Analytic Attitude

Symptoms have meaning. This is the analytic attitude, or more specifically there is an underlying reason why human suffering happens. Distress can be aided by medication, but, it can also be understood in terms of past experiences interfering with the present. The more one thinks about suffering, the deeper one can go in terms of understanding the origins and thereby tame the experience by putting into historical context. Going deeper requires intensifying the treatment, and so this is how psychoanalysis, or intensive psychotherapy, can be helpful to those in distress. If going deeper seems frightening to the patient, to the therapist or to both parties, the therapy will become stagnant and perhaps terminate with the notion that there is nothing more to be done. Stimulating deeper treatment can be initiated by the patient or the therapist, and either way, requires great courage since there is  uncertainty as to what that deeper exploration will uncover. Tolerating this uncertainty with the hope of a calmer, and more expansive life can yield a satisfying treatment experience. And so my class has begun. A stimulating conversation ensued, with much disagreement about whether the above makes sense or not.

Intensifying Treatment: Who Decides?

Springtime is time to teach, for me. Tomorrow starts my class entitled “Building A Psychoanalytic Practice”. Our first reading, by Stephen Bernstein MD, discusses the process in which patients begin coming once a week, and for some, there is a transition to more intensive work, meaning twice, three, four or five times a week. To people unfamiliar with psychoanalysis, this might seem to be an absurd amount of psychotherapy. Yet, for those in psychotherapy who feel a sudden or gradual  sense of being understood, of being heard, of feeling significantly less anxious, intensifying treatment makes a lot of sense. Yes, yes, there is significant time and money involved in such a commitment, but let’s put that aside for the moment. The relationship, as Bion famously said, provides a containment,  meaning a psychological enclosure in which difficult and painful feelings can be processed. Outside of psychotherapy those feelings can lead to panic attacks and generalized anxiety, but in the context of a therapeutic relationship, the opportunity to process those feelings often leads to diminishing anxiety, and hence the person feels contained. The inability to contain a patient is seen as a therapeutic challenge, and not necessarily a reason to refer for anti-anxiety medications. The referral, Bion might say, sometimes implies that the patient’s anxiety has overwhelmed the therapist, leading to greater hopelessness in the patient. The struggle to contain the anxiety is the work of the therapy, and sometimes that work requires greater muscle power which can only be achieved by adding more time, which increases the focus on the anxiety, and shortens the intervals between sessions. Like all relationships, the more they are nurtured, the more rewarding they feel, so too, with psychotherapy, that the more the dyad can focus on the issue, struggle with verbal play to understand the psychic pain, the more likely there will be a sense of understanding and psychic relief. The “break it to fix it” model applies here. The patient must experience the pain, intensely, in order to put himself back together in a way which feels both more expansive and more peaceful. Working with patients to increase the frequency of visits, like all aspects of psychoanalysis, is a very delicate process. Some patients may feel that they are “so sick” they need more therapy, whereas others might feel flattered by the desire to spend more time together. Understanding the meaning of proposing a different treatment is the first step towards testing the waters as to whether a deeper relationship makes sense. Therapeutic regression is expected and so both parties are naturally fearful of the outcome. The more time people spend together the more their blemishes are revealed, the more shame both parties can feel, possibly resulting in rage and disappointment, either with themselves or the other. The stew of feelings is expected, but working through them, containing them, examining them, is the work, the art of deep treatment. For some, this will be a life-changing endeavor, again for both parties, but particularly for the patient. For others, the therapeutic regression will cause a stalemate, and there will be a terrible sense of spinning one’s wheels. To enter takes courage. To learn how to enter also takes courage. And so our class will begin.

A Soulmate

 

 

Nortin Hadler, MD, has been doctoring for a long time. He’s old school. Loves a rich doctor-patient relationship, where the whole person – patient – is seen and comprehended.  Treated in full.  But these days, he says, doctors who care are burning out, retiring early, pulling their hair out.  “Today,” he writes, “health is a commodity, disease is a product line and physicians are a sales force in the employ of a predatory enterprise.” Ok! This hour On Point, Dr. Nortin Hadler on how to heal American health care.

— Tom Ashbrook

 

 

 

http://onpoint.wbur.org/2016/03/29/doctor-patient-care-aca-obamacare

 

 

Continuity of Care

The passionate ranter returns. In light of the changing quality of mental health care, there have been numerous issues which have concerned me deeply. Medication management appointments which are fifteen minutes, for example, remind me how superficial and impersonal my field has become. Worse than that though, is that in newer, larger, systems of care, there is a greater emphasis on seeing a “provider” rather than “your doctor”. As if all providers are interchangeable. The move towards automation, in general, has poured into health care, such that the more the system can operate independent of individuals, but rather on groups of individuals, the stronger the system will be. If the system were dependent on a few highly trained professionals, than their departure would wreak havoc with the overall mission of health care, and so now large medical centers are ensuring that care can be handled by a number of providers and so there is less vulnerability. In the world of mental health care, and in particular, in the world of addiction recovery, there is no value placed on seeing the same provider throughout treatment, but rather the value is “being in rehab” meaning that all programs are treated equally and historical perspective is not valued. It reminds me of working on various boards where historical knowledge, perhaps the most critical way of understanding how to get things done, is not considered and certainly not valued. So, too, with mental health care, it is as if the insurance companies have a check-box, such that if someone has a “substance use disorder” then they need to go to a “recovery place” which, as far as they are concerned could be anywhere in the country. If the patient relapses, they could then go to a second “recovery place” which could also be anywhere in the United States, and on it could go for upwards of twenty to thirty rehabs, in extreme examples. My solution, you ask? I propose that fictional patient Erika, for example, be assigned a treatment team, and that treatment team stays with her through her lifetime. Of course, changes could be made, but by and large, this team has stability for her. She will not have to repeat her life history, time and time again. She will have a relationship with her team that gives her the comfort and security to propel her forward in her life, and at the same time, gives her a safety net if she steps backwards. This is a simple idea. It does not cost more money. Why can’t we do this?

 

Perhaps the reason has to do with a vast network of providers who bounce patients back and forth as a way of taking financial care of one another. Or, maybe the reason is that there is a hopelessness about therapeutic relationships. Perhaps no one has the conviction that therapeutic relationships, as the name implies, helps patients heal. Or, maybe the addiction field, in particular, is in its infancy, and as such, needs to grow up to understand this. As with all of my rants, the answer comes from listening. Patients will tell you, if you ask, that they need this continuity, and without it, the treatment programs will  not work. My hope, as I explain to my patients, is that with a greater emphasis, and a greater measurement of patient satisfaction, this issue will come to light. Patients, although vulnerable, by definition, have the power to complain about their care. Maybe with  big data analytics, this issue will have power. I hope so.

Psychiatry Has Become Neurology: Now What?

Most psychiatrists see patients for brief time slots and with long intervals between appointments. This is the Neurology model of care. Diagnoses are made, followed by brief visits every few months. Neurologists can use imaging studies to be more precise with their diagnoses, but Psychiatrists are hoping that will be true for them one day as well. In the meantime, the identity of a modern day psychiatrist is one who sees a large number of patients per day, and beyond that is responsible for a large patient load, as patients are not seen very often. Consequently, the particulars of the individual are not attended to, and continuity of care is thin, at best. Who then, pays attention to the details of everyday life; the stressors which trigger feelings of sadness, anxiety and psychic pain? Is this the job of the non-MD psychotherapist? Perhaps, but how does medication get administered when the physician only knows the current symptoms, without historical context? Maybe the non-MD therapist has good communication with the physician, such that a more informed medication program can be conceptualized? How though, does this physician keep up with all of the different therapists that his patients are seeing? Let’s do the math. A patient every 15 minutes means 4 patients per hour and 32 patients per 8 hour day and 160 patients per week, and about 640 patients per month. Of course, there are new patients thrown in there, which will let’s say be one hour appointments, but still the numbers grow quickly. My issues are two-fold. How do patients get good care with this model and how does the physician feel job satisfaction if he does not know the people he is treating?

A fictional tale comes to mind. Arden, twenty-seven, alcoholic, unemployed, recently broken up with her boyfriend, reports with little affect, “the reason I feel so terrible right now is that the doctors have not been able to find the right medications to help me.” My viscera begin to speak to me. Wow, I think to myself. My profession has really done it again in that Arden is now believing that the problem she has is not related to her alcoholism, her unemployment, or her recent break-up, but rather it is the doctor’s fault for not finding the “right” medication, as if she has a terrible cancer, and there is just no chemotherapy to help her. The psychiatric profession, by being so focused on psychotropic drugs, has encouraged Arden to believe that her mental state can be fixed by medication, and her problem is that she just has not found the right doctor yet. The shift of responsibility from personal growth to dependency astounds me. The belief that medications can change mental suffering and overcome life’s difficulties is a poor message for patients like Arden. She needs to understand that she has to figure out her pain such that she can grow and make a good life for herself, and in so doing, she will feel better. Psychotropic medications may offer some assistance but they are not “the answer” to her problems. As her fictional psychiatrist I can help her see this, but the advocacy of psychotropic medications is so strong she will likely seek another doctor. Once again, I want to say, Psychiatry has lost its way and that is a double loss for both the patient and the physician.

How Does Child Psychiatry Ruin Lives?

Psychiatrists want to help people. Child Psychiatrists want to help children and their families. Many times there are remarkable and heart-warming stories of intelligent guidance and warmth which saves children and families from lives of suffering and despair. This is a story of the opposite. A story, so scary to me, that I feel compelled to write about it as a cautionary tale. To preëmpt my critics, let me start by saying there are many sides to a story and cause and effect cannot be determined. I float in a world of theories and ideas which prove serious consideration resulting in different approaches to treatment. I do not work in a world of certainty or clear scientific evidence. With that in mind, let me tell you the fictionalized story of Joey, age 25, Caucasian, who grew up in a middle class area of San Diego. Joey is the youngest of four children. His three older siblings, by his report were “easy” and he was “difficult”, or so his mother told him. At 6, his mother took him to an academic medical center, trying to figure out why he was “so difficult.” Academic child psychiatrists diagnosed him with “atypical autism” and off he went, at age 6 on a continual journey of psychotropic medications including Straterra, Wellbutrin, and stimulants. Joey reports that being on these medications not only did not help him, but made him feel defective and disabled. Despite those negative feelings Joey got into a good college and did well, until he hit a disappointment, a break-up of a loving relationship, and by his account this triggered his childhood feelings of being seen as “disturbed” and so he, although never having used addictive drugs before, spiraled down into the world of heroin and cocaine. Yes, all of that could have happened without a mental health diagnosis, without being misunderstood as a child with a mental illness, as opposed to a child with a bad temper. Yes, all of that could have happened secondary to parents who felt inadequate to raise him and made him feel very inferior to his three older siblings, even if they had never sought a psychiatric evaluation and treatment. My point, however, is to illustrate that in this fictional tale, it is plausible that the medical team made Joey’s life worse.

What would have happened, I wonder, if the child psychiatrist had said that Joey is a wonderful kid, outlining his strengths, who needs help with anger management? What would have happened if the child psychiatrist would have guided this family towards a more positive parenting model where Joey was seen as a child who could go on to great things, as opposed to seeing Joey as a person who would forever be disabled and crippled by his limitations? Joey’s story, with all of the uncertainties associated with it, makes me cry. I cry because whether this applies to Joey or other adults out there, growing up with a label that suggests they are limited in their abilities, when in fact, they have enormous potential, I feel the tragedy of what our profession has done to their lives. Yes, I have diagnosed many children as autistic, but my bar is low, as it should be. The label, and I understand it gets very needed services, has the hazard of diminishing the self-empowerment of that child. It has the potential to take a capable person, perhaps with some rough edges, and make them feel small and helpless. Children, and adults, need understanding to flourish in this complicated and demanding world. Psychiatric labels oftentimes limits that understanding and that alone can have dire consequences. Add to that the journey of psychotropic medications which flows from that diagnosis, leads to an identity confusion that can cripple the budding adult. Joey was not crippled by his biology, I suspect, but he was crippled by his psychiatric journey. Tragic, unnecessary.  and it has to stop.

Precision Medicine

 

http://newsroom.ucla.edu/stories/daniel-geschwind-to-head-all-precision-medicine-efforts-in-health-system-medical-school

 

It is no longer the question as to how do you treat Type II diabetes, but rather, how to treat Mr. Jones and his diabetes as it may be a different variant from Mr. Smith’s disease. Sounds great, yes? Dan Geschwind, a neurologist, a family member of Norman Geschwind, also a neurologist  https://en.wikipedia.org/wiki/Norman_Geschwind, heads the UCLA Precision Medicine ?Department and I support him fully. With the new technology of genomic mapping, we can now look closely at the genome of cancer cells and infectious agents to determine the specific form of the disease. So, instead of being diagnosed with “ovarian cancer” in the future, which is almost the present, the exact type of cancer will be determined and treated accordingly. You could say that we move from “gross medicine” to “precision medicine”. Well that all sounds good except when it comes to mental health care. You might think that as I promote individualized care with this blog that the idea of precision medicine would give me a sigh of relief, but alas, it does not. The language of today is that “depression is a heterogeneous disease,” to which I say, duh. To map the particular defect which causes human suffering is indeed exciting, but not likely to be clinically useful. Almost thirty years since the birth of Prozac, we, as a field, are finally admitting that our medications are not robust, and in fact, give relief to a relatively small percentage of people (let’s say 60%-for round numbers, with placebo-30%). Now, you might think that would humble us, but no, humility does not seem to be in our culture. It only encourages the search and promise for the “next best thing” which is now genetic sequencing to determine drug metabolism. http://genelex.com/pharmacogenetic-tests/. With new technology comes new business, not necessarily improved patient care. New does not mean better, my marketing friends tell me, but new sounds better and so money is made. Once again, I pursue my rant. Advances in medicine do not necessarily translate to advances in psychiatry, leaving the “old school” listening tool one of the best methods to  alleviate human suffering. I stand by that.