Wednesday, June 29, 2011

The Chapter I Now Wish We'd Written: Bad Shrinks

When Jesse read our Shrink Rap book, he said we were too nice to psychiatrists in it-- that we didn't mention that there are some really bad psychiatrists out there and he thinks part of the venom towards psychiatry comes from the whole rushed 15 minute med-check culture.

I thought about this and I thought, really?  We have a whole chapter called When Things Go Wrong and we discuss a psychiatrist who is not sensitive enough to a patient (though, granted, the patient is overly demanding and overly sensitive--so I guess not the best portrayal of insensitivity by a shrink), one who is rigid in her formulation to the point of almost destroying a family, one who prescribes medication that makes a patient fat and diabetic, and finally, a psychiatrist who is outright unethical and criminal: who defies all boundaries and gives her patient prescriptions for narcotics to bring back to her!  Like how much worse could I make the shrinks? As one Amazon reviewer said,

The authors are careful to include what might be called opposing views. They give some space to the anti-psychiatry movement, and they consider the recent cases of medications that seem to cause suicidal thinking in some patients. But they balance that against the suicidal thinking that is prevented in some other patients by the same medications. They also talk about the influence of drug companies in a fairly open way.

There are no heroes here. The authors aren't in the business of justifying themselves, and one or two of the fictional therapists we see in the book do spectacularly bad jobs and harm patients.

But Jesse is right,  overall the examples portray psychiatrists who are thoughtful and caring, and while we tried to "explain" our work, not justify it, we did not talk about psychiatrists who just plain bad, or those who are probably good but who put such an emphasis on making money that they don't give the work the time it needs.

So why didn't we (or "I," since this is my post, never discussed with my co-blogger/authors) talk about 'bad' psychiatrists in a broader way?  I'm going to go for bullet points here:

  • We talked about the pros and cons of split therapy, and there are pros.  Clink works in a prison where she sees up to 3 patients an hour.  She's a wonderful, smart, and thoughtful shrink, but I even don't believe that criminals should have psychotherapy with a psychiatrist, especially given that hard-working, insured, law-abiding people in free society can't afford this.  There are all types of issues that make some rapid worse than others: if there is a single chart and the doctor has access to information from the therapist and the care is coordinated, if there are reports from other professionals treating the patient, such as in a day hospital or program setting, where assessment includes a team approach, medications can be managed well with less face-time with the patient.  In a private practice setting, however, rapid care may mean shoddy care.
  • At the time we wrote the book, I had never heard of an outpatient, private practice, psychiatrist who sees 40 patients a day such as the one portrayed in the NYTimes article by Gardiner Harris.  I'd heard of 15 minute med checks, but in the clinic where I work, I sometimes see patients for 15 minutes, or less, not because I'm scheduled so tightly, but because they have nothing to say...all is well,  a family member is there and confirms that things are going smoothly, their therapist is in the room and says things are fine, and the patient wants their prescription refilled and to get out.  I had never heard of an outpatient psychiatrist who sees every patient, regardless of their needs, in a one-size-fits-all 15 minute slot.  I can't imagine how this can be done well.  The New York Times may want to portray this as how psychiatry is now routinely done, but it's not.  
  • Some psychiatrists are insensitive... we did reference the idea of a psychiatrist "with the social skills of an iguana"  (I hope we didn't insult any iguanas!), but the idea of interpersonal sensitivity is a hard one to capture--- people are very different in what they want, and one person can relay a story with "Can you believe he said THAT?"  While another person would find THAT as being a perfectly reasonable thing to say.  There is no psychiatrist out there who is everyone's perfect fit, and even the people I might think I'd never refer to, likely have devoted patients with good outcomes. 
  • The things that often trouble patients the most are endemic to all fields of medicine these days and not just psychiatry and they don't objectively make a doctor "bad," (maybe over-scheduled, disorganized, or forgetful) and include the large areas of running late and keeping patients waiting, or of not returning phone calls.  Patients are often angry about this---often rightfully so--because it leaves people feeling like they aren't cared for or respected.  I'm not certain what there is to do about this one.  
In the end, I decided it's fine that we didn't write about the general topic of 'bad psychiatrists.'  None of us felt any need to pass judgment on our peers, and we created our fictional psychiatrists with the idea that this is how it's supposed to be-- others can use it as a model of what to expect.  Our shrinks listen, they are thoughtful and respectful, and they spend time with their patients and consider the impact of their work within the context of their work environments.  Maybe unrealistically so, but why not have an ideal to strive towards?


rob lindeman said...

"Clink works in a prison where she sees up to 3 patients an hour... but I even don't believe that criminals should have psychotherapy with a psychiatrist "

Really? Psychotherapy in 20 minutes (or less, given time for cons to switch seats)? You're kidding, right?

wv = niumban. Third generation non-steroidal anti-inflammatory and anti-perspirant

rob lindeman said...

"Clink works in a prison where she sees up to 3 patients an hour... but I even don't believe that criminals should have psychotherapy with a psychiatrist..."

Psychotherapy in 20 minutes? Really?

wv = boofor. What hecklers are hear foor.

William said...

@rob - that sentence is expressing that clink is NOT performing psychotherapy in prison, but instead pointing out that in this setting, split therapy is a better idea - that if psychotherapy is being done, it is being done by someone else, and clink is, for the most part, only doing basic care in 20min.

rob lindeman said...

What is "basic care"? I'm not being coy: I do primary care for a living. I just don't know what the expression means.

jesse said...

William, what you said, and what Dinah wrote, was perfectly clear.

Dinah, yes, I had written "At times I felt that the description of the professionals actions were a bit too admiring, but the book would have been far longer if the descriptions had been more realistic and critical."

I was struggling with some complex thoughts and didn't know how to best state them (and still don't).

1) Many patients have told me of experiences with med management doctors in which the patient was so aware of the compact time frame, the "checklist" mentality, and that anything personal had to be brought up with the therapist, that they never told the psychiatrist certain things that would have greatly changed the course of treatment. "I could tell he wasn't interested in that..."

Very frequently a patient does not know what is important, and has to talk a while before both doctor and patient hit upon the crucial bit of information. And the patient needs to perceive the doctor is interested in him, not the symptoms.

2) In our field patients bring to us expectations of how we can help that are much more vague than those brought to an internist. "My heartbeat is irregular" means arrhythmia. Sadness, unhappiness, anxiety can mean near anything and may require totally different responses and time frames. "I'm anxious - it's my third marriage and I'm already feeling dissatisfied..." Any of us could imagine a similar scenario. And somehow what the doctor does must fit into an insurance framework, be affordable, not take so much time our patients cannot go to work or care for their children, and so on.

So the problem is that the expectations of the field can be so great, the possibility of dissatisfaction becomes even greater.

It is the Impossible Profession.

Anonymous said...

I don't think you needed to write about bad shrinks. There was no need to create a negative portrait of your profession, and you clearly showed some examples of some suboptimal shrinking. But it might have been helpful to write about what makes a good shrink, though I'm sure there's no one-size-fits all approach. The good, thoughtful shrinks you confabulated seemed great, and entirely at odds with my own experience. It would have been helpful at the time to have an idea of what a good shrink looks and acts like. Until I found this blog, I didn't think such psychiatrists were out there.

SG said...

I don't think the issue is so much a few bad shrinks but bad psychiatry. What I object to most is the pervasive compromising of science by pharmaceutical companies and all-out advertising.

This toxic influence is so pervasive that one comes to the forlorn conclusion that evidence-based medicine as it is currently practiced is really just a way for pharmaceutical companies to generate new revenue streams. The companies are so savvy they realized if they own the evidence through biased studies and suppressed trial data (failed studies, nasty side effects), they would have physicians eating out of their hands and prescribing their pills for whatever they wanted. I really think this dynamic is similar to state ownership of the media by totalitarian regimes.

Of course this is endemic in all of medicine, but psychiatry is uniquely vulnerable to this phenomenon because it has become so rigorously based on medical therapy (read: pills) since the DSM III ushered in the new "biologically based" model of mental health.

I refer the posters on this thread to the 1boring old man website in which a retired psychiatrist has been relentlessly examining internal emails between pharma execs, presentations by prominent psychiatrists like Madhukar Trivedi, seriously compromised studies like STAR-D, and various political infighting between powerful psychiatrists.

It's all very vertiginous and one comes away with the conclusion that the last 30 years of psychiatric "breakthroughs" are largely built on sand.

Here are links to a few articles in particular from the 1boringoldman site that I think are particularly eye-opening:

-This is about child psychiatrist Joseph Biederman's queasy moral character and his conflicts of interest. It's scary to say the least considering how much sway he has in the childhood bipolar community. Look at the internal company emails starting on page 10 of the word document. The earliest of these emails dates to 1999, which is right when childhood bipolar was starting to catch fire as a diagnosis (a forty-fold increase from 1995-2003). See Anatomy of an Epidemic, pp 232-246 for a proposed theory of this explosive growth of pediatric bipolar disorder, and pp 318-319 for Biederman's role in it.
-This is not a 1boringoldman post (although he has linked to it), but instead a great expose on how widespread corruption is in the health care industry and academia.
-A quick deconstruction of Madhukar Trivedi's CME presentation in which Trivedi tries to resuscitate various flawed studies.
-An astonishing series of articles that exposes the corruption endemic in the promotion of Zyprexa.

I think it is imperative that psychiatry look at ALL the evidence in evidence-based medicine, even if it provokes cognitive dissonance.

We must remember this about evidence-based medicine: it works on paper, but when you factor in human bias, fear, greed, and stubborn attitudes, you could have the most air-tight science (or evidence) in the world, but if it doesn't tell us what we want to hear, then the medical community automatically thinks it's flawed. How is that true evidence-based medicine?

It's time for psychiatry to come to some harsh truths and own up to them so ALL psychiatrists, even the good ones (and yes there are some good ones!) can practice at a higher standard. Even if a psychiatrist does everything right these days, I know they could do far better if they had a more honest and transparent evidence base to draw on.

Sunny CA said...

I think that if you spent too much time in your book on bad shrinks, you would scare people away from going. It is better to provide a model of good shrinks so patients can compare their own experience and know it is OK to look for another shrink if theirs does not match the model. Often patients are told that if they cannot work with their current shrink, it is the patient, not the shrink.

Luckily I have a really terrific psychiatrist now, so know what it is like to be treated by a highly skilled, professional, compassionate, wonderful psychiatrist. When I ended up with a "bad" shrink, I did not have any option. I was being released from the hospital, and to get out of the day-care program I had to bring in the name of the med-management shrink and the psychologist I would see. I called countless psychiatrists who had been recommended to me by my GP and gynecologist and none would take me. Some said they don't take patients coming from the hospital and others said they were booked. I think I did not sound all that "well" over the phone during the telephone "interviews". The "highly recommended" psychiatrists seemed to not want to work with patients that they perceived were close to "the edge" or they were genuinely booked. The psychiatrist I see now was the only one who gave me hope. He said that he was booked, but if I would call back in a few months he would check his schedule for openings at that time. He sounded compassionate and genuine. I waited 5 months before getting the courage to try him a second time at which point he gave me an appointment. In the meantime, I had a less-than-15-minute med check with a psychiatrist that did not listen to me when I did tell him things, which was evidenced by his misquoting and twisting what I said. He is the one who I previously described, who never looked me in the face. He answered the door with his gaze at the floor. He then would turn and walk to a closet when he kept files and would walk back to his seat with a file and then look down in his lap without glancing up. I wondered how he could tell how I was without ever looking at me. The psychologist I concurrently saw (also the only one I could find) considered her entire job to be convincing me that I need to take my medications. She refused to discuss the issues that were bothering me and kept telling me that there would be time for that "later". Later? I was paying her $125 a session to be deferred in talking about my issues? Meanwhile she discussed other patients who had not taken their medications and the awful things that happened to them. One patient, as I recall "got into walking" and ended up walking around the entire Bay Area through San Francisco, around to San Jose and back up to Concord presumably nonstop. I remember her telling me that when she moved to America from England it took her 3 years before she could shop in a grocery store because she was so overwhelmed by the number of product choices that it caused her to run out of the store in a panic. That story did not relate to my state at the time that I was aware, so had no relevance, and in addition left me wondering about her mental state. That shrink and that psychologist never communicated as far as I know.

Katie said...

2 thoughts.
1 - I don't think you guys really comprehend what "bad shrinks" are. I find that "good shrinks" really don't think for the most part that their counterparts do things that they would never imagine doing. I see it in my amazing shrink all the time - that it doesn't occur to her that my prior "bad shrink" would have done such damaging, unethical things. I don't think that's a bad thing in and of itself. It's probably the same in all professions - I know, in theory, that not all people in my field are ethical and good and do the right thing, but it doesn't often occur to me to think that there are really bad people in my field.

2 - passing judgment. I agree that there's no need to pass judgment on your colleagues (think that ties a bit into point one) in your book. But, in real life, I think it could be beneficial to not pass on passing judgment and acknowledge that there are bad shrinks out there who do really bad things in the name of psychiatry and do a lot of damage to vulnerable and even not-so-vulnerable people. There are times when that is a fact, and not a perception, and I wonder sometimes if many of the comments I've read lately are backing up against the same thing -- it is too easy in psychiatry/psychology to "not pass judgment" - or to write things off as misperceived etc. The entire setup of /therapy/psychiatry is designed to make a beautiful cover for that. But sometimes, things are objectively wrong, and shrinks are bad not because they were misperceived or said something insensitive or because they prescribed a medication with side effects. They are bad because they took advantage and did objectively bad or unethical things to vulnerable (and not so vulnerable) people, in the name of psychiatry.

Which is why you end up having to justify and defend your non-bad shrink ways. Leaving people frustrated for the above reasons - and, it's a cycle.

jesse said...

Katie that is a strong post. Yes, being non judgmental with our patients is important, and we likely err in that direction. But I think that we are more selective and judgmental than might be obvious. It is common among psychiatrists to hear simply "I wouldn't refer a patient to him" for reasons that might or might not be explained.

When it comes to really bad things, all the psychiatrists I know are very aware that there are those who have done patently illegal or unethical things, and have either been reprimanded by the Board or not - sometimes proving these things is difficult.

Anonymous said...

Most psychiatrists are probably good. My generally "good" psychiatrist, who I see for 15-minute med checks (sometimes 20 mins. and for which he bills the insurance company as "Medication Mgmt with Psychotherapy, LOL), just did something to me that I think makes him "bad."

Without getting into the details, I'll just vent here on your blog and say that I am involved in an employment discrimination lawsuit that did not get put in suit until a year and a half after I began seeing him and there was no anticipation of any such lawsuit yet--but the loss of the job had already happened before I became his patient. This shrink says he NEVER testifies for his patients because the defendant's attorney will impeach him by trying to show complete bias for the patient, and then things will end badly, etc. I assume he is also talking about damage to the therapeutic relationship, though, he's never specifically said that. So I try not to involve him in the litigation, though I did get him to do one small thing.

Of course, whenever I see him, he always tries to get me to talk about this lawsuit. There came a point where I had to locate an expert psychiatrist (no attorney helping me for now) for potential use at trial about 1 year down the road. My shrink supplied a few names. I struck out with those names. Next time I saw him, he asked about the litigation, so I told him about his list of experts. I told him one name on his list had lied, portraying himself as testifying in mostly all criminal matters, when I knew of that psychiatrist's work for a state governmental agency preparing expert reports in industrial accident claims (i.e., not criminal work). My "bad" shrink interrupted me to get the name of the governmental agency (so he also could get a piece of that payroll where the State pays the doctors to examine injured workers and do a report--something new for him and his own career) and never helped me find an expert psychiatrist after that--nor apologized for his colleague's white lie. Personally, I don't even know what to do next. I never want to see someone's personal career motives show up in my "therapy."

UnmotheredChild said...

Psychiatrists can be warm and caring but they still cannot do 'the work' with a patient [unless they also trained as a psychotherapist]
personally I feel psychiatrists should stick with what they are good at and that is prescribing drugs.
So many times I hear of people going to see a psychiatrist for issues that are normal healthy responses to trauma or stress only to have their 'symptoms' medicated. The body is screaming out for a reason, to be heard and understood, not to be shut down/up with mind numbing drugs.

Dinah said...

Rob-- I think the inmates are lined up in the hall and they show up on time and don't complain if Clink runs late, but I don't know, we'll leave that to her to sort out. Psychotherapy in the prison is done by other mental health professionals, not the psychiatrist.

SG-- I don't think it's just psychiatry, I think other sub-specialties have the same issues with regard to pharmaceuticals, but to the rest of your post, all I have to say is "Yup."

We see individual patients who feel better on medications, so we keep using them, but there is no defense for the deception that has taken place.

jesse said...

Anon: a psychiatrist should always keep the good of the patient forefront in his work. His own interests should not creep in. This is true in any professional relationship, not just in psychiatry. One does not ask favors of one's patients or attempt to use them in any manner.

Dinah said...

SG: May I use the top part of your anti-pharm comment as a free-standing guest blog post?

SG said...


Yes you may. Thank you for your open-minded reception of my posts (especially about PSSD!).

Katie said...

Jesse - I can see how what you wrote about simply not referring to so and so without giving a reason sends a message. The difference, I guess, is that it's not a message received by the patient(s) who was damaged and is trying to figure out where s/he went wrong...except that she didn't. The bad shrink did.

I agree there is a measure of professionalism that should be essential to all professions. It just seems that when it comes to psychiatry, there is so much that is gray area. My old doctor did things that were objectively and subjectively wrong and the treatment was not really any sort of treatment. my new doctor knows that, we have talked about it, and she occasionally remarks on it at times. Every time she does, it feels good - not because I "hate" the old dr so much, but because it validates what I experienced. I experienced bad psychiatric care to an absurd degree -- and inherent in that, is years of blame on me that I was doing something unnameable wrong. And that -- even knowing that it was false, that it was not right, that it was not fair dealt from the bad psychiatrist....well, bits linger.

So while not referring a ptient to so and so may serve purpose in the professional world, for us patients - we don't see the results.

I'm not saying there's a fix. I'm just saying that plays a part, perhaps, in what's frustrating.

Gastric Bypass Surgery Abroad said...

Nice work.

jesse said...

Katie, i agree. It is the gray area I was addressing, in the context of whether we psychiatrists actually do form judgments about other clinicians. We absolutely do, as do all of us, and of course we do not refer to the people we do not regard well. But there is a huge gulf between not sending someone a patient, or simply indicating that you would go to someone else, and legal or professional action against that person.

And yes, if one of my patients had experienced bad care I would be direct about it with him.

Anonymous said...

Speaking of bad shrinks, I had one ask me out. This was a guy who medicated me out the wazoo. This was also the shrink, who I later found out, has multiple arrests for various things and was married even though he told people he was divorced. I later told my therapist who turned him in to the state medical board.

Of course the shrink denied it and said I was a liar, but there were emails he had sent me which I turned over. So, the medical board knew who the liar was.

Sadly, this guy is still in practice as is his colleague who was sanctioned by the medical board for sleeping with his patients. My sympathies to patients who end up in their offices.

wv = damphals. My former shrink liked to hit on damphals in distress.


Anonymous said...

It's very scary to know that psychiatrists (like the two I mentioned) who have demonstrated that they are a danger to patients would retain the authority to hospitalize people against their will. Hopefully, they will not be the covering psychiatrists if you are hospitalized against your will in Texas.


Maggie said...

Several people have brought up concerns that talking about bad psychiatrists will scare people away from psychiatry. I'm having a bit of trouble with this concept, especially because the bad ones seem to be the most accessible. When you get a list of in-network doctors, weed out all of the ones who have stopped taking your insurance and the ones who aren't taking new patients, most of the time the one you're left with is the really bad one: the one who, despite being willing to deal with insurance hassles and despite being on the list everybody gets when they start looking for a psychiatrist covered by their insurance--and therefore having a constant flow of new patients--isn't booked solid.

In other words, the bad ones are impossible to hide. By saying "these are the things to look for in a psychiatrist, these are the things to avoid, if you see this-that-or-the-other-thing, GTFO" you can at least express what's not supposed to be happening.
If you try to ignore the bad ones, that makes it easier for people to assume that the first psychiatrist they see is typical.

I have to agree with what Katie said, too. It's really difficult to brush off a bad experience with a psychiatrist. Those experience tend to come at a time when the patient is particularly vulnerable, there are always questions of perception: was it all him, was some of it me, what did I do wrong, could I have done anything better, could any of the awful things he said have been true?
Even if you realize that the doctor was just awful, that question keeps lingering: could any of it have been true? How can I be sure it wasn't? I've found a better doctor who obviously disagrees, but if one doctor says something and another doctor says the opposite, how do I know that the one who said that I'm not completly worthless is the one that's right? Maybe the one who considered me stupid and undeserving and pathetic was right and the one who treats me like a human being is wrong.
And if it was more than one psychiatrist who was really awful, how do you get over that?

If the psychiatrist that you're "simply not referring patients to" is on the insurance list, that psychiatrist is still going to have no shortage of new patients being referred to him, even if there's not another doctor in the state who would ever make that referral.

Anonymous said...

After reading some comments I hope that it's not common practice for some so called "good" psychiatrists to always stick up for "bad" psychiatrists,so therefore what message is being sent if psychiatrists are hardly accountable for their actions or bad actions?