interesting clinical hypothetical......

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vistaril

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So let's say you are working in mental health/student wellness at Duke, and the girl who has been all over the news lately for doing hardcore adult videos gets referred to your office by her student dorm manager for seeming depressed and anxious lately(or some other rather innocuous referral method).

How do you approach that bad boy of a case?
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What makes this interesting?
 
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Proceed to take psychiatric history like with any other patient? Not sure why that case would be special.
 
Don't watch the videos.
 
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vistaril said:
So let's say you are working in mental health/student wellness at Duke, and the girl who has been all over the news lately for doing hardcore adult videos gets referred to your office by her student dorm manager for seeming depressed and anxious lately(or some other rather innocuous referral method).

How do you approach that bad boy of a case?
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If you think "seeming depressed and anxious" is a "bad boy of a case," what did you learn in residency? This is bread and butter stuff.

And if you're diagnosing sex work as the cause of her mood and anxiety issues before you even met her, you are making some pretty bad logic leaps and are starting from behind...
 
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vistaril said:
Seriously though, how would you address the issue that is likely contributing to what she is going through?
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By identifying it. Hence the need to do a full assessment before deciding what the issue is that is likely contributing to what she's going through. Considering the nature of the behavior and the fact that she's probably a high-functioning person otherwise (granted, the only thing I know about this girl is what I read in vistaril's original post), I'm guessing that there was some underlying psychopathology there. There's a pretty extensive DDx based on the tiny bit of information that I have.

Also, I'm not sure I like the idea of discussing the psychiatric status of a real-life person on an online forum.
 
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notdeadyet said:
If you think "seeming depressed and anxious" is a "bad boy of a case," what did you learn in residency? This is bread and butter stuff.
..
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it's a bad boy of a case not because of depression and anxiety, but because of how to address the whole degrading porn angle.
 
vistaril said:
it's a bad boy of a case not because of depression and anxiety, but because of how to address the whole degrading porn angle.
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The fact you would approach the case with the "whole degrading porn angle" betrays a strong bias that makes me thunk you probably wouldn't be right for the job. Sex workers need to take care to approach therapists who approach them with an open mind or else bias will poison both diagnosis and treatment. I've worked with a few folks who work this trade and some are on drugs or victims of sex trauma and others are not.

And I agree with Shan that formulating someone unmet via the media isn't ethical...
 
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notdeadyet said:
The fact you would approach the case with the "whole degrading porn angle" betrays a strong bias that makes me thunk you probably wouldn't be right for the job. Sex workers need to take care to approach therapists who approach them with an open mind or else bias will poison both diagnosis and treatment. I've worked with a few folks who work this trade and some are on drugs or victims of sex trauma and others are not.

And I agree with Shan that formulating someone unmet via the media isn't ethical...
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Given what we already know about V's preferred entertainment options, (http://forums.studentdoctor.net/thr...g-out-soon-side-effects.973863/#post-13601184) I'd be concerned that he would indeed not be the right doc for the job as well.
 
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vistaril said:
it's a bad boy of a case not because of depression and anxiety, but because of how to address the whole degrading porn angle.
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What matters is not that you view porn as degrading, but what the patient's view of her work is.
 
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I would start with therapy and maybe pills. And then if the patient needed anything, I'd address that next.
 
because it doesn't stop with the hypothetical and goes on to reference a real person
 
Shikima said:
Why? A very important topic to discuss.
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Effect of sex work on psychological well being would be very important, but not the particularities of a person. This is definitely unethical and in addition not interesting in the slightest. The fact that it had to be presupposed that this person would present with anxiety or depression already shows lots of prejudice.
 
Jorje286 said:
Effect of sex work on psychological well being would be very important, but not the particularities of a person. This is definitely unethical and in addition not interesting in the slightest. The fact that it had to be presupposed that this person would present with anxiety or depression already shows lots of prejudice.
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ummm...she presents with that because she has said things have been hard and stressful lately...
 
vistaril said:
ummm...she presents with that because she has said things have been hard and stressful lately...
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Is "clinical hypothetical" a euphemism for fantasy?
 
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The sex work aspect of the hypothetical case is not interesting - what is slightly more interesting is the question of how to relate to a patient who has been the subject of a public scandal. Do you bring it up if the patient doesn't mention it?
 
i'm dissapointed no one said watch her porn videos for patient research
 
vistaril said:
So let's say you are working in mental health/student wellness at Duke, and the girl who has been all over the news lately for doing hardcore adult videos gets referred to your office by her student dorm manager for seeming depressed and anxious lately(or some other rather innocuous referral method).

How do you approach that bad boy of a case?
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I wasn't going to say it, assuming someone else would, but RAs (dorm manager?) don't refer residents to psychiatrists. They can write them up, or send a report of concern to a dean, but they wouldn't directly set up an appointment.

Even that is to assume that she lives in a dorm (not all college students are dorm residents) in addition to the other assumptions (that she seems depressed and anxious).

I will say that, as a non-doctor, I have thought about how doctors handle seeing celebrities (such as Britney Spears), not so much the individual, but all the extra people that come with that. And I wonder if the type of "regular" doctor who would see non-celebrity patients couldn't handle seeing such a patient, so celebrities end up being seen by a different class of doctor (ones who specialize in the practicalities of meeting with celebrities, maybe no public waiting rooms, etc.). It would be ideal I would think if a celebrity met with "regular" doctors and the celebrity quality was completely incidental.

I also wonder if a psychiatrist/therapist is supposed to disclose what they already know about a person (if anything), or wait for the patient to ask. Like say you were treating Reese Witherspoon, would you start by acknowledging that you had heard of her? Would you take into account her DUI when making decisions if she hadn't told you about it and you only knew about it from the news?
 
birchswing said:
I wasn't going to say it, assuming someone else would, but RAs (dorm manager?) don't refer residents to psychiatrists. They can write them up, or send a report of concern to a dean, but they wouldn't directly set up an appointment.
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they would refer them to university student wellness....and in my example you *are* the psychiatrist at university student wellness.
 
Haven't heard the story, but based on this thread it sounds like a college student was making porn. What makes this news?
 
st2205 said:
Haven't heard the story, but based on this thread it sounds like a college student was making porn. What makes this news?
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She was "outed" by a fellow student who recognized her and was bashed by the greek system and she's now speaking out about how there's a double-standard and a lot of the typical not-all-sex-workers-are-exploited themes.

It's not news. It's getting play in the news because she's the idealized porn actress/college student with a Twitter account.

It also doesn't have much to do with psychiatry. I think Vistaril was reaching so that he could bring up porn on SDN under the guise of it being work-related.
 
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Treatment selection is based on an explanatory model of the pathology/symptoms. This is basic case conceptualization skill and process that I would hope any psych resident has done a 100s of times already. You think this case is special because it involves sex work?! Why? What do you think thats about?

Vistaril, I am sure you have seen psychosocial enviornments and histories that are WAY more complicated and challenging than this, no?
 
erg923 said:
Treatment selection is based on an explanatory model of the pathology/symptoms. This is basic case conceptualization skill and process that I would hope any psych resident has done a 100s of times already. You think this case is special because it involves sex work?! Why? What do you think thats about?

Vistaril, I am sure you have seen psychosocial enviornments and histories that are WAY more complicated and challenging than this, no?
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I dunno....seems pretty sordid and complicated to me.
 
vistaril said:
I dunno....seems pretty sordid and complicated to me.
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I dunno either...its pretty clear that you are letting your personal feelings (defenses?) about pornography get in the way here?

The way I see it, we have a woman whose vocational choice may (or may not) be effecting her psychological and adapative functioning. How is that any different than seeing a cop, an air traffic controller, etc.? If you are looking at it throught a moral lense, then I can see where it gets dicey. But, is that where you should be coming from as a mental health professional/practitioner? Most would argue, certainly not. And frankly, thats pretty basic. So, ill ask again, what is your actual issue here? If it legitamtely treatment selection and case conceptualization, then it would help to see how the patients views her problems, or if she really has any, and then proceed with exploring from a cognitive model, dynamic model, family systems model... whatever you think is consistent and can lead to treatment gains. Again, pretty basic stuff.
 
I'm disappointed, but not surprised, at the posters here essentially arguing that a good psychiatrist must take a morally neutral if not positive view of whoredom. While of course we must treat all our patients humanely, are you suggesting that a psychiatrist cannot believe in traditional morality?
 
Trismegistus4 said:
I'm disappointed, but not surprised, at the posters here essentially arguing that a good psychiatrist must take a morally neutral if not positive view of whoredom. While of course we must treat all our patients humanely, are you suggesting that a psychiatrist cannot believe in traditional morality?
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I am a lifelong Roman Catholic and certainly can't support pornography or other sex work. But I am not a priest in my office, I am a professional with a job. Part of that job is to not let my is biases or judgements into the room, nor is it fir me to "tell" my patient what to do. That's what friends are for/do. Mental health professional do something different.

Moreover, whatever my stance on "whoredom" is, there is no real benefit to judging it and using it as some sort of weapon of influence. This would hold true whether I was taking confession and reconciliation or providing professional mental healthcare services.

By the way "whoredom" is an ugly word that identiies a person by your percived sin and neglect their inate humanity. as both a Cathlolic Christian AND professional, I would highly suggest reflction upon use of words such as these.
 
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Trismegistus4 said:
I'm disappointed, but not surprised, at the posters here essentially arguing that a good psychiatrist must take a morally neutral if not positive view of whoredom. While of course we must treat all our patients humanely, are you suggesting that a psychiatrist cannot believe in traditional morality?
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I heard this same argument from psychiatrists and psychologists 20 years ago when they found themselves having to treat folks who'd been through abortion.

The record changes but the song always sounds the same...
 
Trismegistus4 said:
I'm disappointed, but not surprised, at the posters here essentially arguing that a good psychiatrist must take a morally neutral if not positive view of whoredom. While of course we must treat all our patients humanely, are you suggesting that a psychiatrist cannot believe in traditional morality?
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Are you for real here? I don't support or condone drug abuse, either, but I khow that I am going to encounter a helluva lot of it in psychiatry - in all medicine for that matter. Same with obesity...be careful when you starting drawing lines on what you feel is morally acceptable behavior in patients - you mind end up in a very tight corner.
 
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notdeadyet said:
She was "outed" by a fellow student who recognized her and was bashed by the greek system and she's now speaking out about how there's a double-standard and a lot of the typical not-all-sex-workers-are-exploited themes.

It's not news. It's getting play in the news because she's the idealized porn actress/college student with a Twitter account.

It also doesn't have much to do with psychiatry. I think Vistaril was reaching so that he could bring up porn on SDN under the guise of it being work-related.
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And from the (fully clothed, mainstream media) interview I saw of her, seems pretty assertive and able to speak for herself--neither depressed nor anxious.
 
Psychotic said:
Are you for real here?
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I think he is, as his history on SDN contains many "I'm sad that people like you still exist" moments. For instance, when someone mentioned their intern class was all male:

Trismegistus4 said:
If anything, he should be relieved. Dudes git 'r done. Everytime there's some stupid personal blow-up between 2 people in my program, the 2 people are women.

If he's disappointed, it's probably because he hoped to date a lady in the program, which is a horrible idea. For some reason a lot of male doctors think they're supposed to look for love among their female colleagues. Branch out, guys; you can do a lot better than a doctorette.
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Trismegistus4 said:
I'm disappointed, but not surprised, at the posters here essentially arguing that a good psychiatrist must take a morally neutral if not positive view of whoredom. While of course we must treat all our patients humanely, are you suggesting that a psychiatrist cannot believe in traditional morality?
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You can believe anything you like as a psychiatrist. But in order to help a patient you need to foster a therapeutic alliance with them - if you start by judging them for "whoredom," you're not going to get very far.
 
OldPsychDoc said:
And from the (fully clothed, mainstream media) interview I saw of her, seems pretty assertive and able to speak for herself--neither depressed nor anxious.
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she seemed confused to me. I don't think she really has anything to say.......if so, I haven't heard it yet.
 
Trismegistus4 said:
I'm disappointed, but not surprised, at the posters here essentially arguing that a good psychiatrist must take a morally neutral if not positive view of whoredom. While of course we must treat all our patients humanely, are you suggesting that a psychiatrist cannot believe in traditional morality?
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I think it is different than a classic moral issue.

What she is doing is degrading. She doesn't respect herself or her body. Taking a stance on that(and with her) may not be a bad idea. I've seen a couple of references to adult dancing here. Really? Lumping them together because they both involve the adult entertainment industry is like lumping murder and trespassing together because they are both against the law.
 
i'm so glad you are not taking up an academic job. at least your horrible way of thinking would die with you this way. it's the academic equivalent of negative selection
 
Jorje286 said:
Effect of sex work on psychological well being would be very important, but not the particularities of a person. This is definitely unethical and in addition not interesting in the slightest. The fact that it had to be presupposed that this person would present with anxiety or depression already shows lots of prejudice.
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Need to return to the biopsychosocial model. It's not unethical to inquire about abuse and other threats to her life. Very appropriate to inquire how her line of work is/has affected her ability in living her life and the meaning.

This is all on the supposition you have more than 15-20 mins, asking her to open her mouth and throwing meds into it - what ever sticks is the dosage. (Yes, flagrently stolen).
 
Vistaril, what do you think your job is as a mental Health professional?
 
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hamstergang said:
I think he is, as his history on SDN contains many "I'm sad that people like you still exist" moments. For instance, when someone mentioned their intern class was all male:
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Wow. Haven't seen such explicit misogyny for a while. That's horrifying.
 
vistaril said:
What she is doing is degrading. She doesn't respect herself or her body. Taking a stance on that(and with her) may not be a bad idea. I've seen a couple of references to adult dancing here. Really? Lumping them together because they both involve the adult entertainment industry is like lumping murder and trespassing together because they are both against the law.
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1. Those are subjective emotional experiences and judgments, not facts. This isnt high cholestorol here (objective fact), pal. For goodness sakes, if someone doesnt actually have low mood or anhedonia, then they dont need treatment for depression.
2. "Taking a stance?" Is that your job?

Vistaril, these are basics. BASICS! How do you get to 4th year and not have the basics down?
 
I would also add that, if your major objection to pornogrpahy is that fact that it is "degrading".... I would imagine that the origin of that emotion is the objectification of the person, no? If so, what the difference, in your mind, between stripping and having coitus filmed?

From a Christian perspective, I think both are not in the image of God. However, I fully recognize that does not necessarily translate to psychological harm that needs to be treated medically by me. To assume such is quite insulting and does not take into account individual differences, not to mention respect for individual choices and freedoms.

Like others, I have concerns that this post demonstrates either a severe lack of personal awareness or a lack of clinical care competence that is commensurate with your traning level. Perhaps both. Not sure.
 
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erg923 said:
1. Those are subjective emotional experiences and judgments, not facts. This isnt high cholestorol here (objective fact), pal. For goodness sakes, if someone doesnt actually have low mood or anhedonia, then they dont need treatment for depression.
2. "Taking a stance?" Is that your job?

Vistaril, these are basics. BASICS! How do you get to 4th year and not have the basics down?
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oh I just don't agree with your approach to this scenario at all.
 
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