Friday, January 26, 2007

Still Stewing

[ranting by dinah]

I'm still stewing about ClinkShrink's comments about all those Worried Well folks out there. You know, the hoards taking up luxury hospital beds to get their adjustment disorders fixed, or using up the few precious resources available for psychotherapy by talking about day-to-day stuff. She made a comment on our podcast (oops, I didn't listen to it, but I might just to stew some more over this comment) about how if physicians don't ration psychiatric care, it will be done for us, it's coming, it's inevitable. Personally, I think Clink's been drinking the Kool-Aid.

I don't have "a" patient with an Axis One disorder whose symptoms resolved and who still comes but talks about day-to-day stuff. I have many. None, for the record, drink coffee with me.

Here's how psychiatric illness goes:

A patient comes in with complaints. Seeing me takes time, an outlay of some money, and hassling with your insurance company (no secretary, no insurance participation). No one, and I mean no one in over a decade of private practice, has ever walked in the door saying "I'm coming to talk about day-to-day stuff." No one has ever come to be self-actualized. Almost everyone cries. Everyone is in some state of distress and the vast majority of people I see are already on medications or will be by the time they've seen me a few times. Some people aren't, and maybe they want to work on something concrete-- something like a tormenting marriage, or the fact that they are pre-occupied to the point of great angst over a former lover stuck in their head (sometimes for decades) or an ongoing or acute stress in their lives. It's okay if these folks get help even if they don't have a major mental illness?

So, the majority, the gang we all agree deserve care, those Axis I folks, they take some meds, they talk (generally about the day-to-day stuff going on in their lives) and most of them get better, soon. Some still come for a while, until they're sure that the better holds (it doesn't always), or because they don't get all the way better and the symptoms fluctuate, or because the talking lends some comfort in a life where things are difficult. Carrie, summed it up when she said about meeting with her psychiatrist when she's not in acute distess, " If I do not continue to work with him in the way that I am at present, then I believe that I tend to fall very quickly back into my own depressions." I couldn't have put it any better.

This is the deal, the newsflash: in psychotherapy, everyone talks about the day-to-day stuff going on in their lives . They talk about what's happened since they came last. They highlight the trouble spots. Some relate current events to past patterns. Some are more interested than others in talking about their childhoods. Sometimes, people talk about the routine-- I've commented before on a (confabulated, of course) patient who talks about the price of beef at various stores. That patient is on 4 psychotropic meds having tried many others, a couple of hospitalizations, and the last episode of illness lasted many months with many, many awful symptoms. If talking about the price of beef helps, that's fine by me. And trust me, if you met her, you wouldn't for a moment question her right to access psychiatric care.

Why should suffering be valid for discussion only if your distress can be boxed into a Chinese-menu DSM box of symptoms? Why is should it be okay to access care (where you'll talk about day-to-day stuff) if you have a mental illness, but not if you're just miserably suffering without a disorder as designated by some committee? And if you feel that talking is helpful, or perhaps prevents relapse (and why is that??), then why should it only be valid to come for therapy if you're hurting at this very moment? What if you were hurting yesterday or might hurt tomorrow, or just want to tell the doc you're doing better?

And to those who've suggested (or demanded) that patients should see non-psychiatrist mental health workers for psychotherapy and psychiatrists only for meds: Why? What if the psychiatrist wants to see patients for psychotherapy? What if the patient wants to see a psychiatrist for psychotherapy? I'm not saying everyone psychiatrist must do psychotherapy, nor am I saying that someone who wants to see a psychologist or social worker shouldn't. There are plenty of psychiatrists who are still interested in psychotherapy and some of us who don't find seeing four patients an hour to write a script based on a minimal amount of information particularly fulfilling as the only aspect to a career. I'll do a post later on split treatment in public settings -- I tend to blog from my private practice hat, but I work in a public clinic as well.

There are plenty of patients out there with severe mental illnesses who don't keep appointments and therefore waste resources. There are many who refuse to take the prescribed medications, whose own behavior results in repeated hospitalizations at great cost to society. They are the very ill, certainly the rightful recipients of our care, but we don't have an efficient system to define and weed out exactly how much care who should get from which professional and what it's okay for any given patient to talk about.

While I don't believe that society (meaning government-run clinics, medicare/medicaid) owes every person who wants it unlimited psychotherapy with a psychiatrist, I do believe that the definition of Patient-hood lies with the patient. And I don't share Clink's pessimism that this will lead to an overload on the private insurance system and more regulation is to come: Managed Care has been a dismal failure and the pendulum has already started to swing the other way.

Clink (who has posted simultaneously, see No Retreat) seems to think it's one pot of money, and if one guy pays his way for top-notch care, another guy suffers. We have universal education (sort of, think of all those children left behind), yet many people opt out for private or religious education, paying out-of-pocket. That, I believe, is similar to getting care at any private venue that allows one to pick and choose, to ask for what on perceives to be The Best.
Okay, I'm done ranting.

Roy, where's the new picture of our feet?