Wednesday, May 15, 2013

The Stolen Post, Without Permission, from 1 Boring Old Man

There's a psychiatrist who writes a blog that's older than Shrink Rap called 1boringoldman.  It's a great blog, and Mickey, the blog owner, should have more appropriately named himself 1reallysmartoldman.  I go to it sometimes, but it's more political than I like, it's often filled with graphs and numbers (more of a Roy thing), and .....I hesitate to admit this here because obviously that boring old man has better vision than I do....but the font is painfully small and the layout is hard to follow.  It's archived by month/year, not subject, and sometimes I'm not sure I've expanded what I wanted to read.  Oh, here at Shrink Rap, I change the font to large and we put the whole post, no matter how long, on the page so that no one has to search, though I am terrible about tagging topics.  I know, psycritic says we need a new look, but there is something comforting to me about the familiar, even if it's noisy, and think about all the nonsense that travels through your brain, and then multiply that by 3, because there's three of us fooling with the sidebar, sticking on links and ducks, and books and bacon.  I don't really understand why our sidebar offers "Shrink Rap with Bacon," but it does.

Rambling aside, in need of more coffee, I did love a post by Mickey the other day, so I thought I'd just steal it.  If it troubles you, sir, I will take it down.  With a link to the original post (if you're of a certain age, get your reading glasses):

1boringoldman writes:
a thought…

Posted on Sunday 12 May 2013

There was a time – it was a long time ago, maybe 40 years ago – when I could think whatever I wanted to think. I could use a jillion models – be doctor medical model at 8AM, psychoanalytic at 9AM, cognitive behavioral before lunch, and throw in a little existentialism in the afternoon. It was like a toolbox filled with a lot of wonderful ways to think about the problems before me and my job was to bring whatever I could find to help until I found what really mattered – some shared way of understanding that my patient and I could use to make some headway. And in conferences we’d argue back and forth, the various different kinds of us, about what was right and wrong, which was all in fun because there wasn’t any right or wrong just different cameras on the same set, then we’d all go to the pub and be human together. It was an exciting time for me. I miss it – always have.
Then in the 1980s, that all changed. Because I was a psychiatrist, I was supposed to be a biologist. Well, I am a biologist, but that’s just a piece of what I am and what patients needed from me. And because I was a psychoanalyst, I was supposed to be … psychoanalytic, but that’s just a piece of what I am too and what patients needed from me. And so on and so on through the toolbox. And worse, I wasn’t supposed to meander from tool to tool until I found the one[s] that fit that patient on that day, I was supposed to have some consistent evidence-based position that could be validated by some third party to prove I wasn’t a charlatan or a I-don’t-know-what-but-it-was-a-bad-thing. I wasn’t up to it. I’d spent a long time refining my skills at doing it the other way which was some hard work, so I went off on my own and did what I’d learned to do until I retired. I’m so glad I did that.
Now it’s coming full circle. The psychologists are saying that the medical model psychiatrists are off the deep end. The biologists  are at war with each other over which biology is the correct biology. The humanists are after the robots. The analysts have learned to be quiet, but you can bet they’re thinking their thoughts. I’m sure all the existentialists in France and elsewhere are off being existential together. I know a lot of very talented and competent mental health types who come from a wide variety of backgrounds but they are unified by a few simple things – a deeply ingrained practice ethic, a suitable awe for the marvelous and monstrous variability in human beings, a genuine curiosity, broad training and life experience, and humility. If they can’t help you, they’ll at least be able to help you find someone who can.
When I think back on things, the most helpful piece of my training in mental health was becoming a hard science Internist first. The reason is that I knew a secret my psychiatric colleagues didn’t know. The hard science medicine I left was no more precise and assured than the loosy-goosy psychiatry I went to.  Sure there were more tests, more precise diagnoses, more drugs. But there was the wall of physical disease beyond which you couldn’t go. Once you found it, that was the end of the road. With mental illness, there’s no wall. Even with the worst cases of our most devastating illnesses, there’s still something that can be done, even if it is only a small thing. You may not find it, but it’s not because it’s not there.
So in one way, it makes me sad to read all these battles flying back and forth precipitated by the release of the DSM-5. On the other hand, it reminds me of those days long ago when we fought with each other to learn from each other. I’ve missed that more than I knew. And it makes me feel hopeful that what’s up ahead will be a toxic environment for the know-it-all psychiatric KOLs that have so contaminated our world [and detracted from the contributions of biologists with good sense], and their pharmaceutical marketing colleagues, and the opportunistic Managed Care types whose job it has been to keep us from doing ours. Right now, I hope right thinking psychiatrists of all flavors, psychologists of all flavors, social workers, counselors, etc. can brace themselves for a long-needed realignment that is consistent with our shared task. It won’t happen any time soon. We’ve been lost in the wilderness too long for that. But the wind blowing in the trees is at least encouraging to this old man…


mctps said...

Favorited that blog. As a patient, it's nice to find this sort of stuff that I can agree with. It feels like I can just relax and let better minds take care of things.

I tried reading Shrink Rap font from across the room, but failed. I could still read it comfortably from ten feet away, but after that it started to become an effort.

I think it depends a lot on your browser settings. You can usually enlarge a font by pressing shift and + at the same time.

jesse said...

Before you posted this, Dinah, I was thinking of writing something similar but 1 Boring Old Man says it better than I could have. Strangely the issues that Rob brings up speak to the other side of the problems we face. Just what is psychiatry? When I was in training the psychological aspects of people were an integral part of it, and there were different models within which we could work and try to understand and find what would be useful to our patients. Most clinicians found a somewhat eclectic place that blended psychoanalytic, dynamic, behavioral and other constructs with the more traditional medical ones.

Lately it looks as if something is not "evidence-based" it is not considered worthy of consideration, and this unfortunately played perfectly into the hands of insurers who do not want to pay for anything.

But what is psychiatry, then? Just the biological model? Are human problems that do not have a provable biological base of no interest to us? Are the different psychological models worthless? Here we are taking part in a psychiatric blog and psychological comments and ideas are very little valued. Only provable, biologic comments. And so Rob has a field day with his nihilistic position.

You say "I think, therefore I am" and he wants to know the biology behind such a thought. People don't like to comment on how the mind works, only on the provable, most severe "mental illnesses" and even then Rob discusses it as if he needs to defend peoples' right to put guns in their mouths (as has been said) and blow themselves away.

So even when I commented on the concept that people regard their minds (and losing them) in a way different from how they regard a cancer or high blood pressure no one picked up on it.

Now I am beginning to rant. At least this is a safe place to do it. Psychiatry has been transformed and the new DSM-V coding, being accepted as it has been, just shows we have moved to the laptop-in-front-of-us model that will having everything in bullet points but not to the benefit of the whole person. Which is a major shame.

PsychPractice said...

That was a really beautiful post. It gives me some professional hope. Thanks.

Steven Reidbord MD said...

1boringoldman is a great blog, and that's a particularly great post. (I agree, though, that his blog is hard to read due to font and layout.) Somehow our field feels defensive nowadays, like we've circled the wagons both as a discipline and as smaller sub-circles of biology, cognitive theory, psychodynamics, etc. A real pity.

Susan Inman said...

Very, very interesting.
And here's a link to another voice that hasn't made it into the discussion. My latest article for Huffington Post Canada discusses SAMHSA; it's from the perspective of family caregivers for people living with psychotic disorders:

Sarebear said...

Jesse, I picked up on it. I've just been buried in medical appts and tests and scans and stuff. I liked it (what you said, not the tests and stuff.)

I thought what 1bom said was cool. Something felt familiar about it, then I realized my psychologist is eclectic, and so there's a similar feel there (yes I know he's not a medical doctor, my psychologist).

I feel mental health professionals and especially their patients benefit from having a variety of approaches/tools in the toolbox, and I wish that someone in power would/could be made to understand that the managed care restrictions, some of them, on mental health care need to be revised, changed, some eliminated, etcetera because what they are doing isn't helping, in many many cases. And, from my own experience, is hurting things/people.

Maggie said...

"the font is painfully small"

Hold the control key and wheel your scroll wheel up.