Monday, April 01, 2013

My Shrink Rap Life vs. My Real Psychiatry Life



Soon --April 21st to be precise-- Shrink Rap will celebrate it's 7th year as a blog.  No plans yet, but they are sure to include food.

Seven years later, and I want to say that Shrink Rap life remains distinctly different from my real life as a clinician.  Before Shrink Rap, the concept of anti-psychiatry was a foreign one to me.  The idea that there were people out there who saw psychiatry as bad, that psychiatric medications cause more harm than good and should be made illegal for all, that psychiatry was about power, that the patient and doctor were anything but on the same side, that diagnosis -- a word -- was inherently stigmatizing or life-destroying, this all was news to me.  Maybe I was in my own little bubble.

What I've learned on Shrink Rap has been illuminating.  At first, I thought it made me a better psychiatrist, more sensitive to a new realm of issues.  Then I wondered if it was making me a worse psychiatrist; here I was warning people of side effects that our readers had which I'd never seen in years of practice, assuming people were wary of psychiatric medications when they they weren't and their only experiences of them were good-- "made my brother so much better," and assuming people had qualms about treatment that they didn't actually have.  There are are literally days when readers are writing in about how medicines destroy lives and patients are sitting in my office saying, "Please don't ever let me stop this medicine again, I never want to go back to that place."  

In clinical practice, people come to me in distress and I work with them to help them get better.  If I have any sense that my goals for them are different than their goals for themselves, I verbalize my concerns and ask them to make sure that it's their goals that we strive for.   In general, I'm the one striving higher.  It's not all wonderful, some people don't get better and psychotherapy requires chemistry; I've no doubt that I'm not the best psychiatrist for everyone, but I think most patients who don't like what I have to offer just quietly go elsewhere.  And that's fine, too.  My real life world isn't about coercion or trying to get people to do things they don't want to do.  I listen, I try, I do my best, and I have my off days, too, because psychiatrists are human. 

Clinically, people come to get better and for the most part they do.  There aren't power struggles and there isn't a whole lot of clashing. Who would sign on for a career where everyday is full of emotionally charged confrontation? No one has ever expressed anger with a diagnosis.  To me, it's mostly a number that gets put on an insurance form so the patient can get reimbursed, not a stamp on anyone's forehead, and diagnosis has little, in my experience, to do with prognosis.  Most people come requesting medications, so we do that.  Some don't and if I think they might be helpful, I encourage them to at least try, but I've never said, "I won't work with you unless you'll take medications."  Much less a specific medication that is causing problems.  And I certainly can't imagine telling someone they had to stay on medications with intolerable side effects - the good/bad balance is the patient's decision.  People come in eager to see me, either because they want the relief of talking when they are in a bad place, or because they want to share their accomplishments when they are in a good place.   Sometimes people tell me they didn't want to come in, especially if they'd been doing well and had stopped treatment for a while, and I understand that as well.  Everyone is different, and that needs to be respected. 

To read the Shrink Rap comments, you'd think the therapeutic relationship was an adversarial war, and it's just not.  Seven years later, I continue to read the comments and be perplexed.  They don't reflect my personal experience of clinical psychiatry.