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I knew I would be replaced by a robot, but I did not know I would be picking up a robot.

Teaching Child Psychiatric Assessment

A child comes into the Emergency Room because the parents are worried about their behavior. The adult psychiatry resident, not schooled in child development, is called to make an assessment, to triage this patient. Send them home, admit them, call for help, these are the choices. My task today, in one hour, so nearly an impossible task, is to teach psychiatry residents how to begin to triage these children and adolescents. Given that I do a three-hour assessment, and the reality for these residents is that they have, at most, one hour to make this decision, I need to help them pare down my three hours, such that they distill the most important clinical issues. Clearly, this is an inverse situation, in that I, with more experience, could do one-hour assessments, and these residents, in order to learn, should be given three hours, but alas, that is not the current reality.

I will begin by helping them think about where the presenting problem lies?

Emotional?

Cognitive?

Physical?

Behavioral?

Behavioral disorders are the most acute, since those issues can lead to immediate self-destruction or harm to others. We all worry, I will tell them, about seeing the next school shooter, and somehow, tragically, missing the acuity of the situation. At the same time, we know that we will let children and adolescents out of the emergency room, only to find out later, that violence ensued. Our tools are flawed. Our ability to predict, hopelessly fallible.

Next, I will talk about how to get a history, by thinking about the child in four domains.

Family Situation

School Functioning

Community Functioning

Cultural Issues

Returning to the reason for landing in the Emergency Room, the major questions are “why now” and “says who?’ Pre-pubertal children can usually, but of course, not always, return to the care of their parents, but post-pubertal adolescents are much more challenging because they have the means to independently cause destruction. On the other hand, if the parents are part of the problem, or if there is any suspicion of abuse, then the Psychiatry Resident is charged with contacting the authorities, with the possible outcome that the child will land in an emergency foster care situation. The dance between being sympathetic and suspicious of the parents begins. Likewise, this same dance with the child begins as well. Is the child a victim of his circumstances or are the parents victimized by this child, or is it some combination? Eventually, after the data is obtained, both by direct interview and record review, the resident is charged with making a diagnostic formulation and treatment recommendations. Finally, these ideas need to be conveyed to the parents in a way which minimizes defensiveness, as talking to a parent about psychiatric issues in their child is a very delicate conversation. As complicated as all this is, the most challenging issue will be finding outpatient referrals. Child psychiatrists are in short supply, and as such, most families have tremendous difficulties finding good care. Further, the good care that is available is not always well-known to those that work in emergency rooms.

At the conclusion of my lecture, as most of my teaching goes, there is usually a heavy feeling associated with the uncertainties in our field, which is tied together with huge responsibilities, leading to an uncomfortable sense of fear and uneasiness in the provider. I will joke about how this uneasiness might be correlated with the shortage of child psychiatrists. Maybe though, this is no joke.

 

Sonia Nazario

Bio

 

The best talk I have ever heard. She presented her investigative reporting about a boy named Enrique who fought incredible odds to find his mother in the United States. He traveled through five countries, as a twelve-year old, in search of his mother. As Ms. Nazario says, storytelling is the best way to help people understand, and indeed, she told an amazing story. What was gripping and sad about her tale was that she mirrored his journey, herself, so that she could convey the determination and the tenacity that these children, these young people, who cross multiple borders in search of a parent. Her emphasis on wanting to tell Enrique’s story, mirrors my daily attempt to understand my patient’s story. It is through understanding the narrative, the tale, that we connect as human beings, and we reach out to each other. If we do not take the time to understand the story, then we miss out on understanding the common humanity. I cried and cried as she illustrated the danger that Enrique faced, day after day, and yet he persevered, and yet she persevered in parallel. Sonia first told her own immigrant story, and then told Enrique’s story, and at the end she tied them together, as if they were one tale, as if there were more commonalities than differences. She was right. The deeper you dig, the more the differences drift apart. Rarely, am I that moved by one speaker. Sonia Nazario did that for me.

NYer Cartoon Contest

People think we are doing things under the table, and although it appears that way, we are multitasking and doing yoga while we work.

Or….

We made smart-chairs for our meetings and now they have unionized and they are on strike. They are tired of being taken for granted.

That is the problem with a high-tech company. The old days were better, when a chair was just a chair.

Girls And Suicide: Oh No!

http://www.ctvnews.ca/health/suicide-rate-for-u-s-girls-and-young-women-continues-to-climb-1.2266974

 

“From 2007-2013, the rate for young females went from 2.2 to 3.4 per 100,000. That’s the highest since the 3.1 rate recorded in 1981, when such tracking began.”

These girls and young women, 10-24, are increasing their rate of suicide in the US. What to make of this pit in the stomach feeling of sadness and grief for these developing females and their families? No one knows, so we are left to speculation. They are choosing more lethal means, such that before they may have had an “unsuccessful” attempt, but now they are finishing the job, so to speak. I do not have any glib explanation, except to say that psychic pain is invisible until it is so visible that we squirm when we see it. Does this correspond to my chronic complaining about simplistic interventions for mental health care? Maybe, except that before there were simplistic interventions, there were more people getting no care, returning us to the question of whether bad care is better than no care? There is still a gender gap for suicide, but does this statistic represent a perverse desire for females to close that gap, to show that they can be as violent towards themselves as boys can be? I hope not. Is this a result of social media where there is a vulnerability for developing women to feel that are missing out, based on the images they see on their networking sites? What is the shock associated with these suicides? I wonder if there were any warning signs? As a child psychiatrist, I cannot help but feel that we are failing these girls and women. This data is a call to action. The question is what action? Screening tools?  Should we be empowering teachers to do mental health triage to identify children and adolescents at high risk? Are these foster children, such that more attention needs to be given to this population, a population we know is overmedicated, and is high risk for social ills? Psychiatrists should not stay silent, both to help these kids and to stay relevant. Suicide reminds us about why we do, what we do. We help people with psychic, and hence invisible pain. At the same time, we need to be visible to promote this work.

 

Picking A Supervisor

Residents, psychiatric residents that is, pick supervisors to help them learn psychotherapy. From medical student to hard-working internship to inpatient psychiatry, these residents jump off a cliff into outpatient psychiatry land, which requires learning a completely new skill set. Acuity decreases, and the long journey of psychotherapy begins. The skills required to manage emergency situations, skills which are honed over many years, are no longer needed. Instead, the skills of patience, careful listening, thoughtful hypotheses, and a cerebral mode of being, rather than an action mode of being are required. For some, this transition is the reward of many years of training. For others, it is simply terrifying. And for a few, this is “old fashioned psychiatry” with skills that are “hardly useful.” As their second academic year comes to a close, they are faced with the uncertain task of finding a supervisor, a psychiatrist who can shepherd them through their development as a psychotherapist. They want to learn, but they do not want to feel the shame of not knowing. They are faced, as they hover thirty, with the humiliation of being a student, a pupil who knows little, but is expected to grow rapidly. The anxiety, for some, is large, whereas for others, it is yet another hurdle in their long road of professional development. So, how do they choose their teacher: by reputation, by their curriculum vitae, and/or by the chemistry they feel when they have seen these teachers in other settings such as journal clubs or lectures? Or, is the system broken? Maybe the supervisor should choose the student, based on the supervisor’s judgment of which student would have the most growth potential? Or, as I said in a previous post, maybe supervision is not the best way to teach psychotherapy. Maybe they need to have a psychotherapy boot camp, where, with the help of a facilitator they can rely on each other to struggle through the fog of psychotherapy. Or, maybe they need to learn some basic concepts of technique before launching into seeing outpatients? Maybe they need to read, and write papers, to demonstrate knowledge of psychotherapy before seeing outpatients? At the moment, that is not how the system works. The resident picks their teacher, making it so charismatic teachers, those who the residents perceive to be nonjudgmental, are highly sought after, leaving the less assertive residents with the quieter, less charming supervisors. Maybe the system works, despite its flaws. Maybe, though, this is a time for big data, a time to be more scientific about what works. It is a thought.

Binge Eating Disorder

 

DSM 5 has expanded our notion of eating pathology to include a diagnosis of binge-eating, a behavior that almost all of us have experienced from time to time, but as with all of mental health, when the symptom is both intense and frequent, then a diagnosis is made. Along with a new diagnosis, there is now FDA approved treatment for Binge Eating Disorder, Vyvanse, a stimulant medication, typically used for ADHD.    http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm432543.htm

Truth be told, I, and many of my colleagues have been using stimulants to treat bingeing for over 20 years, but now we have support both from the DSM 5 and the FDA. In other words, our treatment went from “off-label” usage to “on label” usage and so for my existing patients this means more security, and for new patients, this means more awareness that there are treatments available. The closet eater can now come out of that closet. This is an exciting step forward, although the concept is simple. Drugs which suppress appetite will suppress the gratification from bingeing. Medical health improves as bodies return to a normal weight range and mental health improves as the patient feels less shame and guilt associated with binge eating.

Since I normally discuss working from the inside out, it might surprise some of my readers that here I am talking about working from the outside in. In essence, both are important. If I could not prescribe medication to help people help themselves, then I would be limited in my toolbox. Likewise, if I could not explore psychodynamic concepts with my patients, I would be even more limited. Binge Eating Disorder is an example of how if we begin to change the behavior first, then we can then proceed to work on the inner workings of the mind which led to this type of self-destructive behavior. Medications change behavior, sometimes, and when we have that tool available, with minimal side effects, then I am happy to prescribe. As with eating, it is the extremes which are a problem, not the middle ground.

Supervision

How do you become a psychotherapist? How do you become a teacher for psychotherapists? Who should be the students? Is it necessary to have a science background? How many years should it take? How many internship hours should one put in? Who should license psychotherapists? Should this be a State license or a federal license? What about lawsuits? What can people sue for? What is evidence that things went wrong in psychotherapy? These are the endless questions in which my field is dazed and confused. Psychoanalytic institutes have a model for training; a model hotly contested, since there are no empirical studies. Traditional institutes have a tripartite model which includes a personal psychoanalysis, four years of classes, and three cases under weekly supervision, where the student goes for one hour a week to report on a patient who is seen four times a week. The lines between supervision and psychoanalysis blur, because since the student goes to his/her own psychoanalyst four to five times a week, then maybe the student should bring his/her questions to his/her therapist and not a separate supervisor. And who becomes a supervisor is yet another question?

Currently, I am working towards passing an examination which will, in one boutique of psychoanalytic training, consider me both a training and a supervising analyst. The training analyst part means that I will see therapists who want to become psychoanalysts, in psychoanalysis. The supervising part has those “fifty shades of grey” which can, as the movie suggests, contain an erotic component. The boundaries in psychoanalysis are clear. The patient comes at a particular time, they pay a fee, and the subject of discussion is the inner workings of the patient’s mind. The boundaries in supervision are subject to interpretation, and hence not clear. The student is supposed to talk about his patient and the supervisor is supposed to give thoughtful feedback, but as with all dyads, unique dynamics develop and the utility of the process is open for question.

In my new study group, we are reading articles about the controversies around supervision, and once again, I am struck at the arbitrariness of the process. Howard Bacal MD writes “a pedagogic ‘big bang’ occurred within the psychoanalytic universe. The ‘tripartite’ system of analytic training officially came into being with the strict separation of its three modalities.” In other words, a model appeared, and it has stuck, and so I am stuck in it. I do not mean that I do not have options, but I do mean that understanding the history enlightens me in that I can work within the model, or I can try to change it. For now, I am working within the model, while generating fantasies about how to change it. The jury is not out whether group supervision is superior or inferior to private supervision. The jury is also not out whether a supervisor should “graduate” to this status by passing an examination, or whether a supervisor should be defined by years of practice. For now, I am growing by learning, even if I am learning just how random professional development can be.

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The world is cracking up.