I say, "Looks like every time you go to the doctor, somebody starts another drug." They say "yes" as if that’s normal. They often know about the "withdrawals" from personal experience, running out of money for medications. I’ve been there for a while, and I’m beginning to notice that if I can get them off of the compendium of drugs, and later start one in what I consider to be the right way – low dose first, minimal expectations, they [and I] are often surprised at the response. There are always things in their lives that need attending to, and I find myself often sayingt, "These medications aren’t for life, and they’re only minimally effective when they work. The point is to feel better so you can ___." Fill in clean up your life, marriage, etc. etc. I’ve come to realize that they basically don’t know in any useful way that their symptoms have something to do with their lives.
An outrageous number have been told, "you’re bipolar," and they incorporate it in what seems at first like a useful way, as if it legitimizes their depression, but in the long run it becomes something of a "fate neurosis" – a life sentence. I have had to learn that in addressing that, I am taking something away from them if I challenge that diagnosis, so I have to walk softly, but it pays off in the end. There are some people with genuine Bipolar Disorders, but it’s obvious who they are [and they are in the minority]. When I first started, a lot of drug-seeking character disordered people wandered through. I must’ve done something right, because I rarely see such patients any more.
About once every clinic morning, some patient shows up with the kinds of problems I treated in practice. Today, it was an attractive talented girl who is almost home-bound because of a malignant envy problem. I’ve seen her occasionally over the last several years, and she’s finally begun to hear that her intense feelings are not truth, but the problem themselves. Today, she brought her mother to apologize to her for "being a jerk." "I thought it was your fault." They talked about her getting a job to practice being among people and planned her starting college in the Fall. If you had asked me if you could treat show-stopping envy by a few sessions in which you mainly just explained that her feelings were a bad compass, I would’ve scoffed. But I would have been wrong, as I saw this morning.
Actually, that little clinic in a couple of old trailers run by a bunch of do-gooder retirees has been sustaining in writing this blog. It’s so easy to get cynical and discouraged reading the APA, PHARMA, DSM, NIMH goings on. In the clinic, I rarely think of such things. Back when I directed a residency program, I used to tell a story to graduating residents when they were nervously planning their next step. When I finished my Internal Medicine Residency, I was the smartest person on the planet. I could roll off differential diagnoses, treatment algorithms, quote journal articles. I was a giant. Then I started practicing, and was humbled by the experience. When I finished psychiatry, I felt like an idiot who knew nothing. It wasn’t until I practiced that I realized how much I’d learned. So I suggested they take a clinic job where they knew what they were doing already, and only gradually build a practice. Most did that, but within a year or so were too busy to stay in the clinic.
“An outrageous number have been told they’re bipolar”. like the young girl that was demonstrated, with her parents, at a lecture a few years ago, “selling” McGorry’s ideas of early intervention,with lifelong drug therapy, modified in Australia, ongoing here.
Thank you, dr Nardo, for another of your sensitive, lovely, positive posts, firmly on the ground with people who have more than one reason for suffering, sowed by the many unjustices of US society, in the unjust world we inhabit, amendable by kindness, wisdom and politics for fairness and justice….
As the beautiful church service for my friends’ son and brother is with me this morning, my anger subsiding to my usual level, I’ll say, with yesterday’s parting words from the chaplain: Thank you! Keep it up! Bless you!
Having just been directed to philosophical therapy and therapeutic philosophy, I thought of you while reading. The poor and poorly educated are prone to black and white thinking, and judging rather than discerning. Most have internalized the shame of being poor in the U.S.A.
To be listened to respectfully and without fear of being penalized for their thoughts and feelings can be a rare feeling, though I found myself getting used to it rather quickly in my early college days— it’s like a nutrient you didn’t know was missing in your diet.
To be gently introduced to thinking about thinking is to be initiated into a whole new level of autonomy. Your clients are blessed to be given the benefit of your respect and the care you take in approaching their problems, conflicts, and relationships without pulling the rug out from underneath them. Given just a taste, I’m guessing that many of your patients can begin to find their own ways out, once they’ve been given permission to trust themselves. (When they know they don’t need permission, is when they’re on their way to self-realization.)
Most working class people don’t have much experience with others being patient with them. Being working poor means always feeling like you have to hurry up, and always being judged wanting. Being let in on the little secret that they are worth the time it takes to sort themselves out can be very liberating.
You really need to read “Life at the bottom” by Theodore Dalrymple.
Here is what the back of the book says about the book:
“Here is a searing account of life in the underclass and why it persists as it does, written by a British psychiatrist who treats the poor in a slum hospital and a prison in England. Dr Dalrymple’s key insight is that long term poverty is caused not by economics but by a dysfunctional set of values, one that is continually reinforced by an elite culture searching for victims. His book draws upon scores of eye opening , true life vignettes that are by turns hilariously funny, chillingly horrifying, and all too revealing–sometimes all at once. And he writes in prose that transcends journalism and achieves the quality of literature.”
It is a painful book to read if one has too much hope. But it is on the mark.
I ought to know, I work in an area deemed “flat Appalachia”.
Thanks for all three of those comments. It’s easy to ignore the profound impact of culture and oh, what a mistake. Wiley, that comment would make a fine book if you ever are looking for something to write…
” There are some people with genuine Bipolar Disorders”
Laughable quackery. Oh, those “genuine DSM labels”. I doubt people who believe in such a unicorn can be of any genuine help.
I read your post again this morning while with a lull in patient visits. Your last paragraph was very true, but, what can you honestly say to colleagues like me who have another 20 years to go before realistic retirement, who have to endure this madness of quick fix agendas not only by psychiatrists, but by therapists, administration of clinics, and patients who as you note don’t really have profound mood or thought disorders, just overwhelmed with the consequences of socioeconomic ruin. Note I did NOT say psychosocial.
People as a whole don’t want to hear truth. It is an obstacle of Everest proportions.
That is why I have my blog. but, back to my intent here, what can you say to colleagues to offer some hope and faith? Honestly.
Dr. Mickey, I think you hit the nail right on the head. “A lot are not used to being paid attention to, so they’re very responsive if you take the time to talk to them, and a little insight goes a long way.” In a society that values wealth over hard work every time, contempt for the working poor and dismissal of their dignity, adulthood, even personhood itself sometimes are close to becoming institutionalized. I experienced it first hand during my own years of doing factory work. Now as inequality and related social madness grows, it’s lapping at my toes again, and those of other white-collar workers. We’re all “losers” now.
Sometimes the dismissive label of “bipolar” and the offhand prognosis of lifelong impairment must look like kindness itself compared to the alternative labels that await your patients just past the clinic door. “Lazy.” “Stupid.” “Trailer trash.” The idiot doctor who stuck the label on them in a five-minute interaction may have been the first person they found who did not simply blame them for every problem in life they faced. And yet the medical labels of the past twenty-five years or so have become even more of a prison in their own way than the old labels … particularly when they come with medications that increase your level of disability and subject you to punishing withdrawals whenever you can’t raise the $50 copay for the frigging Cymbalta or Abilify.
To criticize the drugs and diagnoses is taking a risk – but maybe to advocate the right of ordinary people to have a human interaction with a professional is the craziest radicalism of all. Thanks, Doc.
By the way: for all you doctors out there: do you think a responsible shrink can treat someone via Telemedicine?
Per Johanna’s question at the end above, telemedicine is a less than optimal way to treat someone, in my opinion. That said, with the lack of services in rural areas, and I work in one so the practice is done at this office for C&A patients (which I do not treat), is it better than nothing? Probably, but would I agree to do it for a prolonged period of time? No.
You just have to love the 2 faced message by politicians abound, “we need to provide better mental health care to people, especially children”, yet insurers and clinics nickel and dime providers who are asking for reasonable and fair reimbursement rates.
It is what it is, care has a price. You believe in PPACA (Abomination Care as I call it), then you will truly get what you pay for. PPACA will destroy psychiatry, that is my opinoin.