There are "Brands" of Therapists?

The New York Times has a article by Lori Gottlieb on "What Brand is Your Therapist?" 
The article is about therapists who can't fill their practices, so they start sub-specializing, having glitzier websites, marketing through social media, and consult with specialists about how to gain their market share.  The author is clearly a bit uncomfortable -- the new therapy world demands Facebook pages, blogs, self-disclosure, specializing, coaching, helping patients to feel good in just one session, and isn't about higher goals of understanding motivations and meaningful change.  We're a feel good society, Gottlieb contends.  

Even so, most therapists I know are becoming aware that they need to project more than a tabula rasa. Roth suggested to me that in addition to creating a Web site, therapists should set up Facebook and Twitter accounts (she gives instructions on how to create social-media boundaries, like whether you’ll respond to clients’ posts), blogs, real-time appointment schedulers, teletherapy that’s compliant with federal privacy rules and other features that allow potential clients, she said, “to feel personally connected to you at all times.”

I felt my stomach lurch. I had just learned in graduate school why the formal structure of the 50-minute session works so well: It gives people a designated space and context in which to delve into difficult issues and then leave safely, without wounds exposed. I’d also seen firsthand, by making rookie mistakes during my internship, how breaking “the frame” can interfere with treatment. Constant communication can create a false sense of friendship and also undermine the development of coping skills: the ability to tell the difference between normal states of sadness or anxiety that pass and a true state of emergency. If clients need more, my supervisors always said, they should increase their weekly sessions, not be in touch in between.

I told Roth I had no desire to tweet daily aphorisms or to blog for my patients. “Let’s just focus on the Web site,” I said, “no bells and whistles.” She had two recommendations: addressing viewers in a video on the home page (“to move forward that first meeting in the office”) and coming up with “connecting questions” to bring in my to-be-determined target demographic. She gave me some examples: Is your daughter making choices you’re worried about? Would you like your partner to do more of some things and less of others? Are there people in your life you’d like to say no to? I’d also need a specific tag line, like “Make your home a happier place” (for parents with unruly teenagers) or “Find your way back to love” (for disgruntled couples).

“People want to see the therapist who fits their exact situation,” Susan Giurleo, a branding consultant outside Boston, told me.

So what brand of shrink do you think is best?

My Struggles to Learn the New CPT Codes

Okay, I'm starting to document my attempts to learn the new CPT codes.  Check out my article on Clinical Psychiatry News called "One Psychiatrist's Quest to Learn New CPT Codes for 2013." 
The article has a little bit of attitude to it, but I do wish this was going to be easy.  I do want to tell you that the part about the Amazon reviewer who says the manual is made of paper that is comparable to Russian toilet paper, that is true ( that they said it, I have never felt either the AMA's CPT manual or Russian toilet paper), I did not make that up.

So while the new CPT codes may better capture what it is that we do as psychiatrists, and may eventually end up being fairly straight-forward for those who do only psychotherapy without prescribing, or those who do only medication management, for the psychiatrist who does both and does not participate in insurance networks, it's going to be difficult.  One code, 90807, has captured most of what I do clinically: a 50 minute psychotherapy session with medication management.  The new codes now have 15 variations to capture that same appointment, 3 based on the time devoted to psychotherapy, and 5 based on the complexity of what happens in terms of medication management, medical assessment, education, or coordination of care. If crisis management or difficult family members, or 3rd party reporting are necessary during the session, there can be even more codes.  Technically, every session might have different codes with  different fee, ones that can't be predicted in advance.  I'm sure we'll figure this out, but I don't think the people who designed these codes were thinking about the way every psychiatrist practices.  The challenge is going to be to come up with a consistent coding structure that captures what we do so that the patient can be maximally reimbursed, while the integrity of the system is maintained.

I haven't taken the official course yet, I've just been chatting with people and looking at some of the slide shows the professional organizations have put out.  I hear colleagues say that the documentation is onerous, and I wonder if this will change care.  The more medically complex the appointment, the higher that portion of the reimbursement will be.  Oh, but having a more medically complex appointment may then require that less time is spent on psychotherapy, and that part of the fee reimbursement will go down.  It's all very confusing.    And while the psychotherapy must be distinct in terms of time, the reimbursement for psychotherapy is higher if there is not medication involved, so 30 minutes of a physician's time devoted to therapy (which are distinct from the medical management) pays less than 30 minutes of psychotherapy time by someone who is not also managing medications.  Finally, it's not at all clear why the new Medicare fees have a psychiatric evaluation with medical services done by a physician being reimbursed less than a psychiatric evaluation done by someone who is not a doctor.

If you're a patient, hang on, we'll figure this out.  If you're a psychiatrist and you've come up with a solution to how to make this work, please do tell. 

Losing it All, and Then Starting Over

In honor of an assortment of storms, Clink is over on Clinical Psychiatry News talking about how we deal with devastation.  What we say to patients to soothe them, how we deal with our own losses.  Clink writes:

There is no easy way to salvage the remains of a past life. One can pick through the wreckage, create a monument to lost memories, or let go of the remnants determined to rebuild in new and better ways. There is no right way to deal with it, no better way, only ways that are less painful than others. The only certainty is that life will not be the same. As psychiatrists, the best we can do is instill faith in recovery. 

She includes a lovely poem by Elizabeth Bishop titled One Art.
Do surf over and read, and if you'd like, leave a message here for Clink, she's off this week on vacation.  The link to Clink's article  is here.

CPT Survey Results

I thought I would share the survey responses with you.  The first question was for everyone, the rest of the questions were just for mental health professionals.  I wish I had asked if the clinicians were already using Evaluation & Management codes -- many do not (myself included) and learning to use these and document correctly will be a challenge for the psychiatrists who don't already regularly use them.  They will be required with the changes coming in 2013.  I'll be writing more about CPT coding in the coming weeks.  The good news is that it's still really, really boring.  

Thank you for helping with my survey!

 

74 responses

Summary See complete responses

How long do your psychiatric appointments usually last?
	15 minutes 13 18% 20 minutes 8 11% 25 minutes 5 7% 30 minutes 12 16% 35 minutes 1 1% 40 minutes 0 0% 45 minutes 9 12% 50 minutes 17 23% 55 minutes 0 0% 60 minutes 9           12%

Do you use CPT codes either to directly bill insurance or on statements given to patients?
	Yes 42 No 5

Are you hopeful that changes in CPT codes will provide better reimbursement for your services?
	Yes 24 No 23

How do you plan to learn the new CPT codes?

Read a manual 13 Google it and hope someone else explains this well 13 Take a course 18 Ask a friend and hope they can explain it 8 Instruct my staff/billing administatrors to figure it out 11 I have no idea 7 I didn't even realize the CPT codes were changing in January 4 CPT coding is not relevant to my practice 2     People may select more than one checkbox, so percentages may add up to more than 100%.

Shrink Rap : The Audiobook!

You hate to read.  Or you hate to read books, blog posts are fine.  You haven't read our book Shrink Rap: Three Psychiatrists Discuss Their Work because, ugh, it's reading a book.  
We have good news.  Our book is now available as an Audiobook.  You can listen.  Nope, we're not reading it, it's narrated by Colleen Patrick, a professional.   Our book editor says "It's emphatic, not droning."  So glad it's not droning.  
 Here is the Shrink Rap Audio Site.
So you can download the audiobook from Audible.com, or you can download it from Amazon or you can download it from iTunes.
 Ten hours and 27 minutes of psychiatry  What better way to spend a day?

The New 2013 CPT Coding Manual : Shame on the American Medical Association!

You've heard it everywhere: the wave of the future for medicine is Electronic Medical Records.  They make for better care, easier communication, fewer errors, easier portability, and everyone loves seeing a doctor who spend their appointment hunched over a screen asking questions to fill in the right check boxes.  Yesterday, as I hit "submit" on a prescription, the computer informed me that it had a problem and logged me out with instructions to sign in and start over.  My hospital is spending $100 million dollars on a new system (how many people could we provide care for for that?), and the federal government has deemed the electronic life so important that it's paying physicians to do this, to the tune of $44k.  

With that as a preview, and with the statement that this is soooo important, let me rant about something else which you are going to hear a lot about from me in the coming weeks.  The way psychiatrists and other mental health clinicians code  health insurance claims is going to change on January 1st.  The codes are called CPT codes, and if your doc submits to insurance, you've never thought twice about this, and if they don't, there's an innocuous number on the statement you get (probably 90804, 90805, 90806, 90807, or 90862 -- up until now it's been pretty easy, there aren't a lot of choices here.   So 7 weeks from now, about.  The new codes are more complicated, in fact they are so complicated that multi-hour courses are being offered, webinars are up, Powerpoints are going on professional society websites.  As the codes change, the requirements for how we document changes, and so far, I don't know of anyone who is exactly sure how to do this.  That's actually not true, I know one gentleman whom I call the CPT-God and he will be helping to train the leaders of the psychiatric society this weekend so that they can teach their members.  What about the half of psychiatrists who aren't in professional societies, or those who can't make the sessions..... I'm predicting some confusion.

Okay, so one thing everyone in the know says, in the change from the current CPT (CPT stands fro Current Procedural Terminology, just so you know), to a heavier reliance on the Evaluation and Management Codes (E/M), it's helpful to read a book to learn this.  If you've gone to a pediatrician, or a primary care doctor, and they hand you a slip to give to their checkout staff and it has a code for level of complexity ranked 1-5, and now psychiatry will be doing this, too.  

Okay, so I need to buy a book, read it, and take a course.  Got it.  Course is scheduled.  
So I go to Amazon and I can buy the paperback for $71.73 or the spiral bound for $92.49.  The e-book, on kindle, where I can access it on my computer and my cell phone (nice in the office), oh they don't have that.  No Kindle/Nook version.  Because who needs that electronic stuff anyway?  I tried Barnes & Noble: Nope, no CPT 2013 there.  You can pre-order how-to manuals for just shy of $400, but I think I will pass on that. 

Finally,  I surfed around and the AMA website does offer an ebook for $109.95 (It costs more?  There are no production costs!  You can get my novels off Amazon to a Kindle app on almost any device for 99 cents, and when Shrink Rap came out and people asked us for the Kindle version, our publisher had it available within days!).  So the $109.95 ebook can apparently download to my iPad or my iTouch.  Nothing about my iPhone (the one gadget I use).

Okay, so I downloaded a free 2012 CPT app which gives me the basics on the E/M codes.  The new psychotherapy codes I am starting to get.  It will all be good, I'm sure, but give it time.

So we're in the electronic age or not?

You Need Help!

Maryland psychiatrist Mark Komrad has recently written a book called "You Need Help!"

The title says it all -- the book is about how to get help for someone who doesn't want help, or doesn't believe they need it.  

So I thought I'd bring our readers into the discussion here.

If you're a mental health clinician and one of your friends or patients starts to talk about someone they believe needs help, what suggestions have you made in your professional capacity that have proved to be helpful?

If you are the friend or relative of someone who needs help, but has resisted getting it, what have you done or said to propel that individual into treatment?

And finally, and perhaps most importantly --

If you're someone who didn't think you needed help, what got you into treatment?

Start commenting and Dr. Komrad has told me he will check in and converse with our readers in the comment section!

How Not to Die a Tragic Death from a Drug Overdose

Whitney Houston, Michael Jackson, Heath Ledger, Amy Winehouse, Anna Nicole Smith -- I imagine you know what these celebrities all have in common: they've died from accidental overdoses.

In the first 20 years of my career, I can't recall hearing a single story of an accidental overdose resulting in the death of a young person that I knew, a friend knew, or a patient told me about.  Maybe I've forgotten them, but if so, it's because they were spaced well apart and there weren't memorable trends. One close friend had a young relative, a substance abuser, overdose and end up in an ICU, but he lived.  Somehow, in the past year, I've been hearing more and more stories of tragic deaths of young people, full of life and promise, who partied just a little too hard and stopped their lives in it's tracks.  Not suicides, just a little too much of whatever the substances might be.  

So young people party.  They drink, they smoke weed, and sometimes they pop pills or shoot drugs (though please do note that IV drug use is not considered to be "recreational.")  Given that this is the reality of some people's youths, and these stories are heart breaking, let me offer some words of wisdom.  It's not just the hardcore addicts who are dying, it's not just the shooters, and often the deaths are caused by medications with legal uses.   And the horror of the deaths is not just their tragedy, but the guilt that gets left behind, by the person who left the victim alone, who noticed they seemed off but not enough to call an ambulance, by the person who didn't think much of an unanswered call or text and gets to wonder if they had done something differently, if their friend might have lived.  It's all horrible.

Here are my words of wisdom:

Only take one substance.

Don't drink and take drugs.  Don't do it even if you've done it 2,413 times and it was fine all those times,  Many people who die accidentally have lots of experience with it and have never died before.

Don't mix drugs.  Benzodiazepines may be relatively safe, but once you take your Xanax, add a little oxycontin, and have a beer, you may be in for a very long sleep.  Xanax/Valium/Ativan/Klonopin (benzos) and Oxycontin/Oxycodone/heroin/methadone/morphine/MS contin/percocet/percodan/darvocet/demoral (opiates)  --- these medications have effects that are more than additive and they cause respiratory depression and have unpredictable effects.  This combination of xanax/alcohol/pain killers seems to be especially popular and especially lethal.  Cocaine and stimulants are also a really bad idea.

If you've had a drug problem, quit using, and have been clean for more then a few days, your body starts to heal, and if you relapse, it will take much less drug to get the same effect,  Taking your old dose of medication can be lethal.  This is a major reason why death rates are so high soon after prisoners are released from jail -- they hit the streets and take their former dose of drugs -- it's much more than their body can handle after being clean.

Don't drink on an empty stomach.  Food slows absorption.  The body is made to resist dying from alcohol poisoning -- it's why people throw up, it keeps them from absorbing too much alcohol.  You can overwhelm this safety mechanism if you drink too fast.  

---Don't do shots.  See the above logic.  It's hard to kill yourself drinking beer alone, but I've heard of people doing 21 shots on their 21st birthday or drinking an entire bottle of straight vodka as part of a frat initiation.  This can kill you.  If you must do shots, don't do them on an empty stomach, let a fair amount of time pass between shots, and drink a non-alcoholic drink in between to slow the process down. 

----If you must drink heavily, do it with friends and stay with each other, don't lose your drunk friends.  Don't leave someone who has passed out alone, roll them on their side so that if they vomit they don't aspirate it (aspirate = breathing your puke into your lungs, a common reason people die after heavy drinking or overdosing).  If someone can not be aroused after drinking, call an ambulance! It's better to be embarrassed than to be dead.  Remember, you don't have to be an alcoholic to die of alcohol poisoning.

-----Don't drink and drive.  There is a cab driver out there who needs your business. 
-----Don't drink and go on the roof.
-----Don't drink and walk on railroad tracks.

If you take prescription drugs for medical reasons, don't increase the dose without checking with your doctor first.  If you're not sure if it's safe to combine prescription drugs, ask your doctor or call a pharmacist (any pharmacist, look for a 24 hour pharmacy and call and ask to talk with the pharmacist.)

And probably the best advice: don't abuse drugs or alcohol.  

If you take prescription pain killers, sedatives, or stimulants,  know where they are, and know that someone else can't access them.  These medications aren't meant to be shared.

New CPT Codes Are a Coming

 

In 2013, the CPT codes that psychiatrists use will be changing.  The new ones are said to better reflect what we do.  What does that mean?  Hmmm, I don't know, I thought I'd ask you.  The code for pharmacologic management, the so-called "med check" with no time requirements, is going away, and psychotherapy codes will be for 30, 45, and 60 minutes.  I'm not sure what happens to the 50 minute hour.  I'm going to try to figure this stuff out over the next month and write about it here or on Clinical Psychiatry News.  But first, let me ask you a few questions (these are for mental health professionals only, but everyone else,  hang on, I'll have other questions.  

Do you use CPT codes now?
Are you worried about the changes that are coming?
Do you think this will increase reimbursement to you?
Do you think it will increase reimbursement to your patients?
How do you plan to learn the new codes?
Oh, I'm going to set up a poll, but do feel free to write in on the comment section!

You voted for WHO??

Please don't forget to vote, no matter who you support.

The Trauma Recovery Movement: Where Did It Come From?

For anybody who's interested, you can follow along with me as I learn about this stuff. I put the tape measure pic up because I'm learning about trauma treatment and outcome measures.

I was curious about SAMSHA's National Center for Trauma-Informed Care so I did a little background reading based on material I found on their web site. (And if there's anybody reading involved in this who would like to jump in and provide more information, please do. Shrink Rap also allows guest posts!)

It appears that this arose out of a SAMSHA initiative to encourage study of innovative program delivery systems. It was recognized that certain groups of people had severe and overlapping treatment issues. In other words, there were women with high levels of childhood abuse, adult violence, mental health issues and substance abuse. They wanted to figure out how to best provide treatment to these folks and they theorized that the key link or ingredient, a "cause" if you will, was the trauma history.

A two-phase, multisite study was designed to look at this problem. (1) In the second phase, nine cities were selected to participate. They enrolled thousands of women in a variety of treatment settings. The women all had one or more of the three issues: trauma history, substance abuse and mental health problems. One key fault is that there was a non-random assignment of the patients: they were allowed to self-select the "intervention" versus "usual care" condition. Both the trauma and usual care groups provided mental health and substance abuse counselling. The trauma group was additionally provided a women-only therapy group that employed one of four trauma treatment recovery models. The usual care group provided some additional not clearly specified intervention (I didn't have time to read in detail, it sounded like a generic social skills group).

The results were difficult to interpret because it turned out that two of the nine sites had significantly different study subjects. They had to break out certain sites from the rest to analyze the data. However, when pooled two interesting findings came out: the first was that a program that integrated all services (mental health, substance abuse and trauma/generic) was better than a program that offered disjunctive services. The second finding was that the more core services the patient used, there was a slight but significantly worse outcome. (2)

Outcomes were measured at six and twelve months. Overall mental health scores were measured using the Global Severity Index (GSI) and the Brief Symptom Inventory (BSI). Mental health status was improved more when services where combined, even when there was no change in addiction severity. Traumatic symptoms also improved.

What I take away from this is: integrated treatment is better.

That doesn't surprise me. Maryland is reorganizing it's public health services to reflect this, and the Affordable Care Act also recognizes this. There's also been at least one study (I've got it pinned on my pInterest board) which showed that integrated care post-release can decrease felony recidivism.

But improvement with integrated care does not prove that the treatment effect comes from treating the trauma. I think that's the mistake. This model can be useful for anyone with complicated co-occurring conditions, male or female, traumatized or not.

OK, I'll shut up now. What's new with you, Dinah?



******************************
1. McHugo, et al. Women, Co-occurring disorders, and Violence Study: Evaluation design and study population. Journal of Substance Abuse Treatment 28: 91-107, 2005

2. Morrissey et. al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56: 1213-1222, 2005

Yes, You're Better

One of the fun things about Shrink Rap is that periodically ClinkShrink and I like to wrap our hands around each others' necks and squeeze really hard while screaming.  

So let me refer you to ClinkShrink's post below,  Am I Recovered Yet.  Read that first and come back.  It's a rich post with many different agendas. Don't worry,  we are on opposites sides of town and we are both getting sufficient airflow. 

1.  Clink talks about Tonier Cain who was horribly abused as a child, both physically and sexually.  Ms. Cain's abuse led her to a dysfunctional life of drug abuse, prostitution, and repeated incarcerations.  By dealing (whatever that means) with her trauma, she has overcome these problems, she now lectures on the importance of dealing with trauma, and she is a productive member of society.  I know nothing about Ms. Cain, this is what I gleaned from ClinkShrink's post.

2. Because of Ms. Cain's efforts, laws have been passed requiring that anyone working in a state facility must be trained in trauma-informed care, which ClinkShrink tells us has not been proven to be effective in studies. Remember, Ms. Cain is an individual who benefited, and studies look at populations, not individuals.

----Dinah's commentary:  I am going to stay out of the evidence-based medicine question because, well, evidence-based studies are limiting, they don't look at the full range of what we do clinically, studies are often conflicting, and sadly, we've seen that pharmaceutical companies have skewed some studies.  
      Moving on, I am against the concept of legislating medical care and medical standards.  I agree with Clink (take a breath now) that there should not be laws requiring training in trauma-informed care.  There should be industry standards and mandates; lawmakers shouldn't be requiring CPR training.  The law doesn't require me to have a flu shot.  My hospital, however, has said that if I'd like to continue treating patients there, I need a flu shot (I had a flu shot).  There was a really nice article on the intrusion of legislation into the practice of medicine a few weeks ago in The New England Journal of Medicine, see  "Legislative Interference With the Physician-Patient Relationship."

3.  Clink goes on to question whether Ms. Cain is really better if she continues to be fixated on issues related to her trauma.  Wow.  Let's see, she was a  homeless, drug abusing, criminal who sucked resources from society (I'm assuming that the tax payer funded her forays into prison) who now living in free society, working to help others, on a mission (I love people who have missions), and doing well for herself.  Yup, she's better.  Is she cured?  I don't know.  I don't even care. I'm with the commenter who suggested that the patient is the one who determines better.  She's feeling good about herself, presumably making a living (there's an award winning movie), lobbying for something she believes in, looks like she's raising her kids, getting a message across.  She's not homeless, not smoking crack, not in jail.  Does she need to be an accountant to be 'better?"  Plenty of people get better by focusing on their past problems.  Is the incarcerated drug addict who later becomes an employed addictions counselor who helps others not 'better' because he still lives his days thinking about addiction-related issues?  Yes, they are better.  Is it any different from the person who goes on to be an oncologist because his mother died or cancer, or the person who becomes a psychiatrist because he had personal or family experience with psychiatric problems?  What about my short friend who became a pediatric endocrinologist?

4.  Is she Cured?  Clink defines this as being symptom-free, able to move on to a life not involving a focus on their problems,who no longer requires resources and frees up these scarce resources so that others can use them.  What a funny way to define "cure" in a field where 'serious mental illnesses' are often chronic or recurrent.  I'll go with Freud here: "Well" is about the ability to work and to love.  It's not about the ability to live life free of symptoms. Is she Cured?  What does is matter?  Why does that need to be judged?

5.  Clink tells us that her goal is to get someone to zero symptoms (--I would never qualify, I didn't sleep well last night as I was worried about the election) and free them of being her patient.  "Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices."

I'm not sure what ClinkShrink is getting at here.  I agree that government money should not be used for mandating training in trauma-informed care.  We don't mandate training in schizophrenia (it comes as part of psychiatry residency training and it's mandated by those who oversee residency training programs, not legislators).  I'm not sure what she means by 'government money' or by 'serious mental illnesses.'  So a patient with Medicare should not be allowed to access mental health services for a mild mental illness?  What's mild? Anxiety?  Election-angst?  Irritability with co-workers?  What if a person finds that a medication or a regular psychotherapy appointment helps their personal comfort level, and that by maximizing their comfort, they are better able to function as a parent and thus help a future generation?  What if having somewhere to process their issues makes it easier for them to function as a surgeon, or as a teacher. Okay, you say, not government funds.  But then what if our surgeon who feels better with care, or our legislator who influences the lives of thousands, or our public health researcher who benefits from care, what if they turn 65 and are now having services paid for by Medicare, do we bounce them off?   We don't tell people they can't have repeated doctor's appointments for belly pain, why should we limit care to those with "serious mental illness" whatever that is.  

Okay, I'm ranting. Clink, let go of my neck now. 

Am I Recovered Yet?

Today on our local public radio station I heard an interview with Tonier Cain, a team leader for the National Center for Trauma Informed Care. Ms. Cain is a renown speaker who has appeared at multiple national venues to talk about her horrific childhood history of sexual and physical abuse, multiple adult arrests, history of prostitution and drug abuse, and incarceration in our own Maryland prison system. Her story is remarkable for her 180 degree transformation to become an accomplished organizer and advocate. She has repeated her narrative many times online, on the radio, and even in local theater. She frequently speaks to women prisoners to talk about the importance of trauma recovery therapy.

I was familiar with her story because the state of Maryland passed a law last year which mandated that anyone working in a state facility must be given training in trauma-informed care. I went through this training myself where I saw a shortened version of the documentary "Healing Neen," about Ms. Cain. Following the presentation the instructor asked what we thought about the film. Everyone in the room thought that it was wonderful, that Ms. Cain's story was amazing, that the trauma recovery treatment she had had was miraculous.

"Isn't it amazing how she has overcome her trauma?" the instructor asked.

I should have kept my mouth shut. I really should have.

But I couldn't help myself.

"But she hasn't recovered!" I blurted out. "She just reshaped it. She has recreated her personal and professional identity around her trauma narrative." And that's true---she is now a professional trauma victim/survivor. How is this overcoming her past? How is this recovery?

The room fell silent. People looked at me, a bit aghast and shocked. Some people tried to explain: "Well, you don't ever really COMPLETELY overcome the past, you just learn to live with it."

Well OK, that sounded reasonable. But wasn't the point of the trauma recovery movement that you actually are supposed to recover? That at some point, you stop being a patient? I mean, when I treat someone my goal is complete recovery----zero symptoms----that's what I call recovery. My goal is to free someone from being my patient, as much as possible.  Isn't that the goal of the trauma-recovery movement?

Maybe I just was uninformed. Maybe I needed to read more about it.

I did a PubMed search using the terms "outcome" and "trauma-informed care." This search produced all of four articles. One focussed solely on trauma-informed interventions to reduce seclusion and restraints in the hospital. Another paper discussed the dirth of outcome-based evidence for trauma informed care for people with schizophrenia. There were no controlled trials, nothing in the way of any standard study of anything related to trauma informed care.

Yet education about this recovery movement and treatment approach is being mandated by our state government. There's something seriously wrong here. An intervention with no evidence base is being required and weighed on the same level as a requirement for CPR certification.

The trauma recovery and prevention movement also has moved into the domain of disaster psychiatry. This is the idea that prompt mental health intervention can prevent longterm psychiatric complications for people who experience traumatic events. I've written about this before on the blog in my posts "I Don't Need to Talk" and "I Still Don't Need to Talk", including a review of studies to suggest that for some people these interventions may actually be harmful. In his Mental Illness Policy blog, DJ Jaffe expressed similar concerns in his post "NYS Office of Mental Health: Wrong Response to Hurricane Sandy," where he discussed the diversion of mental health workers to crisis counseling and away from services for the seriously mentally ill.

Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices.

Sandy

So, I've been taking a little break while ClinkShrink posts about the AAPL conference.  I always enjoy hearing about what she's learned there.  We both had the pleasure of being in the sky last weekend as we awaited the arrival of Hurricane Sandy, though my flight, the only one heading to the East coast from Milwaukee that was not cancelled,  did not include unscheduled stops in the wrong part of the country.  Clink and I were both pleased to get home, and even more pleased that our region was spared the brunt of the storm.  In 1999, a large tree fell on my house during Tropical Storm Floyd, and I've never liked storms since then.  If there's a post-traumatic tree disorder, I have it. 

So Seaside Height, New Jersey is a place I remember from my childhood.  The day I got my drivers' license, I drove two miles to a friend's house.  She and another friend jumped into the car and said, "Let's go to the beach."  Now I had been a licensed driver for six hours, and we didn't live near the beach.  "No," I said, "too far."  "Oh, come on."  Why not.  We drove to Seaside Heights, played games on the Boardwalk, and drove home.  No cell phones back then.  I dropped my friends off and returned home around 1:30 in the morning (no laws requiring midnight curfews back then, either).  I walked in and my mother greeted me with, "I was so worried, I thought you'd been caught in a flash flood."  Flash flood?  What flood? "It rained," I said.  She stopped and said, "Where were you?"  Ah, obviously someplace where it hadn't rained.  I like that memory and I don't like seeing photos of the rides in the water.  

To all those who are still feeling the effects of the storm, our hearts go out to you.

Thinking About Bellevue

Little did I know as I was writing that last post on Sunday that just a few days later some of the same docs I was listening to and learning from would end up evacuating their hospital. When I read about the desperate conditions at Bellevue Hospital in New York as the storm struck and the remarkable efforts to evacuate every one of those hundreds of patients---without any loss of life, to my knowledge---I was impressed and humbled.

Every hospital and institution theoretically is supposed to have emergency policies and procedures, and is supposed to run occasional disaster drills to make sure everyone is aware of them, but who ever really believes they'll be needed or used? Those kind of large scale, potential mass casualty events seem to horrible to think about or really imagine could happen. Until they do.

There's not much I can do from a distance, but from my brief contacts with the Bellevue docs I know that those seriously mentally ill patients and prisoners received the best care possible under the worst possible conditions.

Let's hope that when the storm clouds clear and the rubble is swept away, the hospital that re-emerges is a newer, better and brighter one. The patients and staff deserve it.
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Addendum from Dinah: there is an article on the Bellevue evacuation here.