My friend and I took to the white board today to map out a talk we shall be giving at a behavioral medicine conference for a group of non-psychiatric residents. Although I have since erased the dry-erase pen marks, faint residues remain on the surface of the board like the lingering fragrance of incense that was burnt several hours prior.
The talk keeps evolving, primarily because we’re trying to cram hours upon hours of material into a ninety minute talk. The topic itself is also amorphous and is not amenable to transmission via language alone.
I like to lump these types of topics into a poker analogy: “You can read about poker all you want, but it is only when you actually play the game that you develop an understanding for poker.” (I didn’t come up with this analogy myself; I am fairly confident that I got this from an episode of Star Trek: The Next Generation—I think the crew was teaching Data how to play poker. I have now established my geek credibility, thank you very much.)
The residents specifically requested a talk about working with “the difficult patient”.
That’s such an unfair phrase; implicit in that sentence is that the patient is to blame for the difficult interaction. The phrase still persists in medicine, though; if one enters the phrase (with quotation marks) “difficult patient” into Pubmed, 301 articles show up, some published as recently as January 2007 (!).
Amongst other things, we hope to introduce the idea that it is the interaction that is difficult, not the patient. This idea that difficulties reside solely in the patient harkens back to Freudian psychoanalysis, where the analyst was viewed as absolutely objective and that any issues that appeared in the therapy were reflections of the patient only. Modern day psychoanalysis asserts that both analyst and patient contribute to the interpersonal dynamic; why hasn’t the rest of medicine adopted this idea?
Thus far, we intend to
- solicit the residents for general goals they have when interacting with patients (and explicitly explain that when these goals are not reached for whatever reason, this results in the “difficult” experience)
- provide a general framework to help categorize the types of difficult interactions (for which both parties may jointly hold responsibility—and how loathe we all are to accept responsibility)
- solicit the residents for what strategies they have used to ameliorate these difficult interactions and, whether they were successful or not, why they succeeded or failed
And this is the location of the impasse.
Initially, I (we) wanted to give a talk about interviewing skills (since psychiatrists, whether accurate or not, are considered the artisans of the clinical interview). After several incarnations, I now want to cultivate self-awareness in these residents and provide instruction in basic and effective behavioral (i.e. visible and tangible) interventions that can help minimize difficult interactions with patients.
The two are highly interrelated, however, and we just don’t have the time in one lecture period to satisfactorily address both topics.
In order for someone to change his behavior, he must first be aware of his behavior. If you’re not aware of what you’re doing, you will not have any impetus to change it.
Behavior is one point of a triangle in a (cognitive and behavioral) model of mental health. (There seem to be a lot of triangles in psychology and psychiatry.) The other points include thoughts and emotions. If you change one point, the other points shall be affected. (For example, if you’re feeling sad (emotion), you may have thoughts like, “I’m worthless,” and spend way too many hours in bed (behavior). By forcing yourself to get out of bed and do something (behaviors), you will likely change your thoughts and emotions.)
Ideally, we’d like to demonstrate to the residents that their thoughts and emotions affect their behaviors—sometimes in adverse ways. However, we want to make this point in a compelling fashion and not as a bullet point on a Powerpoint slide (because that’s not effective, but it is painfully boring). We also don’t want to be overly shrinky about it because, really, the task of reflecting upon our emotional states can be uncomfortable and threatening. Self-awareness is important, though, and, in the long run, awareness of the internal process will help optimize patient care and facilitate satisfactory interactions for all involved.
That being said, teaching concrete behaviors to the residents will probably be a more satisfying experience for them (because, you know, we live and work in a culture of doing, not reflecting) and, as a result, that will make the teaching experience more satisfying for us (because we want our talk to go well!).
The two points are not mutually exclusive, of course—time is just limited. At this point, our goal is to explicitly (but briefly) state the importance of self-awareness (as the rest of the lecture will implicitly highlight this) and introduce one or maybe two behavioral interventions for their use.
So, I seek the collective wisdom of the internet: What tactics do you use during/to prevent difficult interactions with other people to (1) help reach collaborative goals and (2) maintain working relationships? I’m talking simple, *behavioral* tactics (versus purely *cognitive* tactics, such as thinking, “I’m not gonna get pissed off, I’m not gonna get pissed off…”), such as body language, verbal strategies, etc.—things that are concrete, tangible, and observable. Help me with the list I already have. I am particularly interested in hearing from people who regularly work with patients in health care settings…
… but since we all have had difficult interactions with people, leave a comment and tell me what *behavioral* interventions have worked for you in the past. Thank you for contributing to medical education.
10 Feb 2007 | 12 comments.
Psychodynamics in English.
I have finally found a book about psychodynamic psychotherapy that I actually understand: Individual Psychotherapy and the Science of Psychodynamics by David Malan.
(I’m only on page 54 of 255 pages, so there is plenty of time for my comprehension to fizzle away.)
I am reading the first edition of the text (from 1979; the second edition came out in 1995!); I’d like to purchase my own copy so I can scribble stuff on the pages. This is in contrast to the other psychodynamic books I have tried to read, where I don’t understand the language enough to write anything meaningful on the pages (except for question marks).
It’s not that I have developed a new fondness for psychodynamic psychotherapy (which is related to Freud’s psychoanalytic psychotherapy—you know, with the couch and whatnot)—how could I, when the writings in this field made little, if any, sense to me? As I progress in my residency training, however, I have wondered more and more about the theory and approaches of psychodynamics—I want to be comfortable and familiar with this model as another way to understand human behavior.
And, truth be told, some of the best behaviorists and not-psychodynamic psychiatrists (who hold strong opinions against the practice of psychoanalysis) use psychodynamic theory to inform their own practices. Although all forms of therapy look “deeper” into human behavior (e.g. what thoughts resulted in that behavior? what function does that behavior serve? what other meanings could that statement have?), psychodynamic psychotherapy, by its very nature (”dynamics”), compels people to consider more covert possibilities to explain thoughts and behaviors. (This, however, is also my novice opinion, since I currently have very little theoretical or practical experience with this branch of therapy. It’s a coastal thing.)
Early in his text (page 15), Malan introduces the idea of the “triangle of conflict” as an important tenet in psychodynamics:
One of the main tasks of the psychotherapist is therefore to analyse in his own mind, and then to interpret to the patient, the end-product of these mechanisms, in terms of (a) the devices adopted for avoiding mental pain, conflict, or unacceptable feelings (the defence [sic–the guy is British]); (b) the feared consequences of expressing these hidden feelings (the anxiety); and (c) the nature of the hidden feelings themselves.
For example, according to this theory, someone may complain of feeling anxious (b), particularly around bakeries (I can relate cookies to everything). As a result, this person may make a point of avoiding bakeries and all places that sell confections—maybe he can’t even really talk about cookies or look at images of cookies in magazines or on the internet (a). He rarely goes to restaurants because of the severe discomfort he feels upon seeing cookies. This avoidance is interfering with his relationships; his friends don’t understand why he refuses to socialize—”what is so wrong with bakeries?”—and he doesn’t have much time to do anything but work (because he walks an extra three miles to avoid walking past coffee shops, bakeries, and restaurants on his way to and from work). What is the underlying cause of this behavior (the only thing we can quantify)? Perhaps it is because he lost his virginity in a bakery at the age of 13—except he lost it to his older sister. (Just work with me.) At that age, he knew about the prohibitions about intercourse within the family—this event disgusted him… and he liked it. Thus, this disgust and pleasure are the hidden feelings (c) that he cannot express.
The idea, then, is that upon discussing this situation and facilitating a space where the patient can reveal his hidden feelings (with the assistance of interpretations from the therapist—because, remember, the patient cannot initiate this discussion himself), the patient becomes aware (or gains insight) into his symptoms and their cause, thereby alleviating his anxiety and eliminating the need of defenses.
I can see how that makes sense. We’ve all felt better after sharing our mental and emotional burdens with other people. Talking things over can be therapeutic.
Psychodynamics, however, is not amenable to evidence-based practice. After all, how can we measure “hidden feelings”? Is there a way for us to design experiments where we can demonstrate with laboratory instruments (or questionnaires) that it is the actual discussion of hidden feelings (rather than cookies or sexual relations with different people or avoidance) that results in symptom relief? How do we know that interpretations actually facilitate the clarification of “hidden feelings”? Perhaps the “hidden feelings” would have come up themselves without the use of interpretations. Or, perhaps there is some subtle hypnosis (again, just work with me) occurring that induces the patient to agree with the therapist’s interpretations—loss of patient autonomy, if you will.
This lack of evidence is what causes a lot of people to regard psychodynamics with skepticism—particularly given the usual time course of therapy (years!). Other therapies (such as CBT, DBT, and CBASP) have more measurable outcomes because these therapies incorporate definite goals: “I want to stop cutting.” “I want to take plane rides without freaking out.” “I want to feel less anxious.” (There are validated questionnaires that can quantify anxiety, depression, etc.) These therapies also don’t focus on the “why” of symptoms (though they do not ignore possible reasons); they focus more on increasing function or reducing symptoms in measurable ways.
Psychodynamics, as demonstrated above, attempts to address the “why” of things.
(Tangent: A study recently came out that demonstrated the efficacy of psychodynamic therapy for the treatment of panic disorder. This is big news because there is very, very little data to support the utility of psychodynamic psychotherapy. There are several flaws with the study, but it is a data point for psychodynamics. You can read the New York Times article here or the original study here.)
Although I don’t foresee myself ever becoming an analyst, I still want to add psychodynamic skills into my repertoire to further improve my delivery of patient care. I have already incorporated the “triangle of conflict” model into my skill set to help formulate patients—and, if for nothing else, it has helped me to think more deeply and carefully about the manifestations, functions, and consequences of human behavior.
8 Feb 2007 | 3 comments.
Do You Think of Me When You See Cookies?
When he and I were interns, we frequently purchased Fairlight cookies (I favor the chocolate chip and ginger spice varieties) as a reward for ourselves after a night of call. Although our conversations included topics such as politics, medical education, and the foibles of the hospital, we frequently talked about cookies. Such discussions brought us comfort at strange hours of the night and made us laugh when the day stretched into its 26th hour.
After he completed his internship, he and his wife moved across the country to New York City, where he is now (I trust) a highly competent and respected resident in emergency medicine. Our conversations about cookies and other baked confections have since dwindled into semi-annual affairs.
My appreciation of cookies is legendary. Many people think of me when they encounter cookies. Colleagues (and the occasional brown-nosing medical student) buy cookies for me if they sense that I am having a rough day—they all know that I will immediately smile and express deep gratitude.
It doesn’t take much.
Several months have passed since I last corresponded with my friend. When my eyes alighted upon the e-mail he sent to me this morning, I was already pleased—
—and I snickered when I read the contents of his letter: He had found a worthy chocolate chip cookie in New York City—and he wanted me to know where I could find it (74th Street and Columbus on the Upper West Side, for those of you who are reading from Manhattan).
This is remarkable news, primarily because he had bemoaned the lack of excellent cookies in New York. Seattle boasts several excellent bakeries and cookie factories (see Fairlight above; see also Cupcake Royale, Cougar Mountain Baking Company, and Larsen’s) that sell their wares at low prices (though nothing will ever beat Diddy Riese in Los Angeles).
This Manhattan cookie apparently costs a whopping $3.50.
My cookies consistently receive high ratings from all who consume them, so in case you’re not in Manhattan (or Seattle) and would like to experience the joy of eating a fantastic cookie, read on:
CHOCOLATE CHIP COOKIES (based off of the Hershey model)
2 1/4 cup flour
1 teaspoon baking soda
1/2 teaspoon salt
1 cup butter, softened
3/4 cup granulated sugar
3/4 cup light brown sugar
1 teaspoon vanilla extract
2 eggs
2 cups chocolate chips
Key step #1: Think warm, gooey, lovey-dovey thoughts about the cookies while you are mixing the ingredients. There was a randomized, placebo-controlled, double-blinded study in the New England Journal of Medicine a few years back that demonstrated, with significant statistical significance, that thinking “warm, gooey, lovey-dovey thoughts” while baking will improve the gustatory experience of the eater by at least 50%.*
Combine flour, baking soda, and salt in separate bowl. Mix butter, granulated sugar, and brown sugar until fluffy. Add vanilla extract and eggs. Then mix dry ingredients with wet ingredients. Add chocolate chips.
Key step #2: Put the dough in the refrigerator until it is thoroughly chilled. This helps with molding the cookies to give them that aesthetically pleasing round shape when putting them on the baking sheet.
Preheat oven to 350 degrees.
Roll dough into 1-inch balls (or smaller; small cookies look extraordinarily cute and, in conjunction with the lovey-dovey thoughts already mixed in, somehow taste better) and space them about 1.5 inches apart on a baking sheet. (I personally line the baking sheets with parchment paper.) Bake for about five to seven minutes on the top rack, or until edges just start to brown. Remove cookies from the oven and allow them to cool on the baking sheets for about one minute.
Remove the cookies and place them on a wire rack. Allow them to thoroughly cool before packing them up for consumption.
Makes about 48 soft, mouth-watering, delicious cookies.
* No, of course not.
6 Feb 2007 | 13 comments.
What?
[Mental illness] belonged to the destiny of this history that such a criticism should, after the event, be applied by medicine to all religious phenomena and rebound, at the expense of the Catholic Church, which had actually solicited it, against the Christian experience as a whole, and thus show at the same time, and in a paradoxical way, that religion belongs to the fantastic powers of neurosis and that those whom religion had condemned were victims of both their religion and their neurosis.
- Michel Foucault, Mental Illness and Psychology, page 65
The student in me wishes I had taken philosophy classes in college. The writer in me balks at the length and structure of this (single!) sentence. The brain in me wishes that it was better developed to understand what the heck Foucault is trying to say.
| 9 comments.
“Impartial.”
Every month, the postman leaves a stack of psychiatric journals and magazines for me. (I still don’t understand how these companies obtained my mailing address.) These publications are fondly referred to as “throw away journals” because, well, people throw them away—often without reading them.
I am one of those people. (I have also tried to get off of the mailing list, but my efforts have failed.)
These publications boast a ridiculous amount of advertising. The content within is also of limited utility—because you get what you pay for.
Let’s dissect the anatomy of the January 2007 issue of Psychiatric Times, in order, from page 1 through page 72:
- generic Lilly ad - 1 page
- Lunesta (Sepracor) - 4 pages
- generic Pfizer insert - 2
- board licensing preparation ad - 1
- ADHD education (Shire) - 2
- Lexapro insert (Forest) - 2
- generic Janssen ad - 1
- Adderall XR (Shire) - 3
- psychosis symposia announcement - 1
- Effexor XR (Wyeth) - 4
- ADHD prodrug development (Shire) - 2
- Abilify (Bristol-Myers Squibb) insert - 8
- Rozerem (Takeda) - 3
- Geodon (Pfizer) - 2
- Namenda (Forest) - 4
- Cymbalta (Lilly) - 2
- Seroquel (AstraZeneca) - 4
- electronic medical record ad - 1
- Zyprexa (Lilly) - 1
- physician staffing opportunities - 2
- classifieds - 11
- generic Janssen ad (back cover) - 1
Over half of this publication (37 pages, or 51.4%) is dedicated to advertising, the vast majority of which is for medications. That doesn’t even include the inserts (which resemble the perfume ads that jut out in popular magazines). Only 3 (or 4.2%) of those ads are unrelated to pharmaceutical companies.
In the lower left-hand corner of page 3 is a box of text:
Psychiatric Times serves as an impartial forum for information affecting mental health care professionals and their practices….
“Impartial”? Ha!
People who work in mental health would like to believe that they have the best understanding of human psychology and behavior, but, in truth, people in marketing and advertising likely know a lot more than we do.
4 Feb 2007 | 11 comments.