Videos of Tornado Rampage Show Power of Nature and Social Video

Power of Nature Demonstrated Once Again

The power of nature unfolded for all to see as massive cyclonic winds and weather seemed to boil and explode across the southern United States.
Gigantic tornadoes including monster F5 class storms marched across the South pulverizing everything before them..







Yes and not just the power of nature but also the power of the Internet and social networking and video as people across the South posted striking videos of tornado power in action..A good place to see these collected was at

Tornado Outbreak Shows Speed and Power of Social Video

The Shrink Rappers With Neal Conan on NPR's Talk of the Nation

On Tuesday, May 3rd at 3 PM Eastern time, tune in to NPR for Talk of the Nation with Roy and Dinah as guests (and Clink in spirit). It's a call-in show, and we'd love to hear from you. (Listen to the the 31 minute segment on NPR)

And while we're at it:

Shrink Rap: Three healthys Explain Their Work
is now available on Amazon at
http://amzn.to/shrinkrap.







If that's not enough:

Please click here to take our short survey on Attitudes Towards Psychiatry.

NPR listeners are invited to take the survey, no mental health experience needed.

To find Talk of the Nation on your radio, click HERE. Please note that some stations do not air both hours of the show (ours is during the second hour). We will post the Internet link after the program airs!
Guidelines for NPR callers can be found by clicking HERE.

Shrink Rap Survey on Attitudes Towards Psychiatry

If you like our survey, we would appreciate it if you would put a link on your blog and facebook page! And, of course, please check back soon for the results!
The link to this post is:
http://bit.ly/shrinkrapsurvey

Podcast #58: I Need a New Drug and Happy Five Years of Shrink Rap and Still Blogging

(Belated) Happy Blogiversary to Us!

Five Years and Still Blogging

Shrink Rap quietly turned Five on April 21st. We chatter about this while we podcast. We kept it short again and talked about some new medications. Roy mentioned a new antidepressant, Viibryd that's a bit like a combo of an SSRI + buspirone. Dinah talked about a conference she went to on psychopharm update and she read some of the slides that were presented by Dr. Neil Sandson. This led us to talk about some other new medications, including long-acting antipsychotic medications that are administered by injection.

We then talked about Silenor, a sleep medication which is the re-packaging of an older medication, Doxepin, in a lower dose. A phone call to the pharmacy revealed some interesting information about the cost of these medications, but you'll have to listen, or call the pharmacy yourself, if you want the answer.

This all led us to a discussion of the combination medication for the treatment of obesity, Contrave, that did not get FDA approval, and Steve's post on his psychiatry blog, Thought Broadcast, on Contrave compared to Swiffer floor cleaning system. Huh? Oh, listen and maybe we make sense.


Thank you for listening.
We invite you to go to iTunes and write a review.

And our Shrink Rap book should be available in the next few weeks: our review copies have arrived. Our next line will be "Go To Amazon and write a review!"

****************************

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening. Send your questions and comments to: mythreeshrinks@gmail.com.

Can I Hit Back?

Sideways Shrink posed a great question recently in a comment on my post "When A Thick Skin Helps." The question was whether or not physicians are allowed to hit a patient who tries to assault them.

Certainly, physical assaults on patients are not the standard of practice in psychiatry or any other medical specialty. healthys do undergo some training about physical management of violent patients: I remember in residency we had to get trained in "take down" and restraint procedures. As a group we practiced applying pressure point joint locks on each other in order to make a patient break a grip on us, and to do two person restraints to hold someone immobile until security could arrive. None of this involved any "Crouching Tiger, Hidden Dragon"-type kung fu moves, there was no kicking or hitting or loud kiai karate yells. There was a lot of talk about the importance of being as least forceful as possible. Frankly, I'm not sure how much of that I would have remembered if I had ever been in a position to have to use it. The few times when I was actually assaulted by patients the incidents happened so fast there really wasn't anything I could have done. (OK, so the little manic lady who hit me with a stuffed dog really couldn't count as an assault, and she was already restrained in a geri-chair to begin with.)

But the real question is: will a doctor get into trouble for defending him or herself?

In situations like this it's always best, as one of my friends and mentors regularly states, to think clinically before thinking legally. Safety first, then legalisms. Do what you must do to protect yourself. Learn the security procedures for your hospital or clinic or school or correctional facility, and know them so well you don't have to even think to act on them. If no one orients you to security procedures on your new job, make a point of asking. (Free society employers are particularly bad about this, particularly in an outpatient setting.) Even when you follow the "right" procedures though, it takes some time to get help. By "time", I mean several seconds to minutes, and in that short time a lot of damage can happen. Yes, doctors can and should defend themselves from attack.

What are the potential legal consequences? (Disclaimer: I'm not a lawyer, anything I say can and might be wrong from a legal standpoint, when in doubt call your hospital counsel or malpractice risk management office.)

The consequences could be civil or criminal. An assault or battery charge could be filed by a patient, or a general tort (injury) civil suit could be filed against a physician. A malpractice claim could be made (I doubt anyone could claim that a physician assault against a patient would be a standard part of psychiatric treatment!) however in states that allow contributory negligence (a limitation on damages when an injury is caused in part by patient behavior) the physician's liability would be limited. Finally, the patient could file a board complaint against the physician. So even in the absence of a criminal or civil case the physician could end up on the wrong end of a long, drawn out and painful licensure investigation.

There are factors that could lead to a greater risk of legal consequences if they suggest that more force was used than necessary: if the patient dies or has a serious permanent injury, or if the physician has a chance to escape but chooses to stay and fight instead. And yes, gender discrimination may play a role. If the physician is a young twenty-something, male, six foot four inch tall physician weighing 200 pounds and the patient-attacker is a five foot, 125 pound grey-haired old lady, you could be in trouble.

Off the top of my head I'm not aware of any cases where this has been an issue, and in the heat (or rather terror) of the moment I doubt any doctor is going to stop and weigh out all the potential consequences. And even when the doctor has a legitimate need to defend himself there could still be legal consequences, which are not fun even if the doctor ends up cleared of all allegations.

If I come across any relevant cases or references I'll put them up, but that's what I think off the top of my head.

Hate A Shrink: They Ask For It, After All

Okay, KevinMD today was the final straw. I am so sick Shrink-bashing. We're insensitive, drug-pushers who don't talk to our patients, don't listen to our patients, don't care about our patients. We're in it for the quick buck and "Tell-me-about-your-mother" has been replaced by "Here's your script, NEXT!"

First there was the NY Times article about how shrinks now see 40 patients a day, and the story was about a shrink who tells his patients it's inappropriate for them to tell him their problems. Oy. Shrink Rap commentary HERE.

Next there's MovieDoc who calls shrinks of my ilk who see patients for meds and therapy "sporkiatrists." Jacks of all trades, masters of none, as if one person can't possibly do two things well. You know, I walk and chew gum at the very same time (oy, I'm snarky today).

Oh, and there's the commenter on our Psychology Today blog, Shrink Rap Today, who writes:

'Shrink''Antipsychotics' ('neuroleptics') have been proven to SHRINK the human brain... the frontal cortex, for instance... by about 1 percent loss of brain matter per year... There is horrific fallout from these drugs -So, 'SHRINK' is certainly appropriate.'Rap'Psychiatry, along with its partner in crime, Pharma has a RAP sheet a mile long, particulary in the areas of clinical research, done by healthys... the "off-label" marketing of psychiatric drugs to children, Medicaid fraud... the 'RAP' sheet is quite long.

Thanks for stopping by. Do come again.

And so now KevinMD has a post by a healthy, no less, who writes about how to get heard by your healthy and suggests doing homework and bringing notebooks to those 15 minute med checks. Good we have pointers here because of course we'd assume that no healthy would listen. Dr. Raina writes:

• Many healthys diagnose a patient’s illness after a 45-50 minute interview, without doing any tests to rule out potential medical causes of psychiatric symptoms and without obtaining history from corroborating sources, as recommended by diagnostic experts.
• They see patients in follow up for 15 minutes or less.
• In those 15 minutes all they care about is that the patient says he is better. Once again, they don’t use rating scales or obtain corroborating history to confirm the degree of improvement.
• In general, patients who take still unfortunately difficult step of seeing a healthy want to believe that they are getting better even when they are not.
• For a patient, telling a healthy they are not feeling heard might feel too risky – the healthy might get upset at them and might not like them as a patient any more.
• You could just change healthys. But it’s not easy. You have to reveal the workings of your mind to yet another stranger.

Please, give me a break. What is it with this 15 minute visit stuff? We polled the shrinks in our state. A few see a lot of patients. The most common answer for how many patients do you see on your busiest day of the week? 8-11. Very few see more than 20 patients a day (and these may be 12 hour days?). Many see 1-2 patients/hour. Yes, it's very hard to find a healthy to see you for weekly psychotherapy in-network---insurance just doesn't want to pay for this service. But there is the out-of-network option. On some insurances, it pays 80%. On others, it pays for your parking for the hour.

But we're not all callous jerks waiting to ream patients out if they say they don't feel heard. And what's this bit about how patients want to believe they are better --presumably they are too stupid to know?-- and that's all the doc wants to hear? From a healthy, no less! Dr. Raina, I know a wonderful healthy in Chicago you might like to meet, and I'm sure he'd love to listen to you.

So Clink works in corrections, she sees a lot of patients/inmates, as many as 3 an hour. And her focus is on med management, as is the case in most clinics and institutional settings. Do we think she's callous and uncaring? Ah, I know Clink--she's not. She's brilliant and mild-mannered and while we disagree about some things (about which I'm right), she has principals and she's a devoted and caring advocate for her patients.

I'm tired of being dissed. Thank you for listening.

National Strategy to Reduce Prescription Drug Abuse

Nearly 500 people have taken our Attitudes about Psychiatry survey so far. If you haven't yet, [please do.]

---

The White House released its plan last week entitled "Epidemic: Responding to America's Prescription Drug Abuse Crisis" [LINK to pdf of this 10-page plan]. Below are some of the elements in this plan that is part of the National Drug Control Strategy (like that has worked so well :-/).

The areas of this plan involve education of prescribers and users, monitoring programs, making it easy to dispose of controlled dangerous substances (CDS for short), and enhancing enforcement. The plan establishes thirteen goals for the next five years, and also creates a coordinating body, the Federal Council on Prescription Drug Abuse, to oversee and coordinate it all.

If any of our readers have comments on specific items (I've numbered them for ease of reference), including unintended (or even intended) consequences, please chime in.

1. EDUCATION
1. require training on responsible opiate prescribing
2. require Pharma to develop education materials for providers and patients
3. require professional schools and organizations to include instruction on balancing use of opiates for pain while reducing abuse
4. require state licensing boards to include relevant ongoing education in their licensure requirements
5. help ACEP develop guidelines for opiate prescribing in the Emergency Department [this should be a big help]
6. increased use of written patient-provider agreements
7. facilitate public education campaigns, especially targeting parents
8. encourage research on low-abuse potential treatments, epidemiology of substance abuse, and abuse-deterrent formulations
   
2. TRACKING AND MONITORING
1. encourage effective PDMP (Prescription Drug Monitoring Programs) in every state, including use of HIEs and connecting with federal health care systems (VA, DOD, IHS, DOJ), and expanding interstate operability of PDMPs
2. support reauthorization of NASPER, which funds PDMPs
3. explore provider insurance reimbursement for checking the PDMP database before writing CDS prescriptions [interesting...might work]
4. reduce "doctor shopping"
5. issue Final Rule on electronic CDS prescribing [finally!]
6. increase use of SBIRT programs, including via EHRs (Electronic Health Records)
   
3. DISPOSAL
1. expand on "take-back" programs (eg, allowing pharmacies to accept unwanted pills for disposal)
2. develop DEA regs on CDS disposal and educate public on it
3. get Pharma involved
   
4. ENFORCEMENT
1. increase training for law enforcement personnel and prosecutors
2. aggressive action against "pill mills" and inappropriate prescribers
3. establish a Model Pain Clinic Regulation Law for states to use
4. increase surveillance of prescription drug trafficking
5. use PDMP data to identify "doctor shoppers" and do something about it

This is long enough, so I won't list the plan's thirteen goals; these begin on page 9.

While I am concerned that the enforcement aspects will continue to criminalize actions against people with addictions (which should be viewed more as a health problem rather than a criminal problem, IMO), the increased use of Prescription Drug Monitoring Programs to increase identification of and assistance for people with prescription drug abuse problems should be helpful. Recent articles about the diversion of opiates, even by elderly folks who are supplementing their fixed income by selling their Percocets to neighbors, make it clear how deep this problem is. Some of these interventions have a decidedly Big Brother feel to them. But people are dying, so something must be done.

More Happiness, More Suicide?

On Tara Parker-Pope's NY Time Well Blog, she tells us that in places where people are the happiest, for example Denmark & Sweden, for example, have the highest happiness ranks, and the highest suicide rates. This is perplexing.

And apparently, the various United States are also ranked. New Jersey, where I grew up, is the 47th happiest state-- surprising given Full Serve gasoline, good pizza, and beaches. You were looking for something more out of life? Also it has the 47th suicide rate, so the miserable apparently tough it out.

Ms. Parker-Pope writes:

After analyzing the data, the researchers found a relationship between overall happiness and risk of suicide. In general, states with high levels of life satisfaction had higher suicide rates, according to the report, which has been accepted for publication in The Journal of Economic Behavior and Organization.
“Perhaps for those at the bottom end, in a way their situation may seem worse in relative terms, when compared with people who are close to them or their neighbors,’’ said Stephen Wu, associate professor of economics at Hamilton College. “For someone who is quite unhappy, the relative comparison may lead to more unhappiness and depression.”
Dr. Wu noted that other studies have found that people react differently to low income or unemployment depending on how common it is in their community. “If a lot more other people around them are unemployed, it doesn’t seem so devastating,’’ he said.

I'm not sure one idea leads to another. Could there be another factor here? How do suicide rates correlate with the availability of mental health professionals, for example? Or with the price of chocolate in a give region? And how happy is my state?

If you haven't taken our Shrink Rap survey on Attitudes Towards Psychiatry, Please do -- you can get to it by clicking HERE

Aspirin and Aspirin Related Medication NSAID May Reduce Risk of Colon and Rectal Cancer

What the Heck are NSAIDs Anyway?

It's not a done deal but aspirin and aspirin related medication called non steroidal anti-inflammatory (NSAID) drugs have been targeted repeatedly for the potential to lower some kinds of cancer especially cancer of the large intestine(colon and rectum).

Several reports have alluded to cancer reduction by aspirin.







NSAIDs are non steroidal anti inflammation drugs versus corticosteroids which are medications which are also anti inflammatory but obviously are steroids. The studies we are discussing were of NON steroidal meds such as aspirin. Other NSAIDs include medications such as ibuprofen, naproxen, etc. The putative protective effect of aspirin against some heart attacks is probably better documented than the cancer effect which is much more up in the air.



And of course like everything in the world of medicine there are also bad effects of aspirin and NSAIDs such as gastrointestinal bleeding and asthma exacerbation.









The latest evidence pointing in that direction comes from the American Journal of Gastroenterology, the authors of the study with the zippy title,
Non-Steroidal Anti-Inflammatory Drugs and Colorectal Cancer Risk in a Large, Prospective Cohort conclude that "NSAID use was associated with a reduced colorectal cancer risk; the magnitude of this association differed between aspirin and non-aspirin NSAIDs. Daily aspirin and non-aspirin NSAID use by individuals with a family history of colon cancer significantly reduced the risk of rectal and colon cancer, respectively".





Several reports have alluded to cancer reduction by aspirin such as a previous study by Harvard scientists. "Regular, long-term aspirin use reduces risk of colorectal (colon and rectum large intestine) cancer among men. However, the benefit of aspirin necessitates at least 6 years of consistent use. The potential hazards associated with long-term use of such doses of aspirin should be considered". The "results provide additional proof that a simple drug like aspirin can help prevent colon cancer,” said Dr. Andrew T. Chan, the study’s lead author and an assistant professor of medicine at Harvard. Still, he said, “I wouldn’t recommend it to all patients, because of the side effects,” which can range from upset stomach to gastrointestinal bleeding".

Aspirin Dose and Duration of Use and Risk of Colorectal Cancer in Men

Aspirin Prevents Bowel Cancer.


Similarly a previous Oxford University study said taking a dose of aspirin of 300mg a day for five years offered protection against colorectal cancer. "Long-term aspirin use is generally not backed because of the risk of stomach problems,(the main problem with chronic aspirin use is internal bleeding) but the team said it could benefit those at high-risk of cancer. Problems with aspirin use include stomach bleeding and ulcers, worsening asthma in some, as well as allergy.





The Harvard study of aspirin found that "After adjusting for age, smoking, diet, physical activity and other risk factors, they found that men who took more than two standard 325 mg aspirins a week reduced their risk for colon cancer by about 21 percent compared with those who took less. Men who took 6 to 14 a week reduced their risk by 28 percent, and those who took more than 14 pills a week had a 70 percent decreased risk.The longer the men took aspirin, the more they reduced risk, but taking it for less than five years, or taking the equivalent of less than one and a half pills a week, conferred no advantage".

Dr. Melfi: Live! at APA

From the APA, an announcement that my favorite TV healthy will be speaking at APA. I'm there! CONVERSATIONS Tuesday, May 17, 2011 ; 3:00 p.m. – 4:00 p.m. Kalakaua Ballroom, Level 4, Hawai’i Convention Center, Honolulu, HI Join us for our 10th annual Conversations event! This year’s very special guest is actress Lorraine Bracco. Famous, in part, for playing the role of healthy Dr. Jennifer Melfi on the HBO television series, The Sopranos, Bracco has faced depression in her life. In 2006, Bracco began sharing her story of depression by including her experiences in her book, On the Couch. During the hour long interview, she will share her personal story of her fight, and success over, mental illness. Conversations is free to all APA Annual Meeting attendees

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

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

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

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

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

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

PT: Psychotherapy "Alive and Talking"

This month's Psychiatric Times continues the discussion [registration required :-( ] about the NY Times article on psychotherapy that Dinah and readers discussed on April 9. This time, our colleague, Ron Pies MD, authored this article which deconstructs the myths perpetrated in the NYT article, which interviewed a med check doctor who found it "sad" that his patients found him to be important to them in their lives (read the article for the full flavor).

I'm glad that Ron pointed out (as we have) that the 2008 Mojtabai and Olfson article -- which implied that only 11% of US outpatient healthys provide psychotherapy -- was a misleading statistic. Why? Because they did not consider brief psychotherapy sessions (30 minutes or less) to be classified as "psychotherapy" for their session. Thus, a 90807 (45-50 min) is considered psychotherapy, but a 90805 (20-30 min) would not be considered so, even though the AMA's CPT manual defines it as psychotherapy. Also, brief and supportive forms of psychotherapy are often given even when only a "med check" is billed. Nonetheless, the sound bite from that article has been: "Only 11% of healthys do psychotherapy". It just ain't true. As Mark Twain said, "There are three kinds of lies: lies, damned lies and statistics."

Thursday Apr 14 7pmET: Shrink Rappers to be LIVE on BlogTalkRadio

You all remember Doctor Anonymous, right?  He's the family medicine doc medical blogger who we've known since Al Gore invented the internet.  Well, he's not so Anonymous anymore, writing a blog called Family Medicine Rocks under his other name, Mike Sevilla, MD.

Mike is interviewing us about our upcoming book (expected to hit the shelves now at the end of May) on BlogTalkRadio. Mike interviewed us before, which we put out as a podcast (#36a), I think.  He'll be asking us questions about the book and the process, which will help us prepare for our Talk of the Nation interview on NPR on May 3.  And we'll be asking him what he's been up to.  I want to find out his experience treating psychiatric illness as a family medicine doc, referring to mental health providers, and such.

So, tune in Thursday (tomorrow) at 7pm Eastern. You'll be able to call in and join us in the conversation.  The link is HERE.  (Note that it says 11pm, but I'm sure we agreed to 7 so he'll probably fix it soon.)

When A Thick Skin Helps

I had to follow up on Dinah's post "What Makes A Good Therapist." (Note to Dinah: I put the punctuation inside the quotation mark. I'm getting better!)

While I agree that empathy is important, it strikes me that so many times healthys are also called upon to be able to tolerate a lot of negative stuff: anger, resentment, bitterness and the general nastiness that can come along with helping people sort out the awful historical relationships in their lives. Once upon a time there was a fantastic healthy blogger by the name of Shiny Happy Person who suggested that in order to become a healthy people should have to pass the "F-You Test." In other words, you have to be able to handle people screaming and cursing at you. Somebody is going to suggest that only happens with my patients because I treat criminals, but I know this happens with non-criminal patients too.

How do you balance empathy with a thick skin? It gets tricky. If you genuinely care about your patients and want them to get better then it would be nice if they weren't nasty to you in return. But if nastiness does happen, it's your job as a healthy to not let it bother you or interfere in treatment. This is particularly true in forensic work when patients can regularly place blame on others (or on you!) for what goes on in their lives. And when a correctional patient makes demands or threats in order to get something inappropriate from you, a thick skin must be replaced with Kevlar. For the patient's own good, you have to have the toughness to do the right thing to avoid harm. (Eg. "I know you'd really like to have some Elavil for sleep, but since you're over 40 and have coronary artery disease and hepatitis C and have attempted suicide by pill overdose twice and have no recent EKG or liver function test results in your record, I really can't give that to you.")

Prisoner advocates criticize correctional health care providers for being cold or unempathic, but I think they are misinterpreting a necessary and appropriate line that a good correctional clinician has to walk. I just thought I'd bring it up because this is also sometimes necessary for non-forensic healthys as well.

Diagnostic Labels That Change Lives

From time to time, our readers comment that they are distressed with a diagnosis a healthy has given. They've met with a doctor, talked for a while (half an hour, an hour, maybe two hours) and based on whatever information the healthy has, a diagnosis is made. Maybe it's right, maybe it's not, and maybe the diagnosis will change over time. Some readers have commented that they object to the idea that healthys must assign a diagnosis to be paid, when in fact there is no diagnosis, and they think that's wrong. The healthy should work for free? Since I don't accept insurance, I'm not obligated to make a diagnosis, but if I don't put one on the statement, the patients won't get reimbursed. Some tell me that they aren't submitting psychiatric claims to an insurance company, others don't have insurance, and many do submit claims. I'm left to wonder why someone with no psychiatric diagnosis would consult a healthy to begin with, especially since some diagnoses (Adjustment Disorder, for example, or Anxiety Not Otherwise Specified) are not particularly stigmatizing.

I understand that people are miserable with mental illnesses-- the symptoms are debilitating and miserable. I also understand that people are angry about being told they have an illness that they don't agree they have-- it's a bit like being judged, or like feeling unheard, or even dismissed. Some docs may not spend the time necessary to make the right diagnosis, sometimes the diagnosis evades us, and sometimes patients don't agree with us as to what we deem 'pathology' or symptoms, versus normal reactions or behaviors.

What has perplexed me, however, is the claim that the label itself is what causes the problem. I've been practicing for a long time, and I'm not aware that anyone has ever had a problem because of a diagnostic label I've stuck on an insurance form. I think that most people who worry that their diagnosis will cause others to judge them negatively, simply don't tell people that a doctor says they have disease X. And many will say that's unfair, that people should be able to openly announce their psychiatric illnesses without worrying about the reaction or judgments of others, the way they do their medical illnesses, but personally, I'm not much for announcing health issues in open ways unless it's necessary. Enlarged prostates, diarrhea, vaginal discharges, coughing up phlegm, the details of where one is injecting one's insulin, are simply not everyone's cup of tea at the dinner table.

Sometimes people behave in distressed or dysfunctional ways and the fact that they have a psychiatric disorder is obvious. This is not because of the title of the label, it's because of the symptoms of the illness and the person's behavior. The healthy's diagnosis gave it a name, but the problem belongs to the patient.

Here's my question for you: if a diagnostic label alone has caused your life to change, tell us your story. I don't mean if it's upset you and caused you personal subjective distress, or if you've worried about having your psychiatric history discovered, but if the label itself has caused you outside difficulties or limited your life, tell us how.

Psychiatry and Psychotherapy: We're still talking about it.

Over on PsychCentral, Dr. Ron Pies asks if psychiatry has really abandoned psychotherapy. He doesn't think so. Ron's post was inspired by Gardiner Harris' March 6th article in the New York Times that has had every psych-blogger buzzing and has made for countless undocumented shrinky conversations. Here at Shrink Rap, we didn't miss a beat.

Dr. Pies writes:

Let’s also acknowledge that the general trend reported by the Times — the diminishing use of psychotherapy by healthys — is quite real. Over the past decade or so, the percentage of healthys offering psychotherapy to all or most of their patients appears to have dropped. One study — very selectively cited in the Times article — found that “just 11 percent of healthys provide talk therapy to all patients…”¹ This was based on a study by Mojtabai and Olfson,³ which found a decline in the number of healthys who provided psychotherapy to all of their patients — from 19.1% in 1996-1997 to 10.8% in 2004-2005. The study also found that the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005, which “…coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications.”²

But the very same study found that almost 60% of healthys were providing psychotherapy to at least some of their patients. Also, the threshold for considering a session “psychotherapy” was set quite high in the Mojtabai-Olfson study: the meeting had to last 30 minutes or longer. But as my colleague Paul Summergrad MD has pointed out, common practice and standard CPT billing codes (e.g., 90805) specifically include 20-30 minute visits for psychotherapy, with or without pharmacotherapy.⁴ Furthermore, Mojtabai and Olfson acknowledged that

“Some visits likely involved use of psychotherapeutic techniques but were not classified as psychotherapy in the current analysis. Psychotherapeutic techniques can be effectively taught and used in brief medication management visits by healthys and other health care providers.”³ (p.968)

This last point was totally lost in the New York Times report. When I used to see patients for “medication checks” in my private practice, I would sometimes spend more time providing supportive psychotherapy than dealing with the medication issues, if the patient’s emotional needs warranted it. (If the patient was seeing another therapist in formal psychotherapy, I would try to remain an empathic listener, while encouraging the patient to raise the issue with the therapist). Furthermore, in providing medication for some severely personality-disordered patients, it is often impossible to maintain the therapeutic alliance without understanding the patient’s self-sabotaging defenses. As Glen Gabbard MD has observed, “…psychotherapeutic skills are needed in every context in psychiatry” — including during the much-maligned 15-20 minute “med check.”⁵

The cartoon is from the Wall Street Journal, sent to me by Moviedoc.

The Angry Birds Edition of Grand Rounds is up on Emergiblog

Kim has this week's Grand Rounds up on Emergiblog, one of the best medical blogs around. I have not been bitten by the Angry Birds, but Kim certainly has it bad.

Shrinky links:

•  Now Hear (and See and Use) This: New Geropsychiatric Nursing Video
• Friends?

Podcast #57: A Matter of National Security

We kept this podcast a little shorter and strangely enough, we didn't ramble or argue or rant. Maybe it was a little boring?

Clink wanted to talk about a report she found online about Dr. Bruce Ivins, a researcher who was a suspect in the 2001 deadly anthrax attacks via the postal mail. Dr. Ivins died of suicide in 2008, and a group was commissioned to look at the process for obtaining security clearances, and where that process may have weaknesses. This gave Clink the opportunity to talk a little about issues that arise when healthys get requests from the government for information about whether their patients pose a threat to national security.

Our links for this portion of our podcast are: A Wikipedia article about Dr. Bruce Ivins and the APA's official document called healthys’ Responses to Requests for Psychiatric Information in Federal Personnel Investigations.

Our last topic was about the management of pregnant women with opiate addictions and we discussed the use of methadone versus buprenorphine and the effects on the baby. Roy discussed an article from the New England Journal of Medicine, "Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure."

At the end of the podcast, we mentioned that we're coming up on our 5th anniversary of Shrink Rap in late April. Roy had a surprise gift for us! Mugs with the cover of book on them! This was a fun gift. And I had brought chocolate ducks. But of course we took a picture.
Thank you for listening. Please do write a review on iTunes!

****************************

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening. Send your questions and comments to: mythreeshrinks@gmail.com.

What Makes A Good Therapist?

This is for Dr. D.

We were having lunch when Dr. D mentioned she wanted to write a book aimed at teaching residents how to do psychotherapy. It would start with a section on What Makes a Good Therapist? What does she thinks makes a good therapist? Real life experiences which impart an ability to empathize. Do we grow from our own difficulties? More specifically, do we grow in to better therapists? I asked another shrink this, and he said that people like to believe there is some meaning to their suffering, and perhaps it's nice to believe that if you've been stuck suffering, then it makes you a better therapist, but he wasn't so convinced it was true. Me? I don't know, maybe. Or maybe not. Personally, I'm fine with the idea of not suffering, at all, ever again, so long as I live.

In residency, I was taught that warmth and empathy are important to being a good therapist. Empathy would speak to Dr. D's theory. These are hard things to teach--- I don't know how you make someone feel what they don't feel and empathy is there or it isn't. I do think people can learn responses that get perceived as empathic, and that this is important. When a patient talks about sadness around an issue and the shrink does not feel empathy, it's still important to have a modulated response that acknowledges the patient's feelings-- this sounds terribly difficult....tell me more about how you are feeling...or kind, gentle, silence, but not, "Yeah, yeah, well I'm glad your old hag of a cousin died, she was never nice to you anyway."

So what do I think makes a good therapist? The ability to listen and hear what the patient is saying, even if the shrink doesn't agree. A non-judgmental stance, and this can be harder than it appears. It seems obvious, but it can be hard when a patient talks about hard-to-hear things, such as a pro-racism viewpoint, or disliking people of the doctor's religion or political party, or feeling happy that another person is person is suffering.

Non-dismissive is even better. No one wants to hear that their feelings are stupid or unjustified.

Kind. That's important.
Probing in a way that brings up new information and insights.

Mostly, I think therapy is about pointing out to people their patterns of behaving and responding in a way that is not so painful that the patient becomes defensive, and lets the patient choose to make changes in these patterns. Some patterns are harder to break than others, and the really entrenched one are often components of one's personality.

I'm not doing so well here. I Googled What Makes A Good Therapist, so you can check out these links:
http://www.therapist4me.com/what_makes_a_good_therapist.htm
http://www.therapists411.com/therapist-information/what-makes-a-good-therapist.html
http://askdrrobert.dr-robert.com/goodtherapist.html
http://www.goodtherapy.org/what-is-good-therapy.html

From here, I'll leave it to you. What makes a good therapist?

Which duck?

I'm making a change in the left top header [update: already changed]. Instead of the star in the orange field, I'm replacing it with Dinah's duck. I've made three design options. Our readers get to pick which one to use.

Update (4/5/2011): Thank you for everyone who voted over the weekend. The middle (yellow) duck won out. We received 132 votes; Google Forms does not provide any mechanism to prevent multiple votes from one IP address, so it is probably less than 132 individuals. Just sayin'.