Am I just numbing people?

[Onions]

Recently started my first job after residency here. It's outpatient, pretty good situation for me, they pay decently, give good clinical/administrative support, nobody's breathing down my neck to bang through 4 patients an hour. Most patients don't feel the need to talk to me for a full 30 minutes at every follow-up, which is fine. But I sometimes can't shake the feeling that I'm just giving people pills to help them cope with a reality that is 1) collectively designed by all of us and 2) dissolves any sense of community or interpersonal connectedness by design. Of course they're all anxious wrecks. They are living in artificial scarcity in a world of natural abundance, whether material, spiritual, etc.

I do see patients that I believe genuinely need whatever stuff they are taking. But for the most part, many of them are asking me to numb them, and the DSM gives me license to do so. I want to tell them that they don't need Zoloft, they need community. They need connection to the land. They need to re-sync with the rhythms of nature. Isn't this how most humans lived for the past 200,000 years?

I expect to be fully humiliated for this post on SDN. Do your worst!

---

Members don't see this ad.

 

[brycew85]

"The Industrial Revolution and its consequences have been a disaster for the human race. They have greatly increased the life-expectancy of those of us who live in “advanced” countries, but they have destabilized society, have made life unfulfilling, have subjected human beings to indignities, have led to widespread psychological suffering (in the Third World to physical suffering as well) and have inflicted severe damage on the natural world. The continued development of technology will worsen the situation. It will certainly subject human beings to greater indignities and inflict greater damage on the natural world, it will probably lead to greater social disruption and psychological suffering, and it may lead to increased physical suffering even in “advanced” countries."

https://www.washingtonpost.com/wp-srv/national/longterm/unabomber/manifesto.text.htm

great minds think alike....

 

[psychacad]

Psychosocial interventions are also part of the job. You can give them Zoloft AND encourage community involvement, developing relationships, meditation...etc Many have evidence-based support. I'm not sure how one precludes the other and this should be part of every treatment plan especially in a setting that allows one to do so.

The relationship you are going to build with the patient is in itself part of the treatment. I think this is an issue with particular training environments that reduce the psychiatrist's job to prescribing medication, but this isn't how psychiatry should be practiced or how it's practiced in good places. 30 minute follow ups should provide ample to time for a well rounded treatment. I also think it may be good to revisit your approach. In my experience, patients don't really complain that the time slot is too long. If you ask the right questions, you will get them to talk and open up. If this isn't happening, you have to ask the question: what is it that is preventing this x patient from talking more about what is going on.

"The Industrial Revolution and its consequences have been a disaster for the human race. They have greatly increased the life-expectancy of those of us who live in “advanced” countries, but they have destabilized society, have made life unfulfilling, have subjected human beings to indignities, have led to widespread psychological suffering (in the Third World to physical suffering as well) and have inflicted severe damage on the natural world. The continued development of technology will worsen the situation. It will certainly subject human beings to greater indignities and inflict greater damage on the natural world, it will probably lead to greater social disruption and psychological suffering, and it may lead to increased physical suffering even in “advanced” countries."

You mean pre-industrial feudal society was going great for the human race? lol.

 

[Mad Jack]

Psychosocial interventions are also part of the job. You can give them Zoloft AND encourage community involvement, developing relationships, meditation...etc Many have evidence-based support. I'm not sure how one precludes the other and this should be part of every treatment plan especially in a setting that allows one to do so.



You mean pre-industrial feudal society was going great for the human race? lol.

We work harder than serfs in a world with less social connections, so maybe in the quest to make life more comfortable we've lost a lot of what made life worth living in the first place. People also had significantly mpre simple lives in the past, and it is likely our brains simply haven't adapted to the cognitive and emotional burden that a rapidly changing, technollgical society demands. We've gone from people that lived in intimate communities of dozens and engaged in very predictable menial labor with minimal generation-to-generation change to societies of millions that advance so quickly the knowledge of one generation is nearly obsolete by the time the next comes of age. Our lives are longer and more comfortable, but they are often lives of stress and solitude.

 

[Attending1985]

Recently started my first job after residency here. It's outpatient, pretty good situation for me, they pay decently, give good clinical/administrative support, nobody's breathing down my neck to bang through 4 patients an hour. Most patients don't feel the need to talk to me for a full 30 minutes at every follow-up, which is fine. But I sometimes can't shake the feeling that I'm just giving people pills to help them cope with a reality that is 1) collectively designed by all of us and 2) dissolves any sense of community or interpersonal connectedness by design. Of course they're all anxious wrecks. They are living in artificial scarcity in a world of natural abundance, whether material, spiritual, etc.

I do see patients that I believe genuinely need whatever stuff they are taking. But for the most part, many of them are asking me to numb them, and the DSM gives me license to do so. I want to tell them that they don't need Zoloft, they need community. They need connection to the land. They need to re-sync with the rhythms of nature. Isn't this how most humans lived for the past 200,000 years?

I expect to be fully humiliated for this post on SDN. Do your worst!

I very much resonate with your post. A lot of times it doesn’t feel like practicing medicine.

 

[psychacad]

We work harder than serfs in a world with less social connections, so maybe in the quest to make life more comfortable we've lost a lot of what made life worth living in the first place. People also had significantly mpre simple lives in the past, and it is likely our brains simply haven't adapted to the cognitive and emotional burden that a rapidly changing, technollgical society demands. We've gone from people that lived in intimate communities of dozens and engaged in very predictable menial labor with minimal generation-to-generation change to societies of millions that advance so quickly the knowledge of one generation is nearly obsolete by the time the next comes of age. Our lives are longer and more comfortable, but they are often lives of stress and solitude.

The issue is that I am not sure these assumptions are correct or how "simple" life was then. People have been struggling for survival since forever. Working in the field doesn't sound so enticing.

Not that technology doesn't bring its own set of challenges, but I have a hard time believing that in an era where slavery was the norm...etc, things were 'better'.

 

[TexasPhysician]

I do see patients that I believe genuinely need whatever stuff they are taking. But for the most part, many of them are asking me to numb them, and the DSM gives me license to do so. I want to tell them that they don't need Zoloft, they need community.

So why don’t you? If you believe that any patient could benefit from life changes, why not help them achieve it? Were you not trained in therapy?

If patients refuse to follow your treatment plan, refer them elsewhere.

 

[Mad Jack]

The issue is that I am not sure these assumptions are correct or how "simple" life was then. People have been struggling for survival since forever. Working in the field doesn't sound so enticing.

Not that technology doesn't bring its own set of challenges, but I have a hard time believing that in an era where slavery was the norm...etc, things were 'better'.

Slavery wasn't "the norm" in most nations pre-industrialization. It wasn't really that big of an enterprise until the colonization period. Pre-colonization societies were fairly simple, and working the fields, while hard, was a task that could only be performed from dawn till dusk for a few months of the year. For most of the year, there was minimal work for serfs and non-artisan peasants to do. The work that they did do was cognitively simple, and once mastered a single time would never have to be altered or relearned. Life may have been monotonous, but monotony brings simplicity, and reliance on one's neighbors brings the comfort of community

 

[hebel]

So why don’t you? If you believe that any patient could benefit from life changes, why not help them achieve it? Were you not trained in therapy?

If patients refuse to follow your treatment plan, refer them elsewhere.

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

 

[clausewitz2]

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

See also, cursory sleep hygiene discussions for insomnia. This has been empirically demonstrated to have no meaningful impact on sleep quality or any sleep parameter of interest.

 

[sloh]

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

This is largely what I see in PM&R as well. We placebo numb with meds and injections. Patients just roll their eyes when you talk about meaningful goals, exercise, diet, weight loss, relationships.

 

[wolfvgang22]

Most "medication management" jobs are going to make it difficult to effect lasting lifestyle change through therapy for most patients. Even if you don't have to see four patients per hour, you still don't get to choose to spend time only with patients interested in making real changes in thoughts and behavior. Those patients are always going to be less numerous than those who just want a magic pill to solve all their problems. Many of them may get to see a social worker therapist to complain to, as well. Medication management jobs are set up to deliver a certain level of minimal care to the greatest number of patients possible. I do totally agree that patient rapport is just as important as the medication much of the time.

I'd love to see only a select panel motivated patients for therapy and medication management in a private setting some day (don't we all.) Maybe after my student loans are all paid off and retirement is fully funded, and I feel currency is of less importance. Until then, it is grind, grind, grind and help those how and when I can. "Brief Supportive Therapy incorporating themes of motivational interviewing and cognitive behavioral techniques were provided today for a duration of 20 minutes in addition to medication management." Boom, 90833 add-on code.

 

[clausewitz2]

Slavery wasn't "the norm" in most nations pre-industrialization. It wasn't really that big of an enterprise until the colonization period. Pre-colonization societies were fairly simple, and working the fields, while hard, was a task that could only be performed from dawn till dusk for a few months of the year. For most of the year, there was minimal work for serfs and non-artisan peasants to do. The work that they did do was cognitively simple, and once mastered a single time would never have to be altered or relearned. Life may have been monotonous, but monotony brings simplicity, and reliance on one's neighbors brings the comfort of community

This is....ahistorical. First, slavery was incredibly common in the Mediterranean for most of recorded history. The population of the Roman Empire in the second century was perhaps 15% slave. Sparta at its height was approximately 75% helot, which was actually much worse than chattel slavery in most places and times, in the sense that your social betters being able to and being encouraged to murder you at any time with impunity and having your rulers ritually declare war on you and hunt and kill you and everyone you know for several weeks every year is considered bad. Mesoamerican societies made frequent use of enslaved prisoners of war and lifetime (if non-hereditary) corvee labor systems. A number of North American indigenous groups were well known for conducting slave raids and in the 18th century some estimates have the population in some areas of the Pacific Northwest under indigenous control as 25% slave. Southeast Asian 'mandala states' were built around the central need to invade other places to capture a workforce. We call people in bondage slaves because so many captives from Eastern Europe were in forced labor in the medieval periods that Slav and slave were synonymous in Western Europe.

It's terrible and awful everywhere and in all its forms but it was not the unique sin of colonialism or imperialism by any means. The idea that pre-modern farming was also a tranquil idyll most of the year is manifestly false. For more details, mainly focusing on areas where wheat and barley cultivation dominated agriculture, see: Collections: Bread, How Did They Make It? Part I: Farmers!

Yes, community bonds were stronger, but this was largely a hedge against risk. You made nice with your neighbors and were generous with them when they were in need because maybe they will still have food when famine wipes you out completely. And you want to make sure they feel obligated to share it. Something very similar operates in the fictive kinship networks common in some impoverished communities in North America and I would imagine elsewhere that is industrialized.

Hunter-gatherers in many places probably did work less, overall. At no time has agriculture not been grueling and labor-intensive.

 

[psychacad]

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

.
I don't think the analogy is quite correct. Yes, it is hard and it will take time, but that is the job and should be part of the training. It is not just to tell them to do it and hope for the best, but work over time to instill concrete changes in their lives. Naturally the work will require establishing rapport and a good deal of therapy skills.

 

[Mad Jack]

This is....ahistorical. First, slavery was incredibly common in the Mediterranean for most of recorded history. The population of the Roman Empire in the second century was perhaps 15% slave. Sparta at its height was approximately 75% helot, which was actually much worse than chattel slavery in most places and times, in the sense that your social betters being able to and being encouraged to murder you at any time with impunity and having your rulers ritually declare war on you and hunt and kill you and everyone you know for several weeks every year is considered bad. Mesoamerican societies made frequent use of enslaved prisoners of war and lifetime (if non-hereditary) corvee labor systems. A number of North American indigenous groups were well known for conducting slave raids and in the 18th century some estimates have the population in some areas of the Pacific Northwest under indigenous control as 25% slave. Southeast Asian 'mandala states' were built around the central need to invade other places to capture a workforce. We call people in bondage slaves because so many captives from Eastern Europe were in forced labor in the medieval periods that Slav and slave were synonymous in Western Europe.

It's terrible and awful everywhere and in all its forms but it was not the unique sin of colonialism or imperialism by any means. The idea that pre-modern farming was also a tranquil idyll most of the year is manifestly false. For more details, mainly focusing on areas where wheat and barley cultivation dominated agriculture, see: Collections: Bread, How Did They Make It? Part I: Farmers!

Yes, community bonds were stronger, but this was largely a hedge against risk. You made nice with your neighbors and were generous with them when they were in need because maybe they will still have food when famine wipes you out completely. And you want to make sure they feel obligated to share it. Something very similar operates in the fictive kinship networks common in some impoverished communities in North America and I would imagine elsewhere that is industrialized.

Hunter-gatherers in many places probably did work less, overall. At no time has agriculture not been grueling and labor-intensive.

It really depends on the culture and era, drawing broad conclusions is fairly difficult. I was more referring to post-antiquity, pre-Renaissance Western Europe. Any time in antiquity and prior slavery is incredibly common amongst almoat all cultures, and even into the early Middle Ages it was fairly common. Regardless of the reason for bonds between members of a community, they were bonds nonetheless. Families were also more cohesive and supportive of older generations, which led to more meaningful contacts at baseline.

Now when the major stress of your life is whether you're eating or dying or not, yes, that's a big stressor, but it is a meaningful one. Today we are bombarded by hundreds, even thousands of stressors per week. Stress is no longer an intermittent state, but a constant one for many people. I am really not trying to construct an airtight or complex argument here, just tossing forth the general idea that maybe living complicated and lonely lives has resulted in a state of sensory overload and isolation that tends toward mental illness. I highly doubt that modernity is good for mental health, in any case

 

[birchswing]

My mom is an art school teacher, and she has been teaching Zoom. She said that all of her kids have improved learning from home or in care centers where they have more caretakers per student than they do in the classrooms, but the ones that are leaps and bounds doing better are the "troublemakers" who are now home with their parents. And a lot of those "troublemakers" are ones that were (I guess still are) medicated.

I'm a progressive who has always been very conservative when it comes to family. I see the happiest, healthiest families as the ones where they have purposefully chosen an economic model that allows one parent to be a primary rather than part-time parent, and I think homeschooling is a great idea. (My ideas on antinatalism I've espoused elsewhere are more like libertarianism—they are aspirational, not realistic.) I don't think our political/economic system allows enough security for people to to stake out such an endeavor. Even when it can be achieved, there's little security in it. So, I come to conclude a middle ground where the government incentivizes and pays parents to be parents and discourages excess work (like the Swedish model) to probably be the best middle ground.

Edit: Did anyone see that video of the high school kid whose MAGA hate was taken and a girl was spitting in his face repeatedly while he did not retaliate (I assume because of all the rules about zero tolerance and whatnot)? Watching that make me think of a thread here a while ago about treating anxious teenagers. I just don't see the point in these petri dishes designed to cause these lord of the fly type situations. 12 years of same-age kids together seems like a sadistic plan invented by whoever makes The Bachelor TV show—bringing together people in the most unnatural ways designed to cause strife that is utterly useless.

 

[TexasPhysician]

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

So the OP is complaining that major lifestyle changes should be the goal instead of the easy solution of “numbing” the issue.

You complain that lifestyle changes are too hard, so why try?

This is becoming comical.

 

[TexasPhysician]

My mom is an art school teacher, and she has been teaching Zoom. She said that all of her kids have improved learning from home or in care centers where they have more caretakers per student than they do in the classrooms, but the ones that are leaps and bounds doing better are the "troublemakers" who are now home with their parents. And a lot of those "troublemakers" are ones that were (I guess still are) medicated.

I'm a progressive who has always been very conservative when it comes to family. I see the happiest, healthiest families as the ones where they have purposefully chosen an economic model that allows one parent to be a primary rather than part-time parent, and I think homeschooling is a great idea. (My ideas on antinatalism I've espoused elsewhere are more like libertarianism—they are aspirational, not realistic.) I don't think our political/economic system allows enough security for people to to stake out such an endeavor. Even when it can be achieved, there's little security in it. So, I come to conclude a middle ground where the government incentivizes and pays parents to be parents and discourages excess work (like the Swedish model) to probably be the best middle ground.

There is a LOT of bias in this statement. Most parents aren’t trained teachers with patience that also have enough disposable income to not work. This semester in my large school district - many parents started doing virtual learning (about 50%). The vast majority have already switched within weeks or are in the process of switching to in-person. Parents are recognizing how difficult teaching is off medication and recognize their vast deficiencies in being a primary teacher.

 

[dl2dp2]

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

Is there an evidence based intervention to get people a "stronger sense of community". These suggestions are flying in the face of a science-driven approach to medicine. How do you measure a "stronger sense of community"? And if it's not measurable, what's the point of insisting that it's "better" or "worse"? These statements are basically meaningless. If it is somehow measurable (by standardized instruments, etc), why aren't you measuring it?

Do we know that SSRIs don't improve people's sense of community? I suspect there are papers out there that suggests this is in fact false--i.e. as depression lift, whether through SSRIs or not, people regain a stronger sense of community.

So the OP is complaining that major lifestyle changes should be the goal instead of the easy solution of “numbing” the issue.

You complain that lifestyle changes are too hard, so why try?

This is becoming comical.

There are ways to get people to do lifestyle changes--behavioral therapy of various kinds have shown to work. Very few people do actual, evidence based, manual driven behavioral therapy. Being one of the few people who do this, I end up getting paid $$$$ for it.

 

[hebel]

So the OP is complaining that major lifestyle changes should be the goal instead of the easy solution of “numbing” the issue.

You complain that lifestyle changes are too hard, so why try?

This is becoming comical.

Nope, I was commiserating with an OP who feels things should be approached differently, operating in a mental health system that currently doesn't appear oriented (or at least conducive) towards those goals.

I've felt similar to OP, which led me to design an approach to "med visits" that I really think has a strong incorporation of lifestyle interventions. And I mean seriously, systematically approaching it. I also found an employer that allows me to do weekly psychotherapy with patients.

I responded to you in that way because to me your reply was glib (or at least came across that way). I think OP is bringing up the very interesting question of whether modern psychiatry is always the correct solution to problems of living.

 

[hebel]

Is there an evidence based intervention to get people a "stronger sense of community". These suggestions are flying in the face of a science-driven approach to medicine. How do you measure a "stronger sense of community"? And if it's not measurable, what's the point of insisting that it's "better" or "worse"? These statements are basically meaningless. If it is somehow measurable (by standardized instruments, etc), why aren't you measuring it?

Do we know that SSRIs don't improve people's sense of community? I suspect there are papers out there that suggests this is in fact false--i.e. as depression lift, whether through SSRIs or not, people regain a stronger sense of community.


There are ways to get people to do lifestyle changes--behavioral therapy of various kinds have shown to work. Very few people do actual, evidence based, manual driven behavioral therapy. Being one of the few people who do this, I end up getting paid $$$$ for it.

You've got to be kidding me man! Did you just drop the EB bomb to question the value of interpersonal connection?

There's so much to unpack in every one of your paragraphs. In keeping with the theme of these posts, I find dialogue through this format unfulfilling and wish we could all discuss this over drinks or something.

 

[Attending1985]

Nope, I was commiserating with an OP who feels things should be approached differently, operating in a mental health system that currently doesn't appear oriented (or at least conducive) towards those goals.

I've felt similar to OP, which led me to design an approach to "med visits" that I really think has a strong incorporation of lifestyle interventions. And I mean seriously, systematically approaching it. I also found an employer that allows me to do weekly psychotherapy with patients.

I responded to you in that way because to me your reply was glib (or at least came across that way). I think OP is bringing up the very interesting question of whether modern psychiatry is always the correct solution to problems of living.

Is your employer a health system?

 

[hebel]

Is your employer a health system?

It is. This was a priority for me during my job search and I feel very fortunate that I can.

 

[calvnandhobbs68]

Eh, I can see this being sort of like PCP's recommending lifestyle changes for obesity, HLD, and diabetes. You can tell people to exercise, but a small minority ever do.

I think instructing people to form a stronger sense of community, meaning, and purpose is easier said than done.

I do agree with this and I empathize with OPs feeling as well. But as just noted in the quote above, this isn’t a psychiatry only problem. Most chronic conditions have heavy societal/environmental influence that we as individuals have very little control over.

We’ve all seen the numbers about rates of suicide, SI and depressive/anxiety symptoms just shooting up. From the child side, I definitely feel like it’s an uphill battle to try to limit the amount of screen time kids are exposed to which I do strongly believe heavily influences some of this. You’re basically fighting against an industry whose job it is to make it’s products as addictive as possible so people spend as much time on them as possible. It’s like fighting against the cigarette industry before there was widespread societal backlash against smoking.

 

[calvnandhobbs68]

See also, cursory sleep hygiene discussions for insomnia. This has been empirically demonstrated to have no meaningful impact on sleep quality or any sleep parameter of interest.

Ha I actually had success with this the other day. Had told a college kid to shut his screens off 30-60min before bed and read paper instead if he felt he wanted to read something. Our followup visit he was like “I’ve been doing what you said and it actually works, I go to sleep way faster!” Rare success story.

Of course here I am posting this 15 min before I go to bed so do as I say not as I do I guess....

 

[Attending1985]

It is. This was a priority for me during my job search and I feel very fortunate that I can.

That’s very cool. How much of your patient load is this?

 

[PikminOC]

Is there an evidence based intervention to get people a "stronger sense of community". These suggestions are flying in the face of a science-driven approach to medicine. How do you measure a "stronger sense of community"? And if it's not measurable, what's the point of insisting that it's "better" or "worse"? These statements are basically meaningless. If it is somehow measurable (by standardized instruments, etc), why aren't you measuring it?

Do we know that SSRIs don't improve people's sense of community? I suspect there are papers out there that suggests this is in fact false--i.e. as depression lift, whether through SSRIs or not, people regain a stronger sense of community.







There are ways to get people to do lifestyle changes--behavioral therapy of various kinds have shown to work. Very few people do actual, evidence based, manual driven behavioral therapy. Being one of the few people who do this, I end up getting paid $$$$ for it.

What books and manuals do you use for patients?

 

[Bartelby]

I sometimes can't shake the feeling that I'm just giving people pills to help them cope with a reality that is 1) collectively designed by all of us and 2) dissolves any sense of community or interpersonal connectedness by design. Of course they're all anxious wrecks. They are living in artificial scarcity in a world of natural abundance, whether material, spiritual, etc.

I do see patients that I believe genuinely need whatever stuff they are taking. But for the most part, many of them are asking me to numb them, and the DSM gives me license to do so. I want to tell them that they don't need Zoloft, they need community. They need connection to the land. They need to re-sync with the rhythms of nature. Isn't this how most humans lived for the past 200,000 years?

No doubt there are systemic problems in modern society, and I think there always have been in every human society. I think we should not shrug off these problems, and if we could muster up the collective will to change society to orient itself toward human needs rather than endless-growth economical striving that would be great.

But...

I worry about adopting too much of a victim mindset, especially as a mental health professional. If you accept that being an "anxious wreck" is an inevitable outcome in modern society, then you are heavily identifying with the core of depressive thought. You could pretty much paraphrase it as "it's hopeless, so why even try?" That statement should sound like classic depressive thought to you because it is. You are identifying with a depressive narrative, and by embracing it can do your patients a disservice.

I think you have to be able to hold both. Yes, there are problems in society and we shouldn't look away. But no, that does not mean mental breakdown is inevitable. Many people live fulfilling and contented lives in modern society, and if dramatic positive societal change is not immediately forthcoming you should try to help your patients adapt to reality rather than wishing reality would adapt to them.

 

[dl2dp2]

I responded to you in that way because to me your reply was glib (or at least came across that way). I think OP is bringing up the very interesting question of whether modern psychiatry is always the correct solution to problems of living.

It's not "always correct", but what IS?

I think the solution of this is not to abandon science but to double down on it. Or, at a minimum, segregate out what is science and what isn't, and figure out where you are paying for what ("implementation science").

Whose fault is it when we are paying for therapists to do therapy ("lifestyle intervention"), but most of them don't do actual therapy?

 

[Mad Jack]

Is there an evidence based intervention to get people a "stronger sense of community". These suggestions are flying in the face of a science-driven approach to medicine. How do you measure a "stronger sense of community"? And if it's not measurable, what's the point of insisting that it's "better" or "worse"? These statements are basically meaningless. If it is somehow measurable (by standardized instruments, etc), why aren't you measuring it?

Do we know that SSRIs don't improve people's sense of community? I suspect there are papers out there that suggests this is in fact false--i.e. as depression lift, whether through SSRIs or not, people regain a stronger sense of community.







There are ways to get people to do lifestyle changes--behavioral therapy of various kinds have shown to work. Very few people do actual, evidence based, manual driven behavioral therapy. Being one of the few people who do this, I end up getting paid $$$$ for it.

Mental health and social relationships - Economic and Social Research Council

esrc.ukri.org

Friends are equally important to men and women, but family matters more for men's well-being | Journal of Epidemiology & Community Health

jech.bmj.com

Error - Cookies Turned Off

onlinelibrary.wiley.com

The Connection Prescription: Using the Power of Social Interactions and the Deep Desire for Connectedness to Empower Health and Wellness

Social connection is a pillar of lifestyle medicine. Humans are wired to connect, and this connection affects our health. From psychological theories to recent research, there is significant evidence that social support and feeling connected can help ...

www.ncbi.nlm.nih.gov

https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30253-1/fulltext

I can keep going. Social and community connections have profound effects on mental health.

 

[psychacad]

Do we also really need to "measure" social connectedness and community involvement to be able to diagnose and treat appropriately? The shortcomings of most of the rating scales we use are pretty well documented. It's kinda laughable to suggest that they are some kind of a necessary stepping stone for treatment.

 

[Mad Jack]

No doubt there are systemic problems in modern society, and I think there always have been in every human society. I think we should not shrug off these problems, and if we could muster up the collective will to change society to orient itself toward human needs rather than endless-growth economical striving that would be great.

But...

I worry about adopting too much of a victim mindset, especially as a mental health professional. If you accept that being an "anxious wreck" is an inevitable outcome in modern society, then you are heavily identifying with the core of depressive thought. You could pretty much paraphrase it as "it's hopeless, so why even try?" That statement should sound like classic depressive thought to you because it is. You are identifying with a depressive narrative, and by embracing it can do your patients a disservice.

I think you have to be able to hold both. Yes, there are problems in society and we shouldn't look away. But no, that does not mean mental breakdown is inevitable. Many people live fulfilling and contented lives in modern society, and if dramatic positive societal change is not immediately forthcoming you should try to help your patients adapt to reality rather than wishing reality would adapt to them.

That we live in a society that predisposes toward mental illness does not mean that it is destiny, it is merely a risk factor. Building research and awareness of how and why this occurs can help prevent it by focusing on the things that can be changed.

 

[dl2dp2]

Mental health and social relationships - Economic and Social Research Council

esrc.ukri.org

Friends are equally important to men and women, but family matters more for men's well-being | Journal of Epidemiology & Community Health

jech.bmj.com

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onlinelibrary.wiley.com

The Connection Prescription: Using the Power of Social Interactions and the Deep Desire for Connectedness to Empower Health and Wellness

Social connection is a pillar of lifestyle medicine. Humans are wired to connect, and this connection affects our health. From psychological theories to recent research, there is significant evidence that social support and feeling connected can help ...

www.ncbi.nlm.nih.gov

https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30253-1/fulltext

I can keep going. Social and community connections have profound effects on mental health.

*INTERVENTION*.

We know being fat causes X Y Z. Is there an evidence-based intervention that makes people unfat? Yes, gastric bypass.

People are getting therapy to do social skills training. Sometimes they work sometimes they don't.

Therapists are getting paid $15 an hour over Zoom delivering ineffective treatment, not because it's zoom but because nobody cares what kind of treatment they are delivering.

 

[erg923]

Do we also really need to "measure" social connectedness and community involvement to be able to diagnose and treat appropriately? The shortcomings of most of the rating scales we use are pretty well documented. It's kinda laughable to suggest that they are some kind of a necessary stepping stone for treatment.

Treatment goals should be measurable (anything that exists can be measured...that's the definition of exists), as well as realistic/obtainable at each stage of psychiatric/psychological treatment. That was like day 2 in my Ph.D. program. Otherwise, its just your opinion/point of view. Which is subject to enumerable cognitive biases and fallacies. This is not new, and a bit sad that a physician would have to reminded otherwise.

 

[psychacad]

Treatment goals should be measurable (anything that exists can be measured...that's the definition of exists), as well as realistic/obtainable at each stage of psychiatric/psychological treatment. That was like day 2 in my Ph.D program. Otherwise, its just your opinion/point of view. Which is subject to enumerable cognitive biases and fallacies. This is not new, and a bit sad that physician would have to reminded otherwise.

I guess day 3 was inherent problems in measurement scales in psychiatry but you missed that? We obviously assess at every stage, but almost everything in psychiatry is notoriously "subject to enumerable cognitive biases and fallacies". It would be hilarious if you think rating scales (i.e putting a number to it) solve that problem. So since there's no measurement scale yet for "community involvement", let's drop it off our list of treatment goals, lol.

 

[Mad Jack]

*INTERVENTION*.

We know being fat causes X Y Z. Is there an evidence-based intervention that makes people unfat? Yes, gastric bypass.

People are getting therapy to do social skills training. Sometimes they work sometimes they don't.

Therapists are getting paid $15 an hour over Zoom delivering ineffective treatment, not because it's zoom but because nobody cares what kind of treatment they are delivering.

I'm aware you said intervention. I'm saying we have data, now we need to figure out how to use it. Can't have evidence until you make it. At the least, encouraging patients to engage in social behaviors that are likely to improve their mental health is a good starting point.

 

[erg923]

I guess day 3 was inherent problems in measurement scales in psychiatry but you missed that? We obviously assess at every stage, but almost everything in psychiatry is notoriously "subject to enumerable cognitive biases and fallacies". It would be hilarious if you think rating scales (i.e putting a number to it) solve that problem.

"I wont try to do any science because I don't think it's 100% reliable." Ok. But That's not how (social) science works.

Patient is now more "socially connected" just/only because they (I) say so??? That's teleological argument.

If you prefer to not use any semblance of science in your treatment, that fine. But this doesn't help our profession, and its not how I was trained to run treatment.

We have reliable change index formulas, empirically-keyed instruments...not to mention a variety of functional outcomes measures that we could show you, them, and others that they are now indeed more "socially connected."

If your position is: "Well, patients lie." Yes, of course. Sometimes. That's why we use multiple methods to measure and evidence our treatment outcomes.

 

[psychacad]

"I wont try to do any science because I don't think its not 100% reliable." Yea. OK.

Patient is now more be " socially connected" because they (I) say say so. That's teleological argument.

If you prefer to not use any semblance of science in your treatment, that fine. But this doesn't help our profession, and its not how I was trained to run treatment.

We have reliable change index formulas, empirically keyed instruments...not to mention a variety of functional outcomes measures.

The hilarious part is that you think having someone fill a scale is "doing science." LOL.

I think rating scales can be useful in tracking symptoms if there are roadblocks in treatment course. I'm not categorically opposed to their use. But as every psychiatrist who got reasonable training would know: they are only there to supplement your clinical judgement. Not to replace it. And they certainly don't solve the inherent issues of subjectivity/cognitive biases in psych that we deal with continuously on behalf both patient/provider. In some cases they make them worse.

 

[erg923]

The hilarious part is that you think having someone fill a scale is "doing science." LOL.

I think rating scales can be useful in tracking symptoms if there are roadblocks in treatment course. I'm not categorically opposed to their use. But as every psychiatrist who got reasonable training would know: they are only there to supplement your clinical judgement. Not to replace it. And they certainly don't solve the inherent issues of subjectivity/cognitive biases in psych that we deal with continuously on behalf both patient/provider. In some cases they make them worse.

No. Did I say we/I use face-valid "rating scales" only? I said we measure things. We "measure" them using a variety of approaches. Do we know what an empirically-keyed measured is, for example?

How bout collateral information/reports? Observations. Or, they got a job. Or they interviewed for 3 jobs. They attended 3 social meetings? Do you not ask about or inquire about evidence of these things? Why on earth would you not want to track (measure) these things if that goal is so important to the treatment??? Gotta show it, man.

 

[psychacad]

No. Did I say we/I use face-valid "rating scales" only? I said we measure things. We measure them using a variety of approaches. Do we know what an empirically keyed measured is, for example?

How bout collateral information/reports? Observations. Or, they got a job. They attended 3 social meetings? Do you not ask about or inquire about evidence of these things? Why would you not want to track (measure) these things if that goal is so important to the their treatment?

This is getting absolutely ridiculous. That's exactly my point. If you want to pat yourself on the back for throwing words like "science", "measure", "empirically keyed", feel free to do so.

 

[erg923]

This is getting absolutely ridiculous. That's exactly my point. If you want to pat yourself on the back for throwing words like "science", "measure", "empirically keyed", feel free to do so.

Why is it "ridiculous" to use all means at our disposable to show/demonstrate that our patients are getting better and meeting the goals we set in treatment?

I really think we should actually do it. Not just say it. That's the whole point. You are asserting you wont even try. What do you think that's about?

 

[psychacad]

Why is is ridiculous to use all means at out disposable to show that our patients are getting better? I think we should actually do it. Not just say it. That's the whole point. You are asserting you wont even try. What do you think that's about?

That is not the point at all. Obviously there are ways to assess for community involvement without using a standardized rating scale. In fact that is exactly my point. The post I was referring to was implying since this is probably not "measurable" (i.e 'systermically' with a scale) then we should ditch the intervention because it's not 'EBM'.

But as I said, if it makes you feel better to throw terms like 'science', 'empirically keyed' or whatever, even when I think you don't really know what you're talking about, please continue to do this.

 

[wolfvgang22]

I forgot what this thread was even about now.

 

[dl2dp2]

I'm aware you said intervention. I'm saying we have data, now we need to figure out how to use it. Can't have evidence until you make it. At the least, encouraging patients to engage in social behaviors that are likely to improve their mental health is a good starting point.

I always encourage social behaviors. This is some kind of SBIRT territories intervention, and studies on this type of intervention are definitely mixed at best, and generally they don't have a large enough effect size. This is where science comes in. "I want to tell them that they don't need Zoloft, they need community. They need connection to the land. They need to re-sync with the rhythms of nature. Isn't this how most humans lived for the past 200,000 years?" This does little in changing their actual behavior. Social or otherwise. The question is whether you care about what you do actually making a difference in behavior, or do you want to prescribe a set of virtues in conduct that cannot be followed? The latter isn't medicine or science.

Long term intensive behaviorally oriented therapy can change patterns of behavior--there's decent data on this, mainly from DBT, but also others. Very few people do this in real life and they are not available for $15 on the phone. Even standard manual driven CBT is not easy to find in the community for a referral. Payers also don't incentivize this.

 

[erg923]

That is not the point at all. Obviously there are ways to assess for community involvement without using a standardized rating scale. In fact that is exactly my point. The post I was referring to was implying since this is probably not "measurable" (i.e 'systermically' with a scale) then we should ditch the intervention because it's not 'EBM'.

But as I said, if it makes you feel better to throw terms like 'science', 'empirically keyed' or whatever, even when I think you don't really know what you're talking about, please continue to do this.

Ok. Let me try this:

Why are you so fixated on "rating scales." Surely know how to do more? I do. I think I used the term once in this conversation?

And why do you think I am "throwing around" the term ''empirically-keyed measures?" This is a thing, and has been used in psychiatry since the 1940s. You will (apparently) not use this method? Is that what you are saying?

 

[psychacad]

Why are you so fixated on "rating scales." Surely know how to do more? I do.

And why do you think I am "throwing around" ''empirically keyed measures?" This is a thing. You will (apparently) not use this method? Is that what you are saying?

You really need to read the thread. I am 'fixating' on rating scales, because the post I was referring to mentioned standardized instruments as key for any treatment goal/intervention, and if we don't have them, then we should ditch the intervention.

"
How do you measure a "stronger sense of community"? And if it's not measurable, what's the point of insisting that it's "better" or "worse"? These statements are basically meaningless. If it is somehow measurable (by standardized instruments, etc), why aren't you measuring it?
"

I am arguing standardized instruments (i.e scales) aren't a necessary stepping stone for intervention in psychiatry. In fact, I would exactly 'agree' with you that you can assess for community involvement without using standardized measurements.

At this point, you're either willingly or unwillingly trolling.

I think you were throwing around these words, because anyone who's familiar with what the word science means, knows that medicine isn't science.

 

[erg923]

I forgot what this thread was even about now.

The OPs concerns are valid. Whether he or she has the ability and time to actually do what they seemingly want to do (and which would actually be practicing psychiatry as I understand it) is another question I guess?

I would simply make the argument that case conceptualization and devising measurable treatment goals is important and not a particularly hard skill to master. You can measure anything that actually exists.

 

[erg923]

How do you measure a "stronger sense of community"?

Define the variable definition for that particular patient. Define the steps to obtaining it. Define the end goal(s). How many times has patient done this (or attempted). Document in your treatment plan. Why is this so controversial???

 

[psychacad]

Define the variable for that patient. Define the steps to obtaining it. Define the end goal(s). How many times has patient done this (or attempted). This is not rocket science. Done.

Man, this was the post I'm quoting that I disagreed with. LOL.

I think you are really a troll at this stage. If not, you're just acting like one.

 

[erg923]

Man, this was the post I'm quoting that I disagreed with. LOL.

I think you are really a troll at this stage. If not, you're just acting like one.

Why would you "disagree" with trying to document the progress of your patient?