Marketing Psychotherapy

http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?emc=eta1&_r=0

 

“But psychotherapy’s problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.”

 

Here we go. Brandon A. Gaudiano is a clinical psychologist and assistant professor of psychiatry and human behavior at the Alpert Medical School at Brown University wrote this article in the Op-Ed section of the New York Times. I read it with glee, until I reached the sentence I quoted above. So begins my next rant about how psychiatry, and now psychology, has lost its way. Psychiatrists, as a group, are too quick to prescribe medications, particularly those trained post-Prozac, meaning after 1990. Psychologists, as a group, are too quick to deny the unconscious, and preach that if we just follow a cook-book, we can help people develop coping skills, and science, meaning scientific studies proves this to be true. Freud is quickly thrown around as the evidence that “old-fashioned psychiatrists” have to wake up to the new world. I, like many of my colleagues, who do not seem to have a loud enough voice in this discussion, want to say that you, the typical psychiatrist, and you the evidence-based psychologist are both missing an important component to your discussion. People mess up their own lives because of unconscious guilt, leading them to make decisions which ultimately lead to deep suffering. Without an understanding of unconscious guilt, those in the mental health field are missing the complexity of the human mind, and the difficulties people have, either responding to medication, or to “evidence-based therapies.” Now, my caveat, I am in favor of medication, and I enthusiastically prescribe them. I am also in favor of evidence-based psychotherapies, and I use tools that this data has given us. Having said that, I also appreciate that sometimes, not all the time, childhood traumas, lead to life-long struggles of happiness, connection, and joy. Freud said the goal of psychotherapy is to help people love and work. This goal is often obtained by reminding people that medications can help with anxiety and mood, and evidence-based psychotherapies can help with coping skills, but deep analytic thinking is needed to help you make better choices for yourself. Just this understanding that an unconscious exists can help people understand why their relationships are serially disturbed, why their friendships often go South, and why in each and every job, they seem to run into trouble with the politics. Thinking about patterns can help patients develop psychological tools to be curious about how they might be the author of their own bad experience, meaning they may have been victims as children, but as adults, they can become the writer of their journey, at least to some extent. Do I have scientific evidence to back me up? Nope. What I do have is over two decades of experience working with people, connecting with psychological pain, and understanding together, how the person might have landed there. This experience has taught me, and many of my colleagues, that this inquiry has led to better mental and physical health. Yes, I repeat, this is all anecdotal. No scientific data does not mean it is not true, it only means we have not been able to prove it yet. My student taught me that. That gives me hope.

New Yorker Entry

 

I think this family has some secrets

Life Is A Choice

People say they are stuck when they really mean they do not like their choices. Karina, sixty-one, is unhappily married, frustrated with taking care of her elderly parents, while at the same time frustrated that she is paying for her grandchildren’s private education. “You have options,” I say, helping her to see that what she sees as fixed decisions are really ways in which she chooses to be in her world. She does not have to take care of her elderly parents, but she would tell you quickly that she would feel very guilty if she did not. “Well, that is different, ” I tell her. Feeling cornered is different from feeling like there is no way out. Managing her guilt would help her make more conscious decisions about where she wants to draw boundaries with her parents. This is a vastly altered picture than saying “I have no choice.” The latter is a way in which Karina does not have to think about how hard her choices are. In one way, it might sound unsympathetic of me to not connect with her about the burden of elderly parents, but on the other hand, taking care of can mean so many things to so many people, that each individual must find the way that makes sense for him or her. Without the thought of choices we lapse into victim-hood which leaves us feeling self-pity, with little hope of change. “What if I went to work to feed my family, would you tell me I have a choice?” Karina asks me, trying to convince me that some situations are fixed. “Of course, you have a choice about how to make money, and whether or not you want to go on public assistance.” I say, knowing that going on public assistance is so repugnant to her, that she does not consider this an option. The ability to sit with these difficult options creates maturity that allows Karina to reflect that even in the midst of hard choices, she still has the power to write the story of her life. No one has to write it for her.

Borderline Rant

 

 

http://en.wikipedia.org/wiki/Borderline_personality_disorder

 

23 years in practice and I still struggle with this diagnosis of a borderline personality disorder. I tell my students that I have never seen one, meaning that what they see, I do not. Brianna, twenty-five, has had multiple suicide attempts. She is the product of an Italian immigrant father and an African-American mother. She complains that she cannot fit in anywhere, because of her mixed heritage, and as a result, she often feels like killing herself. My students, who have seen Brianna, say she is borderline or Asperger’s. I propose that she is lost, searching for meaning in her life. Once again, I find myself using lay terminology to express the desperate feelings that lead to self-injurious thoughts and behaviors, in preference to the jargon in psychiatry, which I find to be unhelpful in terms of thinking about how to help patients like Brianna. Once again, I feel the laziness of using diagnoses like Bipolar, Asperger’s (now Autistic Spectrum), or Borderline, as a way of NOT thinking about the struggles of living in this world. Psychiatric diagnosis, sometimes, skims over the complexity of mental existence, leading to yet another irony, where on the one hand, in the neurobiological world, the brain is seen as complex, but in the clinical world, there is a push towards simplicity. Self-injurious thoughts do not necessarily imply a DSM 5 mental illness, but often implies, psychological pain, which is not an illness, but a symptom of a deeper problem of struggling to latch on to the beauty of the world, and the  beauty of oneself. All of this dispute, my plea to get away from jargon, makes me scared that psychiatry will bury itself. Brianna, and so many people like her, need understanding and listening; they do not need a label. Other mental health professionals (non-MDs), and clergy, understand this, but psychiatry, at least a large part of psychiatry, pushes away from the value of embracing the complexity involved in finding meaning in life. Labeling patients Borderline often embodies this issue. It is as if the label stops the psychiatrist from probing deeper into the personal struggles of Brianna. She is Borderline, implying that she needs medication to control her impulses. I do not have an issue with giving Brianna medication to control her impulses, but I do have a problem if the intervention stops there. Controlling her impulses allows Brianna to become more contemplative, and hence more reflective on what is important to her. Medication in this light, opens the door to an internal journey which is messy and complicated, but ultimately helpful to Brianna becoming an authentic, and hence beautiful human being. I repeat. She is not Borderline. She is lost . So is psychiatry.

History of Child Psychiatry

It turns out the field is less than one hundred years old. Who knew? James McCracken MD, chief of child psychiatry at UCLA, gave a wonderful presentation of how child psychiatry, a field in its infancy, has evolved, largely through the prowess of some key researchers, many of whom, cut their chops at, what was then called, the UCLA Neuropsychiatric Institute, and now called the Semel Institute. Given that I trained in the 80’s, I have lived through over a quarter of that history. Dr. McCracken reminded us, painfully, that historically speaking, autism was thought to be secondary to “refrigerator parents” and not to the bad wiring, which we have now come to understand. The ugly history that child psychiatrists “blamed parents” for what is most likely, to be a brain disease, is particularly painful. Parents of disabled children struggle with disappointment, guilt and the life-long worry that these children may never be able to be independent. The idea that child psychiatrists exacerbated these negative feelings by wrongly telling the parents that it was their emotional limitations that caused their child not to have friends. Like with any historical exploration, I, as a child psychiatrist in 2013, must accept that my fore-fathers (there were few women in the field at the time), had theories which hurt families. The lesson to be learned, as psychoanalysts  like to promote, is that uncertainty should be tolerated and so not-knowing should create a position of humility in the physician, rather than the certainty of a harmful theory. In essence, we are moving to a greater biological understanding of mental illness in children, but our movement is slow, and the field still depends on a great deal of subjectivity in the physician. I wonder what the next hundred years will bring.

The Butler

 

“The Butler” is a flawed, but interesting movie, continuing to hold my deep interest in racial tensions in the United States. In particular, the portrayal of the father/son ambivalence is the most moving, as each black male, struggles to fit into a white society, yet manifests this struggle in opposing ways. Cecil, the father, conforms to his role as a servant, paid less than his white colleagues, but still maintaining a salary which allows for a middle class family life. Louis, the son, fights the place of black people in society through non-violent, then violent, then political means. Cecil sees Louis’ choice as a betrayal for everything he worked so hard to have for his family. Louis sees his father as giving in to the power of the white folk. As an audience member, I could see that they were both right, but the strength of their beliefs prevented them from having any empathy for the other, while at the same time, they both seemed to be sentient beings. There is a clear Oedipal rivalry here, with Louis trying to gain his mother’s love by trailing a different path from her husband, who worked long hours, leaving Gloria feeling lonely and abandoned. Louis reacted in a way which caused grief in his father who, we see early in the movie, never had one. This trans-generational experience, of seeing each father, hoping that his son charts a better path, but then realizing that what better means, is not clear, at all. This father/son relationship, set in the midst of a groundswell of civil rights movements, is a timeless experience of seeing how parenting brings up the core need for the child to justify the parent’s existence, in a way, that the parent, not the child, defines. This important thread could have been more robust, but even so, it got me thinking, and for that, I am glad I saw it.

New Yorker Cartoon Entry…

“I think the team is being picked up.”

Dorothy Holmes PhD

 

 

 

http://newcenterforpsychoanalysis.org/edu-event.asp?id=339&month=9&year=2013&the_type=Course

 

Dorothy Holmes PhD is an African American, female, senior psychoanalyst from Bluffton, South Carolina who speaks with the openness and honesty of her unique demographic, in a world, when she trained, was dominated by Caucasian men. She asked her analyst how he could possibly understand what a black woman goes through, and by her report, he responded that he was not going to interfere with her feelings of being alone in the world. This, she tells the audience, is what kept her going. She had a space to express how she perceived that her life must be hard to understand, based on her gender and her race, but predictably, she came to see that there is a sense of common humanity if people extend their imaginations into the other’s subjectivity. I asked her about racial relations in the South, and she kindly told me that I was projecting. “Projecting what?” I asked, worried that I had stepped over a racial line. She did not quite answer my question, but I assumed she meant that hatred is everywhere and that I wanted to believe that somehow, Los Angeles, was more tolerant than Bluffton. In fact, I do want to believe that, but it also may be true, and I was wondering about her experience as a Black woman in the South. At the same time, I recognize that my curiosity about racial relations and its geographic differences, is not necessarily something she wants to speak about. She then goes on to talk about how her patients assume she grew up poor, when in fact, she did not. Her relaxed nature in talking about this discrepancy was refreshing. How people came to assume her economic background could be prejudice, ignorance, and/or their own need to see her as a rags to riches story. I felt like she was an immigrant to our Westside culture. She could speak our psychoanalytic language, while at the same time, she could speak to issues of race and gender, which we, who live, in what feels like a more tolerant place, do not understand. The conclusion was the old saw. Deep listening transcends race, gender and economic situations.

Thinking About Feminism

I started medical school in 1986, a year in which there was a quota for women. The class had to be 33% female. Now, medical schools are 50%, without a quota. How did this change take place, in, what feels to me, to be such a short period of time? The answer is the second wave of the women’s movement, http://en.wikipedia.org/wiki/Feminist_movement,

“Amongst the most significant legal victories of the movement after the formation of NOW were a 1967 Executive Order extending full Affirmative Action rights to women, a 1968 EEOC decision ruling illegal sex-segregated help want ads, Title IX and the Women’s Educational Equity Act (1972 and 1974, respectively, educational equality), Title X (1970, health and family planning), the Equal Credit Opportunity Act (1974), the Pregnancy Discrimination Act of 1978, the illegalization of marital rape(although not illegalized in all states until 1993 ^[26]), the legalization of no-fault divorce. A 1975 law requiring the U.S. Military Academies to admit women, and many Supreme Court cases, perhaps most notably Reed v. Reed of 1971 and Roe v. Wade of 1973. However, the changing of social attitudes towards women is usually considered the greatest success of the women’s movement.”http://en.wikipedia.org/wiki/Second-wave_feminism,

These politics allowed me to have my profession, and yet, although I was aware there was a quota, and that made me joke with many of my female classmates that we should get shirts which said  “we would have gotten in, if we were men,” I still did not have the perspective that I was benefiting from my foremothers. In fact, I had issues with the women’s movement. I felt that the demands on women were too great. It was not possible to work one hundred hours per week and have a family. I mean it was physically possible, but emotionally quite taxing. There was a never-ending feeling of not doing enough. The blending of work and domestic life was challenging, and although there was a generation of women before me who served as examples, the medical training system, at the time,  was male dominated and so role models were hard to find. Although working with people, for so many  hours, can create deep friendships, I envied the women at home who could have tea with their neighbors, and spend hours getting to know each other. It seemed that the women’s movement forgot about the value of female friendships, which served to create a network of closeness and warmth which is tremendously valuable to women, to society, and to families.  On the other hand, I cannot imagine women not having the opportunity to go to professional schools, so I owe my foremothers a debt of gratitude. Having said all that, I resonate with Debora Spar, http://www.glamour.com/inspired/2013/08/why-women-cant-have-it-all-according-to-barnard-college-president-debora-l-spar, who says that women cannot have it all. Each choice involves a loss of other possibilities, as every maturing adult realizes, who has to choose a path in life. The women’s movement felt to me to be misleading, but perhaps it represented an idealization, which, inevitably, as time goes by, becomes more like everything else in life-a step forward, but still a compromise.

See also…https://shirahvollmermd.wordpress.com/2010/01/23/the-pathology-is-political/

A Belated Memorial: Bye Bye to Cedars Psychiatry Training Program

 

 

 

http://www.psychiatrictimes.com/articles/elimination-psych-services-cedars-sinai-could-foreshadow-similar-cutbacks-elsewhere

I am reminded today of a major closure of an adult psychiatric residency and a child psychiatry fellowship in my town. Although this closure happened over a year ago, the ripples are still important. Less psychiatrists will be trained in the United States, and patients in Los Angeles will have fewer mental health resources to access. The sadness around this closure is enormous, both for the faculty, the graduates, and what, were at the time, current trainees. The reason for this closure is confusing, at least to me, but I can assume, there were large financial concerns, anticipating the change in reimbursement from Medicare, which funds a good percentage of Graduate Medical Education (GME). Once again, I surmise that the death of this program suggests that psychiatry is losing it’s place in medicine. I should add that Cedars-Sinai has maintained a Consultation-Liaison service and an Addiction Medicine service, but these are run by trained physicians, and so Cedars-Sinai is no longer giving birth to new and well-trained psychiatrists.

I wonder to myself why I did not blog about this major Los Angeles mental health event last year, and with wild speculation, I think it was just too painful. I know too many faculty members who lost their class, and I know too many patients who have difficult choices about how to continue their care. I also worry that this closure speaks to my broader concern that medicine is so focused on outcome measures, that psychiatry, with few good outcome measures, will deteriorate to a specialty that medical students will not see as desirable, and patients will not feel the freedom to access.

What does it mean that a major Los Angeles medical center closed their psychiatry department, with the exception, as mentioned of consultation-liaison and addiction? I think it means that specialties with machines, good metrics, will flourish, whereas specialties that want to sit with patients through their struggles will flounder. I know that there will always be room for people who want to comfort the mentally and physically ill, but my concern is that these professionals need to be well trained in body, mind and soul. Their training needs to be accessible and it needs to be able to ultimately pay off their massive debts. Should Medicare change their funding of GME, then it is possible that other psychiatric training programs will also close their doors. Psychiatry, simply put, does not pay for itself. It requires government assistance to keep these training programs alive.

The withdrawal of this assistance, might seem like a reasonable choice, given the expense of health care, but, on the other hand, does the apparent rise in these gun massacres, have anything to do with the diminishing psychiatric resources? If there were a connection, would this justify having the government supplement more psychiatric residencies and child psychiatry fellowships? Would more psychiatrists diminish the excessive use of medical resources to evaluate and treat psychosomatic disorders? I think so, but I have no data to back me up. The longitudinal studies needed to get this data are enormous. Should we, as a society, have to wait, or should we use our intuition? If your husband, or wife, or mother, was killed by Aaron Alexis, maybe the argument would feel stronger? Sure, maybe he would never have sought treatment and the same tragedy would have happened, but every time there is a reduction of services, we have to think about the unintended consequences.