The Making of a Professional Patient

🤒🤕🤒😷

Fear motivates me to post today. I have come to realize that the “do no harm” approach to patient care is being violated without malicious intent, but still quite concerning. Newly trained psychiatrists are taught that a psychiatric diagnosis is definitive and as such, certain treatment protocols are indicated, and as such, if the patient “fails” the protocol, they are sent to a higher level of care, which in brief, means they could become, what I have termed, “a professional patient”. Kai, age twenty-one, comes to mind. She is a Caucasian young woman who was having trouble at home and at college, and so complained to her friends that she was suicidal and that she was thinking of jumping in front of traffic. This alarmed her friends, who in short order, called the police who then brought Kai to a psychiatric hospital on a 72 hour hold. This hold was quickly turned into a voluntary admission at which time she was diagnosed with “borderline personality disorder” and she was told that as a result of this diagnosis, she needed to be on Latuda, an antipsychotic medication, and she needed to go to Dialectical Behavioral Therapy. She complied and she was discharged from the hospital and two months later the situation repeated itself. This time the hospital told her that she needed a higher level of care, since the DBT and the Latina did not seem to help her, and so she was sent to a residential facility for three months, on the recommendation of the psychiatrists at the hospital. Why does this story alarm me so much?

Reason 1. Kai is twenty-one years old. She needs to find autonomy from her parents, and she needs to continue on her train of maturity and psychosocial development. Hospitalizations, and residential treatment do not, by and large, promote development, but rather they promote dependency. Few decisions have to be made. By definition, institutional settings are regressive, and they create passivity as opposed to forward thinking life-planning skills.

Reason 2: The diagnosis of borderline personality disorder is often applied to women who create a lot of affect in others. That is to those who make their providers anxious because the treatment plan is unclear. This anxiety in the provider, used to be fodder as a way of understanding countertransference, but is now used as a way of pathologizing the patient, and thereby taking away any emotional work that needs to be done on the part of the provider to give deeper and more meaningful patient care.

Reason 3: Psychiatrists are being trained that diagnoses are definitive, and there is no thought that perhaps the diagnosis is given prematurely, and/or needs to be questioned for quite some time, before treatment is recommended. As such, this twenty minute diagnostic evaluation is nothing short of frightening, for both patient care and for physician training.

Have I said all of this before? Of course. Do I feel I need to say it again? Of course. The fictional Kai is going down the rabbit hole of passive treatment, thereby preventing her maturation. That is a tragedy. The fictional physicians are poorly trained to do assessments, and as such, treatment recommendations do not fit the patient’s issues. The fictional physicians will come to understand that their certainty is questionable, and as such, burn-out and dismay are likely to follow as their career progresses. Do I want to sound the alarm bell? Absolutely. Anyone listening?

Mental Health Specialists

https://study.com/articles/Mental_Health_Specialist_Job_Description_Duties_and_Requirements.html

 

 

The future of psychiatry involves less direct patient care, or so says James Phelps MD of the Samaritan Health System in Oregon. MHS, or mental health specialists, an un-licensed position takes the history, reports to the psychiatrist who then makes suggestions to the primary care physician. Am I missing something? The nuance of the narrative is lost without a skilled listener. Medicine, not just psychiatry, is losing this narrative and replacing it with symptom checklists which right now can be done by college graduates, but in the future, is likely to be done by computer. Large systems of care such as Kaiser or UCLA are going to absorb the liability making doctors less fearful about making recommendations without taking  their own history. No license means no regulation, no specific training and no mandate for continuing education.  I have said on this blog many times how appalled I am that the listening skills of a psychiatrist are no longer valued, but the creation of this new position is a new low for me.  The listening bar has been lowered such that diagnosis and treatment is based solely on symptoms, without any room for, dare I say, intuition. Listening, I trust, will always be valued by patients, but clearly it is not valued by health care delivery systems. Medicine has gone corporate. I know this is not all bad, but for those who have mental suffering, it certainly is bad. Patients with difficult feelings need to be heard. They need to control their narrative. They need to understand themselves. Being evaluated by a mental health specialist will not accomplish that, and for that, I am very sad.

Editor Job: Returns…

Being on a board, often means being bored. Talking about budgets and money management and grant proposals can get dry and tedious. And so, I ask myself repeatedly, why I have stayed on this board, the Psychiatry Clinical Faculty at UCLA for over 15 years. You can read my editor’s note below to see the answer to that question, as I find our overall purpose both meaningful and essential to the next generation.

 

 

 

https://www.pcfala.net/

 

 

As Editor of this newsletter, I am so pleased to see how we, as psychiatry clinical faculty, have continued to pass the baton to our students to say that psychotherapy still matters, and it still matters that it is done by psychiatrists. Our board works tirelessly, now under the leadership of Dr. Sones, to give the adult residents from UCLA, from Harbor, and from Olive View/Sepulveda, along with the child fellows in these programs, the support they need to grow professionally into psychiatrists who are skilled with listening, thoughtfulness and deep caring of patients who need our help. We do this by offering them psychotherapy for a very reduced fee. We do this by offering as much supervision as they choose to partake, and we do this by giving them didactics which center around the doctor/patient relationship. We do this by having meetings and social gatherings throughout the year to remind them that they are part of a larger psychiatric community, and now we added on by offering mentorship to young trainees who want career guidance. This newsletter is a way of saying thank you for all you do and to remind you that your efforts are not just valuable, but essential, to our mission to promote the training and development of well-rounded psychiatrists. During the year, we soldier on, but as we review our work in this publication, we have a chance to reflect on our value as an organization. Indeed, we need to soldier on. The trainees need us. Thank you again for all you do.

Neural Networks

The chemical imbalance theory is out. Neural networks are in. That is what I learned yesterday. With the introduction of Transcranial Magnetic Stimulation (TMS), a neuromodulation therapy for major depression and post-traumatic stress disorder, there is now the theory that mood disorders, and anxiety disorders are a result of a neural network failure and as such, therapies which jolt neural networks help patients feel better. Further, by examining EEGs and looking at brain electrical activity, clinicians might be able to predict who can benefit from TMS therapy. As I understand from Noah Phillips MD, a professor at the VA affiliated with Brown University, we, as psychiatrists, are exploring the notion that patients get better by changing the electrical activity in the brain, a re-boot, so to speak. At the same time, TMS, although FDA approved (it should be now called Food, Drug, and Device Administration), TMS is costly, time-consuming and not paid for by insurance. It is done at tertiary medical centers and in private practice. As with the use of psychopharmacology,  I am of two-minds about this technology. On the one hand I am excited about the new way we understand mood and anxiety, and the expansion beyond neuro-chemicals into neural networks makes a lot of sense to me. The brain is a complicated machine, and like a machine, things can go wrong, and re-setting it is very exciting. On the other hand, this technology supports the loss of a narrative. Patient is sick. Patient gets fixed. Next Patient. The medical model of human suffering dominates the clinical picture, and the individuality of the patient is lost to the physician, leaving the narrative to “lower-level” professionals. Clearly both can operate in harmony. Doctors could administer TMS and do psychotherapy, except that the model of care does not support combining these modalities using the physician as the deep listener. I am grateful to be so close to UCLA so that I can be exposed to the latest and greatest in psychiatric health-care. At the same time, I will always have a sadness when I go to lectures, that there is such little interest in the human component of mental health care. To put it another way, as psychiatry focuses on the brain, it has lost its mind.

 

https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation

Teaching, Teaching and More Teaching

 

So, where, whom and why do I teach? The where is easy: UCLA, New Center for Psychoanalysis and LMU (sometimes). The whom, is also easy. I teach psychiatry residents, child psychiatry fellows and psychotherapists. The why is the challenging question. It keeps me stimulated mentally and it keeps me feeling young and in touch with the next generation. That is the short answer. The longer answer is more complicated. Do I like the admiration that sometimes results from a teacher/student relationship? Yes, and no, is my answer. Yes, it sometimes feels good, but no, with that admiration comes the flip side of “falling down” at times, as the student matures professionally. The teacher/student relationship, like the parent/child relationship is fraught with both idealization and devaluation. Like raising a child, in the beginning, there is a feeling of deep love, on both sides, but as the relationship develops over time, the dynamics get more nuanced, more layered with good and bad feelings. To teach is to grow, I would like to say, and I believe that to be true. Yet, with all growth, comes pain, and struggle, and so the challenges are large. I see myself as a life-long student, and as such, I have signed up for the life-long struggle of learning, growing, and expanding, which can feel exciting, but it can also feel  remarkably humbling. No one said growing is easy, and so it is not.

TalkSpace

Meaningful therapy from every device

It can be difficult to wait days or weeks until your next appointment. With Talkspace, you can send your therapist a message whenever you’re near a laptop, tablet, or smartphone. Your conversation carries over seamlessly across devices and uses banking-grade encryption to keep it safe and confidential.

How Therapy Works on Talkspace

Learn more about ONLINE THERAPY

Getting Started

Get an Assessment

Chat with a matching therapist to identify your therapy needs.

Choose the Right Plan

Choose a payment plan that suits your budget. Plans start at $32/wk.

Find Your Match

We’ll help you find the best therapist for you.

Begin therapy

Start messaging your primary therapist anytime, anywhere.

During Therapy

Your Own Therapist

Once you’re matched, you’ll be working with the same licensed therapist every time.

Write When You Want

You can set aside some time every day, or write when the mood strikes you. Your room is always open.

Regular Responses

Therapists respond 1-2 times per day. If you need more, simply schedule a video chat.

Customer Support

Customer Support is available to help answer non-clinical questions about how Talkspace works.

https://www.talkspace.com/

 

 

Oh my, the world changed again, and I just woke up to text therapy. Talkspace is a company that offers packages for texting therapy. Do I text my patients, you wonder? Absolutely. I have embraced the technology early on, as I find texting a great way to communicate and keep in touch. Having said that, what do I think of therapy that is only done by texting. I am simply outraged. Free association is the mainstay of psychodynamic psychotherapy, and so the critical feature is to allow the patient an open space to understand how their mind works by listening to how they put ideas together. Texting, like tweeting, limits the amount of verbal output and as such, limits the depth of the experience. Plus, writing and speaking are two very different forms of communication, and there is something very valuable to a verbal exchange which happens like ping-pong, where ideas feed each other. This is the basis for the “good fit” in psychotherapy where the patient’s mind and the therapist’s mind need to be able to feed one another for the therapeutic process to get started. To only have text as a therapeutic tool is to me, yet another way, in which mental health is being diluted from a high quality profession, to one that can be done “easily” with a smart phone. The complexity of psychotherapy needs to be embraced and not denied. This Talkspace company, although perhaps profitable, strikes me as a very poor substitute for good treatment. Once again, the question arises about whether I am resisting new technology or whether new forms of treatment are not necessarily better forms of treatment. Both, of course, could be true. In this case, the latter seems clear to me. New is not better, it is just new.

New Job: Editor of PCFA Newsletter!

 

 

 

 

https://www.semel.ucla.edu/pcfa

 

In the continuing plea for a psychiatry of days gone by, I have accepted the job as Editor of the above Newsletter. I have been a member of the board of this organization since 1995 serving in various capacities including child psychiatry liaison, member of the retreat committee, member of the diversity committee, secretary and now Editor of this newsletter. This organization is a support to the psychiatry trainees in UCLA affiliated programs including the San Fernando Valley Program and the UCLA-Harbor program. We provide low-cost psychotherapy to trainees, along with supervision of trainees.  In addition we   provide many didactics. For example, in addition to my work on the board of the PCFA, I do individual supervision to four adult psychiatry residents, a shift for me, as I used to provide supervision for child psychiatry fellows.  In addition, I give the adult psychiatry residents lectures on childhood assessment, and in the past, I gave the child psychiatry fellows a class on child psychotherapy. Now, I am adding on by helping this newsletter publicize our work, as I feel the strong pull to remind psychiatrists, at all levels in their careers, that listening is an important art, which could sadly be lost, if we are focused on fifteen or thirty minute appointments, with infrequent follow-up. It is my hope that by carrying the torch of listening, both by teaching this art and by doing this art with trainees, then psychiatry will maintain one of its major therapeutic tools, that is, the talking cure.

Is Psychiatry As Bad Off As I Say It Is?

Check out Kelly Brogan MD…http://kellybroganmd.com/, a psychiatrist, similar to my thinking, advocates for mental health without medication. Now, I do not completely agree that medications are hurting patients, although sometimes that is true, but I do agree that we as psychiatrists have gotten trigger happy, which means we are too eager to prescribe, and too reluctant to listen and put symptoms in context. I have recently taught second-year psychiatry residents (UCLA-15 total), psychodynamic psychotherapy students (New Center for Psychoanalysis-9 total) and I am about to teach primary care doctors .https://www.cme.ucla.edu/courses/event-description?registration_id=146702 about the diagnosis and treatment of anxiety disorders.  In each of these very different audiences I lament the loss of history taking in psychiatry, associated with the rush to prescribe and the consequences being unrealistic expectations and poor understanding of one’s personal dynamics. Associated with this are tremendous health care disparities in psychiatry where those without means are given care which is significantly lower quality than care given to those with discretionary income. Further associated with this are training programs where students learn to read checklists as opposed to asking and listening to open-ended questions. The patient’s narrative is lost and with that comes the loss of the excitement and joy of self-discovery; this loss being for both patient and provider. Burn-out seems like an inevitable consequence of our new model of care, but it will take many years to document this and so we must wait for evidence to validate our suspicions. Meanwhile patient care is suffering, and those with means can seek out care that makes sense, while those dependent on public funds are left to focus on symptom relief and not bigger picture understanding of what is killing their vitality. “I make students depressed” I say frequently, always to laughter, which goes with the grain of truth this gloomy picture represents. Exposing the problem remains the first step. Hence, I will repeat myself until this broken system starts to mend.

Should Psychoanalytic Teachers Get Paid?

Tonight I begin my new class in the psychoanalytic psychotherapy program at the New Center for Psychoanalysis. My class is on clinical technique, about what do you actually say when you are in the room with someone, if you are attempting unconscious exploration. In the past, this has been a stimulating class to teach with bright and interesting students and I have always felt that I got back more than I gave forward, and yet, many people have asked me why I don’t get paid for this activity. Tradition is the short answer. Those who taught me, whom I am eternally grateful to, were not paid, so I tell those interested that I am paying it forward. Upon further reflection, though, I wonder if the quality of teaching would improve if there was a stipend associated with the activity. Would market forces create a healthy competition where only the best teachers were asked back, and in turn, the teachers would have incentive to be on the top of their game? In the psychoanalytic community, this discussion is taboo. Like so many traditions, the “young” people are not supposed to question older, more established practices. Like the movie “Moneyball,” the senior members are quite certain they are making the best decisions, even though big data showed that, in fact, their “traditions” failed them. As a medical student, doing rotations in different clinical settings, I learned quickly that the practice of medicine was highly dependent on the reimbursement system, where, in the days before productivity measurements,  doctors who were salaried tended to work less than doctors who were fee for service. This seems obvious in that if someone is paid the same whether they see ten patients or twenty patients, then they are going to argue to see ten patients, and vice versa. Reimbursement systems, like all behavioral systems, impact behavior, and physician behavior is included in this paradigm, of course. So, am I saying that I would be a better teacher if there was a salary associated with it? I think so, but I am not sure. It is an interesting question.

Meaning Making: Class in Review

30 students, different backgrounds, all engaged in a lively discussion of what it means to have meaning, and how patient’s come to us (clinicians) in search of meaning because either they have lost meaning or they never felt they had any. The discussion was broken up into to parts. Part one involved the fictional tale of a middle-aged woman who could not find any inner peace. Externally her life seemed enviable, but internally she never felt any traction. To say that she is depressed misses the point, we discussed, as her disposition was cheery, and her self-care was excellent. Yet, she never felt that what she did really mattered, either to herself or to others. In this fictional case, we explored her childhood roots, her exposure to her parents and our presumption about their internal world. We talked about what it meant to her parents that she was born, and how downstream that caused her to feel unimportant and lost. The students asked lively questions about how to help someone have meaning, when no obvious intervention seems to take hold. The obstacles to having meaning were discussed, as in this tale, the obstacles had to do with her internal alliances to her family in which if she did not mirror the meaning her parents put on the world, then she felt a huge sense of unconscious betrayal and so she could not latch on to new passions. The second part of the morning involved another fictional case, this time of a young adult who was trying to find his way in the world and the obstacles he felt in doing so. Issues of gender, sexuality, professional identity were all mentioned, again in the context of trying to make his parents proud of him, while at the same time developing his own sense of meaning. The relationship between meaning and attachments were discussed in length, as most meaning is made through both conscious and unconscious attachments in that passion is derived from feeling like one key person in your life is going to be very proud of you and in that mental image, enthusiasm is born. The underpinnings of happiness were discussed in a positive psychology model as contrasted with the persistent focus on the underpinnings of distress. Meaning is made if the person can have his life make sense to him. That is, often, but not always, a tall order. And so, my next class is on my mind. How about Healthy Happiness? It is a thought.

MEANING MAKING: HOW TO HAVE A THERAPEUTIC CONVERSATION  |  View Full Calendar

Presented by Shirah Vollmer, M.D.

2/4/2017

General Admission: $55.00

Student Rate: $30.00

How patients integrate events into their lives on a deep psychological level is
fascinating and psychoanalytically rich. One person’s motor vehicle accident is a
small matter, whereas the same intensity motor vehicle accident to another
person is a major catastrophe. Understanding the differences in how people
interpret their worlds is the fascinating work of using psychoanalytic thinking in a
therapeutic setting. This class examines how people have both conscious and
unconscious meaning associated with their lives and as such, they react in ways which both make sense to them and, at the same time, confuses them. As
these layers of meaning are uncovered, a therapeutic conversation ensues
which enriches the patient’s understanding of himself, and thereby creates a
calmness which allows them to get in touch with creative juices and along with
that, a deeper sense of vitality. They experience psychological freedom which is
liberating in ways they could not have imagined before they entered deep or
intensive psychotherapy.

 

Learning Objectives
As a result of attending this course, participants should be able to
• Learn how to probe for conscious and unconscious meaning in a patient’s
presenting complaint
• Recognize how psychoanalytic understanding can aid symptom relief
• Identify how stimulating thought in the patient and helping the patient to be
curious about themselves, produces therapeutic gain

Shirah Vollmer, M.D., is a member of New Center for Psychoanalysis, teaches
in the Training and Psychoanalytic Psychotherapy Programs, and maintains a
private practice in West Los Angeles.