Sunday, June 24, 2012

My Psychiatrist Doesn't Listen to Me

I've heard this said about myself as often as I've heard it said about colleagues.
There was a time when people could go to a psychiatrist and he would spend 50 minutes apparently "listening". I have tapes from my own psychoanalytic therapy series with patients in which I literally speak only a few words.  I listened and I listened very carefully.
This 'therapy' was found not to be beneficial for most people.  The public health funding system no longer provides funding for psychoanalysis because it was found most beneficial with only a certain selection of patients and commonly those very same patients could well afford to pay for this intensive in depth therapy.  Psychoanalytic therapy in which a person is seen weekly for roughly 10 to 40 sessions is still utilized and it's "evidence based" efficacy was well documented In the Ontario book, Standards and Guidelines for Psychotherapies, editors Dr. Paul Cameron, Dr. John Deadman, and Dr. John Ennis.
Over the years selection criteria were developed for the "listening therapies" which in contrast to new standard therapy, Cognitive Behavioural Therapy, is more like a typical tutorial.
More often than not though a patient who says his psychiatrist doesn't 'listen' to them is really saying 'my psychiatrist' doesn't 'agree' with me.  I am routinely called the 'non listening' psychiatrist when I tell people
1) Abstain from alcohol, your alcoholism is killing you.
2) Stop doing illicit street drugs.  They are causing your insaniety. They are not the solution.
3) Your partner isn't the problem. You are the problem.  You picked him/her or you trained him/her to be the way they are today. Leave them or change yourself so they can change.  But remember you take yourself with you and your likelihood of poor mate choices increases with the number of failures.
4) You are ready to return to work and work is generally good for mental illness.
These are the most 'offensive' things that I routinely have to tell people and when I do they become ballistic and routinely 'fire' me, and always say I don't 'listen'.  The person commonly figures that the way I will 'agree' with them, especially the painful marijuana addicts, is if they have enough time to 'convince me'.  They see their role on 'selling me' on their 'sickness'.
There were studies on long term and short term therapies and they found that whether you waited weeks or months to tell a person to return to work who would benefit from work, didn't matter.  Even with a strong 'therapeutic alliance' an alcoholic is going to reject you when you ask them to 'change' their behaviour.
Hence, Motivation therapy, with Prochaska's Stages of readiness.  Modern therapies are expected to identify what change is required and then assess when the patient is in the precontemplation, contemplation, determination or action phase of therapy. The limitted resources of society sponsored therapies are then used realistically and appropriately.
Today most people who see a psychiatrist are a very different lot than the ones who saw a psychoanalyst in the past. Today the psychiatrist is part of the medical model and providing 'specialist consultation' similar to a neurologist.  Most psychiatrist may not even be psychiatric psychotherapists and only be psychopharmacologist.
In the glory days of psychoanalysis, the rich paid hundreds of dollars a day 5 days a week for years to suffer through a very tortuous process of self discovery. It wasn't counselling and it was indeed very effective for those highly selected motivated individuals who were willing to invest that much money into their growth personally.  It wasn't found to be very effective in the prison population and of limitted value in those areas where patients were 'sent' rather that 'came' to therapy. It was also more effective when patients paid for their therapy rather than having it paid for by third parties.  The higher the education and the younger and more successful a person was before entering psychoanalysis the more likely the outcome would be positive.
I spent years 'listening' to patients, have hours upon hours of taped sessions where I say only a few words but this is not with patients who have addictions.  The analysts collectively considered alcoholics and addicts as 'untreatable' by the 'listening' therapies though there was progress made when these were done in 'group therapies.'  Transactional analysis remains a successful group therapy and Games Alcoholics Play remains a true classic.
Modern therapies are specific to the patients 'condition', personality disorders often benefitting from a socratic dialogue more than insight therapy, for instance. Supportive therapies are most effective for patients who have regressed to where they are having problems with self care, maintaining work or relationship. 12 Step faclitation therapies are talk therapies which are most effective with impulse dyscontrol therapies.
Cognitive Behaviour Therapies include home work, writing and behaviour assignments. They're not dominated with the patient talking but rather focus on the patient 'doing' things differently.
Today the patient who gets better is the patient who 'listens' as the model of psychotherapy is based increasingly on 'psychoeducation'.  The learning of 'social skills' is evidence based today. Freud's work and the early psychoanalysts in general were 'explorers' . They were like the 19th century biologists who were 'observing' in hopes of understanding. Today thanks to the psychoanalytic work of years specific therapies have been developed that are themselves evidence based.  Focus has moved from diagnosis, which thanks to the early explorers is much better established with tools such as ICD 10 and DSMIV tr than ever before, and more focussed on therapy.
I don't need to listen a person tell me for 6 months about their appendicitis symptons anymore than I need to "listen' for 6 months to a person tell me about their life of woe and self pity before I can prescribe not only medications which if taken have a 80% success rate but also therapies which are equally effective today. In combindation biopsychosocial therapies are more effective than ever before and the treatment of psychiatric illness is approaching the success of physical therapies in those who are capable of 'listening' and taking direction.
Noncompliance with medical regimen or nonadherence to therapy can run about 30% in the physical disease population but as high as 80% in the psychiatric disease population.  It's important that the psychiatrist 'listen' to what patients are saying but they may today be more interested in why the patient didn't follow through with last week's recommendations rather than discussing ad infinitum the blaming of mother for lack of breast feeding.

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