The nature and construction of mental disorders part 3

Peggy: March 8, 2011

Hi Mohammad et al,
Thanks for posting this NYT article. It really captures the current state of psychiatry in USA even here in small town Vermont. It’s both sad and disturbing.

Right now, I’m reflecting on another perplexing trend in my state. Sometimes medicine is indeed helpful in conjunction with therapy. I believe medicine has literally saved people I’ve worked with. In Vermont,  the primary care physician usually does the prescribing because it is extremely difficult to get a consultation with a psychiatrist. When the situation is complicated (someone experiencing psychosis, suicidal depression, acute anxiety, etc. ), we really try to find someone with particular psychopharmacology expertise. However, there are very few psychiatrists in this state to whom I would refer clients.  And when we do try, often they do not have room. Besides, the psychiatrists often want to do the therapy as well –  and most commonly from a psychoanalytic approach. I remember one client who was told she would need to stop seeing me if she works with the psychiatrist. Needless to say, I think the medical model places psychiatrists at the top of the therapy hierarchy, and does not teach collaborative skills. Ironically (but not surprisingly), I hear that psychiatry as a specialty is now one of the least favorite choices in medical school. Even less preferred than primary care!

Lately, I’ve been referring to a group of psychiatric nurse practitioners in Burlington, Vermont. They TALK with their patients. And  they seem more open to helping people decrease medication. But now I hear their practice is filling up. The word is out.

A couple of years ago, I had a memorable conversation with a psychiatrist who has the well-earned reputation as being one of the best psychopharmacologists in Vermont. She confirmed my impression-  she is one of the few psychiatrists she knows who is primarily interested in medicine vs therapy – and at the same time, when she takes someone on, she really devotes herself to the mystery of medicine. She engages in conversation with someone who consults with her, and works with the therapist as well. As a physician, she prides herself on keeping on top of cutting edge new discoveries in medication, mixes, etc. Her patients benefit as well – she also works slowly to help decrease overmedication (SO COMMON these days). And guess what? Her schedule was CRAZY with long 12-14 hr days, on call on the weekend, etc. And for surprisingly little money (because she was not doing the fast med checks). She had a disabled partner, and was having trouble paying the bills. Guess what now helps her make a better living? She goes around the country giving talks on depression for drug companies!!!!!!!!

What a mess!

Does anyone have a psychiatry story of hope and possibility to share? I think I need one.
Peggy

Margaret Wells: March 8, 2011

I don’t have a happy story that comes to mind just now (it’s nearly midnight here) but thanks for appreciating the work of the mental health nurses and celebrating the things we can do well.

Kevin Nielsen: March 8, 2011

Hello everyone,

I have been reading with interest these posts.  I really appreciate them.  I have been waiting and wanting to write a reply that would capture all that I have been thinking of in regards to this.  However, it often feels like I never have enough time.  So, instead, I’ll put in short comments.  First, James I have been thinking about the study group you were involved in and the book you read, The Disordered Mind.  I will remember that.  I just bought Ken Gergen’s book, Relational Being.  It has really got me thinking about the implications of the “bounded being” and how we construct the meanings of things, such as psychiatric disorders…Got to run.  More later.  Thanks to everyone who is making this such a stimulating conversation.

Kevin

Mohammad: March 8, 2011

Hi Peggy and Everyone,
I try to make this short as my shoulder cannot take much typing.
Deep from within the medical establishment, I work closely with a number of psychiatrists. I am made well aware of the hierarchy that medical model somehow needs to have. My theory is that it seems that the white lab coat somehow claims a status that is even hard to believe by most physicians- the healer, the life saver, the preserver of life, the fixer. So, in order to help allay the anxiety of taking on such impossible posture, and to justify the enjoyment of the compensation ratio that is well over others who also have a claim to being a healer, a whole host of characters would need to be recruited to agree and reflect back the image of the healer to counter the pangs and worries of being an impostor.
I think were it not for the compensation and the social status we have chosen to attach to the profession of medicine, one that is often readily claimed by most physicians and felt entitled to, were it not for the promise of making big bucks after getting the degree, most of those who would take on such responsibility would be more like your friend who would have difficulty paying bills like the rest of us but still would spend the time needed to get to the bottom of someone’s story to provide for healing.

The allure of big bucks, one that attracts many to lawyering also, brings to the field the “best and the brightest” and not the most compassionate or the one who wants in his or her core to care for others.
I do hope for the day that there is pay equity amongst all of us care providers and then I imagine we would see more of the very wonderful human beings who are doing great psychiatric work.
I can right away count about seven psychiatrists that I closely work with who are decent human beings, who know their craft, who care about the welfare of those who come for consult, who are humble enough to speak to the limits of the medical cure, and who are willing to yield to psychotherapy as the most important part of the treatment. When the trophies are being handed down, would they jump to say oh it was not the prozac, I don’t know, but it is quiet possible.

We are a nation of number ones. We have a problem with being number two or three…

We are taught to think of ourselves as exceptional, superior, and the best. Would we have the courage to say well this stuff we are handing out should take the back seat to psychotherapy? Some do sometimes!
There is hope, even for the pill cure and certainly for those who dispense it!
Mohammad

Kevin: March 9, 2011

Mohammad and others,

I really appreciate hearing your comments about the complexity and relationship between working in the medical establishment where
prescriptions are usually valued more than talk therapy.  I am a little more than one month into my new job working at a federally qualified health center.  It’s a medical model that has a commitment to a social mission (and will help pay off my student loans).  There is so much I want to write about all of this, but for now just want to say, what has been said by others, on the journey of working collaboratively with people in a setting that sets one up in a hierarchical, expert position.  The psychiatrist and DSM can seem like the priest and holy bible.  I have found many committed people and in the actual practice there seems to be space for more than one way.
This gives me hope.

Kevin

Mohammad: March 11, 2011

Hi All,
I attended a three hour lecture yesterday by three leading psychiatrists, each taking up an hour to speak about the complexities of humanity.
The chief psychiatrist at Hopkins spoke about the absurdities of diagnosis and the diagnostic manual and his hopes as to how the new DSM5 may be more in tune with how people are all unique and we are not really talking about disease. He is on the 161 member committee and doing his part to bring some sanity to the final document. Though he cautioned it will not be what we hope for and further efforts will be necessary.
Another speaker’s perspective was genetics and his hope along with others to find genetic markers.
Yet another spoke about Mood Disorders from the neuroscience perspective and how is it that we have accidentally stumbled on antidepressants and reviewed the evidence for their efficacy.
One word they all used, specifically in terms of genetics studies, was Collaborative.

The recognition is there that without collaboration with other disciplines and amongst the members of the same discipline there may not be any move toward meaningful understanding. I can only hope for humanity to get around greed and fear and begin to relinquish attachment to power.

Though as you can see in Libya, Egypt and elsewhere, it is rather difficult for man to give up its hold on power. One thing about yesterday worth noting is that all three were white male. For whatever is worth one of them is gay, which means a shift from the past when he would have had no place at the table.

Let’s hope for a place at the table for all of humanity with all its complexities and colorful faces.

With Love and Light and Unyielding and Reasonable Hope,
Mohammad

Peggy: March 11, 2011

Mohammad, this is exactly the kind of hopeful story that I/we need to hear!While there are many reasons to worry about the future, there are also reasons to be hopeful.

I love knowing the chief psychiatrist at Johns Hopkins (one of the best teaching/research hospitals in the USA) is speaking publicly -and to  professional audience – about the absurdities of diagnosis and the DSM. Maybe this new DSM will make some changes in the right direction?

Good to to hear there are hopeful new developments in research with genetics and mood disorders. Judging from other medical discoveries  such as in oncology and cancer treatment, I know science has tremendous potential – as long as combined with understandings about the complexities of humanity.

Speaking of complexities of humanity….I’ve been thinking about the complexities that contribute to the domination of the medical model/ medical establishment over other ways of thinking/working/seeing. What keeps physicians at the top of the hierarchy? I know there are many factors.

Mohammad, I’ve been thinking about what you said about the lure of big bucks and assumption that keeps the psychiatrists at a higher compensation ratio:

Quote
I think were it not for the compensation and the social status we have chosen to attach to the profession of medicine, one that is often readily claimed by most physicians and felt entitled to, were it not for the promise of making big bucks after getting the degree, most of those who would take on such responsibility would be more like your friend who would have difficulty paying bills like the rest of us but still would spend the time needed to get to the bottom of someone’s story to provide for healing.

The allure of big bucks, one that attracts many to lawyering also, brings to the field the “best and the brightest” and not the most compassionate or the one who wants in his or her core to care for others.

I do hope for the day that there is pay equity amongst all of us care providers and then I imagine we would see more of the very wonderful human beings who are doing great psychiatric work.

I totally agree that we need more pay equity. It is appalling how little social workers make in relation to other medical providers.

I also want to share an inside view of the making of a physician, and some of what contributes to the sense of deprivation, vision of delayed gratification and sense of deserving more compensation than others. This perspective comes from my experience of watching my son Jordan who as you know is also at John’s Hopkins, now a second year resident in emergency medicine.

I think you know I am a hard worker. “To Be of Use” by Marge Piercy is one of my favorite poems: Here is the first stanza: “The people I love the best jump into work head first without dallying in the shallows and swim off with sure strokes almost out of sight. They seem to become natives of that element, the black sleek heads of seals bouncing like half submerged balls….”

To read the entire poem, click here.

However, everything I have ever done pales in comparison to Jordan’s training to become a physician. I can honestly say I have never worked as hard as Jordan, nor carried the weight of as much responsibility (decisions/interventions carry the urgency of life and death).

Medical school was extremely demanding beyond anything  I have ever experienced in graduate school (as student or teacher). Unless someone comes from a wealthy family,  medical students in the USA accrue significant loans over the 4 years of med school – in the 100,000s of $$. Then comes residency (Jordan’s residency is 4 years) where you make about $40,000 a year, for working CRAZY hours with little room for any other kind of living. So while your friends and family get together, you work. For example, yesterday Jordan finished a month long rotation on the “shock trauma” unit where he worked 32 hour shifts, most of the time fueled by an adrenalin rush. Then there is a short break before you go back again. When I was just in Baltimore visiting, the best way I could enter his life was  to show up at his apartment during a window of time when Jordan wasn’t working or sleeping- we had thought we would go out, but instead spent a wonderful day talking while cleaning up his apartment – the messes that  built up while he has been basically living at the hospital.

I am not sure how the making of an emergency physician compares to the making of a psychiatrist, but I imagine there are similarities.
All of this hard work, responsibility and deprivation  – combined with intimidating loans to pay back – sets ups physicians to believe they deserve extra compensation for about a decade of putting the rest of their lives on hold.  Again, I’m not suggesting that others don’t work hard. And I believe fully that we need more equity. But I also think it is important to understand some of the pressures that contribute to the making of a physician.

What are your thoughts?

Peggy

Mohammad: March 13, 2011

Hi Peggy and Every one,
This may be my last post for a while. I will fly out of DC tomorrow night and arrive in Qatar Monday evening and then fly out of there early the next morning and arrive in Tehran at 4:00 AM Tuesday. I will be entering a new world, one that is far from the world I grew up in and put behind me when I was eighteen. I don’t know what to expect. I do hope to be able to post from there but at the moment I know I will not have daily internet access as the old house I grew up in is not equipped with it. But there are internet cafes and I will be making my way to them when I can. In any case you will be in my thoughts and my heart!
Peggy I cherish hearing about the makings of a physician from a mother’s perspective, especially from yours. I entirely agree. Medical training is grueling and most oppressive and in many ways inhumane. Such test of endurance, to pull those long shifts with so little sleep and compensation, supposedly designed to prepare interns to make accurate diagnosis and deliver proper care in the face of adversity. It is years of hard work, memorizing exactly the acceptable treatment and practicing it accurately. I imagine psychiatry is not any less demanding. Though in the hierarchical world of medicine psychiatrists, I am told, are lower in rank than most and in some cases are not considered “real doctors” and their pay, unless they are very well known, is lower than other specialties. I hope all physicians are well compensated for all the years of hardship, self denial, and great effort. And my hope is that the compensation does not have to do with the number of patients they get to see in a day, as I think that is where we all run into trouble. The connection between the number of patients seen, the number of procedures done, and the pay can be corrupting. I see it in my own practice. In our clinic we have minimum quota of patients wee need to see, “volume of service” that we have to maintain, other places call it “productivity”. For us the minimum is 50 percent, that is out of a 40 hour week needing to bill twenty hours of direct contact, which we are told is far less than most other clinics where the expectations are higher. When a therapist maintains 55 percent or 60 percent productivity for three months then he or she receives an incentive, a bonus, respectively. That is what I find troubling. The possibility of cutting corners to make the bonus at the expense of those who are most vulnerable and needy. And or pressuring patients to come in more often than they would want to in order to maintain the minimum, double booking, etc. to not be at the least nagged at for not being more productive. In our case we simply get more patients assigned to us. Let’s say I have patients who demand a lot of my time through phone calls, visits while they are in the hospital, or work with other care providers and family members but not have direct contact with them in my office. That is not taken into account, indeed it may be considered as too giving and for that I will be urged to cut these things short and see more patients “efficiently”. Once I am assigned more patients I will have to limit my time with each or else I will be at the clinic a lot more than my typical 45 to 50 hours a week. I do need to have a life after all.

I had a conversation with my primary care physician a while ago, a wonderful, compassionate and funny man who spent many years toiling at the same hospital I now work. He typically spends one to two hours with me when I go to see him, asking about all aspects of my life. He looked up the address of the old house I grew up in on google map when I told him where I was going and showed him a picture of it. He explained that one week’s earnings out of the month goes to overhead expenses for his private practice. I don’t think he is wealthy by any means and I am not sure if that is important to him. He seems to love his work and love people. I do hope that he is well compensated for his great work now and all those years of sacrifice he has made. I do hope that he can continue to spend the time that each of his patients need with them without feeling the pressure that he has make his quota for the day. I do hope that his life is comfortable. That he feels well cared for so that he can continue to care for others the best way he knows how. I do hope that for all of us, to be paid well, reasonably, and the level of pay having to do with our training, the years we have spent studying and also how proficient we are and that be regardless of how many people we see in a day. A dream I suppose!

I need to disclose that when my family sent me out of Iran their hope was that I would become a “doctor”. At one point I hoped that too. It was indeed a way to move upward in social status, class and income, while at the same time it was to respond to a calling that I felt inside of me. The fact that I did not make it to medical school in part gives credence to the presence of “the not good enough” and how I look down on myself while at the same time can be so critical of the medical profession. In Freud’s words it would be a case of “doctor envy”.

During the 1979 revolution I was in college in Maine, majoring in chemistry, pre-med, and taking a whole lot psychology, and English and creative writing on the side, and though far from where it took place, much in my life was impacted and drastically changed. Others experiencing the same events may have survived through the storm differently, and most certainly did. I, however, experienced a crisis in my life and went on to toss out the whole of idea of “hard sciences” as I found them cold and not rewarding. One statement by a psychotherapist I consulted, a social worker, has stayed with me. That he “would have hated to have been one of my patients had I become a physician.” I very much agree with him. I would have made a horrible physician and I am glad I am not. I was not cut out for that work nor did I want it. What I wanted, though I did not know at the time, is the work I am doing now. I know I could not do the work that physicians do. I just simply do not have the discipline and do not have the skills in categorizing and memorizing lists of symptoms and treatments, nor do I want to. I think much more globally and often make mistakes and leave things out. I think like a poet, hint at things that are out of grasp and feel my way through. Knowing is not my specialty. I am rather more comfortable, if that is entirely possible, with not-knowing.

When I am off balance in the session then I resort to knowing. But, when I am non anxious and can sit with the discomfort, I simply practice not-knowing and that is when I get a glimpse at the glory of my calling. Curiously asking, co researching, paving the way for discovery of somethings but more importantly influencing others to also accept and be comfortable with not-knowing. As so much is unknown.
I leave you with the last portion of Sengstan’s “Verses on Faith-Mind”:

“One thing, all things:
move among and intermingle,
without distinction.
To live in this realization
is to be without anxiety and non-perfection.

To live in this faith is the road to non-duality,
because the non-dual is one with the trusting mind.

Words!
The Way is beyond language,
for in it there is
no yesterday
not tomorrow
no today.”

With Love and Light and Unyielding and Reasonable Hope, I do look forward to joining you again on this island of belonging!

Mohammad

Peggy : March 13, 2011

Hey – I love the story about your physician. He sounds extraordinary. And so much more to say – but all can wait until your return.

Mohammad, I can hardly believe you leave tomorrow on your journey home to Iran. Please do write if you can from one of those Internet Cafes. And if not, we’ll be eager to hear more upon your return. I cannot imagine what it might be like to return home after 33 years!~ I know you have been planning this trip for many years. So many stories to tell and to hear! May your shoulder be sufficiently healed, your heart open and your relatives and friends greet you with loving embrace. No matter what, remember you have an island of belonging here with us.

With Love and Light and Unyielding and Reasonable Hope,

Peggy

Mohammad: March 13, 2013

On the plane! Taking off soon!
This island is in my heart!
Talk soon!
Mohammad

Kevin: March 15, 2011

Hello Peggy, Mohammad and others,

Mohammad, I am thinking of you as you fly back to Iran. I look forward to hearing more of what you share.  I was heartened to read of your conference and the critical thinking that is going into the DSM.  I was literally just talking/despairing with my wife about the DSM medical world that I have profound reservations about.  It does give me hope and inspiration to read your reflections.  Last night I was watching a piece on youtube about Dr. Gabor Mate.  I really like him.  He wrote a book called In the Realm of the Hungry Ghosts and takes a very environmental, community perspective to illness and in particular addiction.  Very inspiring.

Kevin