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'.