Thanks for the shout-out, Awais! I agree that lack of containment is a widespread issue in the psy-fields, but wasn't aware it was this pronounced in psychiatry. So, it's interesting to see the intersection of psychoanalysis with prescribing.
Thanks. I enjoyed Sorbie’s interview and this reflection on it. Here is a short story for you. In 1993 I was prescribed lithium carbonate and haloperidol. Shortly after leaving the hospital I biked to the North Sea and threw them in. A couple weeks later I told the doctor. I don’t honestly know what I was expecting to happen, but I guess I was expecting some sort of discussion. (I was not in good shape and memories of the time are dim.) His response, which was made to nobody in particular, was a single word: “clozapine”.
Thank you for the shoutout. I hope it gets more eyes on Orestis’ wise words.
This is a good concise description of a problem I’m very familiar with from my days of yore as a patient (or “service user”(!)). The phrase “medication management” makes my skin crawl.
I do 15 mins med checks, but I don't ignore the psychic life of the patient. I just do not spend much time trying to make them change. In 100% of the cases they are also seen by someone else doing psychotherapy.
I'm also perfectly fine telling patients alright, this has nothing to do with drugs, let's hold on for now – or start taking drugs off.
My more often than not - almost always in fact - medically qualified psychotherapists and analysts avoid prescribing for patients in therapy. They see the roles of therapist and prescriber as incompatible. None of that is inconsistent with your remarks, which address a different question. But I made the association
Not sure I ever had a fantasy of “just” prescribing meds, so much as I found this was what paid the bills and something I could understand and bill for. But you are absolutely right, and rather than my disregarding the psychodynamic or psychotherapeutic aspects of any psychiatry, I find I struggle with it and balancing it with professionalism (including boundaries) is extremely difficult.
Awais, you cannot possibly *not* be a psychotherapist, with this degree of recognition of the importance of that aspect of our work. But thanks for articulating it, so well, especially with your closing: "The emotional and relational dynamics are not an intrusion upon the work of prescribing. They are a part of the work itself. Whether you know this or not, whether you accept it or not, that is the job.".
(1) I could not stand to be "just" a prescriber, and I'm grateful that I didn't feel confined as so many do. A lot depends on where one practices and what the institutional norms are in a given place. If you're told that it's OK ( and even rewarded) to just prescribe, only your professional conscience will push you to do what you're correctly calling "the job." (2) I think psychiatrists and nurse-practitioners often put unnecessarily tight boundaries on what's fair to discuss in a med-check for fear of losing control of the session, their time, and the rest of their day's schedule. Many are simply ill-equipped to manage affects and questions, and so they over-compensate by limiting and diverting too much of what the patient brings up for fear of losing that control. Sort of like someone who drives 25 on the freeway so they don't have to worry about a speeding ticket. (3) I bet NPs are not as well trained in patient management as psychiatrists are, so I'm a tad more forgiving of them than the MD/DO prescribers. That's an explanation, not an excuse. I firmly believe the job is as you describe it; we're here to do the best we can, not the least.
I was trained well in psychodynamics which was useful irregardless of the venue in which I practiced.
If the pt. feels you understand their problems and you can show some empathy towards them, it greatly increases compliance. In general, pts. won’t take meds if they don’t understand why they are supposed to take them. Side effects become dramatized and understandably the pt becomes afraid. That destroys any fledgling “therapeutic alliance.”
I blame managed care for this in part and also the insecurity of some psychiatrists who apparently feel that b/c psychiatry had relatively few procedures (basically ECT), they weren’t “real” doctors.
Well now, psychiatry has quite a few effective medications that have made a real difference in mental illness. TMS and SAINT have added to the therapeutic armamentarium.
Some psychiatrists either don’t want to do psychotherapy or don’t feel skilled at it. The thing about doing psychotherapy is that sooner or later, unless you are awfully obtuse, you begin to realize that there might be some similarities between you and the pt. You might not share their specific illness but you do share in the human condition.
This can be threatening to some. The “cure” is a personal psychotherapy, or better yet, a personal psychoanalysis.
So true what you write Awais. We are shaped not only by what happens to us, but by how we are met. Every interaction with a clinician, whether in psychotherapy, psychiatry, pediatrics, or primary care, teaches a nervous system something about safety, threat, dependence, and belonging. The prescription matters. The diagnosis matters. But so does the relational field in which they are delivered. The body is always listening.
The patient on PsychologyToday searches for therapists who specialize in psychosis months after it's cessation, but cannot find any. The website defaults to prescribers if psychosis is check-marked. Almost as if the field of psychology did this on purpose, as if it were designed this way by Big Pharma. He finds a self-described psychoanalytic Psy.D eventually, whose profile says "Jungian" and "Existentialism", but it turns out to be a façade.
The PsyD says "I don't help with integration of psychosis, you should see a psychiatrist".
The MD says "It's not okay for a patient to integrate their experience into a personality system or a world view, this would mean they 'lack insight'. And integration is not allowed in medicine because it doesn't sound evidence based. It's not approved by the Church of CBT, so it's wrong".
The patient says "Then i'll go convert to a religion, and there's nothing you can do about it!"
The local church says "You have sinned, will you confess your sins?"
The patient then creates an account on Mad In America
Mad In America demands that: "You have to become an activist, to join our revolution!"
The patient says "I don't want to become a revolutionary. I want to make sense of my experience".
Thanks for the shout-out, Awais! I agree that lack of containment is a widespread issue in the psy-fields, but wasn't aware it was this pronounced in psychiatry. So, it's interesting to see the intersection of psychoanalysis with prescribing.
Thanks again!
Thanks. I enjoyed Sorbie’s interview and this reflection on it. Here is a short story for you. In 1993 I was prescribed lithium carbonate and haloperidol. Shortly after leaving the hospital I biked to the North Sea and threw them in. A couple weeks later I told the doctor. I don’t honestly know what I was expecting to happen, but I guess I was expecting some sort of discussion. (I was not in good shape and memories of the time are dim.) His response, which was made to nobody in particular, was a single word: “clozapine”.
Thank you for the shoutout. I hope it gets more eyes on Orestis’ wise words.
This is a good concise description of a problem I’m very familiar with from my days of yore as a patient (or “service user”(!)). The phrase “medication management” makes my skin crawl.
I often say that prescribing is the easiest part of my job.
I do 15 mins med checks, but I don't ignore the psychic life of the patient. I just do not spend much time trying to make them change. In 100% of the cases they are also seen by someone else doing psychotherapy.
I'm also perfectly fine telling patients alright, this has nothing to do with drugs, let's hold on for now – or start taking drugs off.
Happens quite often.
My more often than not - almost always in fact - medically qualified psychotherapists and analysts avoid prescribing for patients in therapy. They see the roles of therapist and prescriber as incompatible. None of that is inconsistent with your remarks, which address a different question. But I made the association
Not sure I ever had a fantasy of “just” prescribing meds, so much as I found this was what paid the bills and something I could understand and bill for. But you are absolutely right, and rather than my disregarding the psychodynamic or psychotherapeutic aspects of any psychiatry, I find I struggle with it and balancing it with professionalism (including boundaries) is extremely difficult.
Awais, you cannot possibly *not* be a psychotherapist, with this degree of recognition of the importance of that aspect of our work. But thanks for articulating it, so well, especially with your closing: "The emotional and relational dynamics are not an intrusion upon the work of prescribing. They are a part of the work itself. Whether you know this or not, whether you accept it or not, that is the job.".
(1) I could not stand to be "just" a prescriber, and I'm grateful that I didn't feel confined as so many do. A lot depends on where one practices and what the institutional norms are in a given place. If you're told that it's OK ( and even rewarded) to just prescribe, only your professional conscience will push you to do what you're correctly calling "the job." (2) I think psychiatrists and nurse-practitioners often put unnecessarily tight boundaries on what's fair to discuss in a med-check for fear of losing control of the session, their time, and the rest of their day's schedule. Many are simply ill-equipped to manage affects and questions, and so they over-compensate by limiting and diverting too much of what the patient brings up for fear of losing that control. Sort of like someone who drives 25 on the freeway so they don't have to worry about a speeding ticket. (3) I bet NPs are not as well trained in patient management as psychiatrists are, so I'm a tad more forgiving of them than the MD/DO prescribers. That's an explanation, not an excuse. I firmly believe the job is as you describe it; we're here to do the best we can, not the least.
I was trained well in psychodynamics which was useful irregardless of the venue in which I practiced.
If the pt. feels you understand their problems and you can show some empathy towards them, it greatly increases compliance. In general, pts. won’t take meds if they don’t understand why they are supposed to take them. Side effects become dramatized and understandably the pt becomes afraid. That destroys any fledgling “therapeutic alliance.”
I blame managed care for this in part and also the insecurity of some psychiatrists who apparently feel that b/c psychiatry had relatively few procedures (basically ECT), they weren’t “real” doctors.
Well now, psychiatry has quite a few effective medications that have made a real difference in mental illness. TMS and SAINT have added to the therapeutic armamentarium.
Some psychiatrists either don’t want to do psychotherapy or don’t feel skilled at it. The thing about doing psychotherapy is that sooner or later, unless you are awfully obtuse, you begin to realize that there might be some similarities between you and the pt. You might not share their specific illness but you do share in the human condition.
This can be threatening to some. The “cure” is a personal psychotherapy, or better yet, a personal psychoanalysis.
So true what you write Awais. We are shaped not only by what happens to us, but by how we are met. Every interaction with a clinician, whether in psychotherapy, psychiatry, pediatrics, or primary care, teaches a nervous system something about safety, threat, dependence, and belonging. The prescription matters. The diagnosis matters. But so does the relational field in which they are delivered. The body is always listening.
The patient on PsychologyToday searches for therapists who specialize in psychosis months after it's cessation, but cannot find any. The website defaults to prescribers if psychosis is check-marked. Almost as if the field of psychology did this on purpose, as if it were designed this way by Big Pharma. He finds a self-described psychoanalytic Psy.D eventually, whose profile says "Jungian" and "Existentialism", but it turns out to be a façade.
The PsyD says "I don't help with integration of psychosis, you should see a psychiatrist".
The MD says "It's not okay for a patient to integrate their experience into a personality system or a world view, this would mean they 'lack insight'. And integration is not allowed in medicine because it doesn't sound evidence based. It's not approved by the Church of CBT, so it's wrong".
The patient says "Then i'll go convert to a religion, and there's nothing you can do about it!"
The local church says "You have sinned, will you confess your sins?"
The patient then creates an account on Mad In America
Mad In America demands that: "You have to become an activist, to join our revolution!"
The patient says "I don't want to become a revolutionary. I want to make sense of my experience".