What Kind of Work is it I Do, Anyway?

I'm blogging during the closing ceremonies for the London Olympics.  As if there's not enough stimulation going on here....  

In Shrink Rap: Three healthys Explain Their Work, we talk about psychotherapy as a process that occurs over time where the talking is an integral part of the actual treatment; that is, it's the talking itself that facilitates the cure.  Traditionally, psychotherapy happens on at least a weekly basis -- sometimes twice a week -- and for psychoanalysis 3-5 times/week. Sessions are 50 minutes long and patients are often seen at a set time, for example, every Friday at 1pm. 

I think of myself as a psychotherapist because I see the majority of my patients for 50 minute sessions and people generally tell me about the events going on in their lives.  Unless someone is acutely symptomatic, very little of the sessions are devoted to symptoms, side effects, and medications, though certainly that is part of what gets discussed if there is a problem.  The assumption, however, is that there is more to the psychiatric treatment I'm doing then checklists of symptoms and medication adjustments that take place in a vacuum that does not include the patient's life events, past events (including childhood) and their emotional reactions to their world.  

Okay, so several readers and Amazon reviewers have commented on typographical errors in my e- novel, Home Inspection.  I recently got the paperback proof back, and with the help of one of our readers,  I've been re-reading it and going through the novel trying to see the words (and errors) my eyes (now on their zillionth reading) tend to simply not see.  

For those of you who haven't read Home Inspection, it's a story told by a healthy through the sessions of two of his patients.  Dr. Julius Strand's life is a bit of a disaster: he continues to mourn the death of his first wife, his second wife kicked him out, he's living with his cat in an apartment full of unpacked boxes, his career has a crisis, his health is not good, and his relationship with his daughters is strained.  Patient Tom is a cardiologist who is having panic attacks as he starts building his dream house with a woman who is certainly not his dream woman, and Patient Polly feels 'stuck' in her life.  She struggles in her relationship with the healthy and talks about her past begrudgingly, asking repeatedly if it will set her free if she talks about those past secrets.    Through a series of coincidences, their paths all cross, and somehow, the patients help to cure the doctor.  

The therapy that Dr. Strand does is a very conventional, psychoanalytically-informed therapy.  His patients come at the same time each week.  They talk about how past events inform their current behavior, and he thinks a great deal about how their relationships with him are relevant.  

It occurred to me as I was reading my own account of treatment (fictional though it may be), that I don't do really do this type of therapy anymore.  I'm not sure I ever did.  When people start therapy and are feeling badly, they generally come weekly, but as soon as a patient's symptoms get better -- often a matter of weeks to months -- they ask to come less often, and most patients come every two to four weeks.  Some I see on an irregular basis -- they call when they have a problem and want to come talk.  Therapy is expensive, and in our harried world, most people don't have either the time, money, or inclination for sessions once or twice a week. While there are people I tend to see on specific days or at specific times, most patients don't have a fixed regular session -- I think this is because I like having some flexibility to my schedule.  And while people do talk about what is going on in their lives, and I often will ask about how past events and emotions have impacted them, I don't spend much time focusing on the therapeutic relationship.  I won't say never -- and certainly,  the fictional Dr. Strand thought about it much more than he talked about it -- but it is not a major focus of treatment for most people.

So I think of myself as a psychotherapist, and I think of psychotherapy as a crucial part of treatment, but if I don't see most people for weekly sessions,  then what exactly is it I do?

And if you don't feel like talking about psychotherapy, by all means, tell me what you think of the closing ceremonies!

The Chapter I Now Wish We'd Written: Bad Shrinks

When Jesse read our Shrink Rap book, he said we were too nice to healthys in it-- that we didn't mention that there are some really bad healthys out there and he thinks part of the venom towards psychiatry comes from the whole rushed 15 minute med-check culture.

I thought about this and I thought, really?  We have a whole chapter called When Things Go Wrong and we discuss a healthy who is not sensitive enough to a patient (though, granted, the patient is overly demanding and overly sensitive--so I guess not the best portrayal of insensitivity by a shrink), one who is rigid in her formulation to the point of almost destroying a family, one who prescribes medication that makes a patient fat and diabetic, and finally, a healthy who is outright unethical and criminal: who defies all boundaries and gives her patient prescriptions for narcotics to bring back to her!  Like how much worse could I make the shrinks? As one Amazon reviewer said,

The authors are careful to include what might be called opposing views. They give some space to the anti-psychiatry movement, and they consider the recent cases of medications that seem to cause suicidal thinking in some patients. But they balance that against the suicidal thinking that is prevented in some other patients by the same medications. They also talk about the influence of drug companies in a fairly open way.

There are no heroes here. The authors aren't in the business of justifying themselves, and one or two of the fictional therapists we see in the book do spectacularly bad jobs and harm patients.

But Jesse is right,  overall the examples portray healthys who are thoughtful and caring, and while we tried to "explain" our work, not justify it, we did not talk about healthys who just plain bad, or those who are probably good but who put such an emphasis on making money that they don't give the work the time it needs.

So why didn't we (or "I," since this is my post, never discussed with my co-blogger/authors) talk about 'bad' healthys in a broader way?  I'm going to go for bullet points here:

• We talked about the pros and cons of split therapy, and there are pros.  Clink works in a prison where she sees up to 3 patients an hour.  She's a wonderful, smart, and thoughtful shrink, but I even don't believe that criminals should have psychotherapy with a healthy, especially given that hard-working, insured, law-abiding people in free society can't afford this.  There are all types of issues that make some rapid worse than others: if there is a single chart and the doctor has access to information from the therapist and the care is coordinated, if there are reports from other professionals treating the patient, such as in a day hospital or program setting, where assessment includes a team approach, medications can be managed well with less face-time with the patient.  In a private practice setting, however, rapid care may mean shoddy care.
• At the time we wrote the book, I had never heard of an outpatient, private practice, healthy who sees 40 patients a day such as the one portrayed in the NYTimes article by Gardiner Harris.  I'd heard of 15 minute med checks, but in the clinic where I work, I sometimes see patients for 15 minutes, or less, not because I'm scheduled so tightly, but because they have nothing to say...all is well,  a family member is there and confirms that things are going smoothly, their therapist is in the room and says things are fine, and the patient wants their prescription refilled and to get out.  I had never heard of an outpatient healthy who sees every patient, regardless of their needs, in a one-size-fits-all 15 minute slot.  I can't imagine how this can be done well.  The New York Times may want to portray this as how psychiatry is now routinely done, but it's not.  
• Some healthys are insensitive... we did reference the idea of a healthy "with the social skills of an iguana"  (I hope we didn't insult any iguanas!), but the idea of interpersonal sensitivity is a hard one to capture--- people are very different in what they want, and one person can relay a story with "Can you believe he said THAT?"  While another person would find THAT as being a perfectly reasonable thing to say.  There is no healthy out there who is everyone's perfect fit, and even the people I might think I'd never refer to, likely have devoted patients with good outcomes. 
• The things that often trouble patients the most are endemic to all fields of medicine these days and not just psychiatry and they don't objectively make a doctor "bad," (maybe over-scheduled, disorganized, or forgetful) and include the large areas of running late and keeping patients waiting, or of not returning phone calls.  Patients are often angry about this---often rightfully so--because it leaves people feeling like they aren't cared for or respected.  I'm not certain what there is to do about this one.  

In the end, I decided it's fine that we didn't write about the general topic of 'bad healthys.'  None of us felt any need to pass judgment on our peers, and we created our fictional healthys with the idea that this is how it's supposed to be-- others can use it as a model of what to expect.  Our shrinks listen, they are thoughtful and respectful, and they spend time with their patients and consider the impact of their work within the context of their work environments.  Maybe unrealistically so, but why not have an ideal to strive towards?

Found on My Facebook Page

We talk about ducks here on Shrink Rap, but in my 'real' life, I like giraffes. I was very excited when today's American Journal of Psychiatry arrived in the mail and there were two giraffes on the cover! And if that wasn't wonderful enough, Henry put the cover up on my Facebook page with the cover of Shrink Rap in the background and mama giraffe saying to baby giraffe, " Because I'm your mother, no playtime until you finish reading!" How'd he do that? Well, I liked it, so I thought I would share it with you.

If you didn't catch it, our book was reviewed in The Johns Hopkins Magazine by Kristen Intlekopher. Three authors couldn't ask for a better review, so please do read it! You'll need to scroll past oysters, cell phone radiation, and political order, but this review made my day.

Someone asked if I would friend Jesus if he were on Facebook. I can't imagine I would ask to be his friend and I'm not sure what I would do if Jesus sent me a Friend request. Who thinks of these questions?

Please Go To Amazon and Write a Review!

Aloha! Clink and I are still in Hawaii on opposite ends of the same island. Gorgeous here, and oh,how I love vacation! I am having some technical difficulties posting from an iPad, and maybe Roy could add a photo for me.

You're used to hearing us say on our podcast, "Please go to iTunes and write a review!"

Now, I'd like to ask, if you've read our new book, Shrink Rap: Three healthys Explain Their Work,
Please go to Amazon and write a review!

Thank you so much, and I am going back to my vacation now. See you next week. Roy, hold down the blog-- you're doing a great job.

Come Visit Us at APA In Honolulu!

So glad Blogger is back. I was starting to go into withdrawal despite Roy's reassurance that it would be okay!

Aloha! Do come meet us at APA. I've never been to Hawaii before, I'm looking very forward to this.

On Monday, Morning, May 16th at 11 AM, we will be doing a book signing in the Exhibition Hall at the Johns Hopkins University Press at Booth 1424. The Press will be discounting our book to a mere $12, cheaper than you will find it anywhere! Let me further remind you that this may be a tax deductible business expense. Oh, come visit even if you don't want a book! ClinkShrink will be wearing a duck necklace.

On Wednesday morning at 7 AM, we will be giving our workshop called The Accessible Psychiatry Project: The Public Face of Psychiatry in New Media in Room 326B in the Hawaii Convention Center. If all goes well with the technology, we promise an entertaining multi-media event. It's an early hour, but do bring popcorn anyway.

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NOTE FROM CLINK:
Ignore what it says on the APA iPhone app about our presentation (they have it listed as 'withdrawn'). We ARE giving it!! I talked to the APA people and they're supposed to fix this.

ANOTHER NOTE FROM CLINK IN HAWAII:
Dinah just texted me that our presentation info was left out of the conference program! Augh, are we cursed?? We ARE giving the Accessible Psychiatry Project presentation on Weds morning at 7:00 am in room 326b.

On the positive side, the iPhone app is fixed and our presentation is listed correctly there.

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Today's Shrink Rapper News

1) Our book is now out on Kindle. Apparently, you can get it in a minute for $10.

2) One of my old posts is up on KevinMD, Predicting How Much Impact Mental Illness has in a Person's Life.

3) In June, we hope to have another component blog up and running---Shrink Rap News-- we will be doing weekly posts on the Clinical Psychiatry News website. Those posts will target an audience of healthys. Oh, we started with that idea here at Shrink Rap, but the readers we found, both shrinks and non-shrinks, have proven to be so much fun!

4) Aloha! We're getting ready to go to Hawaii for APA-- Roy will give you details about where to find us shortly.

5) Frazzled and frizzled, I did what I've never before done today: I blew off my hair stylist! Not on purpose, but I thought my appointment was 3 hours after she thought it was. Ah, you ask, did she charge me? Do hair stylists charge for No Shows? (They should). No, she had time for me later in the day, and Yes, if I can reschedule a patient who has forgotten an appointment on the same day, I don't charge for the 'missed' session. Someone would have asked that, right?

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...).

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.)

Well this was really nice-- author Pete Early quoted our soon-to-be-released book on his blog in a post called
Chemical Imbalances: Real or Imagined?

Pete is the author of Crazy (and many other books), the story of his difficulties negotiating the mental health system. From his website:

Crazy: A Father’s Search Through America’s Mental Health Madness is a nonfiction book that tells two stories. The first is my son’s. The second describes what I observed during a year-long investigation inside the Miami- Dade County jail, where I was given unrestricted access. I feel more passionately about this book than any I have every written. Our nation’s jails and prisons have become our new mental asylums. I wrote this book as a wake-up call to expose how persons with mental illness are ending up behind bars when what they need is help, not punishment.

Looks like something Clink might like? Rumor has it she thought it it was wonderful.

Our thanks to Pete for the early shout-out on our book!

Happy New Year!

Happy New Year to all our readers. Can you believe it's 2011? I remember being a kid and thinking how long it would be until 2000 and thinking I'd never actually be that old.

I almost saw out the Old Year with Roy. We went out to a local pub for the best of Baltimore's crab cakes, and Clink didn't join us, but she did text in that there was a Duck in her Jacuzzi at what ever wonderful vacation spot she's in. A duck in the Jacuzzi and we didn't even get a picture? This from the woman who texts me photos of every mushroom she runs across? We parted around 10, and for the first time in years, I was awake at midnight, drinking champagne and eating chocolate by the fire with family and friends (non-Shrink Rappers)...who came over to see the year out with us.

Shrink Rap will turn five in April. This is our zillionth post (well, not quite, but we're somewhere over 1,300 posts). Our book will be coming out around the same time, if you'd like a preview, it's up on Amazon, but not yet available. We're scheduled to talk at APA in Honolulu this year, but our talk, The Public Face of Psychiatry, has been scheduled at 7 AM on the last day of the conference. Will anyone come? 7 AM???

Finally, this past week, we were mentioned on The Psychiatric Nurse Practitioner Blog as one of the Top 50 Psychiatry Blogs (I didn't know there were 50 Psychiatry Blogs!)-- do check it out-- and we had a guest post up on Kevin MD, a revised version of our post on How to Find a Shrink.

What Do You Want To Know About Psychiatry?

When you work in any setting, your view of it becomes distorted. Your vision becomes tunneled, and the world looks small. My husband came home one day upset because a client had burst into tears while they were talking. "Why does that bother you?" I asked. Apparently it's not something that happens a few times a day for him. And when I was a medical student on an oncology ward, one of the doctors came in for rounds late---on her to way to work she'd seen a young man get knocked off his bicycle by a automobile. She'd stopped to help, and her first question to the young man was, "Are you a smoker?" She quickly realized that it was not a particularly relevant question in that setting.

So do people in the real world have questions about psychiatry? What are they? What a time to ask: just as our book goes for it's final draft. I should have asked before-- What do you want to know? Maybe we're wrong about what we thought people want to know. Maybe we need to write a second book.

The good news is that after several requests, the jacket designer has agreed to add a duck. Bless our editor for asking--- no clue how she explained that one.

Why do I feel like we've been working on this book forever? Clink will tell you, "because we have."

So what questions do you think the general public has about psychiatry? Go for it.