Prove That You Need Me

I’ll confess, sometimes after I see a patient I ask myself, “was that really necessary??”  That’s not to suggest that the interaction was a complete waste of time, or that I regularly provide treatment that is excessive or harmful, but I am frequently reminded of an observation I first made many years ago:  we in psychiatry provide a lot of “care” that might be considered unnecessary and, in the long run, wasteful and inefficient.

(Note: I am specifically referring here to certain aspects of outpatient mental health treatment.  The same might occur in other medical specialties, but those aren’t my areas of expertise, so I can’t comment.  Furthermore, I am NOT referring to regular health-maintenance visits to one’s primary physician, pediatrician, or OB-GYN, in which the “care” consists of an examination and, if necessary, screening tests or preventive measures.)

Consider the following examples of wasteful, inefficient care in psychiatry.

I see many patients (particularly in the community setting) who have been “treated,” often irregularly and infrequently, by a variety of psychiatrists or other physicians who have doled out a half-dozen psychiatric diagnoses and a laundry list of medications.  When I see patients like these, their complaints are usually vague and nonspecific, adherence to past treatments has been questionable, and a substance-abuse component is often present.  While these patients may indeed suffer from mental illness (or, in many cases, simply face profound psychosocial stressors that the system allows us to call mental illness), it is unlikely that these patients will receive the resources they truly need from conventional psychiatric practice.  However, it’s convenient—for us as a society—to shunt them into the psychiatric juggernaut, where they often lose any hope for lasting recovery.

Another example is the patient living in difficult, stressful circumstances who is referred to a psychiatrist by a social service agency or by the criminal justice system “for an evaluation.”  Again, these individuals may face huge psychosocial stressors—and may indeed benefit from professional assistance of some sort—but psychiatric care?  It’s hard for a psychiatrist to say no.  Instead, we give a diagnosis, frequently an “NOS” diagnosis, which, in practice, means “he sort of looks like he might have depression or an anxiety disorder or psychosis, but we’re not sure yet.”  This may be justifiable at first, but unfortunately these diagnoses tend to stick—and, interestingly, patients are rarely undiagnosed—locking the patient into a neverending roller-coaster of medication trials and, not uncommonly, a lifetime of psychiatric “disability,” at great expense to all.

Finally, there are those individuals who see a psychiatrist at the urging of their primary doctor or a family member.  They may complain of very legitimate symptoms of irritability or mood lability, guilt or sadness over a recent loss, sleep disturbance or anxiety, or chaotic personal relationships—phenomena which we have all experienced to various degrees.  Sometimes these symptoms are incapacitating; sometimes not.  But we psychiatrists are good at making square pegs fit into round holes; through our DSM-tainted lenses, we give whatever diagnosis “fits best”—often the dreaded “NOS,” discussed above.  Furthermore, because many of us are loath to send a patient home empty-handed—and ill-prepared to do anything other than diagnose or prescribe— we give a medication which we think might “work.”  (And if it does, we see it as affirmation of our diagnosis, but that’s material for another post.)

These three situations are common in psychiatry.  I’m absolutely not saying that patients like these should be denied treatment, “shown the door,” and asked never to return.  As a mentor taught me many years ago, no one sees a psychiatrist when everything in his or her life is perfect.  But sometimes we fail to recognize that the psychiatrist may approach the patient and his or her complaints in the wrong way.

I believe that, when evaluating patients, psychiatrists should use the tools of scientific investigation:  an open mind (although we can use our past experience and intuition, as long as we search for data to support it, too), deep interest and curiosity, a systematic method of analysis, and, most importantly, the lack of bias or predetermined outcome.  A significant aspect of this “data collection” is an accurate assessment of the patient’s resources and ability to overcome his symptoms; if his resources can be augmented by psychotherapeutic intervention or by medication, fine, but if not (or if an accurate assessment of his strengths shows that such intervention is unnecessary), then we must have the willingness to say no and back out.

Let me emphasize once again, I am NOT saying that we should be skeptical of patients, or ignore their complaints.  But we need to acknowledge we are predisposed (as a result of our training, the nonspecificity of the DSM-IV, and the current treatment paradigm in psychiatry) to see “mental illness” where it may not exist, and prescribe drugs in response.  As a result, patients sometimes feel that their complaints “aren’t heard” or are “misunderstood.”  Alternatively (and worse, in my opinion), some patients may actually buy into the diagnosis (when in fact it may just be a figment of the doctor’s—or the APA’s—imagination) and use it as an excuse or a rationale for not taking other measures to engage in lifestyle change.  To provide truly compassionate and patient-centered care, we must act differently.

I know some psychiatrists will respond, “I always see my patients with an open mind, I’m fair and honest, and I give the patient the benefit of the doubt.”  Of course, there are exceptions, but as a product of psychiatric training within the last decade, I can attest to the fact that this approach is rare.

Psychiatrists are taught to look for pathology, not health.  And as they say, “seek and ye shall find.”

A more life-affirming and empowering strategy might be for the psychiatrist to (a) first evaluate a person’s strengths and assets, (b) carefully assess the patient’s goals or desires, (c) determine what prevents him or her from achieving those goals, and, most crucially, (d) determine whether the psychiatrist has the means to help the patient achieve those goals (not necessarily to “correct a symptom” or “treat a diagnosis”).  Then and only then can treatment commence.  Otherwise, we’re spinning our wheels, misleading our patients, wasting our time, and serving no one.

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41 Responses to Prove That You Need Me

  1. Rob Lindeman says:

    Teach your mouth to say “Mr/Ms. X, you don’t need to see me, or any psychiatrist, for that matter.”

    • stevebMD says:

      Rob,

      Ironically enough, I have said precisely this to many patients over the years. And in all cases (well, except for those receiving disability for their “bipolar” or whatever), they’ve been pleasantly surprised to hear this. However, each time I’ve also been visited by my clinic manager or supervisor, who told me I can’t do so– and, oh yeah, be sure to prescribe a med, too, otherwise we can’t bill for your sessions.

      So not only do psychiatrists find it hard to say no, but it is awfully hard to discharge someone from a practice. We’re not taught how or when to do it (see this post), and the health care system makes it impossible much of the time.

      • mara says:

        :( Out of curiosity, what do you do when you suspect that a shrink will not be necessary, but some other form of help will be? Like if someone is not bipolar, according to your judgment, but that doesn’t mean they still don’t need help or wouldn’t need disability checks. I don’t mean people who are milking the system and pretending a bipolar diagnosis. I mean people who are not faking and were diagnosed bipolar. If you deem the person is not bipolar, but you think there is still a disabling psychological issue that needs to be addressed (and cannot be appropriately solved through meds) what do you do?

        I’m not sure what I’m talking about. Maybe someone with an undetected brain injury, severe learning disability, autism, or other kind of issue that really can’t be resolved with meds, is not due to bipolar disorder, and still requires help…Just not your help.

      • stevebMD says:

        mara,

        You raise a very good question. In re-reading my post, I realize I may have sounded a bit too cavalier (self-righteous, even) in claiming that I may “know” who does or does not need psychiatric treatment. Of course, there’s no way for me to know. Psychological well-being is a subjective phenomenon and I cannot experience what my patient experiences (see my post “We Do Not Know What We Cannot Know”).

        Within your question, however, lies one possible answer. You speak about a person who is “not bipolar, but … there is still a disabling psychological issue…” which describes the majority of who we treat in psychiatry. (Not that people aren’t bipolar, but the DSM construct of “bipolar” is far too broad to reliably capture the individual experiences of our patients.) You also mention brain injury, learning disability, autism, etc.– and, in fact, there are numerous other factors that affect a person’s psychological makeup. I guess the “solution” would be to encourage, or require, psychiatrists to consider all those other factors– not just how the patient’s complaints fit into a DSM diagnosis, but every aspect of the person’s being, and treat accordingly (not always with medication). In theory, this is how psychiatrists “should” view patients (think of the multiaxial system, the “biopsychosocial formulation,” etc) but in practice it is not. Square pegs, round holes, and all that…

        Instead of calling this post “Prove That You Need Me,” perhaps the title should have been “I Need To Figure Out What You Need, And If It’s Not What I Can Give, I Either Find It For You Or I Butt Out.” But that would’ve taken too much space. :)

  2. Peggi says:

    Outstanding posting!

  3. lizzy says:

    i LOVED this post. i’ve struggled with mental illness for quite some time, and it always surprises me when a friend says, “oh– i’m bipolar, too!” and i wonder– when they are depressed do they sleep all day and cry all night? have they ever gone for nearly a week without sleep and felt “AWESOME!” usually, they haven’t. but sometimes they are happy, and sometimes they are sad, and by god that psychiatrist told them they were bipolar. it almost ALWAYS has been followed up by an INCREASE in symptoms, as they seem to live out what their psychiatrist has told them they have. blah!

  4. AJ says:

    Great post, and very insightful as always. I wonder, What do you have to say to the psychiatrists-in-training? It seems to me the easy way is to continue preaching the gospel of the DSM/BigPharma/pseudo-EBM, but the few of us who have taken the red pill (matrix reference) might need some guidance to not fall into despair. I’d love to hear your thoughts.

  5. Dr. Balt,

    In one post…

    You summarized, as doctor, what many non-professionals have been desperately wanting to have the medical community hear… for years.

    You validated the views of people who’ve been told to be quiet…
    In other words, you knocked it outta the park.

    Duane

    • Dr. Balt,

      You laid out a great strategy (at the end of your piece) –

      “A more life-affirming and empowering strategy might be for the psychiatrist to…”

      A challenge to you –

      Dont’ just write about it…
      Do it.

      Duane

      • stephany says:

        I agree, talk the talk and also was going to comment that a brain injured person, or autistic, etc as Mara pointed out, that may need help, but not from a psychiatrist is right, because unless a person is seeking a medication intervention this is what you WILL get from a psychiatrist. It would be better off to find a neuro-psychologist for care and a therapist that works with that doctor. In my opinion.

  6. Psychiatrists wear several hats that appear to be incompatible. As a medical specialty we diagnose and give drugs. (I’m thinking of your recent post with this theme. Note that “physician” means one who gives a “physic”, i.e., a medication.) On the other hand we have a venerable dynamic/analytic tradition that opposes diagnosis, and tries to understand people as people and feelings as feelings. And on the third hand we have police powers of the state, where unlike peer support — your other recent post — we are charged with “tying patients’ hands behind their backs” to prevent immediate self-harm.

    Our job is to wear the right hat at the right time, and it isn’t easy. Insurers require a DSM diagnosis to justify treatment, even when dynamic therapists have no use for such diagnoses, and they often don’t apply. Most of us never wanted to be policemen either.

    When I supervise in the training clinic I often hear about “patients like these, their complaints are usually vague and nonspecific, adherence to past treatments has been questionable, and a substance-abuse component is often present.” I urge the psychiatry resident to shelve the medical model momentarily, and learn what the patient is really doing there, and what professional intervention, if any, has the potential to actually help. Biopsychiatry and even “police psychiatry” have their place, but I fear our profession loses its way in a headlong rush to diagnose, i.e., categorize. Your life-affirming and empowering strategy at the end of your post is essentially the dynamic viewpoint with all the psycho-babble left out. In my humble opinion it’s the only way to stay human in this field.

    • Rob Lindeman says:

      It’s true that you inherit the history of dynamic psychiatry. It was a brief history, usefully dated from the publication of “The Interpretation of Dreams” in 1900, to the introduction of Phenothiazines in the 1950’s. Deserving of veneration? Sure, but too brief. Apart from analysts, who still practices dynamic psychiatry?

      The police function, sadly, is much older, dating from the “mad-doctor” period in 18th-century England. As for wearing the police hat, you may be “charged” with the duty to coerce your clients, but “must” you? Can you answer without saying the word “malpractice”?

      • I agree the history of dynamic psychiatry has been brief. I’d say the real phase-out happened with the 1980s “decade of the brain,” when research funding and the APA’s attention firmly turned toward biopsychiatry. But “some” familiarity with dynamics is still a “core competency” of residency training according to ACGME. And in some programs, eg the one where I teach in San Francisco, it remains prominent. Probably the best known dynamically based training program in the US is at Columbia University. So some non-analyst psychiatrists, old and new, still practice dynamically. Not many though.

        Yes, I must coerce patients on rare occasions. *Not* to do so would be malpractice. It’s one of the least favorite parts of my job. What’s interesting to me, though, is the brinksmanship that’s sometimes involved. Some patients “up the ante” until my hand is forced, or nearly so. Like political protesters who decide to get arrested for their cause, some patients get themselves committed apparently to confirm that shrinks, society, or life in general are harsh and cruel to them. They could avoid the whole scenario, but they don’t. In such cases I try everything in my power to short-circuit the dynamic, and keep them out of the ER. On the other hand, there are many severely disturbed (psychotic, frankly manic, profoundly depressed) people out there where involuntary treatment is unequivocally a kindness. In my psychotherapy practice I almost never encounter such patients.

      • Rob Lindeman says:

        Yes, DSM-III provides a firmer end-point for the end of the Era of Dynamic Psychiatry then the introduction of first-generation anti-psychotics. Then we may bracket the era with the publication of two books: Freud’s “Interpretation of Dreams” in 1900, and Spitzer, et al “DSM-III” in 1980!

  7. And I Hate Waffles says:

    First, your placement of “bipolar” within quotes is quite amusing to me. It fits me quite well, I think! Minus the whole disability thing. First I wasn’t bipolar, then I was, then I wasn’t, then I was again, then I wasn’t, again. And then I was. Again. You know what would be really nice? Is if a psychiatrist would listen to me when I say, “I’ve scoured my entire history and aside from that one funky response there’s nothing remotely bipolar in there”.

    This whole topic is funny to me, in a not-so-funny way. My doctor insists I have a psychiatrist, my therapist insists I have a psychiatrist, the hospital insists on hooking me up with the local MHA which also insists on hooking me up to one of their psychiatrists. It would seem everyone but myself actually wants me seeing a psychiatrist. Personally, seeing a psychiatrist drives my anxiety level through the roof and I think I’d actually be just slightly more stable without one!

    As much as psychiatrists might be thinking, “why is this person even here?” or “was that really necessary?”, some clients are wondering if psychiatrists are wondering this, and they’re feeling the guilt for it too. Some clients become so preoccupied by what their psychiatrist might be thinking of them that they end up trying to make themselves seem irrelevant in hopes that their psychiatrist won’t deem them “difficult and irritating”.

    With regard to med-compliance, at least I have a psychiatrist who says, “if it’s awful stop taking it”, so I can stop feeling guilty about my med-compliance. Zyprexa hunger is one seriously good reason to stop taking a medication. When your cravings are so strong you end up eating until you puke and still feel hungry and omgneedwafflesRIGHTNOWori’llDIE, then and only then can you finger-wag about med compliance. I think this drug should be administered to all psych interns as part of their learning experience.

  8. Carol Levy says:

    Seems to be this ties to the other postings youve written where the answer becomes the next tiers, psychologists, social workers, etc. You are needed to do the ‘diagnosing’, and the quotes are a result of all the debate about naming. After that if they do not need meds and medical coverage refer them where they can get some of the other help mentioned, social workers, esp for referral for housing , financial issues, etc.
    It seems to me it keeps coming back to the medical model vs. common sense.

  9. Carol Levy says:

    Thought you would find this of interest:

    Psychiatry And Modern Science: Perspectives On The DSM

    http://www.huffingtonpost.com/2011/12/07/psychiatry-science-dsm_n_1135459.html?ir=Healthy+Living

  10. catsrgreat says:

    So many people who see a psychiatrist are survivors of child sexual abuse or serious emotional or physical abuse. Often, lives are utterly shattered by these experiences. Don’t you think that is where a lot of these “bipolar” diagnoses come from? But there is no help targeted towards abuse survivors – their problems have to be pigeonholed into “major depression,” “bipolar,” etc. in order to send help their way.

    • stevebMD says:

      Yes, I think you are right. To be fair, psychiatric training does encourage the detailed assessment of a patient’s childhood, family background, traumatic events, adverse life experiences, and so forth. Moreover, as Dr Reidbord points out, the ACGME requires training in several modalities of therapy, some of which emphasize these events more than others. And, of course, individual psychiatrists vary in their ability (or willingness) to incorporate these details into their management of a patient.

      My post, however, really speaks to the “norm” which I see practiced so commonly. We commonly give “lip service” (if that!) to these past life experiences and yet we believe (if we give it even a moment’s thought) that they are important contributors to a patient’s current presentation. But we are not encouraged (nor are we paid, most of the time) to address them. Instead, as you write, we label the patient with a diagnosis (which, most of the time, leads to a medication). To keep this from happening — and to avoid doing harm to our patients, I advocate that we first probe deeply into the nature of our patients’ complaints, and then ask what we can do for them. If we are acting in good faith, I think we will often find that we lack the skills to provide what our patients really need. If more of us come to this conclusion, we might be able to change the future direction of this field.

      • Peggi says:

        I am involved with The Compassionate Friends, an international support group for parents who have lost a child. I find the “bereavement exclusion” laughable and even more laughable is the notion that you are diagnosed with MDD if your “symptoms” last more than two months. Most seasoned bereaved parents look at the first FIVE YEARS as being extremely difficult to endure. So, two months??? A bereaved parent who consults a professional often gets a DSM label and, as you say, probably medication. In my opinion, that medication has questionable efficacy, significant side effects, and often withdrawal difficulties. What a ridiculous state of affairs. You’re grief stricken and we help you by putting you on a drug you may find painful to stop. I understand DSM 5 may be considering withdrawal of the bereavement exclusion. This is nuts. Medication brings back your child? Your grief is a “chemical imbalance”???? Where on earth is common sense?

      • catsrgreat says:

        It isn’t just psychiatrists, either – where I am, I am pretty sure you have to get a diagnosis of a major mental illness in order to get help from social services. The diagnosis delivers services that are needed. A person who is a basket case for other reasons besides bipolar, major depression, schizophrenia- the help isn’t coming for them, or it will be a lot harder to find it.

  11. Carol Levy says:

    “I advocate that we first probe deeply into the nature of our patients’ complaints, and then ask what we can do for them. ”
    Lacking the skills requires a retooling of psychiatry, for the mpost part, it would seem.
    Probing deeply? I doubt most insurance companies want to pay you to do that.

  12. Jay says:

    I’ve only recently stumbled onto this blog. I sincerely like what I read. I’m a CMH therapist with 26 years in the trenches and have worked with numerous psychiatrists. I want you on my team!

  13. Iatrogenia says:

    Dr. Steve, this may be your best post yet. Or the introduction to your book.

  14. doctorz says:

    I’m convinced that there’s an inverse relationship in patients between the desire to receive psychiatric treatment and the need for treatment. When I did inpatient work and we needed to clear out the ward when our census exceeded maximum capacity, the way I separated the seriously mentally ill from the hospital dependents was to gather them all in the day room and ask them to raise their hands if they wanted to go home. The ones that didn’t were discharged. Just joking about that, but it probably would have been an effective and efficient way to determine need for treatment, based on my years of experience since then. Most of my patients with genuine bipolar, schizophrenia, endogenous melancholic depression, PTSD, etc, don’t present with such diagnostic claims. While there are some with serious mental illnesses who have gained insight into their conditions after many years of treatment, for most in recent years, particularly individuals with severe personality disorders, I see it as a projective defense mechanism unconsciously utilized to remove themselves from the responsibility of doing the work that life-changing therapy requires. And psychiatrists, who aren’t willing to do the work either, encourage this masquerade, but on a more conscious level, and I find that deplorable. Call me insensitive, judgmental, and the like, but these are my observations and I stand by them.

    • mara says:

      Yeah, I could see people using mental illness as an excuse to not deal with their problems, but what about people where therapy just isn’t the answer? Can therapy actually be harmful? I know that meds catch a lot of flack for being harmful, but are their instances where someone really just needs to find the right meds because therapy was more harmful? In the same way that maybe meds just don’t work for some people but therapy does?

      I don’t know that I would have said something like that a long time ago. But having seen some therapists I noticed it was pretty ineffective for me. I actually posted a comment on some other post here about how group and family therapy really didn’t click with me. And it’s not so much that I didn’t want to do the work, but that I just really didn’t click with therapy. Later I took some meds that were really helpful. Beta blockers really get my panic disorder issues under control. And I don’t do therapy.

      I could see some people wanting psychiatric care as opposed to counseling and still having a serious issue. I know meds and therapy together gets touted as being the gold standard…but I think some people really do better with just the meds. Like I would choose beta blockers over a therapist.

      • Carol Levy says:

        I do not know about ‘therapy being harmful’ but I have seen a lot of harm caused by bad psychiatrists who use the therapy as an opportunity to act out on their own issues

    • Anonymouus says:

      I quote, “call me insensitive, judgemental, and the like….”. I could not have said it better myself about your post. I took the opportunity to look at your web site and was astounded that it included the “Desiderata”, arguably one of the great works of prose. I realize that many doctors work in terribly underserved communities and may become jaded and weary. I am asking you as one afflicted with MI to please re-read it and reconsider the worth of each and every human soul. Believe me, I thought twice about posting this reply when I recall the first sentence…”Go placidly amid the noise and the haste, and remember what peace there may be in silence.”

    • Dr. Z,

      How about gathering all the psychiatrists in the day room?
      Asking them to raise their hands if they are really convinced that their institutionalized approach is at all helpful?

      … The ones who raise their hands are immediately released.

      As far as the patients being released… I gotta hand it to this guy, who didn’t stick around for a vote –

      Gotta love the love the human spirit, huh doc?

      Duane

  15. doctorz says:

    Duane, couldn’t agree more which is the reason I got out of the inpatient business 20 years ago. We set up a voluntary residential program, both short and long-term, 5 years ago, and since then have not referred a single individual for inpatient “treatment” since, unless there was a clear risk of violence.
    Anonymous, I’m not suggesting that people who I feel are compelled to maintain a “bipolar” identity (as an example of the syndrome I described) don’t need treatment. I simply believe that they’re “waisting” their time (ie, multiple atypical antipsychotic trials that have caused them serious physical problems including diabetes), rather than pursuing more effective psychotherapies, such as DBT and rational living therapy which we now offer in our clinic. And I do hold psychiatrists outside of our system of care primarily responsible for perpetuating the myth and causing iatrogenic harm in the process.

  16. “…perpetuating the myth”

    And what a myth, huh doc?
    What a myth, indeed!

    Duane

  17. doctorz says:

    Duane,
    Read the Power of Myth, by Joseph Campbell, sometime. And you’ll realize the mythical times we are in.

  18. leslie says:

    What doctorz is saying is in fact exactly what happens inpatient. If a patient questions the treatment and requests to leave, why then, it’s clear they need to stay longer as they clearly lack insight into their illness. Lacking insight into your illness is defined as disagreeing with the psychiatrist.

    Patients noticed this and even joked about it, not in front of staff of course. I actually had another patient tell me that teh quickest way to get released was to tell them how helpful it was and ask to stay longer. If you tell the truth – that the psych hospital sucks, then it’s evidence you need more treatment.

    Do not ever do what I did which is tell an inpatient psychiatrist that they are making everything worse. Bad move, especially if it’s the truth.

  19. Carol Levy says:

    Leslie, I wrote about my experience earlier in another thread. (Doc said had to stay til my 18th brithday – 3 days away when I said would sign myself out. She told me she would tell parents I was not ready to go to college (already had acceptance – this was summer after graduation HS) if I did sign out. Then, 3 days after my 18th Bday she discharged me. Did I suddenly get “better” in a period of 6 days? (My whole stay was less then 3 weeks, my dx “adjustment rx to adolescence.” )
    For many of these docs it is an issue of control – you want to leave? Not if I’m the one holding the chart and the pen with which to sign the papers.

  20. leslie says:

    Carol, I did read your about your experience and sadly it happens more often than people realize. My psychiatrist’s decision not to release me was solely about control (he was mad because I dressed him down in front of a resident) and not about safety as it was supposed to be. It’s way too easy for inpatient treatment to become about control and not about the patients’ best interests.

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