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?