Saturday, May 31, 2008

Check it Out

Psychiatry 101 is a blog about psychiatry by a mom who was once treated for post-partum depression. She has been a welcome commenter on Shrink Rap with some great comments.

So most recently, Psychiatry 101 sent us a link to Tony White's blog. Tony is a therapist in Australia, he has a blog, and his patients and supervisees read it. He writes HERE about what his patients say about his blog.

Several people have suggested to me that my patients read Shrink Rap and don't tell me. I find that perplexing--- why wouldn't a patient just say "Hey, I came across your blog..." ? In real life, I'm not a particularly intimidating person. At least I don't think so.

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.

Thursday, May 29, 2008

An Ounce Of Prevention

In medicine, therapeutic interventions tend to fall into one of three classes. Tertiary prevention means doing something to reduce the impact of symptoms in a disease that already exists. Secondary prevention is when you try to catch the disease at an earlier stage, either before symptoms develop or before they become severe. Routine blood pressure checks are an example of secondary prevention because blood pressure measurement catches hypertension (hopefully) before complications like stroke or heart disease develop. Finally, primary prevention is when you do something to keep the disease from starting to begin with. Routine pap smears are a primary preventive measure for cervical cancer---the idea is to catch abnormal cells before they transform into cancer.

So how does this all apply to psychiatry?

It's relevant because, unfortunately, in our specialty right now almost all interventions are tertiary interventions. We see patients after a disease has developed, when they are bothered enough by their symptoms (or their families or employers are bothered enough) to make them seek treatment. By the time they come to treatment they have often already experienced some type of morbidity, either in the form of time lost from work or impaired social functioning, or even impaired physical recovery as in the case of hospitalized medical patients with untreated depression.

There have been some secondary prevention efforts. Every October there is a national depression screening day, when health fairs offer evaluations for clinical depression in addition to other general medical assessments. Internists, family practitioners and other primary care providers are starting to include screening for mental disorders as part of routine health care.

The area where psychiatry is still grossly lacking, mainly because of our still-meager understanding of the basic causes of mental illness, is in primary prevention. Simply put, we just aren't very good yet at preventing psychiatric illness.

We do our best primary prevention when the psychiatric disorder is the result of an identifiable physical cause. We can prevent cognitive impairment and lowered IQ by checking babies for hypothyroidism and children for lead poisoning. You can prevent HIV psychosis by preventing the spread of HIV and keeping the disease under control to delay or prevent dementia. General paresis, or dementia due to advanced untreated syphillis, is pretty much gone now due to the invention of penicillin.

Unfortunately, we still don't know how to prevent schizophrenia or bipolar disorder. We may be about to find a way to prevent clinical depression, at least in some patients. The Associated Press today summarized the findings of an article in this week's issue of JAMA regarding the prophylactic use of an antidepressant in post-stroke patients. One hundred twenty-seven stroke patients were divided into three groups: one treated with escitalopram, one given therapy and one group given a placebo. The escitalopram group was significantly less likely to develop clinical depression over the course of the year following stroke than either of the two control groups.

Now I'm waiting for a study to see if prophylactic antidepressants are useful in other at-risk groups, like heart attack patients, who are also prone to clinical depression in the months following the attack.

It's only one study, but it's a start.
And now : an intrusion from Dinah. I've decided I like putting my comments on the front of the post.

So here's the problem with preventative psychiatry in it's infancy. In the studies above, the issue is one of Risk. I don't know that I'd want to take a medication (with all the risks, side effects, possible adverse reactions, and the question of the unknown longterm or short term effects) for a condition that one is at Risk for. Invariably, some people will be exposed to medications who would never develop the targeted illness. It's a hard sell for me, unless the risk is 100 per cent.

I think we like to think maybe if an illness is caught early in it's course, then it won't get as bad, or at least the symptoms can be treated earlier. This is one rationale for on-going psychotherapy in people who want to be seen between episodes: that therapy may prevent future episodes, may give people tools to prevent relapse, and that the subtle signs of illness may be caught sooner before they become full blown episodes.

Thank you for letting me join in here.

Tuesday, May 27, 2008

The Original Sex With Fish

I meant to put this link on last post. Oops. If you missed the famed ClinkShrink Original, here it is:

Monday, May 26, 2008

Sex With Fish, Revisited

Some fish are Journey fish. Some fish are Destination fish. Some fish taste good. Most fish don't have sex and I'm not sure what to say about the fishy version of inter-fish intimacy. Generally, people do not have sex with fish, but I suppose to each his own.

Why is Dinah rambling?

Okay, so every Monday, we get a report of our site visits, our referral sources, a map of the country with shades of green depicting how many readers from how many states: Thank you, California, where the most Shrink Rap readers hail from. We usually have readers from every state, though some weeks, no one visits from South Dakota or Montana or somewhere around there.

We know what people Google that gets them to us. 'Shrink Rap' is one thing. But week after week, for years now, every report lists "Sex with Fish" as one of the top five most Googled terms for a referral to Shrink Rap. Every week. I now look for it. I've Googled "sex with fish." I don't get it. Reef-fish change sex (although I think this might mean gender, so any Reef Fish visiting Shrink Rap should please check off "In Transition" on our Gender Poll on the side bar.

I just thought I'd welcome anyone who was here looking for Sex With Fish. You've found the right place.

Sunday, May 25, 2008

Back Roads: Lost or Distracted?

A few days ago, I posted on The Journey Versus The Destination and I've still been thinking about the comments that came in. Warning: This is going to turn into one more post on illness versus the spectrum of normal, one of our favorite Shrink Rap themes.

First off, there's no such thing as Journey people or Destination people. I made the whole thing up, so there's not really any arguments about definition because...well, it doesn't exist.

A lot of the comments that came in reflected the idea of 'stopping to smell the roses'....the idea that if one is reaching for a goal, there is no time to appreciate or enjoy the process of getting there. This isn't what I meant at all, I just didn't do the best job of describing what I did mean. Mostly what I meant was that there are people who have the ability to set goals, and know how to go about reaching them. Those are Destination people. If, on the way, a destination person changes her mind and sets a new and different goal (I don't want to be President, I want to bake cookies), they are still a Destination person, they have simply changed the destination. Cookies, I assure you, are a good destination, but a Destination person looks at the recipe first, buys the ingredients, and if the cookies burn, they either try again to bake them, or they get a new goal (e.g. buy cookies at bakery).

So MWAK asked how I knew she was a Destination person. Pretty much by definition (remember, I wrote the definition), the number of years, courses, planning ahead, it takes to go to medical school makes physicians Destination people. You can't do this on impulse, you have to sign up for specific courses, many of them boring and hard, do well in them, initiate applications to medical school, get to the interviews at your own expense, arrange housing, take a zillion courses, dissect bodies, go to clinical rotations at the right place and time, pass tests, remember to register for those exams and show up with your number 2 pencils, apply for residency training. Interview at your own expense. Get to the interviews (arranging the transportation and place to stay), survive residency, and it's good to remember which days you're on call. If you can do this while growing and smelling flowers, raising children, playing in a rock band, then more power to you! So MWAK, I read your blog and you have tons of goals-- currently you're on vacation, someone planned it and arranged for your coverage. See, you're at a destination (looks like Seattle), you're a destination person!

I think Mrs. Cake did a good job of capturing what I meant by Journey People. She wrote:

I think I am a journey person (think Drunkard's Walk) who always tried and failed to be a destination person. The number of endeavors I have embarked on, and rapidly failed at or lost interest in, could fill quite a crowded book. Currently I'm convinced it's the not-yet-diagnosed ADHD that kicked my feet out from under me in such a predictable pattern. I am in my 50s and mourn the books I could have written not because I couldn't write them, but because I have the skill and the ideas but not the persistence. dx on the horizon, I hope, but how many of us journey people are members of the 4 to 5% of ADHD adults, 90% of whom are not diagnosed? Mrs Cake

Yes, this is what I meant! People who set goals, sometimes extremely modest goals (I will clean out a closet) and can't negotiate to follow through on them. Time goes by and nothing gets done in a forward moving way towards accomplishing them. Often, these patients are diagnosed with ADHD, and that provides them with an explanation. I haven't found this to be all that helpful. I tell them to read books on ADHD and try the behavioral suggestions: get a Palm Pilot, (or a Franklin Planner), get back-up alarms, make lists, fall into a routine. While some patients find stimulants helpful, for unknown reasons, they haven't been my patients: my patients have had trouble tolerating stimulants and they've been surprisingly unhelpful at getting people to move towards their goals. Often people are equivocal about whether they helped at all and they forget to take them.

So there are two issues here: one is that some people are Destination people and don't know it: they can't meet some goals, but they meet others fine: can't get the house cleaned, can't finish a major paper, can't finish they're degree, but they do fine at getting a job, planning a vacation, getting to social events, whatever. These are Journey people because they are locked into Destinations they feel they
should have, not the ones they want. They would simply do better to redefine their goals to things they Want them to be, not what society says they should be. They need to reframe life, and this is often a hard sell.

I said this in the comment section of the last post, but I'll repeat it here:
Journey people choose goals (sometimes unrealistic ones) and they swerve, take the long road, somehow don't make or take a much longer time than they'd planned, they don't know what the next step is or how to get there, but often they get an interesting ride, see somethings that those of us in the library (or on the treadmill or changing the diapers) didn't get to see, smell, feel, or experience. It's good stuff and it's bad stuff. It's often unexpected, often painful.

The second issue is whether ADHD is an illness that captures this phenomena or whether we haven't simply redefined a spectrum of people who don't meet society's rigid expectations into being ill. I guess you can say that about lots of disorders (shy vs. social phobia pops into my brain). One set of alarmists will talk about the gross under-diagnosis of the illness, another set of alarmists will talk about the gross over-medication of school children, especially boys, and how stimulants are the most abused drugs out there among high school students.

Just to think about. Thanks for joining us Mrs. Cake. And Roy, just to clarify, you're a Destination Person (there's no doubt), you just keep changing the destination.

Thursday, May 22, 2008

Everybody Lies

Back in the Dark Ages when I applied to medical school, all applicants were required to take the Minnesota Multiphasic Personality Inventory or MMPI. This is a personality test designed to identify psychopathology by examining the answers to literally hundreds of questions, many of them innocuous-sounding or not clearly related to any pathological answers. For example, one question that stood out in my mind was "I like to paint flowers." Now, I happen to like flowers and paintings of flowers but never in my life have I ever even tried to paint flowers. You're supposed to answer "true" or "false" to this question. Keep in mind that the answer to this question was going to have some bearing on whether or not I got accepted to medical school. OK, you make your best guess on the "right" (non-pathological) answer, whatever that's supposed to be, and then you run into this question:

"I always tell the truth."

Oy. Talk about your wife-beating question. (In other words, "Sir, when did you stop beating your wife?"). If you answer "yes" then you're obviously lying because everyone fibs now and then. If you answer "false" then you look like a dishonest person who couldn't be trusted to hold a friend's purse much less a scalpel.

So anyway, that brings up the issue of truth-telling in psychiatric treatment.

No patient ever tells the truth. Not the whole truth, not at first, and not in the way they want you to hear it. It's not a matter of intentional dishonesty or deception and it's not a character flaw, it's just being human. I've had friends (not my co-bloggers) who have told me, "Oh, only your patients lie." Well, as Dinah puts it, in my little bubble world it would be nice to believe that the only misleading people were the ones inside the prison walls.

There are many reasons not to tell the whole truth, or to tell it in a way that puts the best light on things. Self-deception (or therapist/psychiatrist) deception is a way to look your best to help the therapeutic relationship form. It's a defense mechanism for people who are feeling self-conscious about their problems or embarrassed about their background or humiliated by their real or self-perceived failures. In extreme cases, it's a way of protecting oneself from negative consequences (eg. "If I tell my doctor I'm suicidal, I'll get 'put away'.") For my patients inside the walls, it's the way they've found to cope with life and get their needs met because they learned early on that simple requests for help often didn't work.

The gradual unfolding of truth, the step-by-step admission of distortions, is part of the treatment process. It's a positive sign that trust is growing between patient and doctor. In psychiatric treatment, at least in my clinic, you don't get punished for admitting you lied.

So now in all honesty, I'll admit that I'd love to paint flowers.

(Wow, this is a first in the history of the blog---I've posted over myself!)

Back To The Salt Mines

A Federal appeals court recently decided that paper money discriminates against the blind. They said that since blind people can't distinguish between the types of bills by feel and have to rely on others (and trust that others will be truthful), the blind are being denied access to currency and are being treated differently than sighted people.

The interesting thing about this case---besides the fact that it may make the U.S. Treasury completely redesign all paper currency---is the fact that advocacy organizations for the blind are divided about whether or not this decision is a good thing. The Council for the Blind, who apparently was a party in filing the litigation, favors redesigning the money. The National Federation for the Blind is not happy about the decision and feels that it will foster stigma against the blind by suggesting that they can't function in society as well as others.

I have to say, I was surprised about the NFB's opinion and didn't expect it, but it got me thinking about disability, discrimination, stigma and mental illness.

The Americans With Disabilities Act bans discrimination against people with physical and mental illnesses who request reasonable accomodation for their disabilities. The mentally ill person must make his or her disability known, and must be otherwise able to perform the duties and responsibilities of the job if the accomodation were made.

The down side of the ADA, as the National Federation for the Blind has pointed out in their legal case, is that mandating accomodation may increase the stigma of having a mental illness by implying that psychiatric patients need a 'leg up' compared to others and are incapable of competing on a level playing field. (Similar arguments were once advanced about anti-discrimination laws for minorities, gays and women.) Nevertheless, I think the ADA is a good thing and is necessary to protect the rights of handicapped workers. It's unrealistic to think that people with mental illness are on an equal footing with people without a diagnosis, even with their condition is completely under control.

Maybe someday psychiatric treatment will be as common and unremarkable as a regular dental visit, but until then we need to be proactive and vigilant about attempts to curb or restrict protections for those with disabitlities.

As for our paper money, I think it's due for an upgrade.
Note from Dinah: Here's an interesting paper on The Unintended Consequences of The Americans With Disabilities Act.
Deleire (the author) makes the point that when people let their disabilities be known, they are less likely to be hired. Since many many people suffer from some psychiatric illness at some point in their lives --probably over half if you include things like anxiety and adjustment disorders. It all gets foggy on what's Reasonable Accommodation and exactly what an employer needs to do fulfill such an act for someone with a psychiatric disorder. My question might be something like, when does society encourage people to be victims, versus when are there simply people with differences. It's not just psychiatry, educators talk about such things all the time with issues of untimed SATs (college entrance tests) for those who can afford testing to officially diagnose a problem/difference--- something that seems to me a clear tilting of the scales in favor of the financially advantaged (the testing costs a ton and is not typically done in public schools for kids with reasonable grades who aren't tanking). It's hard to balance the need for fairness towards those needing some support versus the deleterious effects of having a label.
Sorry to rant on Clink's post. I'll use whatever money they give me.

Wednesday, May 21, 2008

The Journey Versus The Destination

In psychotherapy, people often talk about how they are disappointed with their station in life. By any given age, they should have had more toys, done more stuff, accomplished more More. Some people feel this way because the course of their life has varied a bit from what they'd mapped out-- maybe they didn't make it through college, maybe the love of their life disappointed them, maybe a bad break derailed them. Maybe they didn't like what they started out to do and changed paths a bunch of times in search of something more interesting.

I've taken to saying to these people (and I say it a lot) "For some people life is about the journey, for others it's about the destination. For you, it's about the journey." So what if someone hits 25 or 30 or 90 and they haven't finished college or they haven't finished law school or they aren't well up that longed-for (and often miserable) corporate ladder. If you aren't there, if you don't have the car/house/whatever you thought you'd have, it's disappointing and it causes a lot of preoccupation. I'll point out, however, that many people objectively have all the things one "should" have by whatever age, in the world's eye they have every measure of "success" and yet they still strive, still feel disappointed. There's always more money to be made, more toys to be had, another promotion that should have been gotten, more grants, more publications, the vacation home: a story of failure.

Why do we do this? Why are we always measuring ourselves and why have we set it so that some people are deemed failures (by themselves, by others). It's good if you can support yourself financially, it's good to be happy, enjoy the journey.

If my teenagers read this they would deem me the world's biggest hypocrite. They would be right. I am a destination person: I wrote my eighth grade career report on becoming a psychiatrist (I think I was going to do research at Duke running rats through mazes, but hey...). I went through college in three and a half years, went straight to medical school then residency, was a mom by 30, and I've encouraged (the older one would say "pushed") my kids to do well in school and strive. I struggle with a teenage boy who values television and video games and sees my life as a rat race. Last year he told me his "goal" was to win three-quarters of his on-line games. Oh, he's on the same trip (I think), off to college in the fall, but he'd rather not let anyone know.

So two more comments on journeys versus destinations:
One on the college application process---
oy! The kid filled in one application that had 5 essays: they included asking what professor he wanted to do research with, and "write page 217 of your 300 page autobiography." All the colleges asked what he had to add to ...diversity, life, whatever. It seemed like a lot of clarity, focus, accomplishment and form was wanted from a 16 year old boy. The college application process is a destination thing.

Second: yes, I really did write about wanting to be a psychiatrist when I was 13. Why? Yeah, why? I'd never met a psychiatrist, no one in my family is a doctor (much less a shrink), and I'd never met anyone with a mental illness. If anyone figures it out, please call me.

So: my take on it: Clink is a destination person, even if she does stop to smell the mushrooms. Roy is also mostly a destination person, but within the path, he swerves around a bit.

Monday, May 19, 2008

Bah Humbug Transference

On my post called It's My Life, I'll Blog If I Want To, one commenter ( green tea) wrote:

I would have a really hard time if my therapist had a blog. It would make them seem too "human" too fallible. I think part of the illusion of therapy is that the person sitting across from us brings their BEST person into the room. In the blog, it's hard to maintain that sense of bounded distance. That detachment that invites a client inward, and into themselves. As an aside-- why use the word "transference" when "relationship" is more apt?

Green tea, I have to say that I agree with you. Here's the issue though: it would be wonderful if every therapist was a wonderful, infallible, highly moral, human being who lived life on a higher plane than the rest of us, and if, barring that, the therapist could keep all skeletons, failures, incorrect or unplanned emotional responses safely locked in the closet and out of sight of any patients.

Sometimes this is so important to a patient that the patient goes to lengths to find distance in therapy: maybe traveling to a distant city, paying in cash so that a psychiatric diagnosis won't come around to bite, making every effort to avoid information about a therapist's personal life/blogs/writings/friends, whatever.

Here's my question: Where's the Line? The real life reality is that therapists have issues, they can endorse unseemly political opinions, have messed up children, icky public divorces, dirty secrets that aren't so quiet. Who wants to know that their therapist hasn't spoken to his own mother in 23 years? Or that he's a member of a church that insists all non-members (including said patient) are condemned to an eternity in Hell? That he buys kinky things in porn shops? What about that prison tattoo? I could go on and on.

At what point does one's profession dictate who one has to be in one's private life? If you think you may want to run for President or for the Supreme Court, well....we all want you to be perfect: pick your pastor wisely, don't inhale, never never never pay your nanny under-the-table, declare everything, deduct nothing, watch where you put that cigar, and don't have ECT. Try not to shoot the neighbors, even by accident.

If you're a psychiatrist, some things are clear: you can't be impaired by a mental illness or have an active substance abuse problem. Licensing boards ask about crimes (but not about tattoos). Direct patient boundaries are defined (or at least trying to be). But outside the office in settings that don't entail the purposeful inclusion of patients? Not many would criticize a doc for writing in academic journals. Novels? Blogs? A doctor who smokes but encourages his patients to quit? Take your lithium, but I've got to run to my hang gliding lesson now?

It's good to have a therapist who is a nice person, who is moral and ethical and kind and encouraging. It's good to have a psychiatrist who is well-educated about medications and up-to-date on treatment options (and kind and ethical and moral and encouraging and a nice person). Google your doc well if you want to be certain they don't have a blog or a strange hobby or affiliation, or crimes against humanity.

Why "transference" and not "the relationship?" Because that's how the question was posed to me. Sometimes my patients talk about the relationship, "transference" is not a word I tend to use in clinical practice, mostly because it's not a schema my patients bring to the setting.

Eek Boobie!

Happy Birthday, ABF.
May the Red Sox win for you tonight.

--the regularly scheduled shrink rap will return momentarily
(it's important to honor old friends)

Sunday, May 18, 2008

Over The Border Line

A podcast listener asked us to talk about managing patients with Borderline Personality Disorder. Ugh. I don't want to talk about it.

Instead, I'm going to talk about why I hate the term, why I rarely place it in writing, why I wish it would go away.

Okay, the diagnosis of Borderline Personality Disorder is probably a perfectly valid diagnosis. If you read Roy's post about the differential diagnosis of Chloe O'Brians Personality Disorder (from 24), you'll see the following diagnostic criteria:

A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, with many of the following features:
1. Frantic efforts to avoid real or imagined abandonment such as lying, stealing, temper tantrums, etc.. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, substance abuse, reckless driving, overspending, stealing, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness, worthlessness.
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights, getting mad over something small).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

I mean, okay, these symptoms cluster in some people, so why don't I like them?
Here goes, with no particular rhyme or reason:

  • The diagnosis (unlike, say, Trichotillomania or Major Depression) is pejorative.
  • Clinicians are sloppy with the diagnosis and it's not uncommon for a doc to refer to a patient as "a borderline" as a defense--- the patient is difficult to deal with, he's angry or demanding--it's gotta be him, not the doc.
  • It's what clinicians label patients they don't like.
  • Actually, men are almost never called "borderline"....they get to be narcissistic or antisocial.
  • Treatment-wise, many docs avoid these patients and hope runs dry quickly. The prognostic implications are generally not great, these patient don't have rapid and dramatic improvements.
  • The diagnosis ends up being it's own endpoint, it doesn't leave room for alternate explanations and sometimes patients with Bipolar Disorder look a lot like patients with borderline personality disorder. Oh, while I'm there, patients with Borderline Personality Disorder often have co-morbid Bipolar Disorder (and hey, how about some substance abuse issues thrown in) and if the clinician can get focused on treating the Mood Disorder, sometimes the other noise fades into the background.
  • It doesn't seem to me that every patient who has these symptoms has them forever in an inflexible way. They come, they go, they change, they get better, they get worse.
Okay, so there are those people who tend to live life feeling victimized, who see things in black and white, who cut themselves to ease their pain, who can't maintain relationships, who create drama wherever they go.... I guess we're left to call them Borderlines.

You Puzzle Me

Now that we have a couple years of blogging under our belts, I thought I'd do a little pop quiz for you folks who have stuck with us from the beginning. Click on the link below to go to the Shrink Rap Crossword to test your knowledge of Shrink Rap trivia. You can print out the web page and do the crossword at your leisure.

For people who want to brush up with a quick review first, I recommend these links:

Psych Notes For Smilies
My Planned Nervous Breakdown
True Confessions
Shrinks On Segs

Now get to it!
Click on the red link below for

Shrink Rap Puzzle

Note from Dinah: I love it!! Interactive silliness. You ate too many birthday mushrooms!! Also, please take our sidebar poll.

for me, back to coffee and the New York Times.

Friday, May 16, 2008


I'm told the theme is "fungus." I'm working on it. Love, Dinah

Thursday, May 15, 2008

I Have A Good Doctor

I've heard it said that the good doctors are the ones who don't take insurance. The theory is that if a doctor is skilled enough, he or she can fill up their practice with private-pay patients without having to rely on an insurance panel. I'm not sure this holds up in regions where there are so few specialists that anyone could have a full practice without taking insurance. Regardless, it inspired me to think about how to judge the quality of your doctor, particularly when you have no health care training.

Patients aren't the only ones concerned about quality medical care. Professional organizations have ways of ensuring competence and insurance companies are also now taking steps to measure treatment outcomes and other parameters of care. The interesting thing is that each of these three groups use different measures.

Patients look for things like interpersonal skills, communication style, the amount of care and attention given during appointments and recommendations from friends or family. They may also consider things like convenience (appointment availability or location). Since the invention of the Internet patients can also now go to online physician review sites and searchable databases.

Professional organizations encourage people to consider things like physician training and experience, board certification, participation in continuing education and the absence of malpractice settlements or disciplinary actions.

Insurance companies now are starting to institute "pay for performance" indicators of quality: timeliness of appointments, adherence to practice guidelines, treatment outcome measures and patient satisfactions surveys.

So, does any of this stuff actually guarantee you'll get good care?

Of course not. Personal impressions and outcome numbers don't tell the whole story or may be misleading. Doctors with terrific interpersonal skills can give lousy care and still have loyal patients who defend their bad practices. Doctors who kick small dogs and are mean to their spouses could still be good technically. I happen to think my ophthalmologist is the best thing since sliced toast and I'm willing to wait weeks to get an appointment with him, but I can only trust that when he scans they back of my eyeballs he's seeing what he needs to see. I'd be willing to bet that if I had a rare or serious disease I'd want I doc who was the best (or at least great) at dealing with that disease and I wouldn't care if the the insurance company told me that half his patients died---the mortality rate for my weird serious disease could be 80%. He probably wouldn't take insurance anyway.

Wednesday, May 14, 2008

It's My Life, I'll Blog If I Want To

So while we were giving our talks on On-Line Communities and blogs at APA last week, a gentleman asked a question about "transference." I took the mic, I figured it was a question for me since I have the psychotherapy practice (in addition to being a Community Psychiatrist in clinics that serve the chronically and persistently mentally ill----I'm starting to get touchy about this).

So I talked a little about Transference to The Blog and how some of our readers seem to have their own ideas about us and who we are.

No No No No No! The gentleman wasn't talking about transference to the blog, he was talking about how my the existence of the blog effects my real live patient's transference to me! A totally different question. This has been an issue since day one, at least as an issue that other psychiatrists always raise to me. So far, I've been left to say that I'm not aware that any of my patients have found Shrink Rap. I wrote, way back when, about The Blogging Shrink
mostly in response to commenters who felt uncomfortable with the whole idea of a psychiatrist who blogs, maybe about their patients in a confidentiality-violating way, or maybe about the discomfort of knowing too much about what goes on inside their shrink's mind or life.

Since no one patient has told me they've read our blog, I talked instead about the responses I've gotten when patients have read my novel: Monday at The Charm. The truth is, none of the patients who've read it have been completely comfortable with it. One was obviously uncomfortable, the book is graphic, it has sexual (paraphilic, actually) content and the characters are a bit free with the expression of profanity. Clink, of course, was inspirational.

Whenever people asking me about my writing and my patients' reactions, inside I get a little queasy. Outside, I get a little defensive. It's as though I feel, or I hear, that by having a life other than the quintessential silent shrink life, I'm doing something wrong. You're not supposed to be out there, a literal open book for your patients to read. The old psychoanalysts went to great lengths to remain 'blank slates.' No family pictures in their offices, some didn't wear wedding rings, there were rules about who would leave if the arrived at the same party.

So I'm a writer. I don't volunteer this, my novel isn't displayed in my waiting room. I don't hide or deny it either, and if I have something I want to say, sometimes I say it rather publicly. I don't know how it effects my patients, and I don't know what I can do about this anymore than I could control if a patient found out something about my personal life. "How do you feel about this," is the best I could come up with.

And I'm not leaving a fun party if a patient shows up, but I might drink a little less and skip the tabletop dancing.

Before I go, the same gentleman asked about the gender of our readers: so please do take the sidebar poll.

Tuesday, May 13, 2008

Loss of Psychiatric Beds on Vancouver Island

From the Nanaimo Daily News in Canada:

"VIHA said they had to shut the [psychiatric] unit for as long as a year because they cannot find a replacement for a departing psychiatrist. It's hard to believe that VIHA has allowed itself to end up in this position.

In fact, Alberni-Qualicum MLA Scott Fraser is right when he says, "It's not acceptable . . . . It's not an option. You cannot shut down essential services."

To add to Fraser's incredulity, closing a mental health ward approaches irresponsible if not outright negligent.

VIHA might argue they have no control over the comings and goings of doctors, but it's pretty hard to believe that they did not or could not foresee this long enough ago to take appropriate action.

Either way, the fact that they could not negotiate to have the current psychiatrist remain until a replacement could be found, or that they were caught by surprise, indicates something is wrong within VIHA.

What this also seems to indicate is that the health authority has little regard for those in need of mental health care."

This story says a lot about the way many hospitals view psychiatric treatment... as a community service that is somehow "optional."

Saturday, May 10, 2008

The Psychoanalysis of Oliver Sacks

First, a couple of plugs:

Since we're still talking about the Shrink Rappers' trip to APA, I'd like to steer you to Peter Kramer's piece on what psychiatrists actually do at big psychiatric conventions.

Nothing to do with APA, but we received a nice note from a psychiatrist, and he has a site for quickly looking up DSM-IV-TR codes. Unlike Roy, I actually can't remember all the codes, so check out :

Okay, so Oliver Sacks. I heard him speak just briefly at APA at the Convocation of Fellows. He talked about musical hallucinations, and as he gave his talk, he mentioned that he's been in twice-a-week psychotherapy with a psychoanalyst for 42 years. That's a lot of decades of therapy. Roy's comment: "Kinda weird." Here's what else I know about Dr. Sacks -- I heard him talk on an NPR show a few weeks ago. He was born in England in 1933. His parents were physicians and, more specifically, his mother was a surgeon. When he was a boy, he said on the NPR show, his mother would bring home fetal body parts for him to dissect. His brother does not think he should talk about this. Dinah's comment: "Kinda weird." I'll say it tongue-in-cheek, but this alone might cause one to need decades of psychoanalysis.

Before I say any more, let me add a disclaimer. I've heard part of an NPR's Fresh Air (Listen Here) -- oh, he has a Great NPR Voice. I've read
The Man Who Mistook His Wife for A Hat. I've heard him speak for roughly 15 minutes at APA. I think I saw the movie Awakenings with Robin Williams. I've never met Dr. Sacks, I've never e-mailed him, I have no knowledge of his life beyond what I've heard him say in public. This post borrows from him, but I have no idea why Dr. Sacks has spent decades in therapy, and please don't take my fantasies as reality.

I don't know if Dr. Sacks suffers from a mental illness. Perhaps he does, and perhaps that alone warrants all these years of treatment. But maybe he doesn't; so, now we can digress into my fantasies. Dr. Sacks lives in New York City, a place where many of the worlds' psychoanalysts practice, a place where the practice remains alive, and where therapy is still accepted (or was when I was a med student there) as a means to gain self-awareness and maximize one's ability to live life to the fullest. It's not necessarily about curing illness; it's sometimes about a vaguer, more self-actualizing goal, one that may be an on-going process and one without a specified end.

To divert a bit, I once had a supervisor who volunteered to me that he'd had decades of therapy. Unlike Oliver Sacks, he wasn't a stranger, and I didn't have to speculate: I asked why. He told me his therapist served as a surrogate father, helped him to process his work, and that after he finished analysis, he wanted to continue to see him weekly rather than just bumping into him from time to time.

Personally, I believe that psychotherapy is a personal endeavor--- if it's helpful to you, do you need to justify it? Of course not, but in ways, society asks us to do this. It's expensive, it's regulated, there are not enough psychiatrists to provide care to the mentally ill, so is it right that someone who is not in active distress should take up the precious time of physicians who might be better used elsewhere? I'm told that there are only a handful of psychiatrists in Afghanistan -- perhaps we should ship these psychoanalysts there to help the chronically mentally ill Afghanistan citizens.

Okay, so the question gets even more complicated: should the long-term analysand without a mental illness pass the bill along to her insurance company? This again gets foggy -- I see patients who've rapidly recovered from a Major Depressive Episode -- if they continue to come for appointments, should the bill be passed along to the insurance company even if the patient has no active symptoms of depression at the time of the visit? Not every patient walks into every appointment in distress, and some people go up and down. I imagine ( I don't know) that over the course of 42 years, Dr. Sacks has good weeks and bad weeks, whether or not he has a psychiatric disorder.

There are many who feel that with limited resources, our society should not pay for therapy for people who don't have mental illness; subjective distress is something you should pay for on your own, and self-awareness is the same. Socrates told us that the unexamined life is not worth living; he didn't tell us who should pay to examine it.

Thursday, May 08, 2008

The Shrink Rappers Go To APA

First, congratulations to Clink on her new job and her new appointment to a professional society's board. Way to go, girl!

I learned a lot at
APA this year, some of it useful, some of it simply interesting (but useless).

Where do I start?
ClinkShrink already told you that we met some readers.....Hi, Sophizo, Hi, "Shrink Rap," and if you read the comments to Clink's post, well, there were others in the audience. It was fun. I didn't freak and faint. Thanks to Roy for setting this up and for including me. When is he coming to organize the rest of my life? Who is TigerMom?

So at our presentation: I learned about the Psycho-babble bulletin board and met Dr. Bob. I've always wondered about this because when I've Googled myself I've come upon posts to this psycho-babble board by someone with my name. Sort of a weird coincidence, and this funny idea that people (my patients included) who would think this was me posting...stuff I can't control, and the poster has my exact full name. Very weird, but there's nothing I can do about this, and now I know what Psycho-babble is. I, like Clink, loved hearing the very brave patients talk about how this on-line community has provided support, encouragement, and healing. And then the third part of our workshop included a talk about on-line virtual gaming. I wasn't sure what to make of this-- I have a kid who sometimes plays sports on-line, but I'm not aware that anyone I know lives an average of 8 hours a day (3000 hrs/year) in a virtual world with millions of players, hierarchies of players, the exchange of money for virtual 'property.' I'll have to start asking.

I heard Oliver Sacks talk about musical hallucinations. Dr. Sachs has been in twice a week psychoanalysis for 42 years (or was it 46). I had the sense that it was with the same analyst. This probably deserves it's own blog post.

Greist talked about OCD--- I'm not sure I learned much new, but it was good to know I wasn't totally out of touch. Dr. Greist is an amateur race car driver.

I went to a very good symposium on treatment for substance abuse. For cocaine addiction, people are using
antabuse (disulfuram), modafinil (I hope I have that right) and d-amphetamine: this brought the predicted questions from the audience about addiction. Marijuana dependence is a rapidly growing reason for seeking treatment-- especially in older folks (meaning people in their late 40's, and 50's) as well as adolescents. Marinol is the pill-derivative form of THC. There were talks on methadone and buprenorphine, and on motivational interviewing.

I didn't learn as much as I wanted to about the metabolic syndrome. One studied showed that people gained less weight (on average) on
zyprexa if they also took modafinil (provigil). They still gained weight, and the study only went 3 weeks out.

Max missed me, the judge enjoyed coffee with my husband, and everyone liked the wind-up walking brain I brought home. I had lunch and dinner and cocktails and overall I felt like The Bernstein Bears and Too Much Conference. Happy to be home.

Wednesday, May 07, 2008

How To Say Goodbye

In a few weeks I will be less of a ClinkShrink than I currently am. I'll still be a ClinkShrink, I'll just be doing it in fewer prisons. It feels odd to schedule my patients for followup knowing that I will no longer be there for their followup appointment. I am faced with the question of how to say goodbye to my patients, some of whom I've treated over multiple incarcerations in the last fifteen years.

Patients come in and out of my life fairly quickly. With a caseload of at least 150 patients or so, there's no way I can specifically remember each one. Often they disappear without warning, released to parole or transferred to other facilities. Sometimes I read about them in the newspapers later, either arrested or killed. That bothers me. I used to think that inmates didn't get attached to prison doctors because they move quickly through the system and see someone new at each pretrial facility. Generally though once they get into the sentenced side of the system, the prison side, this settles down and you have a chance to develop some longterm relationships. And the longer you work in the system the more inmates you get to know. Dinah thinks that when you're 'only' doing med checks the therapeutic relationship isn't important, but I can tell you it is. I'm going to miss (not all, but many) of these guys. If it matters to me, I'd be willing to bet it's going to matter to (not all, but many) of my patients.

The patients it will matter to are the ones who ask for me by name when they get arrested, the ones who insist on getting on the phone to say 'hi' when the nurse pages me for medication orders, the ones who honk and wave when they drive by me on the street, or run up to me in the recreation yard to tell me how they're doing. These are the patients who prove to me that kindness and a good rapport counts, even when you're 'only' doing med checks.

So I've been saying goodbye this week, not without a fair amount of guilt. Eventually I will be replaced but not right away, not for the full amount of time, and likely by someone with little or no correctional experience. I have sympathetic anxiety pains for the new clinician who has no clue what he's walking into, as well as for the inmate who sees the new face and has to start all over again.

But starting over is what the correctional experience is all about, for patients and sometimes also for physicians.

Tuesday, May 06, 2008

It Was Nice Meeting You

So Dinah, Roy and I ventured down to Washington DC to the American Psychiatric Association conference to talk about the use of computers in psychiatry. I was hoping to get a picture of our feet under the panel table, but that didn't happen. What did happen was that various Shrink Rappers met a couple Shrink Rap readers, and we appreciated the feedback you gave us. I hope our fellow psychiatrists enjoyed all the presentations at that session as much as we did. I personally enjoyed hearing patients talk about how online discussion boards helped them get better. That was pretty cool, and not something you hear every day. I thought it was pretty brave of them to put their histories out there in public, and I appreciated their willingness to do this for the education of psychiatrists.

Thanks again.

Saturday, May 03, 2008

My Creepy Shrink Is On the Wall Street Journal Blog

Check out the Wall Street Journal Health Blog-- Thanks to Scott Hensley for writing about those mean psychiatrists. Most aren't, just so you know. But Cruella.....

My 15 minutes of Blog Fame, though I am quite glad that Cruella is well-disguised.

The Shrink Rappers are off to APA. The blog may be quiet for a few days.

Note to my co-bloggers: Clink, all my emails to you bounce back. And I dropped my phone into the toilet tonight...the SIM card is saved and I could transfer it, so you can call me, but most of my numbers haven't transferred, and I haven't figured out how to text on the temp phone. Call if you need me.

Thursday, May 01, 2008

My Therapist is a Creep

Pic removed when I looked at it more closely and realized what it was--I am so sorry to all. I will look more closely at what I'm posting...oy.

Vaguely confabulated, but.....

So an acquaintance (let's call her Marsha) mentioned she'd been in therapy with a psychiatrist (let's call her Cruella) I know through professional channels. I shivered, oh did I shiver. "How'd it go?" I might have asked if this really happened. "Awful." No surprise there. Therapy with Cruella sounded to be just as I'd imagined; she was weird, kind of nasty, and just the thought of talking to her about my deepest darkest or looking to her for comfort made me ...well... shiver.

Many people think psychiatrists are weird. Maybe we are. The truth is that most of the psychiatrists I know are at least kind, well-meaning, interested, and want to help people. Cruella does not fit this mold, she's weirder than any TV shrink I've seen, prone to outbursts, and doesn't relate well to people; I've seen her cut people with words, I've watched her hold the room hostage. My opinion, of course, and my best guess is that Cruella has nothing nice to say about me. So be it.

I forgot to mention that Cruella is very smart, and I'm sure she's a very competent psychopharmocologist. But this is the thing-- I would never refer anyone to her. Why? Because she's weird and not nice.

What's this got to do with anything? The truth is that people all have fantasies about their real life psychiatrist-- one is the supposition that the psychiatrist is a nice person who's life is vaguely in order. Did you want to see a marriage counselor who's on his fourth marriage and has three children who've been placed with foster parents for abuse? I don't think so. And while I know many psychiatrists with their own long stories, many of them I would still refer patients to-- they are good at what they do despite the Whatever in their lives.

I think if I walked into Cruella's office I would run the other way at breakneck speed. Marsha stayed for a while, looking for hope or something good. She didn't find it and eventually left, soured by the experience, but it took a while for her to figure out how not-nice Cruella was.
Can you be a mean person and be a good therapist? I don't know, but I don't think so.

Grand Rounds Smack Down!

Doc Gurley from Posts From an Insane Healthcare System has pounded out a true heavyweight Grand Rounds this week.  Check it out.