Thursday, January 29, 2009

Response to the Comments on the Last Post



So I wrote about the 12 ways to drive ME crazy...and it got a few comments. I've nothing better to post about, so I thought I'd address those comments here. My co-bloggers seem to have gone dark with posting. I hope it's okay if I reference the random commenters.

One commenter wrote in an additional idea:
13. Spend the treatment session being totally non-compliant and then tell everyone how useless your therapist is.

Fortunately, if my patients are feeling I'm useless, they aren't telling me. Many are non-compliant, and that just goes with the turf of being a shrink. I've been at it too long to take it personally or to be driven crazy by it.

Return of Saturn (what a great blog name!) is worried about returning to care after a few no shows and a few years. Personally, I'm always flattered when people return to treatment. I'm sorry they are feeling badly, but I like that they feel comfortable enough coming back. And No Shows are a pretty common thing, they aren't something that gets held in long term shrink memory. They do generally get charged for, however.

For everyone who commented on Calling Between Sessions: it's only necessary if a shrink specifically asks to be called. No one is waiting on unrequested calls. If a shrink requests a check in, then ends up chasing the patient down repeatedly, well....it gets to be plain inconsiderate. Often, however, we work on the No News Is Good News theory and lost sleep is the exception, not the rule.

Mindful wants to know what personal intrusive questions I get and the worst of them isn't going on the blog. Try This for a post on Questions for the Doctor.

Anonymous wants to know why I like Seroquel better than Xanax and says it's more toxic. I like Seroquel better than Xanax because you can give someone a very low dose to take as an emergency medication (yes, off label, and yes I explain this) and it's not addictive and doesn't cause physical dependency, so they can take it or not take it, while Xanax gets you committed fairly fast. Given all we now know about the metabolic issues with Seroquel and the atypical antipsychotics, I'm a lot more hesitant about giving these medications and it's fairly rare that I use them off label. At this point, this is really an emergency measure for someone feeling pretty desperate or on the verge of hospitalization. And Xanax isn't much of an issue any more because so few shrinks prescribe it on a standing basis that it's been a very long time since a new patient has come to see me already on Xanax.

The same Anon is also concerned that I don't want patients to come off meds when they aren't having side effects, or don't realize that they are until they come off meds.
I have to say that I have very few contentious discussions with patients regarding medications. Most people are on medications because they feel better on them, and I'm more often saying it's time to at least consider coming off (many people don't want to risk a relapse and I respect that). I'm with Roy here, who commented that it's really about working with someone and the risk/benefit ratio. My Drive ME crazy list referred to the quite rare case where someone has repeatedly come off meds only to relapse and either the relapse has resulted in hospitalizations, violence, or the patient's misery being so tangible that it felt like my own (and months of very distressed phone calls). Many patients stop their meds: I tell them what I think they should do, what I think the risk of relapse is, and from there, it's not my decision. And I don't stop treating anyone who says they feel better without meds and is willing to risk the unknown. I don't know what to say about side effects: if someone says they aren't having them, I don't argue. And often it's hard to tell the difference between a symptom of illness and a side effect of meds. I do a lot of my thinking out loud and try to share my thought processes with my patients. It's the best I can do.

To Spotsy and Mind Mechanic: thanks for the support.

And to Roy: mostly you got the list of what you do that drives me crazy right. The podcast, however, was your baby, and so it doesn't bother me that you don't post them after we make them. I love your company for it's own sake, so I don't lose sleep over unposted podcasts. ClinkShrink, however, may feel differently. Please please please don' t post what I do that drives you crazy. I don't want to know.