Medication seeking patients

[wolfvgang22]

How do you deal with medication seeking patients on a daily basis. I'm talking about patients thta either don't go to psychotherapy, or if they do go, they only complain and never actually participate. The patient that has a generally chaotic, low income life situation that probably worsens 80% or more of their illness. Such patients often complain their medications stop working, or only work partially, because "I'm still not happy". The patient then asks for yet another pill to solve the problem. I'm looking for more ideas on how to handle this.

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[nitemagi]

I often start with agreeing about how difficult their life is, and that a medication will only help part of the way. But I want them to feel better. So why not try some therapy. Meaning try it for X period. No harm.
I might also incorporate some CBT concepts that we can all be playing a part in perpetuating our own misery, and thus taking an honest look at our own role in the process, with the help of another. Rather than externalizing blame.
I may frame it in Gestalt therapy terms, with the idea that many problems come from not knowing the boundary of what's me and what isn't. Holding onto things that don't belong in us, or pushing things out that do belong in us (a jungian shadow concept as well).

 

[Member 1337]

Big Pharma spends millions on commercials advocating "the pill" that will "cure what ails you," physician advocacy groups spend millions on PSA's encouraging patients to "get help," "see your doctor," "get treatment" to live better lives, and it's still the cultural expectation that a real doctor will give you a prescription (talisman) to fill and consume and get fast relief like chewing on painkillers. This is compounded by the economic climate and business practices insisting on "patient safisfaction" and "customer service," where a negative review on rateyourawesomepillpusher.com (or patient survey) reflects poorly on the practicioner, even if they were backing proper evidence-based boundaries and appropriately "advising against" unhelpful treatment options. I can't blame our patients for wanting to believe this mythology over the often excruciatingly challenging and typically slow work of real psychotherapy.

In an ideal practice, one that won't punish you for telling the patient "no," one idea is to nip it in the bud. This sounds counterintuitive but works systemically in the patient's best interest. During the intake, explain what the diagnosis is. Explain the evidence-based treatment options. Explain what is helpful and what has shown to be not helpful. If they refuse to trust your evidence based recommendation, they can be quickly referred to another practice for a second opinion right off the bat. Hopefully the doc we refer them to will have a relationship modified by the input we provided about best practices and the patient will be that much more willing to consider different options.

I'm a huge fan of developing rapport and sticking through difficult situations with patients - but sometimes we know the writing's on the wall and the patient is not coming to us for help but for a pill. Giving them a pill will not help them and we are playing the same harmful game just like everyone else if we delude ourselves into churning out scripts. For example, benzodiazepenes as primary treatment for PTSD is not best practice. I still see this all the time - multiple progress notes from years of PTSD treatment: here's 2 more months of Xanax; RTC in 2 months. If a patient shows up for an intake and insists on continuing to demand Xanax and they continue to refuse to engage in any other treament options, it's time for a referral - because we're not helping them at all.

 

[F0nzie]

Scenario 1:

The accountability move.

Me: "how many times per week do you forget to take your medication?"
Patient: "3-4 times per week".
Me: "do you think you would feel better if you took them everyday?"
Patient: "...(pauses and thinks). Yes, probably."
Me: "ok let's give this another 4 weeks. Would you like a free medbox?".

If I have time I may explore reasons for missing meds which may range from simple forgetfulness to frustration involving feelings of loss of independence or control.

Scenario 2:

Highlighting the treatment engagement

Me: "Medications are 50% of the treatment. Therapy is the other 50%. Since you are not in therapy you are only receiving 50% of the treatment. Actually I take that back. You miss your medications every other day so that puts you at 25%.

Therapeutic silence.

 

[mojetter]

LOL @Fonzie...they probably filed a complaint after that advice.

To the OP, i used to work at a facility like that, after a while I had to leave because the "switch, switch, switch" pressure became too great and the requests for benzos was crushing. At a point I had to tell many that there was no medical change I felt would help and most did not like that advice.

Hopefully your situation gets better...the clinic (assuming you work in a clinic) where you practice needs to take more responsibility for enrolling patients in other modalities of treatment (therapy, groups, partial, IOP, psych rehab programs, case mgmt, etc). I work at a community hospital now with a high rate of local poverty but the pressure to "fix my mood" is NOTHING like my previous experience because it is therapy driven. All patients here have to see a therapist and psychiatrist to remain in the clinic. Maybe 20% of my appts need rx adjustments and when they do they're usually minor titrations.

 

[wolfvgang22]

Scenario 1:

The accountability move.

Me: "how many times per week do you forget to take your medication?"
Patient: "3-4 times per week".
Me: "do you think you would feel better if you took them everyday?"
Patient: "...(pauses and thinks). Yes, probably."
Me: "ok let's give this another 4 weeks. Would you like a free medbox?".

If I have time I may explore reasons for missing meds which may range from simple forgetfulness to frustration involving feelings of loss of independence or control.

Scenario 2:

Highlighting the treatment engagement

Me: "Medications are 50% of the treatment. Therapy is the other 50%. Since you are not in therapy you are only receiving 50% of the treatment. Actually I take that back. You miss your medications every other day so that puts you at 25%.

Therapeutic silence.

This is exactly what I do a lot. It works about 50% of the time. Yep, I do get complaints when I do it. Fortunately, my administration is supportive. But since I'm in the VA, every time there is a complaint, it has to be addressed when the patient complains. It gets old explaining " I didn't give him Xanax because he won't get better as long as he is using meth and four bowls of Marijuana every day", or "There isn't much I can do with a pill." These conversations eat up an ever larger portion of my time. So I spend lots of time trying to avoid confrontation and complaints. I think this is how the doc I replaced became a pill pusher, prescribing tons of benzos.
I do work in a clinic.

 

[birchswing]

If you ever wonder why I complain so much here, it's because I've never been to a place where you could complain even reasonably without an invitation to leave (this isn't stated, but I'm fairly good with implicit intersubjectivity). There are likely many people waiting to take my spot as a patient at any particular outpatient facility. That's why I had trouble understanding high no-show rates as well (someone said up to 50%). Where I go, if you miss an appointment you're not going to be able to get another one for months.

 

[keifernny2]

This is exactly what I do a lot. It works about 50% of the time. Yep, I do get complaints when I do it. Fortunately, my administration is supportive. But since I'm in the VA, every time there is a complaint, it has to be addressed when the patient complains. It gets old explaining " I didn't give him Xanax because he won't get better as long as he is using meth and four bowls of Marijuana every day", or "There isn't much I can do with a pill." These conversations eat up an ever larger portion of my time. So I spend lots of time trying to avoid confrontation and complaints. I think this is how the doc I replaced became a pill pusher, prescribing tons of benzos.
I do work in a clinic.

I have a similar position in the VA, and my strategy has been #1) start with utoxes if you're not doing them already. At least once each year, maybe more if you don't trust it. There are so many patients that miraculously don't have their controlled substances in them. These patients don't need them #2) when a patient "runs out early," or "forgets to refill," and is out of their meds, this is the perfect time to try something new. I would also prefer to refer them to a therapist in the meantime when they're dealing with anxiety, however I don't have that referral option due to staff shortages. #3) as a final option, get a job where you don't have to explain yourself to your local congressman for saying "no"

 

[F0nzie]

I don't get into benzo arguments. I refer out to psychiatrists with more experience.

 

[wolfvgang22]

I don't get into benzo arguments. I refer out to psychiatrists with more experience.

Bwahahahaha....I've done that once or twice. But that's a mean thing to do to the older psychiatrists, and I mostly like them.

I do UDS's a lot.
I definitely use hospitalizations, patients that no-show a few times, and patient forgetting to refill medications as a way to hit the reset button on benzos and polypharmacy and start fresh. It occasionally works. I'm doing that with one person who is on a ton of valium and I think has dependent personality disorder more than anything else.

I am fortunate to have a lot of therapists (LCSW's)available and a very robust department resources. The quality of the LCSW's varies quite a bit. Some are great, others just kind of shoot the breeze with the patient, who then comes back and says "well, therapy didn't work."

 

[whopper]

It's been my experience that impulsive, younger, and less educated people with nothing to lose are less interested in learning what's better for them in the long-run. Be that as it may we still have an obligation to try.

Older, educated, less impulsive people on a responsible track tend to understand the speech the responsible docs tend to give when it comes to giving out controlled substances in a limited manner.

When I get patients already on a high dosage I give them the speech (in outpatient), there's two ways to do it. We wean you off nice and slow over the course of several months, maybe a year while we get you right with the meds that aren't controlled substances-this means you follow our directions and agree to work with us, or 2-I get you off in a few days if you do the following: lose your meds, ask for a refill before the month is up, have a dirty drug screen, etc.

It's all up to you. Nice and slow or hard and fast. I hope you pick nice and slow.

 

[Shikima]

And it's a wonder why I say no to controlled substances.

 

[birchswing]

Finish the sentence:

So, ask your doctor about_______.

For me, Latuda comes to mind and I don't even know what it is. Must be the last one I heard about. The people who do *that* are very good at what they do. I would look at this from a more macro point of view rather than one that is reliant on individual choice. How much choice does any person have given a particular system (including Wall Street demands, Madison Avenue techniques, great trust in doctors, pills, and the medical model, high work-hour weeks, short appointments). Even if you were to change someone's mind, you're competing with other doctors, some of whom believe the opposite of you. There are doctors who believe a pill should fix it and don't want to engage with patients. That's the medical model: a bone is broken or it's being fixed. Anything else is a racket. The belief that psychiatric illness is the same as other illness leads to the idea that has been sold to consumers and believed by many doctors: Paxil is the insulin of anxiety. I've been told that by a psychiatrist. I didn't do therapy until years after I had been on prescription drugs. My first psychiatrist thought it was a waste of time. So a former patient of that psychiatrist comes to you and doesn't want to do therapy. It's not necessarily an individual choice. It might be a systemic effect. They might have been sold a belief: by doctors, commercials, public advocacy groups. I think people are like mackerel. Much of what we believe is in reference to what we're told is so. And within that framework, you sprinkle some fishfood here or there and herd the mackerel. What lifestyle are most psychiatrists selling? Healthy living and high quality therapy? Reading this, to me, is like reading about a cashier at the Piggly Wiggly upset that the customers don't come in demanding organic kale. Does the Piggly Wiggly even have organic kale?

 

[wolfvgang22]

Good points, birch, all too true.
Psychiatrists are placed in a double bind. We have patients taught to expect a miracle cure by big pharma and told the customer is always right by hospitals, and we are expected to keep these patients with now unrealistic expectations"satisfied". On the other hand, we are also expected as professionals that care about our patients to treat patients based on scientific evidence, which show that psychotherapy is key to overcoming most psychiatric illnesses. We are expected to first, do no harm, and held legally liable and at risk of losing our credentials and livelihood, all our life's work, if we fail to offer the best available treatment and there is a suicide or murder or severe medication adverse event. And we are expected to patient to be made both well and satisfied Right Now, in 15 to 30 minutes.

You are right that there is not a lot I can do as an individual physician about over-arching conflict of interests. Thus, I'm more interested in ways to persuade patients and protect myself for our mutual benefit on an individual basis to go against societal conditioning, to actually get well, one at a time.

I had a 50-something year old male with PTSD and severe depression in my office yesterday who has been on nearly every psychiatric medication you can name, over 30 of them, all of which either caused an intolerable side effect, or were ineffective after a week or two so he quit taking them, or he was using lots of drugs/alcohol and missing appointments. He tried to kill himself several times. He has "black out" episodes, during one of which he recently allegedly committed a felony, and now faces charges. He failed to improve much over a period of nearly 20 years, seeing a series of half a dozen psychiatrists, each of which changed his medications. He has never had psychotherapy, and wants to know what pill will help him now. He was never interested in therapy before, it was inconvenient, scary, and he has low energy anyway, spending a lot of time in bed. He asked for Xanax immediately. I offered to try evidence based treatment instead. Somehow, he seems satisfied....today.

 

[Shikima]

Good points, birch, all too true.
Psychiatrists are placed in a double bind. We have patients taught to expect a miracle cure by big pharma and told the customer is always right by hospitals, and we are expected to keep these patients with now unrealistic expectations"satisfied". On the other hand, we are also expected as professionals that care about our patients to treat patients based on scientific evidence, which show that psychotherapy is key to overcoming most psychiatric illnesses. We are expected to first, do no harm, and held legally liable and at risk of losing our credentials and livelihood, all our life's work, if we fail to offer the best available treatment and there is a suicide or murder or severe medication adverse event. And we are expected to patient to be made both well and satisfied Right Now, in 15 to 30 minutes.

You are right that there is not a lot I can do as an individual physician about over-arching conflict of interests. Thus, I'm more interested in ways to persuade patients and protect myself for our mutual benefit on an individual basis to go against societal conditioning, to actually get well, one at a time.

I had a 50-something year old male with PTSD and severe depression in my office yesterday who has been on nearly every psychiatric medication you can name, over 30 of them, all of which either caused an intolerable side effect, or were ineffective after a week or two so he quit taking them, or he was using lots of drugs/alcohol and missing appointments. He tried to kill himself several times. He has "black out" episodes, during one of which he recently allegedly committed a felony, and now faces charges. He failed to improve much over a period of nearly 20 years, seeing a series of half a dozen psychiatrists, each of which changed his medications. He has never had psychotherapy, and wants to know what pill will help him now. He was never interested in therapy before, it was inconvenient, scary, and he has low energy anyway, spending a lot of time in bed. He asked for Xanax immediately. I offered to try evidence based treatment instead. Somehow, he seems satisfied....today.

Similar case, without the criminal charges - 67 y/o dude who is struggling with PTSD and has been abusing controlled substances for a long time to the point he fell down the stairs and would get angry if you attempted to take away his Norco and Xanax. He and his wife present for an 'emergency' appointment as an intervention - his wife will leave if he doesn't get help with his substance dependency and deal with his past once and for all. What brought it all to a head is that his son, a narcotics det, called him out on it which got everyone riled up and unfied into a single voice.

We are doing a disservice if we aren't pushing for therapies which ... DO.NO.HARM.

 

[mojetter]

Finish the sentence:

So, ask your doctor about_______.

For me, Latuda comes to mind and I don't even know what it is. Must be the last one I heard about. The people who do *that* are very good at what they do. I would look at this from a more macro point of view rather than one that is reliant on individual choice. How much choice does any person have given a particular system (including Wall Street demands, Madison Avenue techniques, great trust in doctors, pills, and the medical model, high work-hour weeks, short appointments). Even if you were to change someone's mind, you're competing with other doctors, some of whom believe the opposite of you. There are doctors who believe a pill should fix it and don't want to engage with patients. That's the medical model: a bone is broken or it's being fixed. Anything else is a racket. The belief that psychiatric illness is the same as other illness leads to the idea that has been sold to consumers and believed by many doctors: Paxil is the insulin of anxiety. I've been told that by a psychiatrist. I didn't do therapy until years after I had been on prescription drugs. My first psychiatrist thought it was a waste of time. So a former patient of that psychiatrist comes to you and doesn't want to do therapy. It's not necessarily an individual choice. It might be a systemic effect. They might have been sold a belief: by doctors, commercials, public advocacy groups. I think people are like mackerel. Much of what we believe is in reference to what we're told is so. And within that framework, you sprinkle some fishfood here or there and herd the mackerel. What lifestyle are most psychiatrists selling? Healthy living and high quality therapy? Reading this, to me, is like reading about a cashier at the Piggly Wiggly upset that the customers don't come in demanding organic kale. Does the Piggly Wiggly even have organic kale?

Thanks for your feedback Birch, you sound like you have an informed opinion.

I get that patients feel powerless and sometimes bullied by the process but the advice we give is coming from the "best practices" that have been proven to help people.

Your mackeral analogy isnt anything close to the interactions I have had with patients it is the rare patient who comes in hypnotized from past advice resulting in now resistance to advice because of what the system has taught them.

As it relates to therapy, therapy is WORK. Plain and simple. Its like going to the gym...you dont always want to go and you dont always leave seeing results, but over time the results appear....time as in 9mos, 12mos, 2 years. Many patients want their anxiety (for example) to go away in 10min and their resistance to a 12month (with life long efficacy) recommendation is based on that.

So far as what life we sell...I make the analogy of an Oncologist treating a cancer patient...I am not guaranteeing anything except I will try to help that person to relief of the disorder their genetics or their God gave them. Im just a proxy on their way to helping them help themselves and hope for their best but I have no interest in taking over their lives and promising them the magical solution for what ails them....

 

[smalltownpsych]

Good points, birch, all too true.
Psychiatrists are placed in a double bind. We have patients taught to expect a miracle cure by big pharma and told the customer is always right by hospitals, and we are expected to keep these patients with now unrealistic expectations"satisfied". On the other hand, we are also expected as professionals that care about our patients to treat patients based on scientific evidence, which show that psychotherapy is key to overcoming most psychiatric illnesses. We are expected to first, do no harm, and held legally liable and at risk of losing our credentials and livelihood, all our life's work, if we fail to offer the best available treatment and there is a suicide or murder or severe medication adverse event. And we are expected to patient to be made both well and satisfied Right Now, in 15 to 30 minutes.

You are right that there is not a lot I can do as an individual physician about over-arching conflict of interests. Thus, I'm more interested in ways to persuade patients and protect myself for our mutual benefit on an individual basis to go against societal conditioning, to actually get well, one at a time.

I had a 50-something year old male with PTSD and severe depression in my office yesterday who has been on nearly every psychiatric medication you can name, over 30 of them, all of which either caused an intolerable side effect, or were ineffective after a week or two so he quit taking them, or he was using lots of drugs/alcohol and missing appointments. He tried to kill himself several times. He has "black out" episodes, during one of which he recently allegedly committed a felony, and now faces charges. He failed to improve much over a period of nearly 20 years, seeing a series of half a dozen psychiatrists, each of which changed his medications. He has never had psychotherapy, and wants to know what pill will help him now. He was never interested in therapy before, it was inconvenient, scary, and he has low energy anyway, spending a lot of time in bed. He asked for Xanax immediately. I offered to try evidence based treatment instead. Somehow, he seems satisfied....today.

Similar case, without the criminal charges - 67 y/o dude who is struggling with PTSD and has been abusing controlled substances for a long time to the point he fell down the stairs and would get angry if you attempted to take away his Norco and Xanax. He and his wife present for an 'emergency' appointment as an intervention - his wife will leave if he doesn't get help with his substance dependency and deal with his past once and for all. What brought it all to a head is that his son, a narcotics det, called him out on it which got everyone riled up and unfied into a single voice.

We are doing a disservice if we aren't pushing for therapies which ... DO.NO.HARM.

These two cases point out the need for effective substance abuse treatment that can deal with co-occurring disorders. The research is really clear that both disorders need to be treated concurrently, but how much of that is really available. Most substance abuse programs are in way over their heads with these cases and these patients cause big problems in mental health settings as their defenses run circles around everyone and generally just frustrate us.

 

[Ceke2002]

In terms of therapy vs medication, don't forget a lot of people may get their ideas of therapy from media representations (Lifetime movies I'm looking at you in particular) where it's almost portrayed as some sort of miracle cure, because the nice Doctor came along and said just the right thing and hey presto the patient is cured, families are reunited, and rainbows and fluffy kittens fall from the sky. One of the most common laments I hear among patient support communities isn't necessarily "I can't find a medication to fix me", it's "I've been in therapy for X amount of months and I'm still not better". It's not necessarily that the patient doesn't want to work at therapy, it's just hard to maintain that enthusiastic level of "yes, I'm going to work hard and I will get better" when several months have gone by and you're not really seeing the sorts of results you might have expected.

 

[splik]

We are doing a disservice if we aren't pushing for therapies which ... DO.NO.HARM.

This is not really true, of course psychotherapies cause harm. Any treatment that can do no harm can't do any good either, because it must be inert. The harmful effects of therapy are woefully understudied, but people can and do get worse during therapies. Sometimes the type of therapy, the intensity, the timing, the patient buy-in is problematic and this can be damaging and bad therapy can mean the patient never agrees to have the treatment that helps. psychotherapy can also be very repressive - I mean American psychiatry basically bastardized psychoanalysis and turned into a tool for conformity and repression unlike in europe where psychoanalysis was seen as a tool for liberation. All sorts of abuses can occur in psychotherapy, and much more likely to occur than in standard psychiatric practice. Psychotherapy may be the wrong treatment for some people. It drives me mad when I hear psychiatrists saying nonsense like "everyone can benefit from psychotherapy". Not saying that is what you were saying, but it's just not true.

We do a disservice if we don't consider psychotherapy like other treatments: there are different types, durations, intensities, modalities; there are indications; there are cautions and contraindications; there can be adverse effects; there may be good reasons why people might not want to engage that need to explored; there may be other treatments that are more appropriate or better tolerated by the patient. not all patients want it. not all patients are in a place where they can benefit.

 

[smalltownpsych]

This is not really true, of course psychotherapies cause harm. Any treatment that can do no harm can't do any good either, because it must be inert. The harmful effects of therapy are woefully understudied, but people can and do get worse during therapies. Sometimes the type of therapy, the intensity, the timing, the patient buy-in is problematic and this can be damaging and bad therapy can mean the patient never agrees to have the treatment that helps. psychotherapy can also be very repressive - I mean American psychiatry basically bastardized psychoanalysis and turned into a tool for conformity and repression unlike in europe where psychoanalysis was seen as a tool for liberation. All sorts of abuses can occur in psychotherapy, and much more likely to occur than in standard psychiatric practice. Psychotherapy may be the wrong treatment for some people. It drives me mad when I hear psychiatrists saying nonsense like "everyone can benefit from psychotherapy". Not saying that is what you were saying, but it's just not true.

We do a disservice if we don't consider psychotherapy like other treatments: there are different types, durations, intensities, modalities; there are indications; there are cautions and contraindications; there can be adverse effects; there may be good reasons why people might not want to engage that need to explored; there may be other treatments that are more appropriate or better tolerated by the patient. not all patients want it. not all patients are in a place where they can benefit.

Don't forget the adverse affect on the therapist when we get a referral from some of these patients who can "benefit from therapy". In addition to high no show, there is the lack of a presenting problem that can make it a bit tough. I'm is to dealing with teens who don't know why they are in my office, it doesn't usually take to long for them to identify problems, but an entrenched adult, not a chance. It can make for a painful hour. i have one this morning, the referral states patient said "my wife thinks I need therapy". Maybe I should start my vacation a day early.

 

[Shikima]

Then, by all means, please continue to prescribe Xanax 1mg QID and Ambien 10mg at bedtime.

 

[Psychobabbling]

How do you deal with medication seeking patients on a daily basis. I'm talking about patients thta either don't go to psychotherapy, or if they do go, they only complain and never actually participate. The patient that has a generally chaotic, low income life situation that probably worsens 80% or more of their illness. Such patients often complain their medications stop working, or only work partially, because "I'm still not happy". The patient then asks for yet another pill to solve the problem. I'm looking for more ideas on how to handle this.

These patients usually present themselves at the first session, with a history of various medications trials. Right off the bat, I tell them I don't have what they seek (an instant make life better pill). Not that I don't empathize, because some of these patients have living situations/interpersonal problems I can barely begin to fathom. It's kind of like weight loss - it's super easy to put on weight and eat whatever you want, unrestricted. But losing requires discipline, commitment, and changing habits that don't lead to the outcome we desire. Perseverance, with a lot of compassion, can get you there. And medication X/Y/Z might help make some of this easier to do, but nonetheless, there is work to be done. (hands in the middle)....1, 2, 3, BREAK!

 

[splik]

Then, by all means, please continue to prescribe Xanax 1mg QID and Ambien 10mg at bedtime.

this is the kind of patient who would be a poor candidate for psychotherapy. you are going to have a very hard time getting buy in from most of these patients who become very attached to their medications and they essentially become safety behaviors. fact is, there is no therapy that is going to give the patient the reinforcing quick relief you get from Xanax. some patients do express an interest in treatment but you usually need to build alot of motivation first and find reasons for the patient to taper off. these patients usually need to start tapering off before they can really get the most out of a cognitive-behavior therapy. you cannot learn any new skills if you are obliterating your anxiety by popping a xanax before coming to therapy.

 

[smalltownpsych]

Then, by all means, please continue to prescribe Xanax 1mg QID and Ambien 10mg at bedtime.

My day wasn't that bad! I think I'll just get on the plane to Boston and enjoy my week off instead.

 

[F0nzie]

I wrote for some Ativan recently to my patient that is scared of needles. 1 mg PO Q month. To be administered prior to receiving Invega sustenna injection. Made me feel mean n bold! My RN was like whoa-ho doc!

 

[Ceke2002]

This is not really true, of course psychotherapies cause harm. Any treatment that can do no harm can't do any good either, because it must be inert. The harmful effects of therapy are woefully understudied, but people can and do get worse during therapies. Sometimes the type of therapy, the intensity, the timing, the patient buy-in is problematic and this can be damaging and bad therapy can mean the patient never agrees to have the treatment that helps. psychotherapy can also be very repressive - I mean American psychiatry basically bastardized psychoanalysis and turned into a tool for conformity and repression unlike in europe where psychoanalysis was seen as a tool for liberation. All sorts of abuses can occur in psychotherapy, and much more likely to occur than in standard psychiatric practice. Psychotherapy may be the wrong treatment for some people. It drives me mad when I hear psychiatrists saying nonsense like "everyone can benefit from psychotherapy". Not saying that is what you were saying, but it's just not true.

We do a disservice if we don't consider psychotherapy like other treatments: there are different types, durations, intensities, modalities; there are indications; there are cautions and contraindications; there can be adverse effects; there may be good reasons why people might not want to engage that need to explored; there may be other treatments that are more appropriate or better tolerated by the patient. not all patients want it. not all patients are in a place where they can benefit.

Exactly, and adding to what I said previously I think this is where there's as much a disservice in the way therapy is viewed and/or portrayed by the lay person and within the media et al, as there is in the pharmaceutical companies in the US pushing patients to ask for the latest wonder drug, and the attitude of a pill will cure what ails you. Even the descriptor that is sometimes used for therapy, the 'talking cure' implies that therapy in and of itself is merely sitting down and talking to someone when obviously it is so much more than that. And yes, it can cause harm, especially if the therapist is improperly trained, doesn't know what they're doing, or simply isn't cut out to be a therapist in the first place (just because you have the training doesn't mean you can necessarily do the work, or do the work well, imho at least).

Some of the negative sides of therapy that I've experiences myself include:

The Rescuers. Here they come to save the day - just remember to not do anything stupid like ruin their internal fantasies by not being miraculously cured in a preset amount of time.

The Agenda Pushers: What do you mean my pet political project has absolutely nothing to do with your presenting issues? Quick, bring me my soapbox I'm not sure if I've lectured you enough this session.

The One Size Fits All: Hello, I'm the Oprah Winfrey of therapy - You get treated with X therapeutic modality, and you get treated with X therapeutic modality, and YOU get treated with X therapeutic modality...ah heck, EVERYONE get's treated with X therapeutic modality!

The Abuser: Just how many ways can one person psychologically screw you over? The answer is 'a lot'.

 

[birchswing]

I just read this:

http://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?_r=0

Having witnessed my own psychiatrist in session over the last 6 years or so (when she was just out of residency), I feel like I've seen her go from being very enthusiastic about medication to a slow resignation about what she can do. I think that's in part why she's into alternative supplements now.

I wonder if the conversation in this thread would be entirely different if the rate of progress in medication development continued the way it did in the 50s and 60s. The conversation seems like it could easily be the opposite.

I recently read about the inventor of benzodiazepines, Leo Sternbach. Was he ever prolific! Even given my own problems, because benzodiazepines are so useful when used appropriately, I find him to be pretty amazing.

Seems to be one more story of American exceptionalism being a result of the diaspora of immigrants we had in the mid 20th century.

What happened to drug development? Benzodiazepines were an improvement on barbiturates. But the newer classes of benzodiazepines were a step backward in terms of addictiveness. Like that article points out, there seems to have been very little progress in medication development.

I also recently saw the movie Cake.

I love these type of movies (slow, introspective). It's about a woman with a prescription drug addiction. I won't give any more away (not that it's really plot driven), but I bet anyone enjoying this conversation would enjoy the movie.

 

[Shikima]

this is the kind of patient who would be a poor candidate for psychotherapy. you are going to have a very hard time getting buy in from most of these patients who become very attached to their medications and they essentially become safety behaviors. fact is, there is no therapy that is going to give the patient the reinforcing quick relief you get from Xanax. some patients do express an interest in treatment but you usually need to build alot of motivation first and find reasons for the patient to taper off. these patients usually need to start tapering off before they can really get the most out of a cognitive-behavior therapy. you cannot learn any new skills if you are obliterating your anxiety by popping a xanax before coming to therapy.

I say horsehockey (rather than a more graphic term).

I often hear on this board about us complaining about instant gratification and drug seeking patients.... discussing and complaining about other physician prescribing habits. All in the name of endorsing continued behaviors which are maladapative and in some cases, manipulative.

As dogmatic as it sounds, we cannot have it both ways proscribing to contrary thoughts.

One one hand we know that there are many situations where it has been research and published that all people can benefit from psychotherapy to one point or another - even those with schizophrenia. There are plenty of stressors which can cause destabilization - even goes into detail on this in K&S. This can easily be correlated to all mood, anxiety and psychotic disorders.

Then to turn about and cite that psychotherapy is harmful, what a dichotomy. I really doubt that you're seeing people in clinic and just refilling without exploring various psychosocial issues.... from your history of posts, I know you're not doing this. And to explore these difficult areas while prescribing medications, you are engaging in a therapeutic relationship. Even psychoeducation is therapeutic.

It seems that continuing with 'med management' alone is worthless. We seem all agree on this point. We all agree that denying service and telling someone with a command, "Thou shall seek out therapy" is equally boner-fied. Therapy isn't all psychodynamic (despite what residency wants to instill on us) and it's more broad based than CBT alone. Utilizing MI is a good way to build that trust and motivation - if not, we refer onto other services. There is A LOT of energy which is expended at this point in urging them to develop an awareness for good health. We also have a duty to create holistic plans which include mind, body and spirit towards wellness and getting them up on the proverbial horse again - many of use blaze on past this point. The social dynamics alone are more than we can manage alone and with the aide of good case managers, therapists and therapy, can help them live a more meaningful life.

 

[Ceke2002]

I say horsehockey (rather than a more graphic term).

I often hear on this board about us complaining about instant gratification and drug seeking patients.... discussing and complaining about other physician prescribing habits. All in the name of endorsing continued behaviors which are maladapative and in some cases, manipulative.

As dogmatic as it sounds, we cannot have it both ways proscribing to contrary thoughts.

One one hand we know that there are many situations where it has been research and published that all people can benefit from psychotherapy to one point or another - even those with schizophrenia. There are plenty of stressors which can cause destabilization - even goes into detail on this in K&S. This can easily be correlated to all mood, anxiety and psychotic disorders.

Then to turn about and cite that psychotherapy is harmful, what a dichotomy. I really doubt that you're seeing people in clinic and just refilling without exploring various psychosocial issues.... from your history of posts, I know you're not doing this. And to explore these difficult areas while prescribing medications, you are engaging in a therapeutic relationship. Even psychoeducation is therapeutic.

It seems that continuing with 'med management' alone is worthless. We seem all agree on this point. We all agree that denying service and telling someone with a command, "Thou shall seek out therapy" is equally boner-fied. Therapy isn't all psychodynamic (despite what residency wants to instill on us) and it's more broad based than CBT alone. Utilizing MI is a good way to build that trust and motivation - if not, we refer onto other services. There is A LOT of energy which is expended at this point in urging them to develop an awareness for good health. We also have a duty to create holistic plans which include mind, body and spirit towards wellness and getting them up on the proverbial horse again - many of use blaze on past this point. The social dynamics alone are more than we can manage alone and with the aide of good case managers, therapists and therapy, can help them live a more meaningful life.

I agree with what you're saying, but someone correct me if I'm wrong but I thought Splik was talking about Psychotherapy being damaging from the point of view of it being used as haphazardly and without due consideration for individual patient needs, the training and skills of the therapist, and so on, as Psychiatrists who just throw Xanax etc at the problem. I believe it was erg923 that had an interesting link to a study that was done into the potential harm of various psychotherapeutic modalities. And you know I'm all about Psychotherapy, I just think it needs to be approached with the same sense of evidence based care as anything else in Psychiatry. That's just me though.