Seeking the Opinion of a Psychiatrist?

A local therapist contacted me this week and asked what my philosophy was about when he should get a psychiatrist involved in the care of his patients. 

It’s an interesting question. When should a psychiatrist, a mental health physician, get involved in the care of a mental health patient? When an assessment is needed for a medical diagnosis? To help develop a treatment plan? When medications are indicated? When the patient is complicated? All of these?

One could argue that an assessment with a psychiatrist is a staple of any thorough mental health assessment, but there would be several problems with sending everyone with a mental health issue straight to a psychiatrist. First, there is a serious shortage of psychiatrists. The Hogg Foundation www.hogg.utexas.edu notes that in 2009, 171 Texas counties did not have a single psychiatrist. Due to the shortage, securing an appointment with a psychiatrist is difficult. Wait times in my county can exceed 6 months, especially for appointments with child and adolescent psychiatrists. Even for those capable of securing an assessment with a psychiatrist, there remains the problem of professional bias. The fact is, doctors prescribe medical treatments. It’s what we are trained to do. Only rarely do physicians provide reassurance and recommend that patients not take treatment for an illness. Involving a physician often means beginning down the road of prescription drugs, and in some cases medications are unnecessary (or even harmful).

So in answer to my therapist colleague, I said, “When a patient needs medication. Or when the situation is complicated and you need help from another professional.”

But this answer is disheartening. We are taught in medical schools that psychiatrists should be the leaders of mental health assessment teams, that we should be the experts who develop diagnoses and then work with teams of professionals to provide appropriate care. In the real world, we are impossible to connect with. When our patients see therapists, we rarely coordinate with them. When we treat patients in the hospital, we too often fail to talk with the outpatient providers to coordinate care.

If you’re a patient or family member experiencing behavioral or emotional problems, my advice is that you first seek guidance from a counseling professional. Counselors are readily accessible and if your problem is beyond a counselor’s expertise, he or she will make a referral to an appropriate professional. 

For counselors, I say find the psychiatrists (and other mental health providers) in your community who collaborate well, and develop team relationships so you can make referrals when necessary.

Dear Introverts, We're Sorry. -Extroverts

The introverts are speaking up and educating the rest of us about how our perceptions of normal are skewed toward an “extrovert ideal.” Now acknowledging you’re an extrovert can feel like confessing that you’ve been an insensitive jerk for eons. To all the introverts, we’re sorry.

After reading a recent HuffPost article by Kali Rogers titled An Open Letter From Introverts to Everyone Else, I decided to come out publicly in this blog post as an extrovert. Now, for those who know me well, this is probably not a surprise. Meanwhile my professional friends in medicine and mental health and almost everyone I know in the writing world are all introverts. As are my spouse, all my closest friends, and almost everyone I love most in the world. I think it’s wonderful that the growing discussion about introversion and extroversion helps expand our understanding of one another. And I will try to do better. We all will.

Here’s my open letter in response to Kali Rogers:

1.    We appreciate the reminder that weekdays are “me” days for our introverted friends.

Thank you for reminding us. After a long day of work, you need some alone time to re-charge. We extroverts don’t mean to sap all your energies when you’re trying to recharge. We really don’t. We are honestly just full of social vigor. We enjoy talking to you, and seeing you. Doing so helps us replenish our energies at the end of a long, tiring workday. But we can get those needs met on workdays by hanging out with the other extroverts who need the same thing. So feel free to decline our aggressive invitations. Just tell us you’re in need of a bit of quiet time, and we’ll respect your decision to head home for some rest.

2.    We will try to “have a reason” when we call you one the phone, instead of just dialing you up to talk about nothing.

Whoa, boy! We’ll do our best, but honestly, we might forget. We pick up our phones and just dial people we like. If we call you up for no reason, most of us extroverts can take any feedback you want to give us. We can be thick skinned, and in this case it’s a good thing. You can ask us to get to the point, or remind us you don’t enjoy chitchat, and we’ll apologize (for the ump-teenth time) and let you get off the phone. It’s okay to screen your calls when you don’t feel like talking. Just text us later and check in so we know you still love us.

3.    We will attempt to remember how important it is for you that social events happen with people you know, not just a room full of strangers. 

Right. Hanging out with strangers is stressful for you, not loads of fun like it is for us. Again, we’re really sorry. It can be kind of hard to imagine how an activity we get so much pleasure from can be such a nightmare for you. Don’t let us be insensitive about this. Confront us if we’re oblivious, and remind us that we are different from each other, and that’s fine!

4.    We understand you have just a few friends, not a “bajillion” like us.

We know this about you, introverts, and honestly, it’s one of the biggest reasons we enjoy your friendships so much. Our extroverted friends are fun to hang out with, but sometimes they aren’t very invested in us on a personal level. You introverts are often our most loyal friends, and we love you for it.

5.    We have seen how intense and passionate you get about the topics you find important.

We know introverts. We know. Politics, religion, money, complicated relationships; these are the topics you want to discuss. You would rather have substance in your conversations than fluff. Us extroverts, on the other hand, we like fluff. Our conversations are sport. We volley the discussion back and forth just to see if another person can keep up, and that’s entertaining. Forgive us if we feel uncomfortable with the deep content. It slows down the fun and makes us think. But we want you to contribute to the discussion, so chime in! We can adjust.

6.    We won’t make you reach out. We will do it for you..

It’s okay, introverts. We extroverts reach out constantly. We are often in perpetual contact with someone, and if you don’t call us, we’ll probably call you anyway. As long as we know you still love us.

7.    We appreciate the reassurance that you like us.

We like you, too! You introverts are our most trusted friends. You know how to keep a secret. You’re there for us when it counts. You’re real and genuine. We love everything about you. Just remind us to be sensitive to your needs. We aren’t trying to steamroll over you. But sometimes you’ll have to give us a gentle reminder that you and we are different, and that’s a beautiful thing!

Hey, Young People: Face Your Fears So You Can Start Your Life!

Jordan, a high school senior, didn’t complete her university applications over the holiday break as planned, leaving her past deadlines for submission. Since 3rd grade, she has wanted to become an English teacher, a career, which requires her to follow through on her dreams of higher education. She doesn’t understand why she put off completing apps, except that leaving home next year feels overwhelming. Fear left her paralyzed.

Most of us know what it’s like to be afraid of innocuous uncertainties. We fear the unknown. We fear the unexpected. We fear change. We fear what’s hidden. Perhaps it’s human nature to suffer petty fears.

Yet not all fears are to be avoided. Some fears protect us from harm: The hidden could be dangerous. The unknown could hurt us. Something unexpected could attack us. Change means a loss of stability, a loss of control, a shift in routine that had become safe and secure and comfortable.

For established adults with careers and support networks, fear of change means nothing ever changes, we get bored, frustrated, irritated, and unhappy. We turn down an opportunity, and remain stuck in a dissatisfying life. 

Jordan is at the beginning of her first adventure away from the family. If her fear prevents her from taking the leap out of her parents’ home, leaving home may become progressively harder with time. One semester hiding under the covers, waiting for courage becomes a lifestyle of procrastination, avoidance, and shame.

What can she do now?

Jordan cannot give up on herself. She will need to push herself to move forward. If she’s passed the deadlines for her top pick universities, but wants to start school next fall, she will need to an alternative plan. She will need to hold herself accountable. Ask for help. She will need to risk being brave and vulnerable. 

What can others do for her?

Her enablers need to resign their roles. Concerned friends might choose to confront her avoidance, point it out, and speak up. Parents might start requiring steps toward independence, before the hourglass runs out. They might clarify expectations: “After high school, we can’t let you live here unless you’re learning and growing. You’ll need to take classes or begin working.” Loved ones might rally around and say, “We love you. You’ve got this! Get moving!”