Sounding like something straight out of science fiction, DARPA recently announced grants to fund research and development of implantable brain-stimulation chips aimed to relieve, or even cure, mental disorders. The Defense Advanced Research Projects Agency thinks big, and it has the money, i.e., our tax dollars, to back it up. Decades ago, DARPA brought us the internet. In comparison, revolutionizing psychiatry ought to be a walk in the park — right?
Find a need and fill it: “Current approaches — surgery, medications, and psychotherapy — can often help to alleviate the worst effects of illnesses such as major depression and post-traumatic stress, but they are imprecise and not universally effective.” You can say that again. So DARPA created a program called SUBNETS (Systems-Based Neurotechnology for Emerging Therapies) “to generate the knowledge and technology required to deliver relief to patients with otherwise intractable neuropsychological illness.” SUBNETS aims to create an “implanted, closed-loop diagnostic and therapeutic system for treating, and possibly even curing, neuropsychological illness.” In other words, computer chips in the brain.
SUBNETS will pursue the capability to record and model how these systems function in both normal and abnormal conditions, among volunteers seeking treatment for unrelated neurologic disorders and impaired clinical research participants. SUBNETS will then use these models to determine safe and effective therapeutic stimulation methodologies. These models will be adapted onto next-generation, closed-loop neural stimulators that exceed currently developed capacities for simultaneous stimulation and recording, with the goal of providing investigators and clinicians an unprecedented ability to record, analyze, and stimulate multiple brain regions for therapeutic purposes.
SUBNETS is hedging its bets. With an overall budget of $70 million, it is funding both a diagnosis-based arm, in the manner of the DSM5 of the American Psychiatric Association (APA), as well as a “trans-diagnostic” approach, in the manner of the Research Domain Criteria (RDoC) of the National Institute for Mental Health (NIMH). The ideological rift between the APA and NIMH last year was awkward and impolitic; fortunately, SUBNETS has the resources to avoid choosing sides. A research team at the University of California San Francisco (UCSF) will receive up to $26 million to study diagnostic groups, specifically post-traumatic stress, major depression, borderline personality, general anxiety, traumatic brain injury, substance abuse and addiction, and fibromyalgia/chronic pain. Another team at Massachusetts General Hospital (MGH) will receive up to $30 million to tackle trans-diagnostic traits, such as increased anxiety, impaired recall, or inappropriate reactions to stimuli. Both groups will include public and private partnerships, including with device manufacturers Medtronic, Draper Laboratory, and the start-up Cortera Neurotechnologies.
What to make of this? Well, it’s certainly ambitious. As I read it, the effort relies on several unproven premises. First, that psychiatric diagnoses, as currently construed, can be differentiated by monitoring activity in specific brain pathways. This has been tried before without success, and it isn’t clear that sensor technology was the reason. An alternative model would suggest that mental states are an emergent property of widely integrated brain states. If so, chips implanted in specific areas could no more capture this complexity than carefully listening to the trombone section could capture a symphony.
Another assumption is that carefully focused electrical stimulation can treat a variety of mental disorders. The efficacy of transcranial magnetic stimulation (TMS) to treat depression provides some support for this idea. In contrast, typical comparisons to deep brain stimulation to treat seizures and severe obsessive-compulsive symptoms only go so far. Analogous stimulators may quell a panic state or chronic pain. It is less clear how complex interpersonal patterns, such as those seen in borderline personality or substance abuse, could respond to this type of intervention. Of course, we shall see.
A central tenet of SUBNETS is that implanted technology can promote healthy (or curative) neural plasticity. Plasticity is a popular concept at the moment, highlighting the fact that brain wiring is not static, as was previously assumed. “Neurons that fire together wire together” — that is, synaptic connections change dynamically in response to input, i.e., life experience. This property underlies the hope that implanted stimulators may change the activity of neural pathways in a permanent way, “firing” the pathway together to make it “wire” together, and allowing the device eventually to be removed. Again, we shall see.
Of course, there are many stumbling blocks ahead. Implanting brain chips is no small matter, and this approach is unlikely to be used in the foreseeable future for anything short of the most severe, treatment-resistant disorders. Initial public commentary immediately honed in on the “military mind control” aspect of the project, with visions of soldier drones being controlled on the battlefield via implanted chips. The potential abuse of such technology is manifest and terrifying, and careful controls and standards are needed to assure freedom, not to mention safety.
At the most mundane level, the technology will only work if the science behind it is sound, and that remains to be seen. Nonetheless, if even a portion of the SUBNETS agenda comes to pass, it would represent a monumental leap for psychiatric treatment.
Lucia Sommers of the Department of Family and Community Medicine at UC San Francisco commented on my last post, noting that clinical uncertainty among primary care physicians (PCPs) is usually regarded as tolerable at best. She was delighted that I called such uncertainty intellectually attractive, and something to embrace in psychiatry. Sommers and her coauthor John Launer recently published a book that argues for managing clinical uncertainty in primary care using “collaborative engagement with case-based uncertainty in the setting of small groups of clinicians.” This contrasts with medicine’s tradition of practitioners working independently. In her comment, Sommers asked me to describe how psychiatrists manage clinical uncertainty, and specifically whether “supervision” — cases “presented for discussion to at least another psychiatrist if not a small group,” similar to what she advocates for primary care physicians — is a good strategy in my experience. This post is my response.
At its most fundamental level, human psychology exists to manage uncertainty. Confronted with an incomprehensible, threatening world, the infant soon differentiates “good” from “bad.” Initially a crude split without nuance or shades of gray, this primitive psychological distinction, second only to distinguishing “self” from “other,” represents a huge step forward. It sets the stage for approach versus avoidance — the first “management” the infant undertakes. Further psychological development allows subtler gradations to improve upon this harsh dichotomy. Developmental psychology describes how secure attachment with caretakers, and an increasingly stable sense of self, contribute to tolerance of uncertainty. With normal development, and under most circumstances, we no longer cling desperately to sharp black-or-white categories. We make finer distinctions, and can also tolerate degrees of uncertainty.
Adult development takes this process further. Mastery of an academic or occupational field solidifies a stable professional identity, which contributes to comfort with uncertainty. Many years ago I learned a type of computer programming from my friend, an accomplished software engineer. I felt anxious when confronted with programming challenges: Would I fail to discover the solution? Waste long hours trying? Feel stupid in the end? In contrast, my friend felt no such anxiety. He explained that even when he was uncertain how to solve a problem, he knew he soon would, or at least would soon recognize it was impossible. He was able to wrap his arms around the whole field in a way I could not. Uncertainty for him no longer carried implications of permanence, nor of personal failure, i.e., narcissistic injury. It wasn’t threatening. In this frame of mind, a programming challenge is merely a puzzle, an engaging intellectual pursuit which can even be fun.
Although the stakes are higher, the same applies in medicine. An intern faced with clinical uncertainty shares my erstwhile self-doubt as a beginning computer programmer. Is my uncertainty humiliating? A sign of failure? Will I ever figure it out? With more experience comes confidence that uncertainty isn’t psychologically threatening. It’s an intellectually engaging puzzle, often with a gratifying emotional reward at the end. In specialties such as primary care and psychiatry, uncertainty becomes the norm. We get used to it, expect it; we realize it doesn’t tarnish us individually.
An additional factor that may sound esoteric but is crucial to thriving in uncertainty is the flow state. Variously described as being “in the zone” in sports, “centered” in Eastern meditative and martial arts practices, and “in the groove” in musical performance, this is a mental state of heightened awareness, engagement, and creativity accompanied by a relative lack of self-consciousness and conscious intent. Whether in extreme sports, music improvisation, video gaming, or academic brainstorming, moment-by-moment uncertainty is less disruptive and feels more welcome in the flow state. Although uncommon in typical medical practice, the flow state can arise during intimate discussion with a patient, during research activities, and when intensely absorbed in medical work-up or treatment planning — the very times when clinical uncertainty is actively addressed.
Peers are a good source of emotional support whatever one’s level of expertise. Seeing that a problem is inherently difficult is reassuring; its apparent difficulty does not reflect on oneself. Social interaction bolsters self-esteem, and often humor is shared to defuse fear and anxiety. Similar challenges shared by others promote camaraderie and a sense of being “all in the same boat.” And tales of challenges successfully overcome can instill optimism, and sometimes offer practical solutions for the problem at hand.
My own experience with psychiatric supervision is hierarchical, not peer-to-peer. Supervisors model a great deal non-verbally and often unintentionally: our attitudes toward patients and their issues, the focus of clinical attention, our approach to formulating cases, levels of formality and informality, and so on. The supervisor’s engagement with clinical uncertainty is one such factor, sometimes discussed explicitly, more often modeled non-verbally. Ideally, this role-modeling inspires and encourages supervisees to nurture clinical curiosity, and to avoid frantic efforts to resolve uncertainty with premature conclusions.
Having not read the Sommers/Launer book, I cannot comment on their rationale for “collaborative engagement with case-based uncertainty in the setting of small groups of clinicians.” Psychologically, such collaboration is apt to confer the benefits of peer support mentioned above. In addition, it is often more fun and energizing to work as a team, although teamwork can be frustrating at times too. As a practical matter, putting multiple brains to the task may resolve clinical uncertainties more quickly and/or accurately compared to a practitioner working alone. Alternative tactics for resolving clinical uncertainty include consulting with recognized experts and conducting literature searches.
In my experience, psychiatrists manage clinical uncertainty by accepting that uncertainty is inherent in the field. It is therefore not a source of shame or a sign of personal inadequacy. Released from these emotional burdens, we are free to be curious, to keep an open mind, and to enjoy uncertainty as a puzzle to be solved, an engaging intellectual challenge. Relatively unstructured dialog in psychotherapy may particularly induce flow states in both participants, with enhanced capacity to accept and work with uncertainty during the hour. And finally, while many office-based psychiatrists practice individually, social support from peers, supervisors, and treatment teams can enhance comfort with clinical uncertainty. I have every reason to believe the same holds true in primary care.
A few years ago I wrote that uncertainty is inevitable in psychiatry. We literally don’t know the pathogenesis of any psychiatric disorder. Historically, when the etiology of abnormal behavior became known, the disease was no longer considered psychiatric. Thus, neurosyphilis and myxedema went to internal medicine; seizures, multiple sclerosis, Parkinson’s, and many other formerly psychiatric conditions went to neurology; brain tumors and hemorrhages went to neurosurgery; and so forth. This leaves psychiatry with the remainder: all the behavioral conditions of unknown etiology. Looking to the future, my fervent hope that researchers will soon discover causes and definitive cures for schizophrenia, bipolar disorder, and other psychiatric disorders comes with the expectation that these conditions will then leave psychiatry for other specialties. We will always deal with what is left. At minimum we psychiatrists should accept this reality about our chosen field. After all, there appears to be no alternative. Some of us go beyond this to embrace uncertainty as intellectually attractive. We like that the field is unsettled, in flux, alive.
Yet many of us clutch at illusory certainty. Decades ago, psychoanalysis purportedly held the keys to unlock the mysteries of the mind. It later lost favor when many conditions, particularly the most severe, were unaffected by this lengthy, expensive treatment. Now the buzzword is that psychiatric disorders are “neurobiological.” This is said in a tone that implies we know more than we do, that we understand psychiatric etiology. It’s a bluff.
Patients are told they suffer a “chemical imbalance” in the brain, when none has ever been shown. Rapid advances in brain imaging and genetics have yielded an avalanche of findings that may well bring us closer to understanding the causes of mental disorders. But they haven’t done so yet — a sad fact obscured by popular and professional rhetoric. In particular, functional brain imaging (e.g., fMRI) fascinates brain scientists and the public alike. We can now see, in dramatic three-dimensional colorful computer graphics, how different regions of the living brain “light up,” that is, vary in metabolic activity. Population studies reveal systematic differences in patients with specific psychiatric disorders as compared to normals. Don’t such images prove that psychiatric disorders are neurobiological brain diseases?
Not quite. Readers of these exciting reports often overlook two crucial facts. First, these metabolic differences only appear in group studies and cannot be used to diagnose individual patients. As of this writing there is no lab test or brain scan to diagnose any psychiatric disorder. Attempting to do so would be like diagnosing malnutrition based on height. While malnourished people are shorter than the well-nourished on average, there is wide overlap and height is not diagnostic. Second, etiology — the cause of these differences in brain function — remains unknown. Differences in brain function (and structure) are not necessarily inborn. Brain anatomy can change as a result of life experience, and metabolic activity (function) from experimental manipulation of cognitive effort, induced mood, guided imagery, etc. Just as multiple factors affect a subject’s height, multiple biological and psychological factors affect brain findings as well. Thus, learning that patients with borderline personality show decreased metabolism in the frontal lobes (hypofrontality) is neither surprising nor indicative of a neurobiological etiology. We already know the frontal lobes inhibit impulsive activity, and we already know borderline personality is characterized by impulsivity. What else would we expect?
Genetic studies consistently show both heritable and environmental factors at play in psychiatric disorders. Since the 1960s, psychiatry has called this combination the diathesis-stress model: an inborn predisposition meets an environmental stress, leading to an overt disorder. The model helped shift the field from “nature versus nurture” to “nature and nurture” — and no research discovery or neurobiological rhetoric so far has shifted it back. Patients and their doctors still contend with diathesis and stress: recreational drug use tips one patient into psychosis, sudden abandonment tips another into borderline rage. Indeed, clinicians remain much more able to influence stress than diathesis. A dispassionate assessment of what we currently know should lead to humble agnosticism about psychiatric etiology. Genetics, biology, and environment all play a role, but beyond that there isn’t much we can say. This is why all current psychiatric medications treat symptoms and are not curative.
In this light, the popularity and zeal of neurobiological language is startling. The American Psychiatric Association (APA) subtly changed the wording in its new Diagnostic and Statistical Manual, DSM-5, to imply that all psychiatric conditions are biological in nature. The National Institute of Mental Health (NIMH) assumes that “Mental disorders are biological disorders….” The National Alliance on Mental Illness (NAMI) says, “A mental illness is a medical condition….”
A more ground-level version is expressed by editor-in-chief Henry A. Nasrallah, MD in the latest edition of Current Psychiatry. In an editorial not-so-subtly titled, “Borderline personality disorder is a heritable brain disease,” Dr. Nasrallah proclaims BPD a “neurobiological illness” and “a serious, disabling brain disorder, not simply an aberration of personality” — as though these were distinct alternatives rather than two terms for the same thing. After citing a number of biological findings which fail to prove etiology (e.g., the hypofrontality mentioned above) and which show partial heritability, Dr. Nasrallah concludes that “the neuropsychiatric basis of BPD must guide treatment.”
Of course, it already does. We already treat borderline personality disorder the best we know how, with psychotherapy (shown by functional imaging to modify brain metabolism, by the way) and often with adjunctive medication to treat symptoms. What more do breathless declarations of brain disease buy us, other than reduced credibility? It’s not as though any of us currently withhold neurobiological treatment as a result of outmoded ideology. On the contrary, the moment the FDA approves a cure for borderline personality disorder based on an established neurobiological etiology, I will gladly refer my patients to the neurologist, virologist, or genetic counselor who would thereafter treat such patients.
Traditional psychodynamic therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave. This isn’t completely unfounded: there are therapeutic advantages to losing track of time, “swimming in the material,” and letting one’s therapeutic focus be broad. The patient’s chief complaint, i.e., the ostensible reason for coming, often gives way to more troubling underlying conflicts and concerns that might never appear in more directed or time-limited work. Highly defended material may be uncovered and worked through in the fullness of time.
All the same, and as many critics have pointed out, this is a cozy arrangement. If the therapist is happy to have a paid hour, and the patient is gratified to pay for the undivided attention of a caring doctor, nothing need change. Ever. Many patients fear becoming emotionally dependent on their therapists, i.e., finding it too comfortable to stop. And some therapists, being human, are not above maintaining a pleasant status quo.
Psychoanalysts and analytic psychotherapists anticipate this concern, and hold that a patient’s dependency, like everything else, can be explored, understood, and overcome. However, in highly non-directive therapy, i.e., with a mostly silent therapist, this can take a long time and be painful for the patient in the meantime.
My approach to dynamic work is more interactive. While I believe transference and countertransference are highly useful tools, and that both manifest and latent content are important, I also strive to help paients in the here and now, whenever doing so doesn’t interfere with long-term gains.
In this light, I often tell patients that I aim to make myself obsolete in their lives. Saying this can quell dependency fears, but it’s open-ended enough that I’m not promising how long (or briefly) we’ll work together, nor that I guarantee they won’t feel dependent along the way. I can’t promise these, because I don’t know. But I can give my word that I won’t allow myself to get so comfortable with our arrangement that I forget why we’re meeting at all. It’s a comforting statement that has the advantage of being true. It feels good to have a patient not need me anymore, a little like the bittersweet feeling when a child goes off to college. And in a way, hearing myself say so out loud helps me remember it.
The trade-off, a psychoanalyst might point out, is that I short-circuit any fantasies patients might harbor that I seek to trap them, that I want them to feel dependent. Patients might gain more insight about themselves if I let such fantasies germinate, and then collaboratively explore them. It’s an important point to keep in mind, but on balance I usually feel this modest bit of support helps the therapeutic alliance much more than it forestalls exploration.
A successful psychotherapy is when a patient leaves with the satisfaction that she “got what she came for,” and no longer needs, or even wants, to see a therapist. And a successful psychotherapy practice is one where patients come (in need) and go (improved), the therapist becoming obsolete one patient at a time.
KevinMD.com published a post a couple of days ago from medical student Joyce Ho in which she admitted to discomfort raising the topic of religion with patients. As a “polarizing” issue that could make the doctor-patient relationship “more unprofessional,” Ms. Ho imagined that patients would fear playing into their doctors’ prejudices, particularly if the doctor were atheist, and that this fear would push some patients away from the inquiring doctor. Despite her instructor’s recommendation to ask gentle, open-ended questions about faith and spirituality in the context of a patient’s support systems, “personally, I still will not actively ask about religious preferences if the patient does not bring the issue up.”
As a new reader of KevinMD, I was first to comment — a mistake, in retrospect. I imagined her concerns were merely new-doctor jitters, a phenomenon as old as medicine itself. I pointed out that students at first find religion, sex, and many other topics difficult to broach with patients. Yet uncomfortable topics such as these are often important, and may go unmentioned unless the doctor asks. Trying to be supportive, I noted that patients usually worry less about a doctor’s own religious beliefs, or lack thereof, than they do about their doctor’s care and concern. Frankly, I didn’t imagine my comment was controversial in the least.
To my dismay, comment after comment followed that a patient’s religion is none of his or her doctor’s business. To some extent this was conflated with complaints of unbidden chaplains appearing at hospital bedsides, and awkward offers by medical staff to pray with a patient who wanted no such thing. But even leaving aside those obvious blunders, there was rampant mistrust of doctors even inquiring about religion, spirituality, or faith.
Apparently, Joyce Ho was right. Commenters on the blog assumed we doctors jump to false conclusions — “assume certain things about certain religions” — and are apt to over-interpret based on limited information; that we are “busybodies” to ask about such matters; that the information is irrelevant at best; that “doctors might judge you”; and that we cannot help but oversimplify the beliefs of any patient who has given religion or spirituality serious thought. A self-identified atheist living in the Bible Belt was grateful no doctor had ever asked: “We in the South have enough problems … without also having doctors who think they should be discussing religion with their patients….” The comment with the most “agrees” was this anonymous one-liner:
I wouldn’t want my doctor asking about my religion. That’s not necessary. I’m glad mine don’t do that.
How has it come to this? Haven’t patient advocates and caring doctors fought for years — decades — to retain humanism in a medical system that inexorably drifts toward the impersonal and mechanical? What happened to the hope, if not expectation, that one’s doctor sees the person behind the symptoms, the whole patient? And what on earth happened to the premise that one’s doctor can be trusted with sensitive personal information? Religion, after all, is hardly the riskiest thing one might tell a physician in confidence.
A close look at the commentary reveals the sad truth. The healing doctor-patient relationship is no more. The Bible Belt atheist sees religion as a source of doctor-patient antagonism. For the rest, the patient’s relationship is not to a doctor, but to a “system of care.” This system aims to fill blanks in an electronic record; one commenter advised doctors to ask, “Would you like me to list a religious affiliation?” in order that this particular blank can be left unfilled if the patient desires.
Of course, antagonism and “listing” a religion in a database are not why medical students learn to take a patient’s social history, including hobbies, interests, and social supports secular and otherwise. It’s to know their patients as people, to build rapport, to honor beliefs and relationships their patients hold dear, to appreciate their patients’ strengths as well as weaknesses. It’s to offer personalized counsel, so that (to take the most basic example) the non-religious are not advised to seek solace in church, nor the faithful to neglect it. Occasionally it’s to develop a differential diagnosis for a medical condition unexpectedly related to a patient’s social interests or behavior. And often it’s to learn a patient’s values and preferences regarding end of life care, so that when that patient is unable to express them, his or her trusted doctor already knows.
All of this applies to a doctor, a well-meaning, trustworthy (if fallible) human fiduciary who listens in confidence. In stark contrast, systems of care suffer diffusion of responsibility. They spread personal information in unpredictable ways, outside the patient’s control and awareness. Thus, one commenter wrote, “I don’t want that kind of information in my medical record,” while another elaborated, “Blue Cross and the xray technician and everyone else who comes in contact with the chart have no need to know what religion the patient is unless the patient chose to share it with everybody.”
Health reform provides long-overdue expansion of health coverage. On the supply side, it promotes systems of care to enhance efficiency and decrease costs. It’s important to realize what we may already be losing in the bargain: the traditional personal relationship with a physician entrusted to handle intimate details of one’s life with discretion and wisdom. If it is no longer safe to divulge one’s religion, what about one’s sexual habits, recreational drug use, risky hobbies, and myriad other touchy subjects? Widespread self-censoring of this information, to prevent it from entering large medical databases, may turn out to be more hazardous to public health than all the inefficiencies of the old approach.
A patient I see for psychotherapy, without medications except for an occasional lorazepam (tranquilizer of the benzodiazepine class), told me his prior psychiatrist declared him grossly undermedicated in one of their early sessions, and had quickly prescribed two or three daily drugs for depression and anxiety. He shared this story with a smile, as we’ve never discussed adding medication to his productive weekly sessions that focus on anxiety and interpersonal conflicts. Indeed, the lorazepam is left over from his prior doctor. I doubt I would have ordered it myself, although I don’t particularly object that he still uses it now and then.
Of course, there’s a completely innocuous way to explain this difference between his prior psychiatrist and me. My patient could have looked much worse back then, in dire need of pharmaceutical relief. However, he didn’t relate it to me that way, and I have no reason to doubt him. There’s also the possibility that I’m missing serious pathology in my patient — that I too would urge him to take medication if only I recognized what I’m now overlooking. But… I don’t think so. I’m left to conclude that his prior psychiatrist and I evaluated essentially the same presentation rather differently.
In particular, I’m struck by the term “undermedicated” (more often spelled without the hyphen, according to my Google search). This judgment most often comes up in speaking about populations, as in the debate over whether antidepressants are over-prescribed or under-prescribed in society at large, or whether children are diagnosed with ADHD and prescribed stimulants too often, or not often enough. Under- and overmedication are also commonly mentioned when describing medication management of pain, a thyroid condition, mania, or chronic psychosis in an individual. Here the terms express disagreement with a particular dosage, where the benefits of treatment and adverse side-effects or risks are deemed out of balance one way or the other.
“Undermedicated” also implies that adding medication is the preferred or only sensible treatment approach. While this may always be true in hypothyroidism, it clearly isn’t with regard to physical or emotional pain. The term rhetorically denies non-medication alternatives. I would also add that, to my ear, “overmedicated” and especially “undermedicated” sound dehumanizing, as though referring to a machine that is out of adjustment, or a chemical solution being titrated on a lab bench. Since the natural state of human beings is not to be medicated at all, it sounds a bit odd to hear someone — as opposed to one’s disease — assessed this way. Perhaps I am especially sensitized to this after reading a controversial article by Moncrieff and Cohen that highlights the “altered state” induced by psychotropics and their lack of known, specific mechanisms of action. There is often a supposition that medication dosage correlates with symptom relief. This is not always true of subjective states, underscoring that the complexity of human experience often belies simple “over/under” judgments.
My patient’s mood and anxiety vary with his interpersonal situation. It wouldn’t occur to me to turn his “thermostat” up or down in general, even if drugs reliably could do this. Yet I know colleagues who’d argue that one, two, or even three daily medications could help him overcome his everyday challenges of dealing with people. These approaches point to different fundamental viewpoints in psychiatry. Does the patient have a disease, an as-yet-undiscovered chemical (or electrical, viral, inflammatory, etc) imbalance in the brain that is best remedied by a medical intervention, accurately dosed neither “over” nor “under”? In acute mania or florid psychosis, as in hypothyroidism, it seems to me the answer may be yes, although this is unproven and time will tell. Perhaps, too, in severe melancholic depression. But in social anxiety? Self-consciousness? Feeling discouraged about one’s career? The field’s perspective on these has shifted in recent decades, such that now a hidden biological cause is assumed by default, or at least held out as a rationale for treatment. It is only by making this dubious assumption that one can speak of undermedicating such complaints, or the people who have them.
Over on the Shrink Rap blog I got caught up in an off-topic debate. The post was on why psychiatrists avoid insurance panels, something I’ve written about myself. But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on. After a week, prompted by minor irritation with San Francisco’s transit system the night before, I finally posted a comment. I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money. I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown. Nonetheless, the comparison made the point that more affordable mental health services are inevitably “bus-like,” and that there is a legitimate role for higher-cost “taxi-like” services for those willing and able to pay for them.
It’s important to realize that all analogies are flawed. They only highlight certain similarities between two situations. There will always be differences too, the salience of which are inevitably disputed by partisan debaters. For this reason analogies illustrate far better than they convince. One commenter noted that even “bus-like” mental health services are not always available. A psychiatrist pointed out that many of us accept reduced fees or otherwise “come to some agreement” with cash-strapped patients in ways taxi drivers don’t. Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy “shallow at best.”
Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the “5150” here in California), is uncommon in office psychiatry, and in any case didn’t bear on the point I made. I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office. My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients. This fear keeps some who “truly need psychiatric intervention … from even attempting to access ‘help’.”
I had already let it drop when our host asked everyone to return to the topic of insurance panels. But it’s a point that bears discussion, here if not there. Do patients avoid office psychiatrists for fear of being placed on a legal hold?
I’m sure the answer is yes, at least sometimes. In the first place, many patients do not know what triggers a 5150. Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words. Often I’ve reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment. Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up. Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.
But there’s much more to this than simply not knowing the law. In my experience a great many patients fail to distinguish feelings and actions. They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing. Yet the distinction is hugely important in life, and with regard to legal holds. Feelings never justify a hold, whereas behavior, or its “probable” likelihood, does. If this distinction is unclear, even feelings seem dangerous.
At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished. Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world. Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well. A crucial part of dynamic psychotherapy is gradually trusting that the therapist won’t fulfill this fantasy. Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist’s power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.
I hasten to add that we psychiatrists don’t make this any easier for ourselves or our patients when we are sloppy about applying legal holds. Patients’ fears of subjectivity and loose criteria are partly based in reality. A casual “better safe than sorry” attitude may send the wrong message, trampling the treatment alliance and savaging trust. Meticulous care in applying the 5150 is a “frame issue” as central to therapeutic success as any other treatment boundary. As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).
Of course, there are circumstances when we rightly apply a legal hold in the office. A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting. Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police. Such people, however, are not seeking psychiatric assistance to avoid dying or killing. If they were, they would accept help, including inpatient treatment if needed.
I once had a patient who came to see me, he said, so I could convince him not to die. If I failed, he would kill himself. I quickly replied that I wouldn’t play this game, although I was more than willing to talk with him about his suicidal feelings. We met five or six times; he wasn’t truly interested in overcoming suicidal feelings, and I wouldn’t engage in the no-win challenge he set up. He left — no hold applied — and months later I learned he was still very much alive.
Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a “death by cop” scenario. The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret. Fantasies of punitive authority, forcing the hand of those in power, and/or getting one’s just desserts, are made real. Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy. Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.