T for Two and Two for T.

Today's New York Times has an article about couple's therapy and how difficult this is to do.  The piece is by Elizabeth Weil and is titled, "Does Couples Therapy Work?" 


I don't do couples work.  I didn't plan it that way, but very early in my career, I realized I'd had minimal training in couples therapy and people with marital problems deserved to be treated by someone who had experience in this area.  


I do sometimes see my patients with their spouses,  or even significant others, and it's always an interesting experience.  I also hear from my patients that they will see their partner's therapist for couples therapy, and I'm never sure how that really works--- to me it seems that the allegiance, or agency, of the therapist needs to be clear.  You're either working for the couple, or you're working for an individual.  I don't know how you do both.


Since I only do individual work, it's very clear to me: I'm aiming for what's in the best interest of my patient.  While I may like or respect or wish the best for their parent/child/spouse/or roommate, my goal is to help my patient.  Sometimes it's a single goal: It's never in the best interest of my patient to do something that will cause physical harm to anyone-- if for no other reason than I think my patients are happier when they live in a setting where they get treated by me, and not by ClinkShrink (--meaning, not in jail or prison). 


Sometimes I ask people to bring in a family member.  Usually this is because either I need more information about the history, the current situation,  or about what symptoms the patient may be exhibiting in their natural environment.  More often, I ask people to bring in a family member because I need to enlist their help in either caring for a patient or monitoring them.  Perhaps someone wants to go off a medication and past attempts have been unsuccessful-- it may be helpful to educate a family member as to what the symptoms of a recurrence are and an extra set of eyes may help catch problems earlier than I would be able to alone.  Perhaps a patient needs more help in negotiating the day-to-day issues in life, like getting to a doctor to evaluate that mass, or to evaluate a memory problem.  


More often, people ask me if they can bring their spouse, and it's not my idea.  I often ask what the agenda is to be, why they want their person to come.  Here are some reasons why people bring others to therapy sessions:
--They want me to fix the other person. (I can't do this).
--They want to confront the other person about a problem in a place where they feel safe (Can I go home now?...This is never fun).
--They just want me to meet the person they talk about a lot.  (I often like meeting them and having a face and live person to put to the stories).
--They want me to explain what's wrong with them to someone who cares but doesn't seem to understand (I'm happy to try).  


In a clinic setting where I see people for medication management, it's not unusual for people to bring family members into every session.  The patient may not be someone who talks about their emotions or feelings, or even has any interest or ability to relay to me stories from their lives.  Perhaps they have a brain disorder (like mental retardation or a history of a disabling stroke) and the medications are targeting disruptive behaviors or psychosis, and the person who comes is often the one to identify whether things are going well or not, in conjunction with the patient.

What are your thoughts on bringing significant others to sessions with a psychiatrist?

The Shrink Rappers Rap With Dr. Mike Sevilla on Family Medicine Rocks!

In case you missed it, we were on Dr. A's BlogTalkRadio show last night-- Family Medicine Rocks hosted by Dr. Mike Sevilla. Sarebear and Crazy Girl called in-- it was fun! And we got to ramble about our book and what went on behind the scenes, with a shout out or two to our oh-so-tolerant editor, Jackie.

If you missed it, don't worry, it's preserved for all time on the internet and here's the link to the Family Medicine Rocks website/blog with all the info. Mike writes:

We had a great conversation about the origins of the book, the process of editing/finalizing the book, and how they didn't kill each other during this process - Hehe.

The setup for the book is interesting that they wrote fictional characters to explain how psychiatric patients are taken care of. For example, since Roy takes care of hospital based patients, his section talked about that. Clink is a forensic psychiatrist and she tacked questions like "What's it like in a prison setting?" And, Dinah is in private practice and she talked about issues like "What it's like inside the walls of a psychiatrist office during an appointment."

Oh, but I cheated just a little and changed Roy and Clink back to Roy and Clink, just for our Shrink Rap blog (they've long ago outed themselves...).

In Treatment: Season2, Episode 3: The Turtle in Therapy

Oliver is back for therapy because of his parents' separation. All three family members are in the waiting room plugged into their iPods (Oliver has a shuffle). A smiling couple walks out of the office, "That wasn't so bad." Beacons of hope: Paul cured them, perhaps he can cure the Oliver family.

Oliver's having a rough time. He's reading Lord of the Flies, people think he's fat, and oh, he has the class turtle with him, one he's sure he can't keep alive. To every question, Oliver says, "Because my mom would call my dad and they would fight." Paul does a good job in addressing Oliver's questions about the happy couple who left-- "I don't talk to my other patients about you and I can't talk to you about them."

Bess (Oliver's mom) distorts Paul's words: "You don't think we should get divorced....parents should stay together no matter how unhappy they are and ultimately it would be better for the children?" Ah, this has to be pushing newly-divorced Paul's buttons. And it's suddenly clear that one of the issues here is that Mom is still hung up on Dad. It's a kind of ugly session when dad announces he has a new girlfriend... kind of amazing it isn't bloodier. Little Oliver gives Paul's next patient a rather hopeless look and the forgotten turtle remains in the office with Paul. He (?) retracts his turtly little head into his shell.
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The Silent Psychiatrist

This morning, I woke up and got ready for work. Time to go and I called to the kid to come. Only nothing came out. Nothing. I felt fine, but I'd lost my voice. Completely, barely a whisper emerged.

It was just before 8. Kid announced she felt sick and went back to bed. I fetched the carpool kids (--the issues of what to do about carpoolers when one's own child is sick could be its own entire blog). My first patient was for 9:00 and it seemed like too short notice to cancel. I did croak out cancellation calls to the next couple of patients with the thought that they might have a hard time conducting the session without my input; some people don't come in and just talk spontaneously, they look to me for direction, a little more than I sometime wish and a lot more than my voice could tolerate today.

As shrinks go, I talk a lot. As people go, I talk a whole lot. I think I'm probably in the top ten percent for talkativeness in the general population, though I quiet down when ClinkShrink tries to monopolize the podcast.

So suddenly, I couldn't talk. I figured it would be a good experiment, or at least a good blog post. I listened and I let the sessions flow a little more organically. There were places I'd normally interrupt to ask questions-- I didn't. At the end of the session, I asked how it went. The first patient said it was fine once he realized I felt okay (I felt fine). With that, I called the rest of my patients and left the choice to them-- a couple came, a couple didn't. There was one session I'd wondered about, and I did end up having to do a fair amount of talking/croaking.

I wondered if I would be a better therapist-- I sometimes think I talk TOO much. I don't think it was better. I don't think it was particularly worse, either. I'll be happy when I can just talk again. Camel says to rest my voice, Roy says to gargle with salt water. Off to hot tea with honey now. Thank you for letting me croak here.

A New Use For Gangs

(A BGF tattoo)

I found a new use for prison gangs today. It was completely unexpected.

The patient was a very large, somewhat scarey-looking guy with a history of bipolar disorder. When manic (and psychotic) he got violent. He was transferred back to my facility for refusing to take his meds in a lower security setting. I forget what happened there, but he just wasn't doing well. Back in my facility he was among his associates from the Black Guerilla Family, a well-known prison gang. They respected his size and definitely didn't want him getting sick. They made sure he went down from the tier to the pill line to get his medication.

You'd never guess he had a mental illness when he was well. He was still big and scarey-looking, but he was also articulate. He talked about being able to haul someone into a shower and "mess him up" without guilt or remorse. He talked about staying vigilant, knowing that being part of the BGF made him a target for other gangs. He talked about being bothered by the fact that his violence and lack of conscience didn't bother him. He talked about "wearing a mask" and passing as normal. I could have listened to him forever, and it would have made a good documentary about sociopathy.

But anyway, back to the gang. In psychiatry you hear a lot about the importance of social networks and family support and how this can prevent relapse for people with psychotic disorders. What you don't always think about is how a prison gang can serve this same function. The BGF helped keep my patient well.

He finished the appointment by asking how I was doing and if I was OK, which I thought was rather interesting. It was a bit like Tony Soprano, someone who could execute a guy without batting an eye, being concerned about the ducks in his pool. And I was the duck.

JCP: Family Intervention Overcomes Poop-out

Your taking an antidepressant for major depression, but after a year or two it seems to wear off; what some call SSRI Poop-out. A recent article in the Journal of Clinical Psychiatry finds that a family intervention approach to this problem is more effective than increasing the dose of the antidepressant.

Can anyone educate us about the "McMaster model"?


Family Intervention Approach to Loss of Clinical Effect During Long-Term Antidepressant Treatment: A Pilot Study

Background: The return of depressive symptoms during maintenance antidepressant treatment is a common phenomenon, but has attracted very limited research attention. The aims of this investigation were to explore the feasibility of a family intervention approach to loss of clinical effect during long-term antidepressant therapy and to compare this approach with dose increase.

Method: Twenty outpatients with recurrent major depressive disorder (diagnosed using Research Diagnostic Criteria, i.e., patients were at their third or greater episode of major depressive disorder, with the immediately preceding episode being no more than 2.5 years before the onset of the episode which led to antidepressant treatment) who lived with a partner and relapsed while taking antidepressant drugs were randomly assigned to (1) family intervention approach according to the McMaster Model and maintenance of the antidepressant drug at the same dosage or (2) dose increase and clinical management. A 1-year follow-up was performed. The study was conducted from January 2002 to December 2004.

Results: Seven of 10 patients responded to an increased dosage; all but 1 relapsed again on that dosage during follow-up. Seven of 10 patients responded to family intervention, but only 1 relapsed during follow-up. The difference in relapse was significant (p < .05). Conclusions: The data suggest that application of a family intervention approach is feasible when there is a loss of clinical effect during long-term antidepressant treatment, and this approach may carry long-term benefits. The results need to be confirmed by large-scale controlled studies but should alert the physician to explore the psychosocial correlates of loss of clinical effect.

(J Clin Psychiatry 2007;68:1348-1351)