Blasphemy

[psych]

Hi. I've been mia for awhile and recently re-realized what an anazing resource sdn can be. I know I have a lot to learn. This could be the most obnoxious post you will ever read. I definitely appreciate that, but the disillusionment I've experienced since I began residency training has reached a peak (at least I hope). It's taken its toll on me. I want to talk to other psychiatrists about this (I suppose this is my first outlet)...
...Maybe it's because I've been in an existential crisis for the past two years (well, crisis sounds a bit dramatic)... To give you an idea of what I've been struggling with: my personal threshold for what is "pathologic" is much higher than other people I've worked with in the field. :/ ? I think I might be too biased re: the phrase "don't believe everything you hear."
Perhaps my buddhist aspirations are influencing my perspective... [Feel free to disregard the rest of what I say if the term "buddhist" made you cringe.]
Others have mentioned in this forum when you're holding a hammer, everything looks like a nail. I can't help but strongly agree (and I'm sincerely frightened by this). I admire the philosophy of equanimity and the beginner's mind. We are all human, imperfect, trying to reduce the sufferin of one another. At least that is a goal of mine... Sounds cliche but perhaps these beliefs are what are interfering with my professional development. Bare with me- it's entirely possible, I'm the one who is shortsighted. My point is that, (here comes the blasphemy) occasionally I feel as though the entire field of psychiatry is some grand delusion that people buy into in our society (even highly educated people that go through medical school). Am I the only (internal not scientologic) one that has felt this way? The human mind is undoubtedly one of the most fascinating and complex things we will ever study. One of my issues is that patient assessment seems like such a subjective interpretation (looking for a cluster of "symptoms" to match some manmade "criteria" to fit a "diagnosis" elicited from an interview with a specific "psychiatrist" at a given point in time) . I can't help but see the parallel with the bible...
Okay, okay... It's interesting how much this doesn't even matter because we are chasing our tail- ultimately treating symptoms with these powerful meds -that obviously do more harm than good in some people . I feel like I'm violating the Hippocratic oath by making people obese, develop DM, HLD --> ultimately heart dz (with these propogated chemicals (medications) I don't even "believe in")... I can't possibly do intensive psychotherapy on all my patients! Am I totally deluded?? Don't worry, I am perpetually questioning myself in addition to the authoritarian dsm (as well as the pharmaceutical companies). Refuting that our psychotropics are NOT a magic bullet doesn't interest me. I just want to have faith in what I do. I want to strongly believe the benefits outweigh the risks (which will probably be impossible with my BPDs). Regardless, I want to improve the QOL of my patients and I want more than anything to have confidence in the treatment I provide. Is that too idealistic? I know psychiatry isn'tperfect. I have a ton of 20min med mngt appts scheduled for the next year/probably my?lifetime? From what I've gathered thus far, to be an effective psychiatrist, psychopharmacology will be my specialty (so I better be the expert). I'm going to try my best to learn all I can but I can't help but feel disheartened by all the research telling me meds don't work and either are beneficial (possibly 2/2 to elaborate statistical analysis, the placebo effect) or (are for the most part) unhelpful or harmful due to side effects. For a little while, I imagined dedicating my life to psychotherapy but I recognize that is a pipedream. Cherry picking my patients may not feel so good after awhile. Psychotherapy is hard and not for everyone.
P.S if you made it to the end of this, I commend you. I'm particularly disorganized tonight. Just to clarify, I do not mean to disrespect the field. I'm positive my rant stinks ignorance/lack of experience. I desperately want to reignite my passion for the practice. I want to be a great psychiatrist. If anyone has advice on how to do this, I appreciate your response in advance.

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[slappy]

Have you tried talking about this with your mentors who might be in a better position to provide the guidance you're looking for during what sounds like a crisis situation, if only because they probably know you a lot better than we do?

 

[birchswing]

As a patient, you sound like the perfect psychiatrist to me. You want to help but you are concerned about causing harm.

I used to be anti-psychiatry across the board because of the non-judicious use of medication (specifically benzodiazepines) I suffered at the hands of two misinformed or noncaring psychiatrists as a child.

If you turned away 50% (made-up number, not sure what it would really be) of your patients referring them to a nutritionist, a trainer, a therapist, a neurologist, etc., I'd say you'd be a great psychiatrist.

The best doctors I have found are the ones who are creative. Just because a lot of psychiatrists have done things badly in the past doesn't mean you have to. My aunt saw a psychiatrist who realized she needed micro-doses of lithium. That's different from the types of psychiatrists I've seen who would conk someone like her out on Zyprexa, then add some stimulant to counteract the fatigue, etc.

My current psychiatrist is fairly creative, or at least responsive, in helping me get off benzos, which I'm in the process of.

And realize that most of the time I go to other specialists, I don't walk away with a script—I don't know why it should have to be different for psychiatry.

It could be better. The fact that you realize that makes you a good doctor. I don't see anything wrong with telling a patient, "I think you're doing OK. I recommend you do X, Y, and Z . . . if you're still having difficulty come back and see me." That's what most specialists do. For some reason, psychiatry—in my experience and it sounds like yours—hasn't been that way. But it doesn't have to be.

 

[psych]

No I haven't. This is the first time I've tried to address this inner conflict (which is why my above post is probably hard to follow. I'm sure my my opinion will unveil itself more this year since I'll have more autonomy. I plan to (gentley) open up more to my attendings. I haven't done this because I fear it's just my ignorance that has fostered this skewed/inaccurate view of how we define and treat psychiatric illnesses.

 

[psych]

That's very kind of you birchswing. The irony is that I feel as though I am betraying the field.

 

[birchswing]

That's very kind of you birchswing. The irony is that I feel as though I am betraying the field.

You can probably find like minded practitioners once you're in the field. Or carve out a niche. You are the field.

 

[nitemagi]

It's not about cherry picking your patients to do therapy, though it is true that not everyone can afford therapy and not everyone wants therapy.

Therapy IMPO is an absolute tool for doing good work. And there are many types of therapy. Picking one therapy only to learn is basically like adding a screwdriver to your toolbox. A hammer and a screwdriver are great, but do not a carpenter make.

It's useful to be critical of the field, and to think critically about it. How else does change occur?

At the same time it's useful to learn the field before you criticize it. Learn that hammer really well before you weigh in on the inefficiencies of hammers.

Contrary to popular notion, this field is WIDE OPEN for the right clinicians. People want good psychiatrists. They want people to figure out how to make the system better. While many of us just want a paycheck by the time we finish residency, and thus take a job just doing med visits, it's the forward thinking ones that have the opportunity to change things. Become the head of a mental health department in a hospital. Or a county. Or a state.

Or open a private practice offering good therapy AND good med mgmt. The meds work, there's just a lot of noise blurring out the signal.

 

[whopper]

I feel as though the entire field of psychiatry is some grand delusion that people buy into in our society (even highly educated people that go through medical school). Am I the only (internal not scientologic) one that has felt this way?

There's several factors you mention that bring up questions.

Maybe you feel this way because your teachers are too rigid and possibly not educating you in a manner that would satisfy your concerns. I can imagine a situation where a resident is with a bad attending that medicates everything, leading that resident to judge the field based on that one doctor.

A class that psychologists take but psychiatrists do not (and we ought to do that) is Abnormal Psychology. It shows scientific principles being used to identify what is exactly normal vs abnormal.
Add to that, simply because something is abnormal doesn't mean it's bad. Having a genius IQ, being extraordinarily happy, being a billionaire, being as healthy as a 25 year old when you're 40 these too are abnormal.

What we peg as pathological should be open to high scrutiny and debate especially given the theoretical nature of our field. A lot of that determination is based on the law, not just from psychiatry. Our field has several cases where the law stepped in and mentioned that while what we saw was abnormal, we were not in a position to force treatment, only recommend it.

A residency program should at least have some emphasis on avoiding polypharmacy and treatment approaches without the use of medications, and when one is appropriate vs not using one.

Another emphasis is that legally, patients are required to be explained the meds they are being recommended and their treatment options. There are exceptions, such as a violent and psychotic patient needing to be medicated on the spot, or a patient that doesn't yet have the cognitive ability to fully understand a medication but is willing to accept it with the doctor believing it can be helpful.

 

[Armadillos]

This sort of thing related to the psychotropics comes up a lot (almost weekly at this point) and is at the heart of most of the angst on this board.

Can we have a more thorough discussion on it with people mentioning which studies they feel support their perspective? Because as someone still in medschool its pretty confusing because I see tons of studies showing effectiveness of various psychotropics then there are other studies showing they don't actually work well or dont improve well being. Also in practice during my rotations, seems like FM/IM docs think SSRIs are the greatest thing since sliced bread (maybe they see all the responders?) and psychiatrists seems to be very cynical about them. But then on the otherhand I might hear a psychiatrist say something like "Yeah this medication is not helpful and doesn't work in this situation, only 15% of these patients will be helped by it", but I feel like throughout medicine there are tons of meds/treatments with a NNT of way worse than 6 that people use all the time without thinking twice. Its all very confusing and at times kind of disheartening to someone choosing the field. Help?

 

[MacDonaldTriad]

The debate about the over and under use of psychotropics superficially can appear to be a bunch of thoughtless psychiatrists who are over liberal in their practice because of a lack of concern over risks. Yet despite the emphasis on evidence based practice, poly pharmacy, with mixtures of similar classes of meds continues to be the rule rather than the exception. I submit that this is more because psychiatry is hard, and many of our patients struggle hard to get better. There is such thing as over steering, and adding a new medicine with each new complaint is clearly wrong and bad practice, but how many visits do we need to see a patient who is suffering before we decide to be less conventional? Before Prozac came out in 1985, we were sparingly using TCAs because they had more side effects and it was hard to get someone to take them unless they were really needed. Now, SSRIs are very broadly used and probably inappropriately in many cases. It is because they are easy to manage and take. Antipsychitics were similar with Risperdal in 1992. Suddenly it was common to use “a little ego glue” without clear psychosis.
Some of the most ludicrous combinations of medicines I have seen come from psychopharmacologists who have national reputations for advancing evidence based treatment. If you ask them about it, they have always come to these combinations with a lot of rational thinking and trials. They end up looking fairly similar to the psychiatrists they are critical of except they put more thought into justifying (rationalizing) their actions. In their defense, the whole country is giving them the referrals that have failed about everything so this is apples and oranges.
We have talked before about how small the pool of things we know for sure are and how often we don’t follow these. MAOIs are best in Panic, go to Clozapine more quickly, we under use ECT and long acting injectables…. If a psychiatrist only practices evidence based medicine, he or she would be only helping a fraction of the problems out there.
It is easy to see how students become disillusioned. The more they learn, the less they feel they possess a complete universe of necessary knowledge. If someone goes into psychiatry seeking the answers, they will be quickly disappointed because there is nothing black and white in what we do. Ambiguity is dominate and ubiquitous.

 

[OldPsychDoc]

I don't think this is a departure from what's been said above, but day to day, 1:1, clinical practice is usually very different from being rigidly taught a diagnostic scheme that attempts to pigeonhole patients into phenomenologically derived diagnoses, then treat only with agents tested and "approved" for those criteria-defined diagnoses. Patients don't come to you stating "I have 5 of 9 criteria for major depressive disorder." They come saying "I'm depressed", "I'm anxious", "My wife says I have a problem..." Our job is to flesh those chief complaints out.

I frequently find myself thinking about an old mentor's basic 3-question diagnostic scheme: "Crazy/not crazy; sad/not sad; when did it start?" Add on a few questions about substance abuse, lifestyle, relationships, family history and development and you're well on your way to a decent preliminary biopsychosocial assessment. Then you ask the critical question of "How is this causing you clinical significant distress or impairment?" (or, you know, something like that ) and you can start proposing a treatment plan using the multiple tools at your disposal. And then you start the long journey with your patient... That's the beauty of psychiatry.

 

[vistaril]

Hi. I've been mia for awhile and recently re-realized what an anazing resource sdn can be. I know I have a lot to learn. This could be the most obnoxious post you will ever read. I definitely appreciate that, but the disillusionment I've experienced since I began residency training has reached a peak (at least I hope). It's taken its toll on me. I want to talk to other psychiatrists about this (I suppose this is my first outlet)...
...Maybe it's because I've been in an existential crisis for the past two years (well, crisis sounds a bit dramatic)... To give you an idea of what I've been struggling with: my personal threshold for what is "pathologic" is much higher than other people I've worked with in the field. :/ ? I think I might be too biased re: the phrase "don't believe everything you hear."
Perhaps my buddhist aspirations are influencing my perspective... [Feel free to disregard the rest of what I say if the term "buddhist" made you cringe.]
Others have mentioned in this forum when you're holding a hammer, everything looks like a nail. I can't help but strongly agree (and I'm sincerely frightened by this). I admire the philosophy of equanimity and the beginner's mind. We are all human, imperfect, trying to reduce the sufferin of one another. At least that is a goal of mine... Sounds cliche but perhaps these beliefs are what are interfering with my professional development. Bare with me- it's entirely possible, I'm the one who is shortsighted. My point is that, (here comes the blasphemy) occasionally I feel as though the entire field of psychiatry is some grand delusion that people buy into in our society (even highly educated people that go through medical school). Am I the only (internal not scientologic) one that has felt this way? The human mind is undoubtedly one of the most fascinating and complex things we will ever study. One of my issues is that patient assessment seems like such a subjective interpretation (looking for a cluster of "symptoms" to match some manmade "criteria" to fit a "diagnosis" elicited from an interview with a specific "psychiatrist" at a given point in time) . I can't help but see the parallel with the bible...
Okay, okay... It's interesting how much this doesn't even matter because we are chasing our tail- ultimately treating symptoms with these powerful meds -that obviously do more harm than good in some people . I feel like I'm violating the Hippocratic oath by making people obese, develop DM, HLD --> ultimately heart dz (with these propogated chemicals (medications) I don't even "believe in")... I can't possibly do intensive psychotherapy on all my patients! Am I totally deluded?? Don't worry, I am perpetually questioning myself in addition to the authoritarian dsm (as well as the pharmaceutical companies). Refuting that our psychotropics are NOT a magic bullet doesn't interest me. I just want to have faith in what I do. I want to strongly believe the benefits outweigh the risks (which will probably be impossible with my BPDs). Regardless, I want to improve the QOL of my patients and I want more than anything to have confidence in the treatment I provide. Is that too idealistic? I know psychiatry isn'tperfect. I have a ton of 20min med mngt appts scheduled for the next year/probably my?lifetime? From what I've gathered thus far, to be an effective psychiatrist, psychopharmacology will be my specialty (so I better be the expert). I'm going to try my best to learn all I can but I can't help but feel disheartened by all the research telling me meds don't work and either are beneficial (possibly 2/2 to elaborate statistical analysis, the placebo effect) or (are for the most part) unhelpful or harmful due to side effects. For a little while, I imagined dedicating my life to psychotherapy but I recognize that is a pipedream. Cherry picking my patients may not feel so good after awhile. Psychotherapy is hard and not for everyone.
P.S if you made it to the end of this, I commend you. I'm particularly disorganized tonight. Just to clarify, I do not mean to disrespect the field. I'm positive my rant stinks ignorance/lack of experience. I desperately want to reignite my passion for the practice. I want to be a great psychiatrist. If anyone has advice on how to do this, I appreciate your response in advance.

Look does this field have numerous problems? Of course. Does that mean you can't still have an enjoyable career in it? Of course not.

You've got to start accepting the way things are, and once you do that you'll start to have less angst over it.

This doesn't have to be your passion. Find something else that is your passion.

 

[psych]

Look does this field have numerous problems? Of course. Does that mean you can't still have an enjoyable career in it? Of course not.

You've got to start accepting the way things are, and once you do that you'll start to have less angst over it.

This doesn't have to be your passion. Find something else that is your passion.

Acceptance. That struck a chord. Ty. I feel a little better.

 

[smalltownpsych]

It sounds to me like you have the makings of an excellent psychiatrist. The type that I would feel very comfortable referring patients to. Don't get too frustrated with the fact that we know so little about what is going on with the human brain and that many in the field have their own difficulties with coping with the stress of this. Continue to cultivate the beginners mind and recognize the strength that provides. In this field, we have to be able to embrace uncertainty and a little bit of Buddhist perspective will go a long ways toward that.

 

[splik]

i am not sure why you feel bad about these fairly lukewarm criticisms of the field. I think psychiatric training needs a radical overhaul as does the practice of psychiatry in general.

1. Psychiatry has become too beholden to the DSM, with a complete de-emphasis of descriptive psychopathology a la Kraepelin, Bleuler, Jaspers, Schneider etc, and little attention to the medical differential diagnosis of psychiatric presentations (autoimmune, infectious, metabolic, vascular etc)

2. We have not given enough attention to the toxic effects of psychiatric drugs, the toxic etiology of some psychiatric presentations, and iatrogenic syndromes such as supersensitivity psychosis, tardive dysphoria syndrome, tardive dysmentia, antidepressant-induced chronic irritable dysphoria and so on. People stay on ridiculous combinations of drugs for far too long, with no attempt at withdrawal and there is little training in sensible ways of actually withdraw people off of antipsychotics and other psychotropic drugs.

3. Older effective psychotropic drugs are vastly under-utilized - for example MAOIs in the treatment of atypical depression, TCAs in melancholic depression, lithium augmentation for depression, clozapine in schizophrenia

4. Psychiatrists don't take care of the syndromes that they cause in their patients (such as diabetes, hypertension etc).

5. There is too much emphasis of psychodynamic models of mind whilst psychiatrists remain oblivious to other less ridiculous psychological theories that actually provide a useful framework for understanding problems we see in clinical practice

6. psychiatry has completely eschewed the social basis of psychopathology and its prevention and treatment. most of our patients are at the mercy of wider social forces and psychiatry is the last thing they need, and certainly the least important part of their recovery. Yet in adult psychiatry the role of social factors in psychopathology is completely underplayed, and somethings ignored. It is surprising how many people do not know or refuse to accept that if your a Black you are much more likely to become psychotic in this country.

7. Evidence-based practice is openly scorned and denounced. I have heard academics across the country deride the landmark papers in our field, and clinical psychiatrists pay little attention to what (limited) evidence is out there.

8. Debates about the concept and nature of mental illness and the mind-brain problem are at the heart of our work yet we try and remove ourselves from these issues espousing meaningless terms like 'biopsychosocial' to remove ourselves from the fray.

Personally I think psychiatry is exciting because of the murky issues about the concept of mental disorder, and there is something very humbling about the recalcitrance of human misery to our current treatments. Read lots, and ask lots of questions of your patients, try out different treatments, and take the opportunity of getting supervision from different people with different approaches (and try and get at least 1 psychologist supervising you, I have 3 and they usually have more thoughtful things to say than psychiatrists). Oh and remember there are many syndromes not well covered in the DSM that are fun to see (like psychopathy, morbid jealousy, delusions of misidentification, De Clerembault syndrome,
Ganser Syndrome) etc. You won't see these if you don't look for them! Catatonia and dissociative phenomena are also way more common in subtle forms and again if you don't look for them you won't find them.

 

[Ceke2002]

You sound quite a bit like my Psychiatrist, and I love my Psychiatrist to bits (not literally). He's a practicing Buddhist, treats individuals not diagnosis, sees diagnosis more as a cluster of symptoms on a spectrum rather than a set in stone idea of ticking a certain number of boxes in the DSM/ICD, is open to complementary practices as an adjunct to traditional Psychotherapy, and utilises pharmacology only when it's absolutely clinically necessary. He also just happens to be the best Psychiatrist I've had in 20 years, and the only one I've made any real progress with in terms of symptom reduction/ongoing management. So there are practitioners out there who do think more along your lines, and patients who will quite happily flock to them because sometimes having an individually tailored treatment program that respects the complexities of the mind and incorporates a number of traditional and non-traditional treatment aspects IS actually preferable to just having pills thrown at you.

 

[jakeislove]

I don't think this is a departure from what's been said above, but day to day, 1:1, clinical practice is usually very different from being rigidly taught a diagnostic scheme that attempts to pigeonhole patients into phenomenologically derived diagnoses, then treat only with agents tested and "approved" for those criteria-defined diagnoses. Patients don't come to you stating "I have 5 of 9 criteria for major depressive disorder." They come saying "I'm depressed", "I'm anxious", "My wife says I have a problem..." Our job is to flesh those chief complaints out.

I frequently find myself thinking about an old mentor's basic 3-question diagnostic scheme: "Crazy/not crazy; sad/not sad; when did it start?" Add on a few questions about substance abuse, lifestyle, relationships, family history and development and you're well on your way to a decent preliminary biopsychosocial assessment. Then you ask the critical question of "How is this causing you clinical significant distress or impairment?" (or, you know, something like that ) and you can start proposing a treatment plan using the multiple tools at your disposal. And then you start the long journey with your patient... That's the beauty of psychiatry.

I'm gonna use that!

 

[nancysinatra]

i am not sure why you feel bad about these fairly lukewarm criticisms of the field. I think psychiatric training needs a radical overhaul as does the practice of psychiatry in general.

1. Psychiatry has become too beholden to the DSM, with a complete de-emphasis of descriptive psychopathology a la Kraepelin, Bleuler, Jaspers, Schneider etc, and little attention to the medical differential diagnosis of psychiatric presentations (autoimmune, infectious, metabolic, vascular etc)

...

5. There is too much emphasis of psychodynamic models of mind whilst psychiatrists remain oblivious to other less ridiculous psychological theories that actually provide a useful framework for understanding problems we see in clinical practice

6. psychiatry has completely eschewed the social basis of psychopathology and its prevention and treatment. most of our patients are at the mercy of wider social forces and psychiatry is the last thing they need, and certainly the least important part of their recovery. Yet in adult psychiatry the role of social factors in psychopathology is completely underplayed, and somethings ignored. It is surprising how many people do not know or refuse to accept that if your a Black you are much more likely to become psychotic in this country.

7. Evidence-based practice is openly scorned and denounced. I have heard academics across the country deride the landmark papers in our field, and clinical psychiatrists pay little attention to what (limited) evidence is out there.

8. Debates about the concept and nature of mental illness and the mind-brain problem are at the heart of our work yet we try and remove ourselves from these issues espousing meaningless terms like 'biopsychosocial' to remove ourselves from the fray.

Totally agree with you, especially these points! Especially #6.

As for #7 I would say that critical thinking is also openly scorned and denounced by many in our field. I was ostracized in my residency because I would ask things like, "how is the DSM validated?" "Why are we being taught using simplified secondary sources that promote a 'psychodynamic' approach without allowing us to learn and discuss the psychoanalytic theories behind it?" If you start questioning the science, ethics, and power dynamics of psychiatry, remember that money and (fragile) egos are at stake, and in some quarters, those questions won't go over well. Start questioning the use of atypicals - oh it turns out Dr. So and So gives lectures for Seroquel in their off hours and has made a "name" for themselves as a "psychopharmacologist" (whatever that is). See my point? It's like everyone's peddling their own snake oil cure in this field. I bet internal medicine was like this once - 150 years ago, maybe.

And god forbid, don't ever question that holy grail of psychiatry, that sacred cow: CBT. CBT must be admired and promoted or else!

And don't tell me "psychiatry is an art" either. When someone's on 7 psychotropics, that's not artful.

 

[hamstergang]

Totally agree with you, especially these points! Especially #6.

As for #7 I would say that critical thinking is also openly scorned and denounced by many in our field. I was ostracized in my residency because I would ask things like, "how is the DSM validated?" "Why are we being taught using simplified secondary sources that promote a 'psychodynamic' approach without allowing us to learn and discuss the psychoanalytic theories behind it?" If you start questioning the science, ethics, and power dynamics of psychiatry, remember that money and (fragile) egos are at stake, and in some quarters, those questions won't go over well. Start questioning the use of atypicals - oh it turns out Dr. So and So gives lectures for Seroquel in their off hours and has made a "name" for themselves as a "psychopharmacologist" (whatever that is). See my point? It's like everyone's peddling their own snake oil cure in this field. I bet internal medicine was like this once - 150 years ago, maybe.

And god forbid, don't ever question that holy grail of psychiatry, that sacred cow: CBT. CBT must be admired and promoted or else!

And don't tell me "psychiatry is an art" either. When someone's on 7 psychotropics, that's not artful.

Depends on where you are. At my program, asking such questions was encouraged and done by the faculty that trained us. They would point out the gaps in the evidence, talk of the limitations of the DSM, show us the research (or lack thereof) on the meds that usually left us wanting to use the cheapest ones, and mock CBT for thinking it can cure everything (while also teaching us CBT so we could cure everything...).

We clearly had very different experiences and it has left us with very different views of the field. If we polled everyone, I wonder how the percentages would play out.

 

[smalltownpsych]

Totally agree with you, especially these points! Especially #6.

As for #7 I would say that critical thinking is also openly scorned and denounced by many in our field. I was ostracized in my residency because I would ask things like, "how is the DSM validated?" "Why are we being taught using simplified secondary sources that promote a 'psychodynamic' approach without allowing us to learn and discuss the psychoanalytic theories behind it?" If you start questioning the science, ethics, and power dynamics of psychiatry, remember that money and (fragile) egos are at stake, and in some quarters, those questions won't go over well. Start questioning the use of atypicals - oh it turns out Dr. So and So gives lectures for Seroquel in their off hours and has made a "name" for themselves as a "psychopharmacologist" (whatever that is). See my point? It's like everyone's peddling their own snake oil cure in this field. I bet internal medicine was like this once - 150 years ago, maybe.

And god forbid, don't ever question that holy grail of psychiatry, that sacred cow: CBT. CBT must be admired and promoted or else!

And don't tell me "psychiatry is an art" either. When someone's on 7 psychotropics, that's not artful.

The holy grail and sacred cow are pretty apt terms to capture a dynamic or psychological phenomena of some sort that plays out a bit much in our field. First it was psychoanalysis, then behaviorism, then humanistic, then meds, then CBT. Some of it has to do with the fact that most of the time we haven't got a friggin' clue what to do. I am a damn good psychotherapist and can implement evidence-based therapies extremely effectively and integrate a wealth of our knowledge and still every single day I am confronted with the limitations of this field when a patient sits across from me, tells me what they are dealing with and ask if I can really help them. Being able to live with the uncertainty takes a lot of "effective self-care" (another immeasurable construct) so that I can keep being effective or I could just limit my thinking to a small box and eliminate all uncertainty.
In my opinion, the DSM-5 is one of those little boxes. It is better than the first DSM with all of it's Freudian constructs, but we have a long way to go to understanding even the most basic of constructs.

 

[notdeadyet]

Depends on where you are.

This. When folks decry how "programs" turn up their noses at evidence-based medicine or medical model, are slaves to the DSM or RDoC or phenomenology, or are beholden to CBT or to psychodynamic or to psychoanalytic or to psychopharm, I can't help but feel they are reflecting on the program(s) at which they trained or teach.

There are others. And many are more open minded than the ones you describe. Some actually encourage a diversity of thought and healthy debate. No need to throw out the baby with the bathwater... Just find a new tub...

 

[vistaril]

This. When folks decry how "programs" turn up their noses at evidence-based medicine or medical model, are slaves to the DSM or RDoC or phenomenology, or are beholden to CBT or to psychodynamic or to psychoanalytic or to psychopharm, I can't help but feel they are reflecting on the program(s) at which they trained or teach.

There are others. And many are more open minded than the ones you describe. Some actually encourage a diversity of thought and healthy debate. No need to throw out the baby with the bathwater... Just find a new tub...

the problem is it really doesn't matter where you train at.....most people are just going to go out and do what they want eventually for various reasons.

 

[nancysinatra]

Depends on where you are. At my program, asking such questions was encouraged and done by the faculty that trained us. They would point out the gaps in the evidence, talk of the limitations of the DSM, show us the research (or lack thereof) on the meds that usually left us wanting to use the cheapest ones, and mock CBT for thinking it can cure everything (while also teaching us CBT so we could cure everything...).

We clearly had very different experiences and it has left us with very different views of the field. If we polled everyone, I wonder how the percentages would play out.

That's the kind of atmosphere I would have liked!

 

[nancysinatra]

This. When folks decry how "programs" turn up their noses at evidence-based medicine or medical model, are slaves to the DSM or RDoC or phenomenology, or are beholden to CBT or to psychodynamic or to psychoanalytic or to psychopharm, I can't help but feel they are reflecting on the program(s) at which they trained or teach.

There are others. And many are more open minded than the ones you describe. Some actually encourage a diversity of thought and healthy debate. No need to throw out the baby with the bathwater... Just find a new tub...

That may be true but I think the lack of consistency is incriminating itself. I am waiting for the day that "healthy debate" is universal and the sorcerer types are weeded out of our field. That's just my view; I've never claimed it's gospel descended from heaven. You could find people within my own residency program who were open minded and who I think are great doctors. But I've had one too many encounters with "old school" psychiatrists, of the type who, a few years back, might have said:

"Patient, I challenge you to know that I am right when I tell you your refrigerator mother definitely caused your schizophrenia/autism/whatever."

"Patient, your denial that homosexuality is an illness is merely resistance to my highly advisable treatment."

"Patient, it's not your assaultive husband that's the problem, it's your self-defeating personality disorder."

Even nowadays you hear: "Patient, I am certain you have bipolar disorder because of your risk-seeking behavior and I highly advise you take this mood stabilizer" and it turns out later the doctor was wrong, despite their "certainty." It might turn out the doctor is merely risk-avoidant. It's subjective.

How about: "Patient, marijuana is an illegal drug of abuse which will be highly harmful to you," and then the next day, it's legalized and obtainable by prescription?

See my drift? I'm not "opposed" to the old school theories. I find many of them compelling. But our field is so coercive! "It's just the rules" is how all inpatient units run. If it was hard for me, as a resident, to ask questions, how do you think it feels for patients?

There are many programs and individual psychiatrists who do not exemplify this mindset, but only in psychiatry can you get away with such a mindset. Surgeons and internists can't just say to patients: "Patient, you are in denial when you say that bloodletting won't cure you." Those fields don't have DSMs, they have Harrisons and other respectable tomes. But a psychiatrist can say whatever hocus pocus they want.

I bet I could practice straight up astrology as my "therapeutic orientation" and as long as I gave out an SSRI + atypical to each patient (or even if I didn't) and no one killed themselves, no medical board could fault me. How's that any different from blaming someone's woes on "black and white thinking?" I mean, what the heck is that?

 

[nancysinatra]

the problem is it really doesn't matter where you train at.....most people are just going to go out and do what they want eventually for various reasons.

Exactly - and it's not like this is OB where you pay the big time malpractice rates and actually have to worry about harming your patient. We can be erroneous till the cows come home and no one will know the difference.

 

[psych]

Hi peeps.... Thanks again for the previous responses! Well all I can say is it's me again... I feel like I've made progress perhaps even big strides since my original post. There was a disillusionment period that I have since come to terms with.

At one point I decided okay, placebo/drug/nocebo/whatever.....ultimately none of that crap truly matters in most patients. So of course I turn to how I can truly help my patients.

Now I'm questioning "therapy" and the "therapeutic relationship" which seems (to me) to have an erroneous perpetual positive connotation. Is it normal to be a pgy3 and feel like this. It could be because I know very little about beneficent therapeutic techniques. My supervisors say "trust your intuition" not manual ect.. Okay... I guess... That's why I've become an expert in this field?

 

[whopper]

It hardly ever happens in inpatient, but in outpatient, ER, and consults, medstudents and residents will often-times see me label a case as BS.

What that means is I see someone and do not think the person has a mental illness that needs to be treated. I often times will dx it as adjustment disorder, dingus NOS (when we got some guy just being difficult so some idiot thought he had bipolar disorder), or simply our colleagues trying to cover their asses.

Before I worked at U of Cincinnati, I thought I was an exception in this regard. Maybe I still am because unfortunately I've seen too many clinicians be willing to put a dx even they do not believe in because they have either the erroneous idea it's required for billing (or perhaps billing truly requires a hardcore dx in which case it's still wrong-because it falsely brands, it's insurance fraud, and it can lead to a domino-effect where the person continues this false dx for years) or they pathologize everything. At U of C, I noticed most of the clinicians there do what I do, but hey, this is a reason why I wanted to work there despite a massive paycut. Most of the doctors there have at least half a brain.

First few years of psych training is so heavily focused on inpatient that IMHO it can make some students and residents not see it in the grand scheme of things. More specifically that inpatient really is only for the sickest of people. Yes I know they got rid of the GAF but a GAF did help you see the big picture better. No one with a GAF above 40 should be admitted unless there's something that warrants it that if that's the case it's likely less than a 40, unless it's a private institution that likely will offer more holistic treatment options.

 

[slappy]

It hardly ever happens in inpatient, but in outpatient, ER, and consults, medstudents and residents will often-times see me label a case as BS.

What that means is I see someone and do not think the person has a mental illness that needs to be treated. I often times will dx it as adjustment disorder, dingus NOS (when we got some guy just being difficult so some idiot thought he had bipolar disorder), or simply our colleagues trying to cover their asses.

Before I worked at U of Cincinnati, I thought I was an exception in this regard. Maybe I still am because unfortunately I've seen too many clinicians be willing to put a dx even they do not believe in because they have either the erroneous idea it's required for billing (or perhaps billing truly requires a hardcore dx in which case it's still wrong-because it falsely brands, it's insurance fraud, and it can lead to a domino-effect where the person continues this false dx for years) or they pathologize everything. At U of C, I noticed most of the clinicians there do what I do, but hey, this is a reason why I wanted to work there despite a massive paycut. Most of the doctors there have at least half a brain.

First few years of psych training is so heavily focused on inpatient that IMHO it can make some students and residents not see it in the grand scheme of things. More specifically that inpatient really is only for the sickest of people. Yes I know they got rid of the GAF but a GAF did help you see the big picture better. No one with a GAF above 40 should be admitted unless there's something that warrants it that if that's the case it's likely less than a 40, unless it's a private institution that likely will offer more holistic treatment options.

I do the same and so does every attending I've ever worked with. Also, I do not understand why so many clinicians outside the ivory towers mislabel people as bipolar. Borderline, maybe I can fathom. But, bipolar? No.

I never liked the use of GAF though. It just seemed like one more highly subjective piece of documentation. Although it always amused me when I saw a GAF score of 37 or 24.

 

[smalltownpsych]

I do the same and so does every attending I've ever worked with. Also, I do not understand why so many clinicians outside the ivory towers mislabel people as bipolar. Borderline, maybe I can fathom. But, bipolar? No.

I never liked the use of GAF though. It just seemed like one more highly subjective piece of documentation. Although it always amused me when I saw a GAF score of 37 or 24.

I always used a 5 point spread on my GAFs and actually remember a supervisor arguing for why 37 or 24 type of score on a GAF made sense. I failed to see the logic. They were also implying that I was doing my job half-assed because I wasn't devoting enough thought and consideration to this aspect of diagnosis. I felt pretty validated when DSM-5 came out, and am so glad I don't have to use that unreliable metric anymore.

 

[whopper]

I never liked the use of GAF though. It just seemed like one more highly subjective piece of documentation. Although it always amused me when I saw a GAF score of 37 or 24.

I used to agree with you on GAFs until Doug Mossman, my former PD, taught me otherwise. Besides that you can get shredded in court for a wrong GAF, if one used the GAF scale the way it's supposed to be used, that is use the actual system recommended in DSM-IV where you look at the patient's severity of sxs, then their functionalilty, and rate it according to the scale it actually does work well.

Problem is no one was using it right. They got rid of it because, IMHO, people were screwing it up, not the actual system itself. My opinion is the same with the schizophrenia subtypes. They do exist and they did help in some cases. E.g. paranoid schizophrenics are capable of worse and pre-meditated violence more so vs disorganized schizophrenics.

 

[MacDonaldTriad]

GAFs work if you use the anchor points. Unfortunately almost no one does.

http://www.ncbi.nlm.nih.gov/pubmed/21223457

 

[smalltownpsych]

Looking at that study, the first thing that jumps out at me is the range. How do you get a GAF of 85 when you also meet diagnostic criteria for a current Major Depressive Episode? The mean score of 55 seems about right for an outpatient sample since they would probably tend to be in the moderate range as the mild range is less likely to be in treatment and the severe more likely to be in outpatient. I agree that if the GAF were used correctly, then it could be useful but I doubt if it ever will because in actual practice I find low inter-rater reliability even when looking at Mild, Moderate, and Severe.

 

[billypilgrim37]

Insurance companies ruined any usefulness of the GAF when they linked level of services to it. Coming in? 21-29 (because they don't understand that the 30 goes with the 21-30). Getting better but not ready to leave? 30-39. AMA DC? 40, because they had to be low enough that you wanted to keep them in the hospital, but well enough that you could justify not involuntarily committing. PHP/IOP? 41-49, because they have to be good enough to be out of the hospital but not good enough for regular outpatient. Regular outpatient? 51 or higher. Because the lawyers will figure out that the 50 goes with 41-50 and burn you for not seeking a higher level of care. So you can really only use a 50 when you recommend a higher level of outpt care and they refuse! (Again, to show that they need to be in higher level of care, but aren't so sick that you can't still have them)

 

[smalltownpsych]

Insurance companies ruined any usefulness of the GAF when they linked level of services to it. Coming in? 21-29 (because they don't understand that the 30 goes with the 21-30). Getting better but not ready to leave? 30-39. AMA DC? 40, because they had to be low enough that you wanted to keep them in the hospital, but well enough that you could justify not involuntarily committing. PHP/IOP? 41-49, because they have to be good enough to be out of the hospital but not good enough for regular outpatient. Regular outpatient? 51 or higher. Because the lawyers will figure out that the 50 goes with 41-50 and burn you for not seeking a higher level of care. So you can really only use a 50 when you recommend a higher level of outpt care and they refuse! (Again, to show that they need to be in higher level of care, but aren't so sick that you can't still have them)

I completely agree and had to laugh a bit as I have had to use that "hidden" GAF scale a few times, but the ironic thing is that metric probably leads to more reliability than the way most clinicians use it which I sometimes thought was the dart board method.

 

[MacDonaldTriad]

Admission GAF = 1, Discharge GAF = 99, Outpatients = 50.001 and by the end of 6 visits the treatment plan's objective measurements of improvement shall predict a 50.002.

 

[whopper]

I agree that if the GAF were used correctly, then it could be useful but I doubt if it ever will because in actual practice I find low inter-rater reliability even when looking at Mild, Moderate, and Severe.

GAFs work if you use the anchor points. Unfortunately almost no one does.

Yep, exactly. I remember I sat in on a session where on senior resident during the weekly resident lunch sessions was telling the junior residents that the GAF was a load of bull$hit. The GAF itself would work well if docs actually did it the way it was supposed to be done As a whole we did not.

I actually agreed with her until forensic fellowship. My PD made me read how to do the GAF line-by-line and do them correctly and after doing that for a few weeks I was actually thinking that the GAF could've been a very good system.

Another problem is we psychiatrists don't get trained in psychometrics, and in residency no one gave a damn about GAF. Sharper lawyers are aware of this and that is why many of them try to use the GAF as an easy target to catch off-guard psychiatrists who likely never scored it right to begin with.

 

[hamstergang]

One criticism of the GAF I saw somewhere was that one could get a certain score for either symptom severity or degree of functional impairment. So you almost had to explain which one the number meant in your assessment (else you leave it ambiguous), but then why bother with a number if you're going to explain it anyway?

 

[whopper]

I saw somewhere was that one could get a certain score for either symptom severity or degree of functional impairment.

That's what I would do. If someone was functionally impaired but their mental status wasn't too bad, I'd write down something to the effect of GAF 25, but due to functional, not mental illness reasons.

 

[erg923]

My supervisors say "trust your intuition" not manual ect..

Is there evidence for the validity of that statement? lol.

We like to self-affirm. We like to think our intuition is this magical thing that can help guide patient care/therapy. Yes, this "art" of therapy works beautifully...until it doesn't. And then who pays the price? Well, not you. You get paid the same whatever the outcome, right? Like anything, sometimes its right, but often times its wrong. Cognitive psychology tells us we will pay more attention to when we are right and ignore, and thus underestimate, when we are wrong. Not sure why educated academics would want to play dumb to such an equivocal finding in the social and cognitive psychological literature. Could this be Splik's # 5 at work here? Psychological science exists for a reason. Use it.

Manualized treatments are manualized for a reason. Providing structure, consistency, and accountability in their own treatment/healthcare (ie., practice assignments) for a person who's life lacks these elements, is a GOOD thing. Patients, generally, will appreciate a therapy that seeks to get things done.

While obviously all patients want to be able to cathart about problems with an empathetic therapist, psychiatrists sometimes seem blind to the fact that the vague explorations and "do-nothingness" of psychotherapy is also one of the biggest criticisms among the lay public. You would have to be asleep not to have heard this stereotyped criticism of psychotherapy.

"Relax and let your intuition guide you" is advice I would expect a member of the clergy to give a young Carmelite learning pastoral counseling. Or perhaps to a Jedi preparing to blow the death star. This is not exactly "words of wisdom" I would expect to be coming from a mental health professional. Again, the science (and outcome literature) is there for a reason, folks. Use it.

 

[erg923]

I used to agree with you on GAFs until Doug Mossman, my former PD, taught me otherwise. Besides that you can get shredded in court for a wrong GAF, if one used the GAF scale the way it's supposed to be used, that is use the actual system recommended in DSM-IV where you look at the patient's severity of sxs, then their functionalilty, and rate it according to the scale it actually does work well.

Problem is no one was using it right. They got rid of it because, IMHO, people were screwing it up, not the actual system itself. My opinion is the same with the schizophrenia subtypes. They do exist and they did help in some cases. E.g. paranoid schizophrenics are capable of worse and pre-meditated violence more so vs disorganized schizophrenics.

I have not given a GAF in years. No inpatient work until recently, and now its not required.

 

[Ceke2002]

Is there evidence for the validity of that statement? lol.

We like to self-affirm. We like to think our intuition is this magical thing that can help guide patient care/therapy. Yes, this "art" of therapy works beautifully...until it doesn't. And then who pays the price? Well, not you. You get paid the same whatever the outcome, right? Like anything, sometimes its right, but often times its wrong. Cognitive psychology tells us we will pay more attention to when we are right and ignore, and thus underestimate, when we are wrong. Not sure why educated academics would want to play dumb to such an equivocal finding in the social and cognitive psychological literature. Could this be Splik's # 5 at work here? Psychological science exists for a reason. Use it.

Manualized treatments are manualized for a reason. Providing structure, consistency, and accountability in their own treatment/healthcare (ie., practice assignments) for a person who's life lacks these elements, is a GOOD thing. Patients, generally, will appreciate a therapy that seeks to get things done. While obviously all patients want to be able to cathart about problems with an empathetic therapist, psychiatrists sometimes seem blind to the fact that the vague explorations and "do-nothingness" of psychotherapy is also one of the biggest criticisms among the lay public. You would have to be asleep not to have heard this stereotyped criticism of psychotherapy.

"Relax and let your intuition guide you" is advice I would expect a member of the clergy to give a young Carmelite learning pastoral counseling. Or perhaps to a Jedi preparing to blow the death star. This is not exactly "words of wisdom" I would expect to be coming from a mental health professional. Again, the science (and outcome literature) is there for a reason, folks. Use it.

Hear, Hear! My Psychiatrist is very empathetic and able to establish a good rapport with me in session by being able to tune in to aspects of things like my interests and general personality to create a sense of therapeutic connection; however, that does not mean our sessions are purely intuitive, 'fly by the seat of your pants' type affairs. There is still a lot of structure to them, and whilst he may decide to 'adapt' the manual/particular evidence based techniques to suit my personality/individual requirements, it doesn't mean he just goes ahead and throws the manual out all together. I've been with other therapists who did work on intuition alone - "We don't need to structure our sessions based on some arbitrary book or training method, because I'll just 'feel' the direction we need to go in" - needless to say that direction tended to be running around in circles getting nowhere fast.

 

[Ceke2002]

Now I'm questioning "therapy" and the "therapeutic relationship" which seems (to me) to have an erroneous perpetual positive connotation.

As a patient I have an excellent therapeutic relationship/bond with my Psychiatrist. That does not mean; however, that it is 'perpetually positive'. We don't just sit there holding hands and singing Kumbaya all session. He challenges me when its needed, and we don't always agree on everything. Sometimes he'll make an observation that I think is way off the mark and I'll go away and think about it and then come back and tell him outright 'dude, you missed the target like whoa!' He doesn't just sit there giving me pats on the head, or blowing smoke up my arse telling me how simply fantastically wonderful I am, and tralalala lets go skip through a field of daisies whilst singing each other's praises. That's not a good therapeutic bond to me, that's, I don't know what the hell that is, a Norsca advert perhaps?