Wednesday, October 23, 2019

Comments by Stevie

Showing 58 of 58 comments.

  • Mr. Whitaker, did you ever think that societal problems were causing the escalation of mental health problems? Or, the the corporatization of health and mental healthcare were handcuffing psychiatrists so that psychiatrists are burning out at epidemic rates and suiciding at the highest professional rate?

  • Bob, wish your considerable journalistic talents would now turn toward the societal issues causing so much increasing psychological distress, including the overuse of medications:

    – inadequate drug testing and misleading PR by Pharma;
    – inadequate insurance coverage that limits psychotherapy;
    – the control of psychiatry and medicine by the payers, causing over a 50% burnout rate in physicians;
    – rapid changes in society and technology leaving many more insecure;
    – a President that is increasing conflict, divisiveness and scapegoating;

    Please consider leaving this “dead horse” for a time and look at what’s causing so many of us to have our souls die.

  • Dr. Levine, maybe you want to take a look at the expanded edition of The Dangerous Case of Donald Trump, released a week ago and edited by Bandy Lee. The book in both its editions has elicited the condemnation of the American Psychiatric Association due to the “Goldwater Rule”, which some psychiatrists feel is secondary to the ethical risks from this Presidency.

    Someone on this site should review the book.

    Yours,

    Stevie

  • I’m heartened by this blog. Yes, it is a much bigger issue. That medical care has become a big business has thwarted and limited physicians in having enough time to listen to patients and provide compassionate care. Meds become a time-saver. This will get worse as ObamaCare is getting dismantled. It does no good, really, to scapegoat psychiatrists when we are burning out due to our systems. We should be in this challenge together.

    Hey-Hey

  • Maybe if he and many here would be more optimistic about psychiatry, he would have recovered more. It is also crucial to know that appearing much better, as Kermit Cole wrote, can be a clue that someone has decided to commit suicide and is relieved by that. This is a tragedy that perhaps could have had a different outcome with a different view of psychiatry.

    Hey-Hey

  • It is difficult to accept the points by Dr. Hickey when he uses Dr. Carlat to support his criticism of Dr. Pies. Dr. Carlat was a notorious well-paid spokesperson for Pharma for many years, until his conversion to something else. Dr. Hickey took Dr. Carlat’s points out of his contradictory history.

    Stevie

  • Well, maybe we have something in common, Steve, besides our name. And, I appreciate your kind and respectful reply. It is this kind of interaction that can move all of us back in the same direction, not the blanket scapegoating of psychiatrists.

    I think many social changes contributed to the transition: the limited success of talk therapy with certain conditions; the promise and marketing of medications (including “thought leader” psychiatrists paid a lot to talk them up); the power of for-profit managed care to influence what care gets provided and paid for; and competition among the different mental health professionals (including psychologists who still want to be able to prescribe medications).

    But, believe it or not, younger psychiatrists seem to realize what they have missed and want to learn about more than medications. They do want to know what is wrong with medications. The older ones like me are retiring (and I know there will be some applause out there), though we still try and try to have constructive conversations about what needs to change. All sides have valuable perspectives, if we listen respectively to them. Many have been chased away or stay away from this site.

    -Dr. Moffic

  • Gee. Richard. I check in now and then to see if anything has changed. Guess not. The “good ole days” are still here at MIA.

    But the “good ole days” of the 1960s in psychiatry are gone. In fact, I found it fascinating and helpful to talk to people no matter how unusual their words were. Often, if you empathized and looked for symbolic messages, much could be learned. But it took much time and patience.

    Glad to know I was missed.

    Dr. Moffic

  • Laura,

    You make good points and I’m loath to respond too much, given some of the reactions. All I’ll about managed care is that most psychiatrists (other than those who are in private practice and have self-pay patients) hate managed care and feel managed care has used and distorted the field (say with “medical necessity”) for the financial gains of the companies (which are immense). Personally, I have a more mixed view of managed care, including supporting the need to reduce hospitalizations (and time in the hospital) and unnecessary treatment, which I tried to present in the book “The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare” (1997). Most systems of mental healthcare nowadays are run explicitly or implicitly by business people; what makes money and keeps the system afloat tends to rule the day.

  • Duane,

    People don’t have to read my comments or blogs at all. I don’t think I’ve been disrespectful and actually, in contrary to your viewpoint, I don’t think anybody needs to earn respect. I try to convey respect and dignity as much as I can as a principle of being a human being who lives in an interdependent society.

  • I think I answered Laura’s first question fully. I respond to the situation at hand here. Have I learned here? Yes. Have I don a 180? Nowhere close. Of course, Duane would say I’ve gone in circles, but I’ve enjoyed the recent interactions with Laura and Nathan.

  • He was already on an outpatient commitment and I didn’t know him that well. Actually, we psychiatrists don’t recommend whether to extend that or not, just send them our treatment view. As far as I could tell so far, he hadn’t changed from when he came in.

  • Thanks for sharing information on this book. The title jives with what most physicians should strive for: the variation of the “do no harm” ethical principle attributed to Hippocrates, which really is “do as little harm as possible”. Do you know what is recommended in this book is similar to other strategies that have been relayed in this to getting off medication?

  • Nathan,

    As I think I’ve said elsewhere, I and many psychiatrists have done the last thing you’ve said. I’ve also worked in a low-paying prison. My principle was to focus on those in most need who also wanted care. I can’t remember the last time I played any role whatsoever in forced treatment of any sort. My main question in an evaluation was always “what gives your life the most meaning and let’s see if I can help you achieve that”. Of course, at times I might disagree or say I couldn’t help, i.e., get or prescribe certain drugs. That question I found to be the best inroad into one’s inner world. I don’t think it is of much use here to state it, but a psychiatrist has (or at had) the broadest training of any mental health clinician, including anthropology and the humanities. The training of folk healers is different, but valid and valuable in itself. There is just so, so much we don’t know about the brain and mind (which may be different than the brain).

  • Laura,

    By cultural, I meant just one influence on our subjectivity.

    For your first question, I’d answer no. Certainly, many of our leaders in politics, new movements, and religion had intense emotions and/or thoughts outside of the norm. I suppose we could also add the recent example of Steve Jobs in his inventiveness and leadership. Of course, many everyday people too. Different on a spectrum, perhaps, but surely not necessarily abnormal.

    The answer to the second for me would be no also.

    I think psychiatry has whatever power it does from a societal political decision akin to what Nathan wrote. As I answered Nathan, I would add that psychiatrists, when they are trying to work with people, would like to have more power to have the time to get to understand the subjectivity you mention. Although this is being eroded, we always talked more about the “art” of psychiatry than the “science”. I know others will say, well, just take the day and take whatever pay you can. That is one solution, but for now the demand to see us is great and when insurance is involved (and that will only increase under Obama’s plan), those companies have more power in many ways (? like the real power behind the throne??

    Steve

  • Nathan, I agree with you just about with everything you said. However, I would add that “psychiatry”, generally led organizationally by those in private practice, gave up the power of leadership in institutions (state hospitals, community mental health centers, etc.) long ago. As individual psychiatrists, most of us wanted to have enough power to do more than just med checks, a quest most of us have lost.

  • Why would you assume that others who do not respond are not hurt? I believe it is impossible to have an on-line dialogue with someone who feels “disgust” toward me. So, I’ll close my responses with this passage (and, if offensive and necessary, take out the religious references):
    “O God, help me avoid every abuse of speech. Let no untrue word escape my lips. I pray that I may never speak badly of others, or speak empty words of flattery. Help me stay away from profanity. Teach me, dear God, when to keep silent and when to speak; and when I speak, O God, save me from using Your wonderful gift of speech to humiliate or hurt others”.
    -Reb Nachman of Bratzlav

  • OK, Laura, let me try to respond as a “cultural” psychiatrist (and I never use the word primitive because I think it is derogatory, but others do so I put it in quotes). A cultural psychiatrist is interested in how the cultural values of other people influence how they view variations in emotional expression and thinking. Of course, this can verge on stereotypes and needs to consider individual variations. Cultures can include ethnic groups, religious groups, economic groups, countries, tribes, refugees, etc. We know that in some cultures around the world historically and currently, such variations are much more accepted into the wider society and medication is much less used. In a so-called Western or industrialized society, Gheel is the best example I know. One could say that we would need less professionals if there was better societal acceptance of variation in emotional expression, thinking, and some behavior. Many cultures have there own “healers” to go to first; I talked about some of that in my last blog, ranging from shamans to curanderos to clergy. Sometimes these within-cultures healers will refer onto cultural psychiatrists. There is an organization called the Society for the Study of Culture and Psychiatry that focuses on all of this, mainly from a research perspective.

    I greatly appreciate the tone of the discussion and questions. It makes me think we can learn from each other.

  • I put the politicians up there because ultimately if you want some human and civil rights laws to change, they will need to cooperate.

    Supporting your view may be how so-called “primitive” and historical cultures and societies do so much more to accept, support, and value the more extreme emotions and thoughts you mention. “Cultural psychiatrists” understand this.

  • Malene,

    I’m sorry I did not answer all your questions. They are good ones, but would take a long time to consider and answer properly, and right now there is not enough time for me to do so, so I just made the brief comment I did.

    I’m not sure how our interaction here is at all like China and Tibet. Personally, I’ve been a strong and clear advocate for a “free” Tibet. I’ve even written a blog on China for PT, but you may not like it since I advocated for the development of some more psychiatry there. I also think there is a time and place for angry, vehement protest and criticism; when that is and how that is directed we seem to disagree about.

  • Duane,

    I would now say I essentially believe in what Dr. Steingard recently blogged about Anogosognosia, though I have also been informed by other commenters here. I probably should not have used the word “many” in the blog, but if psychiatrists work with upwards of a million patients, maybe a small percentage of that would still be “many”.

    For most situations, I would say that people diagnosed with severe mental illness do have the right to decide on their treatment, even if they have that “condition”, unless (and this is the very difficult decision) they seem to be of imminent danger to themselves or others without an obviously known good reason to be so. Another exception might be those who have conveyed in advance that they want a certain kind of help if they are ever is a condition where they can not decide as usual for themselves (including the much different Alzheimer’s).

  • Thank you for the comment about the Joseph blog. It was not meant to be a call for a cease fire, but for what we might have in common as far as a healing approach. Feeling like this is a war or battle will make me feel too much on edge and defensive.

  • I’m here for a dialogue where I can learn as well. If it seems like I am interested in defending psychiatry, I am not. I am not even practicing psychiatry anymore. However, I may not have the same conclusions and recommendations as others.

  • Thanks, Laura, and of course we disagree to some degree on some things. As to power, or at least potential power, I would put the politicians on top, and they are ultimately crucial for any human rights advancement. They influence everything from medication approvals to new laws.

  • Well, then, tell me how to make that distinction in a critic that does not identify themselves, or decides not to be truthful, or even might be paid to say something? I am not claiming or suggesting that would fit anybody on this site, but it could. When critics make blanket criticism of psychiatry and psychiatrists, it is hard for me to completely have “good faith”. If my wording in Psychiatric Times conflated the two unintentionally, I apologize.

  • Duane,

    I don’t know any psychiatrists who are so “simpleminded”. No sense being a doctor or psychiatrist if we will automatically taper someone off meds whenever that is desired without discussion and providing our opinion. I guess that is one reason to get rid of psychiatrists, or at least the education of psychiatrists. This is the same reason most psychiatrists will not – and should not – put someone on the medication in the television advertisement when the patient wants what they saw on TV (now there’s another area that should be addressed – the misleading ads on TV). For some people, “autonomous decision-making” is essential for mental health; for many others (especially from certain ethnic cultures), they would prefer expert advise. When – and if – we can get some agreement on this complexity of tapering, and get more points of view, then those psychiatrists might come out of the woodwork and even participate in this site.

  • I apologize for the delay in responding as our computer needed fixing and then I was away. When someone says “it is totally irresponsible of Dr. Moffic”, then we lose the ability to dialogue. I am just giving my opinion; if I am wrong, that is not necessarily being irresponsible. To me, being irresponsible is not incorporating all the information and data one can obtain, and then proceeding as best as possible in action. It seems to me that this site, as valuable as it is for criticizing psychiatry, is missing any other consumer/public point of view. Let’s say there are 50,000 psychiatrists, as Duane says, and perhaps we average 200 patients each (I had more than 400 when in practice). So, we have maybe a million patients. Do we know and hear from those who are satisfied? Those who have mixed feelings? In stopping meds, some may need very slow titration off and some can stop easily cold turkey after chronic use, and many other in-between. To do so the best way possible, I think one needs detailed discussion with each individual. Alternative “certification” may be a great idea, but not if the criteria are too narrow. Again, just my opinion.

    Maybe this needs repeating, but I write for what I think is useful for a particular audience. This is akin to how I worked with patients; I would never try to shove something down their throats (meds) that they did not want to try or when there were other alternatives. If you consider all my blogs for three different sites, here, PT, and Behavioral Healthcare, you’ll have a much better idea of how I really view things, if that matters.

    Lastly, I think it is indeed of utmost importance to distance Scientology from this site. I just don’t know if that is possible, given how what is behind one’s moniker or stated beliefs can not readily be checked.

  • No, Duane, I am not defending psychiatry, like you I am only giving my opinion about the state of emotional care or whatever we decide to call it. If you want to keep labeling me in another way, that is up to you, but just as I can learn from others here, perhaps others can learn something from me. If this site is just to bash psychiatry in any way possible, that is up to this site.

    Yes, I know way over 50 who would meet much or all of your criteria. How do I know these people so that it is more towards a fact than opinion. I have had – and had – leadership roles in many of the more fringe psychiatric groups that tend to be more critical of psychiatry: the Group for the Advancement of Psychiatry (where Mr. Whitaker was invited to speak last April, and where he was not tarred and feathered, Past President and current Board member of the American Association for Social Psychiatry, Founding Board member of the American Association of Community Psychiatry, ethics chair of many committees. Would I recommend any of them to become involved with this site right now? No, but I do know that some are watching and reading some of the stuff. When we are more welcome, I’ll let them know.

    What revolutions are you using as a model? The USA? Great for certain populations, not for the Natives. South Africa? Political freedom for the oppressed, but the political leaders that came out of the oppressed have shown much corruption. Revolutions, as exciting are they are, like any attempt to make things better, have very serious potential side effects and aftermath.

    “Tough skin”. Yes, I have it, but I am continually saddened by words that hurt others unnecessarily.

  • Duane,

    I think you are missing the point I am trying to make. We can not answer your question unless we agreed on your criteria, then did a survey of all psychiatrists, and tried some way to verify their responses. In other words, the same kind of “scientific” study we want for other issues. Just throwing out stats to make a point can be very misleading; one could say the same was done to push medications. All I’ll say again is that there are many other psychiatrists who feel horrible for the injustices we know of, desperately want our field to improve and would participate more if they felt welcome. Does this site just mainly want “like-minded” points of view, or to my mind, more hopefully, the “like-intended” that Kermit Cole relayed? “Like-intended” would include different points of view with the hope for some consensus and improvement in certain causes.

  • Sinead, I don’t think you are placing the real blame and power where it should be. Yes, doctors could have collectively tried to oppose the insurance companies and their control over what is “authorized” for healthcare, but they we would have faced a class action lawsuit over restraint of trade. And we can do better nevertheless. But, just for a minute, compare what psychiatrists can do – and do do – in Canada, which has a single payer system, allowing for adequate time with patients and reimbursements. There is much less reliance on medication there. Of course, maybe Canadian psychiatrists and family practitioners are just very much more humanistic and caring than their USA counterparts.

  • To the other Steve,

    I respect your perspective, but most of us do not think the way you think we do. We have trouble using the biopsychosocial model due to other forces – really!. So, we do the best we can with the short time we have. Diagnostically, we do know that we use DSM only because we have to for insurance and usually don’t even pay attention to the criteria! We try to see the patient as a person. And, we certainly don’t think a “cure” is likely – full recovery maybe. Criticizing us for something we don’t use or believe in is a waste of time.

  • From an “insider”, I think this focus on a “medical model”, whatever that is, is a bogeyman. I don’t know many who work together with those who want our help who think in terms of a medical model. The model we use most often is biopsychosocial (formed by the internist George Engel in the 1970s), and some of us add spiritual onto that.

  • Apology very much accepted, Duane. Yes, the comments have been more “healing” this time around. Yes, I was on vacation, but actually stopped blogging here for about two months because prior blogging felt “harmful”. However, I suppose we don’t know what comments have been deleted and not seen (correct me, editors, if that is a wrong assumption).

    To get back to the medication concern in the context of the overall message I am trying to discuss, and perhaps to do so prematurely, I would say this for now about medication information for anybody who wants and needs it:
    -as much information from as many reliable sources as possible should potentially be helpful in any healing potential
    -besides information on the medication, there should be information on how that knowledge was obtained
    -the information has to be understood as well as possible, so that should be tested out as much as practically possible
    -alternative ways of prescribing and stopping medication need to be compared as best as we currently can
    -constructive criticism will help prescribers change their ways more than derogatory criticism
    -alternatives to medication, when they are available and exist, should also be discussed and presented and understood
    -the placebo and nocebo aspects of medication always need consideration

    But, again, my intention in this blog was not to focus in on medication.

  • I guess I didn’t see MIA as heavily populated with academics and mental health professionals, but maybe you can cross me off of that list now that I am retired.

    If the “movement” is open enough, there will be the support of the likes of me, if that is wanted. Maybe we will even have some useful ideas and suggestions. I think all of the “rights” movements had some crucial support of those not directly in need of those rights.

  • The rich responses continue. I very much appreciate the support for keeping the topics open, but respectful. I am also thankful for supportive or critical comments, again if done with respect. Doing so, I believe, are micro acts of “healing”.

    Just a couple of brief clarifications here. I know I’m a bit careless still with terminology and facts, in an attempt to get to broader issues and points. I’m sorry if that distracts from what I am trying to get across or makes what I say less believable.

    Richard Lewis asked “Are you serious?” No, not completely. I guess the tongue-in-cheek comments about Freud did not come through to some on-line. A hint of my own criticism of Freud was that I said that some of his legacy became ossified.

    Laura Delano asked, why use “therapist” as a term? Actually, I picked it as short-hand and didn’t mean it to refer to professionals; if so, I would have used psychotherapist. Maybe “healer” would be a better term to have used, More encompassing.

  • As some repliers have noted, I have tried a blog again, and perhaps one that looks (but to my mind and intention is not) contradictory to prior ones. Rather, I hoped it would seem like an expansion, a hope to find, develop, and recognize the best of all healers and healing, past and present, fictional or not, whether that may be those who are professionally trained or not. And, surely, those who are professionally trained can learn from those who are natural healers.

    No, I don’t want natural therapists licensed (though in some states most anyone can find a license of some sort as a “therapist”) or to become a commodity, but more for us to appreciate and keep in mind what is available. Yes, it is also at the risk of bringing in religion and all the controversy and conflict that can bring. Yes, it is also at the risk of bringing in art and music, where people can have wide opinions. But, at times religion can be healing, art can be healing, and music can be healing, all of which at one time were part of professional healing settings, but hardly ever anymore.

    I only can conclude so far that for the most part the discussion is what I personally had hoped for in participating on this site – expansive, positive, and constructive (even if critical). These replies are so rich, that this is all I can reply for now, but perhaps more later.