a reply to Jayme, who commented on my post Shrinks Aren't Perfect, then I realized the answer was its own post.

Jayme wrote:

I am having a hard time empathizing with psychiatrists being falsely portrayed in the media when psych patients are portrayed far worse, more often, and with incredibly damaging consequences. I don't see much discrimination against psychiatrists because of bad media portrayals. I'd really like to see you gripe about society's lack of empathy toward psych patients instead of your own. I hope this is taken with the spirit it was intended. Thank you.

Absolutely, I agree that the media portrayal of people with psychiatric disorders is awful and stigmatizing. I don't really care how the media portrays psychiatrists for my own sake--I make a living, I have a blog, what more could I want? I knew the profession carried stigma when I chose it, and I chose it. People don't choose to get mental illnesses. The media tends to portray the mentally ill in ways that obliterate any other aspect of their being. Often psychiatric patients are depicted as weird, creepy, or outright dangerous.

The psychiatric setting is used in media for 1) the entertainment value complete with distortions and 2) in terms of story development, the setting can often provide insights/information into a character that couldn't be gleaned in other ways--though this is more true in terms of written/literary plots where point of view limits access to information.

The issue of portraying the psychiatrist negatively is not one that means much to me-- face it, some psychiatrists are pretty weird. I may be pretty weird. The issue of portraying psychiatry in a negative light is that it creates a negative aura around mental health care delivery which spreads out to include the patient, it fosters the stigma, and it makes people with problems hesitant to seek care. You're going to go see a psychiatrist? Shrinks are so messed up themselves, how can they help you? You're doc might turn out to be Hannibal Lechter (pass the Chianti, please) or that transvestite serial killer from Dressed to Kill. Or maybe he'll just be twitchy and pompous like Niles Crane on Frasier.

In the movies, psychiatric patients aren't normal people living normal lives who either get overwhelmed with their problems or get afflicted with a mental illness, who then see a doc and get helpful treatment from a kind and caring person. There's nothing about what one sees on TV or in the movies that would make you want to see shrink.

An "Anonymous" commenter has been kind enough to provide the reference to the Letter I read in Psychiatric Times: The author is Harvey Roy Greenberg (not of Shrink Rap) and Anon writes:

Re: Dr Melfi. The guy who has the same middle name as your co-blogger did not write that she sometimes made mistakes or failed to be empathic all the time. He wrote that her treatment was riddled with EGREGIOUS mistakes and that at times she betrayed a STARTLING lack of empathy. Never watched the show, can't say what she did or didn't do,but there are mistakes and then there are mistakes. No shrink can be empathic all the time but when it comes to a STARTLING lack, then that shrink should refer or the patient should run. Shrinks everywhere: please try to remember that this is a TV character. It is wacko to get this connected with a TV character. As for Beautiful Mind, the ECT and other treatment depicted therein date back many years. If someone suggests that their patients watch it they might also add that disclaimer. This other Roy guy was not writing about you, but you sure took it personally and your reaction seems way out of whack with the provocation. I'm just not getting it.

The Sopranos is different from other media portrayals of psychiatry. Yes, I know it's a TV show, and yes, I've seen every episode (thanks to Blockbuster and HBO on DVDs). Tony Soprano is a nice normal Mafia boss, he "works," he loves, he functions as a Mafia boss will function, and he seeks psychiatric care because he starts having panic attacks. He may be evil, but he's not crazy, and his mental illness is a small part of who he is and what he does. He is a difficult patient-- he steals his doctor's car to have it repaired, he declares his love for her, he sends her flowers, he curses her out and leaves, he has affair with a woman he meets in her waiting room and that patient commits suicide after Tony ends the affair. The list goes on. We also get to see Dr. Melfi's therapy/supervision sessions so we have some insight into just how conflicted she is about treating Tony. Off hand, without reviewing every episode, I don't recall any Egregious errors. I guess the question might be asked, What would be an egregious error in psychotherapy? Dr. Greenberg is a psychoanalyst, perhaps his idea of an error is different than mine? A Startling lack of empathy? There are moments when it would be startlingly difficult to empathize with Tony--especially as a woman listening to his continued sexual indiscretions. Sympathy? Well maybe, but Empathy? He spares Dr. Melfi the details of his violent life--in the first season he talks about working out difficulties with an adversary where he cages running the guy down and breaking his legs as "We had coffee."

Finally-- Roy is back soon, and our regular podcast schedule will resume shortly.

Shrinks Aren't Perfect

Oh, gosh, I got home and realized I don't have my reference. I was reading Psychiatric Times today and came across a letter to the editor. All I remember is that the writer's middle name was Roy, though not of Shrink Rap.

So apparently there was an article that said the media was getting better about their portrayals of psychiatry. The middle-named-Roy guy (not of Shrink Rap) wrote in to say that he disagreed, that medial portrayals are not getting better. He cited the movie A Beautiful Mind as being an unfavorable and inaccurate view of our profession. He noted that fictional psychiatrist Dr. Jennifer Melfi of The Sopranos is held up as a realistic TV psychiatrist but, he said, she makes mistakes and often lacks empathy.

I have a confession to make. Sometimes I make mistakes and sometimes I lack empathy. I try to be understanding. sympathetic, to bounce back a patient's emotional life in words that make them feel understood-- really this is the meat of therapy. Sometimes, people describe to me reactions that just don't resonate with me--- in the situation they are describing, I just wouldn't feel the way they feel. If it's a huge disconnect, I ask more questions, get more detail, but sometimes I just can't get on the same page. This is particularly true when people talk about having literally violent reactions to minor provocations, just to give an example. And there are times when it's clear I've simply said the wrong thing-- if it's obvious by the look on the patient's reaction, I try to address it, but sometimes people feel injured and it's not apparent until much later.

Dr. Melfi makes mistakes. At times, she lacks empathy. No wonder I like her so much.

$#!&*@$ You!

Someone said something rather nice to me the other day. He said, "You don't deserve to be cursed at." I thought that was rather sweet.

I have to say that after a couple decades in the profession I rather took it for granted that getting sworn at occasionally was part of the job. I could be blessed in my morning clinic and cursed in my afternoon clinic and it just goes with the territory. I don't really take it personally and it rather amuses me that people could see me so differently in a single day when I am really the same person all day. (I mean, not having a twin like the psychiatrist in Double Billing. Oh by the way, the next installment of Double Celling is up too.)

I'm not a therapist but I know in therapy the clinician expects that at various times in treatment people may become annoyed or upset or angry for reasons that may or may not be reality-based. Being a good psychiatrist means being able to handle a patient's strong emotions with them while remaining a stable figure in the patient's life. You just can't have thin skin about it.

So anyway, it was interesting hearing this from a non-mental health professional lay person. From the outside it does seem odd. On the inside it's just a way of life.

Reading the Mind with Oxytocin

This is one of the images in the Reading the Eyes in the Mind test.
Is this woman feeling aghast, irritated, reflective, or impatient?

Is this man feeling ashamed, alarmed, serious, or bewildered?
Click the WOMAN'S EYES to take the whole test.

I continue to be fascinated about the role that oxytocin appears to play in social behavior. Here's a study from Biological Psychiatry where:

...30 healthy male volunteers were tested for their ability to infer the affective mental state of others using the Reading the Mind in the Eyes Test (RMET) after intranasal administration of 24 IU oxytocin. RESULTS: Oxytocin improved performance on the RMET compared with placebo. This effect was pronounced for difficult compared with easy items. CONCLUSIONS: Our data suggest that oxytocin improves the ability to infer the mental state of others from social cues of the eye region. Oxytocin might play a role in the pathogenesis of autism spectrum disorder, which is characterized by severe social impairment.

...In sum, this study shows that a single dose of intranasally
administered oxytocin is sufficient to cause a substantial increase
in the ability [of] affective mind-reading and therefore in interpret-
ing subtle social cues from the eye region of other individuals.

Reductions in oxytocin levels have been found in people with autism, as have impairments in cognitive processing of facial features in relevant brain structures (amygdala, fusiform face area). Blocking oxytocin in mice blocks their social recognition. Oxytocin has been shown to increase metabolic activity in these areas. Thus, oxytocin may help us recognize another's emotional state by improving our empathic ability to "read" what someone else if feeling.

There's got to be a similar area in the brain that processes auditory emotional clues, but I am not aware of any.

It would be interesting to know if therapists tend to have higher levels of oxytocin, if the level in the therapist is related to feelings of connectedness by their patients, and if oxytocin nasal spray can improve a therapists empathic abilities. (Reminds me of Deanna Troi, the Betazoid therapist on Star Trek: TNG, who had a type of mind-reading capability. Wasn't there a show where she lost her capabilities?)

A Shrink Like Me!

We're back to our regularly scheduled program now.

It was April 24th, back when Roy was having Grand Rounds mania and Shrink Rap was under lock and key, when the New York Times printed an article by Dr. Richard Friedman,
Understanding Empathy: Can You Feel My Pain. Dr. Friedman begins his piece by quoting a patient who asks if he's ever been depressed; does he know where she's been?

It's a funny question. Why does a doctor need to have suffered from an illness to treat it? We assume our oncologist hasn't had lung cancer or metastatic colon cancer, he hasn't gone through what his patients are going through, and yet we'll assume he's sympathetic and competent. If the doctor has had the disease, or has had a close relative with it (why is that never the question?) then perhaps he is more understanding, but really, how would this help his competence to treat a given disease? In fact, sometimes those who've conquered something are less sympathetic, sometimes those who've conquered say an addiction, or lost weight, or stopped smoking, or have somehow suffered, develop a bit of condescension toward those who aren't doing as well-- a bit of I did it Why can't You? Maybe it's better if the doctor is an outsider, a technician there to make the proper moves without the burden of his own history or agenda.

Friedman goes on to talk about patients who come with requests for specific flavors of therapists: gay, feminist, African-American, Jewish. These patients want a shrink who identifies with their lifestyles, who better knows what it is to be them.

I think there are two different issues here. Clearly, one can treat an illness if one hasn't had it; mental illnesses really are no different and plenty of patients get treated for schizophrenia by docs who've never been psychotic. Having been depressed doesn't change one's ability to write the right prescription, to imagine what it is to suffer, to listen, learn, and appreciate a patient's distress. If anything, it may color the doc's view. Want more? See my post from last September, A Taste of Our Own Medicine.

The second issue is more about therapy-- does it help to have a therapist who is familiar in some ways with the patient's world or culture or core beliefs? Dr. Friedman says No: "What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex. "

And what do I think? It seems to me that just as some patients respond to one medication and not another, some people have very strong feelings about who they are comfortable speaking with, while many don't care. I've had many calls from patients who want to see a female psychiatrist. I don't question it (what am I going to do about it anyway?) and I've come to take it at face value. I imagine there are women who prefer to talk to a man or who just don't care about their shrink's gender. The reality is this: if a patient lives in a place where there are options for who will be their therapist, and the patient has means to pay for it, they will select who they want to see--- there is no means for telling someone who wants to see and pay for an available female/gay/Jewish/Hindi psychiatrist, "No, don't do it." For those who go to clinics, where there may or may not be choice, the clinics vary in how responsive they are either willing or able to be to such requests.

In an ideal world, I suppose I think that anything reasonable that makes a patient more comfortable should be accomodated so long as it doesn't make someone else uncomfortable. It's not an ideal world, and some orders are hard to fill.

Any thoughts? I, of course, want a therapist with a blog.