Does Botox Change The Shrink?

So I'm a little older than I used to be and recently when I look in the mirror, I've noticed some lines in my forehead when I make specific expressions.  I'm not so sure I like them; when they show up in photos, they definitely make me look older.  And yet, I know that these lines aren't just from aging, they are an occupational hazard.  Part of attentive listening in psychotherapy involves using your face to convey, in non-verbal ways, obviously, feelings and expressions and interest and even questions.  These are my quizzical lines.  Really?  Don't you think you're kidding yourself there?  Give me a break.  Not a word gets uttered, but oh so much gets communicated in silence, with the movement of just a few muscles.  Yes, Clink, here and there I have a moment of silence.   A short moment, but still.  Wrinkles as an occupational hazard.  


Every now and then I have the thought that maybe I should Botox those lines away, but my first thought is always, will it interfere with my work?  Who am I as a psychiatrist without the Quizzical Look?  Will my patients relate to me differently?  Will they have worse/different/better therapeutic outcomes if my facial muscles are paralyzed?   Oh, and since they came from my work, can I tax deduct the cost of botox treatments?  


No worries, I'll stay wrinkled....or quizzical....as long as Clink continues to be a nun look-a-like and Roy remains a geek. 

Weiner Diagnosis?

 

In Shrink Rapper world, we get a lot of email from publicists about books, TV spots, upcoming events.  This was in my spam box today:

Rep Anthony Weiner is expected to resign today after weeks of scandal surrounding his lewd text messages, tweets and photos.  Even in his tearful media conference, Weiner could not explain why he participated in such behavior.  According to NYU Medical Professor and Internist, Dr. Marc Siegel, the congressman’s behavior is systemic of a larger psychological problem, which must be addressed before fixing the addiction to online sexual activities.  

 

Dr. Siegel says, “This seems to be an example of extreme narcissism, inflated self image, depersonalization, loss of contact with reality, addiction, and the power of the Internet as a medium (like the Wizard of Oz you feel you are hiding behind the curtain)”.

 

To discuss the dangers of addiction and steps to overcome the serious illness, Dr. Siegel is available to offer is medical knowledge.  As a medical practitioner and FOX’s House Doctor, Dr. Siegel has spent years diagnosing and treating people in the national media spotlight.

 

If you are interested in speaking with Dr. Siegel, please contact me at .

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

Oh my, I thought.  I read it twice. An internist is going to comment on Anthony Weiner's narcissism, motivations, sense of self, and contact with reality?   Sounds like a shrinky thing to me, but the Goldwater Rule prohibits psychiatrists from commenting on the mental state and diagnosis of someone they haven't personally examined.  Does that mean it's okay for other specialists to talk about the mental state of someone they don't know?  Hmmm...   I guess we'll see what he has to say, but I'm not so sure about this.

Should Psychiatrists See Patients for Psychotherapy?

The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it. ClinkShrink sees patients in forensic settings (name your jail) and she sees a remarkably high volume of patients. She deals exclusively with medical issues-- patients may say or hear things that impact them positively, but the formal setting of therapy to talk, as a process over time, to resolve specific issues, to deal with past events, and to alter patterns of behavior, is not what she does. Roy has worked in many settings, but his current hat is as a Consultation-Liason psychiatrist in a large community hospital-- he mostly evaluates patients and makes treatment recommendations, but he doesn't see outpatients over long periods of time. He used to do that.

Psychiatrists (in the old days) used to see people for psychotherapy routinely, especially before medications were available. I think I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications: one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects, and there isn't a set-up for patients who are prone to dividing their care-takers into good guys and bad guys.

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest demand. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough shrinks to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

I believe that people should do what suits them, given the realistic constraints of their environment. I'm even okay with the psychiatrist beauty queen. With regard to psychiatrists doing psychotherapy: I like the work and there seems to be a demand for it. I also work in a clinic where the option does not exist to do this kind of work, but it does afford me the opportunity to see a different population of patients and to work as part of a team.

(Roy made me proof read this; my first draft was a disaster.)

Eat, Pray, Love: One woman's quest to find herself

 Elizabeth Gilbert is a novelist.  In her non-fiction real life, she had a bad spell: a contentious, ugly divorce, an overly needy relationship with a distant rebound lover, a bout of depression.  She goes on a journey to heal, to find herself-- a pre-planned, publisher-financed 4 months of pasta and language classes in Italy, 4 months of meditation at an ashram in India, 4 months with a medicine man in Bali.  It's kind of everyone's fantasy, no?  Okay, parts of it are kind of my fantasy.  Parts of it.

When I read a book, or listen to a lecture, or turn on the TV, grab my popcorn at a movie, I'm looking for something.  Sometimes, I simply want to be entertained (a worthy goal in and of itself).  Sometimes, I want to learn something that will change how I see the world, or how I relate in some small way.  Sometimes, I'm looking for something that resonates, that I can relate to, that holds true.  A great plot will draw me in-- so nothing about 24 or The Sopranos or LOST feels anything like my life, but still, they draw me in.  

I started Eat, Pray, Love, and honestly, the author felt like a patient.  Her life is chaotic, her relationships packed with drama, she spends an awful lot of time sobbing on bathroom floors, and she makes no secret of her love-hate relationship with anti-depressants and what her therapist advises.  Her therapist and her Guru.  At first, I found it hard to relate to her, even though she was running away from her real life.  Does everyone else occasionally have this fantasy, even if real life isn't so bad?

I got to page 154, somewhere in India, and suddenly Elizabeth Gilbert became someone I could relate to.  Now people who don't know me very well sometimes think I'm laid back.  Anyone who does know me knows I'm a worrier, prone to obsessing about....anything and everything.    So Elizabeth Gilbert is talking about Sean, an Irish farmer she's met at the ashram and she's talking about Sean's "search for inner peace through Yoga."  He's home in Ireland, sitting with his serene dairy farmer father in front of the hearth, telling him about the wonders of his spiritual discoveries:  

      Da--this meditation stuff, it's crucial for teaching serenity.  It can really save your life.  It teaches you how to quiet your mind.

      His father turned to him and said kindly, "I have a quiet mind already, son," then resumed his gaze on the fire.

     Gilbert goes on to talk about people who don't have quiet minds, who are restless, and she includes herself in this group.

     The other day in prayer I said to God, "Look-- I understand that an unexamined life is not worth living, but do you think I could someday have an unexamined lunch?"

    In my last post on impulsive suicides, when I mentioned writing about this book, a few readers wrote in asking about the Amazon reviews-- one in particular calls her 'self-absorbed and irritating.'   Self-absorbed, self-indulgent, absolutely.  At some level, aren't most people self-absorbed?  I suppose it's a matter of degree-- since I listen to people's self-absorption all day, it doesn't particularly bother me, it's not a fatal flaw.  I wasn't irritated.  I suppose at some level, I just enjoyed the fantasy of it all.  The journey to self-discovery is, of course, and old and oft-told story.  Now please excuse me while I boil the pasta and recite my mantra for a while.

Stories From The Office

I'm not sure where I'm going with this story or even why I'm telling it. I've convinced myself that it's okay to tell it, even though it's a real patient story, and I'll confabulate some details, but basically it's true. I haven't seen the patient in over ten years, I don't recall his name, I'm not sure if he's even alive. It's one of those stories, however, that sticks in my head; one I think about from time to time, one that makes me wish I could tell it to the people it involves.

So John (not his real name) was an elderly, but not old, gentleman. He laughed easily and found joy in many things. He and his wife of 53 years had many wonderful things going on in their lives.

He talked about his father who had come to this country from Europe. His father had very definitive ideas about how John should live his life and the rules were spelled out quite clearly. As a young man, John had fallen in love with a young woman and he'd wanted to propose-- his father disapproved and wanted him to put his education first. The young woman married someone else and my patient met his current, and only, wife. He'd long ago lost touch with his first love, but he did know what had become of her-- she'd become quite prominent in her own career and John knew that she still lived in town.

He had spent 54 years thinking about this woman, feeling he'd made a mistake, pining for the one that got away. His wife was kind and attentive, and they got along well, but he'd lived out his adult life quietly wondering 'What if?'

And why is this a blog-worthy story? In fact, I've wanted to write about it for 2 years, I' m not sure what has quite stopped me.

So the patient told me his first love's name. I knew this woman-- she is the mother of one of my friends. I didn't know her 54 years ago, but in the here and now, she's a cranky soul and, if you ask me, my patient is better off with the lovely wife he has. The funny thing is that my friend's dad is a lot like my patient.

I wondered then if I should say something. What would I say and would it help? I didn't, by the way-- I was afraid it might make things worse and that I would regret having opened this door. It's always a little awkward when my worlds intersect.

Dr. Fear Factor

Saw this on the APA site today. I sorta predicted this in Reality Therapy Vlog...

---

"A new TLC [The Learning Channel] show is looking for experts in cognitive behavioral therapy and anxiety disorder treatment to take on eight challenging patients in a groundbreaking television series to alleviate their phobias.

Everyone knows what it feels like to be afraid or to feel anxious, but there are some people who can be so debilitated that it interferes with the tasks of everyday life. Their friends and families try to understand, but the relationships are strained. Meet eight individuals who are prisoners of their own minds. In order to take back their lives from their overwhelming emotions, they will undergo a unique treatment directed by two of the country’s top anxiety disorder specialists. On a two-week journey of hope and self-discovery, eight individuals and two therapists will board a bus winding along Route 66, crossing eight states, and 2,400 miles with the aim of curing the neuroses for good. People on the bus will not only face their individual fears, but will also help each other through intensive group therapy.

The show will be an uplifting experience for the participants and the viewers. The patients will be challenged, yet always in a safe but dynamic environment. They will have the guidance and support of two exceptional therapists and their bus-mates, but they will be emboldened to take an active role in their own recovery.

The journey from incapacitating dread to dynamic vitality will be documented for The Learning Channel. The Learning Channel is a network dedicated to groundbreaking programming presented in a sensitive and educational manner. This program will be produced by LMNO Productions for TLC. Eric Schotz, Bill Paolantonio and Kathy Williamson are executive producers."

They are looking for two doctors -- a cognitive therapist and an anxiety disorder specialist -- to go on the road with them for 10 days. Any takers?

Roy: Quotes seen around the blogs

girl MD: "i've already had one cup this morning, but there's no such thing as too much coffee."

* * *

shrinkette: "I've made a rule here: 'No medical advice is given on this site.' But suppose that a commenter says: 'To taper a med, do A, B, and C.' Does that violate my rule? Should I delete the comment?"

* * *

bioethics: "Truth is an important component of the fiduciary responsibility of the physician to his or her patient. But as with the physician's prescription of a medication for treatment of a patient's illness, the maximum dose is not often the appropriate dose to prescribe, should the dose of truth administered to a patient be titrated too? "

* * *

blogborygmi: "If I were a fat pediatrician, I might be a little reluctant to counsel a fat child, myself, because, you know, little kids can't abstract like adults can."

* * *

mind hacks: "Transcranial magnetic stimulation (TMS) is a technique whereby magnetic fields are used to temporarily alter the function of the brain by inducing an electrical current in the brain tissue. ... Much weaker magnetic fields (about the strength of a loudspeaker) ... have also been used to induce unusual experiences by stimulating the temporal lobes ... A new project called Open-rTMS aims to develop this latter type of system (actually, generally not referred to as TMS in the neuroscience literature) and publish the plans and software online. They're currently looking for people to sign up to the mailing list and kick the project off, so if you're looking for a way to alter your state of consciousness with magnets, this might be your chance."

* * *

rebel doctor: "On-line poker is a dangerous and seductive mistress. I fight her allure (usually unsuccessfully) every night."

* * *

john grohol: "I have not been able to see either of these [reality TV] shows since I don’t have access to that channel, but the premise of both is disturbing. I’m also troubled by the idea that there are likely psychologists working as consultants in designing the shows and the experiments."

Roy: Reality Therapy Vlog: "PsychoTherapy 2.0"

I started to comment on Dinah's post, entitled That's Entertainment???, about reality TV shows exploiting folks with mental illness, and my comment turned into this new post. I have come to the following reasoned conclusion. Ahem.

I am quite certain that at some point, soon, there will be a reality therapy show... more likely an internet video log, or vlog. You know, a webcam in your office, for the world to see what happens in therapy. "Bringing The Couch into your living room."

Every Tuesday evening from 7-7:50, for example, "Melissa" can be seen talking with her therapist (live). God forbid if she's late, as the shrink would then look into the cam, telling why he thinks she's acting out because of the interpretation he offered the previous week, and her troubles confronting authority figures... maybe even with video-snippets from prior sessions, driving home the point. I'm sure if you miss a session, or "show", you can download it to your iPod from iTunes, and watch it when *your* patient no-shows, all the while wishing that you could have a successful therapy vlog, like Dr. Pheel has.

Some patients will even develop their own following, like groupies, cheering their successes on, or jeering at the more narcissistic or annoying "clients". I suppose if there are advertising sponsors, then the therapy would be free for the patient, and the therapist would reap some financial benefit. Perhaps Google ads popping up on either side of the screen, at the mere mention of a product or service by the doctor or patient:

Sponsored Links Toxic Waste Weight Cleanse the waste "weight" and lose more pounds and inches. www.puristat.com

"Doc, ever since I started taking the Paxil, I've gained so much weight. And I've been constipated. It's really depressing."

Sponsored Links Constipation Gone Forever Read about the #1 natural remedy for constipation. It works! www.DrNatura.com

Netizens would flock to the patients' blogs to see what they are *really* thinking between sessions, leaving comments about how insensitive the shrink is; or how she should let go of the idea that her bitch of a mother will ever care about anyone but herself; or about how she is such a misandrist (or, he, a negative animus); or that her iatrist is using the wrong otropic drug; or that she could become a "clear" if she just joined the org; or maybe even that, for the low price of just $9.99, in four easy installments, that she, too, could have her very own Emotional Support Duck, thus, forever doing away with the perverse dependency on her work-a-day psychiatrist.

It would get people interested in therapy again, like in the 60's, but only more tricked-out and jazzed-up for the plugged-in generation. Who needs insurance? If your problems are interesting enough, or bizarre enough, all you need is a therapy sponsor. If you are willing to try out the latest pharmaceutical, the drug company may even sponsor your reality therapy vlog, though probably with a side contract stating that for a given sum of money you will not divulge any unpleasant reactions you might experience, such as a blue tint to your vision, spontaneous flatulence, or painful erections lasting longer than 4 hours or 10 inches.

Some day soon, this year or next, web-enabled therapeutic voyeurism -- dubbed PsychoTherapy 2.0 -- will become the biggest thing to hit Psychotherapy since Managed Care. Or Prozac.

Or even Freud.

That's Entertainment???

[posted by dinah]



It took me a while to figure this out, from the headline, Mental health chiefs blast 'dangerous' Big Brother, I somehow thought "Big Brother" referred to one of those altruistic organizations where men adopt fatherless boys to nurture and mentor. Finally, in my Pop-Culture Deprivation state, I figured out that Big Brother is a reality show where they throw a bunch of people into a house together and stick 'em on TV so people can watch them bitch at each other about who left the dishes in the sink. Or so I imagined.

Not this show.

"Sam Brodie, a pre-operative transsexual, is thought to have mental health issues," notes The Daily Mail. "Sam, 18, has already told housemates: "'I'm the most paranoid person ever.' " The article goes on to report, "Sam is among a host of vulnerable contestants put into the house.
Shahbaz threatened to kill himself live on television before quitting the show, Lea has tried to commit suicide and has undergone extensive plastic surgery because she was unhappy with her appearance, Nikki has suffered anorexia and Pete has Tourette's Syndrome. "

Since I get paid to listen to such stories, I just can't fathom how anyone else might enjoy watching this for entertainment. Here in America, we'd never stand for such things.

Okay, I'm off to clear the sink before the cameras arrive...

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