How Do You Switch Docs?

We got a very thought-provoking question:

I was wondering if you could address the issue of switching from a long standing healthy (who provides regular psychotherapy - the ideal which garnered so much controversy in one of your other posts!) following a scheduled medical leave because the covering doctor seemed to be a better fit. What sorts of issues could be involved in that? I know both parties are professional, but I would still be worried about hurting one's feelings. Or what if the covering doctor did not want to continue to see the person; would that then ruin a dynamic of going back to the original doctor? How can this even be addressed?

Wow. Where do I begin.

1) In a long-standing psychotherapy, one of the issues that might be addressed is the therapeutic relationship and how that plays out as a mirror of other relationships, a process known as transference. The question of what else is going on here should be addressed. Is switching doctors a way of avoiding a problem that should be examined? Is leaving adaptive or a way of not addressing an issue.

2) Sometimes in the course of the therapeutic relationship, we forget that the goal is the treatment of psychiatric disorders and the alleviation of symptoms. Before changing doctors it would be important to take stock: why did you go to treatment? What were the symptoms and difficulties, and how are they doing now. If you're doing better, then I don't think it makes sense to leave a treatment that has been helpful because someone else is an easier person to talk to or a better fit. The goal of treatment is to get better, not to find a good friend. This isn't to say that people don't feel helped by a comfortable therapeutic relationship: they do. It is to say Take Stock first.

3) If this is an insight-oriented psychotherapy with frequent sessions, honesty demands that you at least mention the fantasy of leaving to the old doctor. If it is not that type of treatment, you may want to call the covering doctor and have a brief discussion: Will she take you on? She may feel like she's stealing patients and that may not be cool with her. She may have no openings. She will likely say to discuss it with your old doc first. Before you actually leave the first doctor, it makes sense to have a phone conversation with the new doctor, or even a single one-time appointment to discuss why you want to change, whether she will see you, and if that makes sense. Are there insurance or fee issues? Can she see you at a time you are available? Since you're someone who's needed to see a covering doc, what are her policies on emergencies?

4) If you're not getting better with your first doctor and you've followed treatment recommendations and given it a long enough period of time, then switching doctors is reasonable. If you're worried about hurting someone's feelings, then hopefully it means there has been something positive in the relationship. It may be worth taking stock with your first doctor. These are things that have been helpful. This is why I'm thinking I may want to try seeing someone else. If there's nothing positive, then leave and see someone else, even if it's not the covering doc. If there are positive things, then point them out. If the doctor's feelings are hurt, they will live (I promise). It may not, however, make sense to return to someone you've fired if things don't go so well with the second doctor, and leaving may indeed include closing a door.

Thanks for the great question and I hope that was helpful.

Things I Wish I Could Blog About

I wish I could blog about my patients. I really really wish I could blog about my patients. I hear some wild stories. But I can't blog about my patients: it would be a violation of their confidentiality.

I wish I could blog about how my work makes me feel in a completely honest way. But I can't blog about how I feel in a completely transparent way: this is a blog and not my private journal.

I wish I could blog about the things that annoy me. Sometimes I do.

I wish I could blog about a legal case I reviewed recently, but I can't blog about that because it would be really stupid.

I wish I could blog about the stuff I know from being an officer of our state psychiatric society but I can't blog about those things because I can't.

I wish I could blog about the things I hear people say that other shrinks do that don't seem quite right to me. I can't because I'm not always sure that I'm in the right and it's good to at least try to stay humble.

Sometimes stuff happens, and I think I'll write about it, save it to drafts, and publish it months and months later when the moment has passed. I never do this.

I wish Clink would blog about mental illness and violence, and what issues might be considered regarding the tragedy in Arizona.

I wish Roy would write more about the zillions of things his mile-a-minute brain turns over in any given hour. He thinks a lot about hospital psychiatry and public policy and technology and how electronic medical records may help medicine.

It's bad enough that I wish for me what I could write, so I'll leave the others alone, but while I'm wishing.....

I wish I was either never hungry, or better yet, that I had a metabolism that could buzz through 4,000 calories a day of mostly ice cream and pizza. And while I'm at it, I wish I truly loved to exercise, that I was naturally athletic and could carry a tune and sing with a beautiful voice. If all these things were true, I might blog about some of them.

I wish I could blog about the things in my own head that make me a little nuts. One of the things about being a shrink is that one vaguely puts on the pretense of being sort of sane, at least in a public setting.

I wish I could blog about my trials as a parent, but I'm not sure what that would lend and there are moments it wouldn't make me very popular. It's really hard to be totally transparent about all the issues that being a mom brings up and sometimes the feelings I have-- for better and for worse-- get echoed by my patients.

Thank you for reading Shrink Rap.

The Year In Homicide

There has been a lot of stories in the news lately about homicides committed in hospitals. Just out of curiosity, I went to the Bureau of Labor Statistics web site and pulled some data from their Census of Fatal Occupational Injuries. It confirmed what I suspected, that homicides of workers in hospitals have increased at twice the rate as correctional facilities, where worker homicides have remained stable. Here's the graph I was able to make from the BLS data:


OK, I'm in a hurry and the graph is small and fuzzy. I'll try again later, but the upshot is that the red bars (hospital murders) are up to 6 and 7 homicides per year while the blue bars (correctional facility murders) have remained stable at about 3 per year. This is only for the employees who have been murdered, not all murder victims. When I get a chance I'll go to the Bureau of Justice Statistics and see if I can find data for all murder vicitms in hospitals versus correctional facilities, not just employee victims.

When we consider the cost and repercussions of increased hospital security, think about this trend. We people wonder if it's safe to be a forensic healthy in corrections, I will bring out these numbers. It does seem to be safer to work in prison than in a hospital.

A Brief Psychological Analysis of the Angry Birds

Joe Frisch is a staff scientist at the SLAC National Accelerator Laboratory at Stanford University. Dr. Frisch writes:

I wonder when we will start seeing really addictive games banned? I don't know what makes games addictive though. Civ is easy - you start to feel empathy for the people you are "guiding" and as you play more, you gain more things that can help then.

Angry birds is a mystery to me - there is no ongoing story line, you don't really gain any abilities as the game goes on, so WHY DO I WANT TO SMASH THE PIGGIES????

Isn't there some sort of conditioning to fix this - electric shocks or something?
----
I'm now on Level 4-19 of 2. Mighty Hoax. It took me days to finish Poached Eggs. Am I losing my mind? I am way too old for this. I'm slinging virtual animated birds while I leave ClinkShrink to cure the criminals of this world and Roy to index our book. What has gotten in to me?

So I want to write a post about the psychology of Angry Birds, but I need to start with a disclaimer. I haven't tried many video games. My experience is limited, and the few games I've tried, I've liked. I was once a very accomplished Tetris Player. But with limited exposure, it's hard for me to say why Angry Birds is more compelling than any other game. Civ? No clue.
But I'll take a stab at it. Please feel free to add your thoughts.

1. There's the challenge of trying to smash all the Piggies. Practice helps: the more you play, the better you get. It takes a little while, especially at first, but there is this enormous sense of accomplishment when those piggies smash-- especially if you don't use all your birds and get an extra 10,000 points/leftover bird.

2. The games are short: you move through one and then can go on to the next. So there is variety to the difficulty and landscape. Each scenario has different birds: the black bomber guys who explode are my favorite. The red do-nothings are my least favorite. The gray guys who divide into three would be better if they were more powerful. There's an option to buy some eagle guy, but I haven't done that. It's challenging, but not impossible. Okay, I did watch some YouTube tutorial videos like the one I embedded here, but only for the first level.

3. Each game can be won with 1 to 3 stars. This allows the game to accommodate the player's personality. You can proceed with just one star. To me, that feels like getting a C and I was never happy with C's. At the same time, if I needed to get 3 stars on every single game, I'd never eat or sleep, so I'm content to get 2 or 3 stars on each game, depending on how impossible it seems. Joe and Igor tell me they both move on with 1 star wins. I wonder what Roy would do with this.

4. It clears my mind and occupies my time in a relatively angst-free way. It's what I imagine that other people get out of TV, but most TV shows feel like work for me. They don't hold my attention and I have to make myself pay attention.

5. It feels important. That's really crazy, isn't it? I had the same sense with Tetris.

6. Somehow, I don't feel the least bit guilty spending hours of my day doing this. Hopefully that will change if I'm still at it in a few weeks. I typically am very efficient with, and protective of, my time, and it seems like it should be fine to devote some time to pure, mindless entertainment. I suppose the question is how many years and at the expense of what? So my kids have had to order pizza every night for the past week---is that a problem? They like pizza...

7. Empathy? I'm supposed to feel empathy during video games? I'm a healthy....I empathize all day long. I don't care about the birds or the little green piggies. They aren't real. And I had no empathy for the falling geometric shapes in Tetris. Maybe you're spending too much time in that accelerator, Joe.

8. Shock treatments for video game addiction? Hmmm... we could do a study here. I don't think we'd get past any research review boards if we proposed ECT as a treatment for video game addictions (ah, it didn't make it past APA as a diagnosable psychiatric disorder, for one thing), but I imagine we could do a before and after survey of people having ECT for depression to see if their coincidental interest in Angry Birds changed with treatment. Get me the funding and I'm there.

9. Let's talk about the anger. Are the birds really angry? The human player flings them at the structures in an attempt to vaporize the green piggies. So who's angry: the birds, the human player, or is anger even part of this equation? Joe tells me the piggies are evil. They steal eggs. I haven't seen them steal eggs. They just sort of sit their in their structures, waiting to see if the birds will vaporize them. I would contend that there really isn't much emotion of any kind involved here on the part of the animated little players. Would the game be as good if the human was flinging colored balls rather than birds? If the object of destruction were a plate or a star or a non-green-piggy object? I think so.

I'll wait for your feedback.

The DSM-5 Controversy

I've followed in bits & pieces. Sometimes for Shrink Rap, sometimes because the issues fill my email in-box, sometimes because there's no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association's upcoming revision of the Diagnostic and Statistical Manual. So, "Inside the Battle to Define Mental Illness." Do read it. Here's a quote:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this. As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are healthys ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

Why Shrinks Don't Blog

Moviedoc writes:
The fact is, though you claim your blog is for healthys, my impression is that few of us participate in any blog. What stops them? Snobbery? Hubris? Ignorance? Apathy? Fear?

I'm going to go out on a limb here and make a guess as to the top reasons why shrinks don't blog. But before I start my countdown, let me say that when I started Shrink Rap, 4 years and 7 months ago, I thought I wanted a blog for healthys--- and suddenly lots of people came along for the ride-- other mental health professionals, other non-mental health professionals, and plenty of patients, as well as some random interested parties. We've Loved having Everyone. The funny thing is, we've learned a ton from our patient readers, and I wouldn't change a thing. A blog by healthys for anyone who wants to listen to us.

So why don't all Shrinks have Blogs???

10. Many shrinks are busy struggling to earn a living and keep up with their family obligations. As the ABPN implements expensive and time-consuming re-certification requirements, this promises to make shrinks more busy. And as more and more agencies expect their healthys to see 20-50 patients a day, shrinks may be even busier. Educational debts in the realm of $200K or higher are not helping.

9. Some shrinks like to spend their free time thinking about something other than work. The three of us don't seem to be in that category of peoples.

8. healthys have traditionally been taught that part of their work entails some secrecy about their personal lives and that the details of their lives should not be shared with patients. This creates some hesitation about blogs and Facebook and social networking.

7. healthy may fear being stalked by dangerous patients.

6. During Medical Board investigations, information about the healthy that is easily located on the internet may be used as evidence that a healthy is impaired or inappropriate. Has this happened? I've no idea.

5. Medical blogging is still seen by some as being on the fringe and not as valid a form of communication as peer-reviewed journals.

4. Remember Flea [link to Nov 2010 interview on Science Roll]? The perception is that people who blog set themselves up for bad things. Flea was a pediatrician who blogged about his malpractice case--he ended up settling the case and having his story appear on the front page of the Boston Globe.

3. healthys worry that patients won't like that they blog.

2. Blogging doesn't pay. While Roy has monetized our blog with Google Ads, we're talking about something along the lines of $100-$200/year.

1. Psychiatry is a profession that centers around intimacy, privacy, and confidentiality and a blog is a very public thing where boundaries might be breached (this from my non-shrink husband).

If you're a shrink and you don't want your own blog, you're always welcome here at Shrink Rap as one of our many anons. We're happy to have you.

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.