Psychiatric disability

disability

Since psychiatric disability is often invisible and unquantifiable, considering oneself psychiatrically disabled can take on many meanings.  Certainly there are those who assess their limitations, whether imposed by thought disorder, anxiety, or mood extremes, and accurately gauge themselves disabled.  It is a strength to accept reality for what it is, to live one's life accordingly, and to claim the assistance society offers.  However, self-labeled psychiatric disability is not always accurate.  Clinically depressed patients sometimes underestimate their abilities and call themselves disabled the same way they call themselves failures, or bad or stupid — as self-denigration.  Others who yearn for nurturing or attention use disability as way to obtain these from caregivers.  And there are those who feel entitled to special privileges and treatment, and make undue claims on others using disability as a tool.

When I see a clinically depressed patient who is temporarily unable to work, I fill out disability paperwork, usually the California SDI form.  Such forms always ask me to estimate when the patient will be able to resume working.  With proper treatment, most depressive episodes significantly improve in less than three months, so that is what I usually estimate.  I consider this a little on the generous side, as I want my patient to have the disability benefit he or she deserves.  However, unlike recovery from pneumonia or a broken leg, recovery from depression varies widely.  Some patients are back to baseline in less than a month, others take much longer than three.  I have long been fascinated by the dynamics of predicting recovery.  Depression, almost by definition, leads to pessimism.  For this reason, my three-month estimate often strikes the depressed patient as too soon — too soon to hope to be well, perhaps too soon for me to expect much improvement of them.  Yet part of helping someone overcome depression is to lend optimism and hope.  I'd rather err on the side of quick recovery than to pessimistically assume long-term disability.  Indeed, when I've sometimes overestimated the recovery time, and the patient feels well in three weeks instead of three months, I feel I've made the more serious error.

A small subset of patients I see are, for want of a better term, "professional patients."  It is their identity to be ill and disabled.  It is their defining characteristic, the first way they introduce themselves.  Saying it this way risks "blaming the victim," as these people did not choose to be sick.  They are not malingering (intentionally faking illness).  However, even unwanted illness can assume a purpose for itself.  Disability becomes a calling card to see a variety of doctors, to call the crisis line and talk, to try a shopping bag full of medications.  It becomes a ready answer to that very difficult question: Who am I?  Some patients remain psychiatrically disabled because it is a way to be in the world, the only way they find comfortable or familiar.  It can be challenging to explore the meaning of such disability in therapy.  Patients sometimes complain that I don't "believe" them, that I should take their disability on face value.  I prefer to help them find more options in life, as sometimes disability itself is a state of mind.

From the psychiatric perspective, there is a fine line between assertiveness and undue personal entitlement.  On the one hand, it is healthy and strong to assert one's needs, to make a place for oneself in the world.  On the other, diagnostic terms like "narcissism" apply to people who feel, without reason, they are so special they need not obey the same rules as everyone else.  As described in my last post, some claims to keep pets in "no pets" housing, or to bring them to work or shopping for "emotional support," seem to cross over this line.  Since narcissism is ego-syntonic (not seen as a problem by the patient himself), it is frequently difficult to address in psychotherapy, or to interest the patient in therapy at all.

I have given three examples of dynamics that may prolong self-rated psychiatric disability: depressive pessimism, dependency and identity needs, and narcissism.  I could equally and conversely write about denial and counter-dependency as factors that might prevent a truly disabled person from acknowledging it.  However, the legal entitlements granted on the basis of disability make the former a more interesting social conundrum.  On the one hand, our sense of charity calls for helping the distressed and disadvantaged.  On the other, we recoil at self-declared victimization as a means to special treatment.  When disability is subjective and difficult to quantify, as it is in many psychiatric conditions, society does not know whether to embrace or reject it.  A culture of innate entitlement only makes this approach-avoidance conflict more acute.

The customer is not always right

I often remind psychiatry residents that while a patient's treatment preference is important, it does not take the place of their own evaluation.  It is a bittersweet irony that many of us are mistaken about, or repelled by, what would most help us.

Some patients, with depression for example, only consider medications, and have tried many to no avail.  Even after a dozen adequate but unsuccessful medication trials by past psychiatrists, some call me in desperation to ask whether the 13th, usually with the newest heavily promoted product, could be the miracle they seek.  I generally tell them -- right on the phone -- that it is unlikely.  I also assure them that if they come in for an evaluation anyway, I will respect both their preference and past experience.  What I don't tell them:  People who avoid psychotherapy because they fear having to face uncomfortable memories or feelings often end up getting the most benefit out of it.  By the end of our first in-person meeting, I hope to engage such a patient's curiosity about his or her emotional life as more than simply a collection of symptoms.

Conversely, some patients pursue psychotherapy for years, and would never dream of taking psychiatric medication ("mind-altering chemicals").  This makes excellent sense when the problem is based on personality factors and relationship issues.  But sometimes it's not.  Even the best psychotherapy won't quell the hallucinated voices of schizophrenia, nor the behavioral excesses of mania.  Some patients are too depressed or anxious to use psychotherapy.  (And sometimes the problem is medical, not psychiatric at all.)  At these times it becomes my duty to advise medication, to explain why I do, and to explore with the patient their concerns and hesitation.

Some research says the best treatment for depression is a combination of medication and psychotherapy.  This often seems to be the case for problems other than depression, too.  As a psychiatrist I can provide one or the other or both.  And on rare occasions, neither:  A few patients have come to me who do not have a treatable problem at all.

The challenge for psychiatrists and other mental health professionals is that patients choose their own providers; they select us knowing their own preferences, and ours.  Persons who seek medication and not psychotherapy will likely see a psychopharmacologist who will share their viewpoint and only discuss medication.  Even more often, persons who seek psychotherapy and not medications (or a medical perspective) will see therapists who are not physicians.  Despite the advantages -- there are many more non-psychiatrists to choose from, and the fees are usually lower -- patient self-selection carries the risk of confirming their own prejudices.  It may sound harsh, but the "customer" is not always right.  It is incumbent upon us professionals to look past patient preference to what is most apt to be helpful -- even if we do not provide it ourselves.

Online anonymity and transference

I've been online quite a few years now.  Actually, I first used the internet in college in the late 1970s.  There were only a handful of non-governmental university sites back then, and I happened to be an undergraduate at one of them.  A decade later, in the late 1980s, I was a member of the first online community, called The Well.  In the years that followed, I was active in online forums about psychiatry and other topics.

By the early 1990s, after my psychiatry residency and research fellowship, I had begun to think about the psychological dynamics of online communication.  Now that it's almost 2009, many dissertations and books have been written on the subject, online communities are commonplace (e.g., see here, here, and here), and most everyone is at least somewhat familiar with online communication.  But nearly 20 years ago it still felt new and ill-defined, and an idea dawned on me that seemed to explain a lot about what I saw happening online.

In the 1980s, the main place for freewheeling discussion online was Usenet, a huge collection of topic-based forums (newsgroups) covering every imaginable subject.  From highly technical discussions of computer technology to frivolous chatter about celebrities, this text-only, worldwide, generally anonymous medium served as a massive reservoir of information and "computer culture."  In addition, local "bulletin board systems" (BBSs) provided similar forums on a much smaller scale, and individual email discussion lists arose where subscribers could read and post commentary outside of Usenet.  In all of these, emoticons (e.g., smiley faces), in-group jokes, and acronyms (like LOL for "laugh out loud") were popularized, and have left their mark ever since.

What most caught my attention, though, were the extremes of emotion expressed.  I was struck by the incredible hostility many users directed toward others.  Snide putdowns, withering sarcasm, and utter contempt were fair game and surprisingly common.  This was collectively called "flaming," as in blasting someone with flames.  Flaming was social behavior that would never be tolerated FTF, IRL (face-to-face, in real life).

My first thought about flaming was that it existed because flamers could get away with it.  They were untraceable due to anonymity and unreachable due to lack of physical proximity.  There were typically no consequences for flaming other than flames directed back in response.  But this failed to account for the hostility in the first place.  Are young men (the demographic of most internet users back then) naturally inclined to such levels of raw aggression anytime they can get away with it?  Not entirely implausible, but a sad conclusion if true.

Then I noticed the opposite as well.  Organized online dating would not catch on until the advent of the World Wide Web and commercial websites in the 1990s, but cyber-romance was already well-known in 1980s computer culture.  People who scarcely knew each other -- and only through text, no pictures -- would flirt eagerly online.  There was an idealization of the unseen other, a belief or hope that he/she was everything one dreamed of.  Of course, stories were rampant of disappointing (or horrifying) results when a meeting finally took place FTF.  But these romances struck me as the other side of the flaming coin.   Hmm, idealization and devaluation -- where had I heard of those before?

Transference was a concept invented by Sigmund Freud to apply to the psychoanalytic situation.  The analysand (patient in analysis) experiences feelings toward the analyst that are "transferred" from parents or other important figures in the analysand's life.  These feelings are often erotic if positive, harshly rageful if negative, and often a mixture of both.  Successfully analyzing the transference is a main task of psychoanalysis, and thought to be central to its curative effects.  For this reason, transference is promoted in psychoanalysis.  By sitting outside the analysand's field of view, refraining from personal disclosure, and maintaining "therapeutic neutrality," the analyst provides space for the patient to ascribe facts and feelings to the analyst and to react to them.  These facts and feelings are created in the patient's imagination, and are not realities about the analyst.  However, the patient's emotional reactions are real, and shed light on long buried feelings and emotional assumptions about others.

I realized that online anonymity, and online communication more generally, unwittingly encouraged transference.  During the 1980s era of text-only discussions on the internet, users literally sat outside each others' field of view and provided little personal disclosure.  (This formed the basis of a now famous 1993 cartoon in The New Yorker.)  Facts and feelings were ascribed to the unseen others online.  These presumed facts and feelings in turn prompted primitive erotic and aggressive feelings, and these in turn led to cyber-romance or flaming.  The main difference from psychoanalysis was the lack of a professional to interpret and contain the transference.  Thus, there was nothing healing or curative about it; it was bad-tasting medicine with no benefit.

Transference helps to explain important aspects of online dynamics in the 1980s.  But much has changed since then.  The graphical user interface of the World Wide Web began to erode user anonymity by the mid-1990s, as home pages with photographs and personal information were uploaded by the millions.  This trend has accelerated with Web 2.0 and current social networking sites like MySpace, Facebook, Twitter, and many others.  Anonymity now seems to be the last thing on the minds of internet users.  Personal details and the minutia of everyday life are routinely shared online.  Job-seekers google potential employers and vice versa.  Potential romantic partners google one another.  In theory this discourages transference; my own unscientific impression is that flaming has become passe, cyber-romance more cynical than idealistic.  I now wonder if we need not fear unwitting transference so much as its opposite: an undue familiarity that makes romantic love and admiration of heros less possible.

Placebos (2)

In my last post, I wrote about the use of placebos in clinical practice -- or more accurately, about giving medical treatments based on psychological comfort, not physiological effect.  However, the area where placebos are most used and accepted is human research, not clinical practice.  Psychiatric research in particular introduces some interesting conceptual issues regarding the use of placebos. To decide whether any new medication actually helps patients, the "randomized, double-blind, placebo controlled study" is the gold standard.  In this type of experiment, research subjects who all have the same disease (or are all equally healthy) are randomly assigned to take either the new medication or a placebo: an identical twin of the medication lacking any of its active ingredients.  The subjects do not know whether they are in the medication arm or the placebo arm of the study -- they are "blind" to this fact.  Their doctor, or whomever rates their outcomes in the experiment, does not know either; this makes the experiment "double-blind."  If the only difference between the two arms of the study is the presence of the active ingredients, then any outcome differences, on average, between the groups can be attributed to those ingredients.

The reason such experiments are double-blind, and the reason for the placebo in the first place, is to separate the medication's physiological effects from any rating bias or placebo effects.  Outcome ratings can be distorted by raters' expectations; people often see what they want to see.  Placebo effects are psychological factors in the subjects that improve rated outcome.  These include wanting to please the experimenter by getting better, hope that the medication will work, improvement due to feeling attended to and cared for, etc.  A "controlled" experiment carefully dissects away rating biases and placebo effects, so that only physiological effects count.

There is great value in knowing that an antibiotic and a sugar pill lead to different medical outcomes.  Patients can feel attended to and cared for -- they can feel "better" -- and still die of infection.  Disease has a life of its own, apart from subjective experience.  Western medicine prides itself on its scientific foundation, and rightly so.  We don't want merely to feel better, we want to be better.

However, the situation is less clear with many psychiatric disorders.  Depression and anxiety, for example, do not appear to have lives of their own, apart from the patient's subjective experience.  If the patient feels better, he or she is better.  Thus, the rationale for placebo controlled studies in this area bears further reflection.  Why does it matter if mood or anxiety improvement from a medication is physiological, or "merely" a placebo effect?

One answer is that we hope to further our scientific/medical understanding of such disorders, and placebo controlled studies help us do that.  Another is that drug makers and the FDA justify the value of pharmaceuticals by virtue of their active ingredients, not the psychological features surrounding their use.  Yet another is that placebo effects are idiosyncratic and vary across the population, and we strive for more predictability.  Nevertheless, as discussed in my previous post, for a given patient it ultimately doesn't matter why a treatment works, as long as it really does.  (For a more technical discussion, see this British Journal of Psychiatry editorial.)

Another fascinating conceptual problem is whether and how to include placebo controls in psychotherapy research.  Psychotherapy, like depression and anxiety medication, treats distress that is inseparable from subjective experience.  Thus the importance of differentiating "active ingredient" and "placebo" effects is unclear at best.  In addition, the treatment itself consists of the very psychological influences a placebo controlled study aims to remove.

By analogy with medication studies, psychotherapy researchers have tried to isolate the "active ingredients" in therapy, and to fashion studies with a treatment arm and a placebo arm differing only by the presence of those ingredients.  So far, no active ingredient has been identified as essential (although the overall efficacy of psychotherapy is not seriously in question, see here and here).  What if there are none -- what if psychotherapy is all "placebo effect?"

This sounds like psychotherapy is quackery, much like the headline "Half of Doctors Routinely Prescribe Placebos" sounds like quackery exposed (see my previous post).  But if psychotherapy is compared not to medication but to other human relationships, the "active ingredient" idea seems out of place.  The helpfulness and support of a parent, teacher, spouse, sports coach, or minister cannot be reduced to any specific ingredient.  Growth or self-improvement gained from such relationships comes organically and emergently, not as a result of a discrete intervention.  This does not make the value of such relationships, or the benefits gained, any less real.

Placebos are essential for careful medical research, yet carry overtones of fakery and worthlessness.  When the placebo concept is applied in an overly broad fashion, its negative connotation can tarnish highly beneficial human interactions that are neither fake nor worthless.

Colleagues as patients, and vice versa

Yesterday I was called by a psychotherapist who had referred a few of her clients to me in the past (she provided the therapy while I prescribed medication for the same people).  This call was not about a typical referral, though.  The therapist sought a medication evaluation for herself. Most of the medical field accepts without question that colleagues can treat one another.  A dermatologist looks at an internist's rash, the internist treats the dermatologist's high blood pressure.  It doesn't matter that they share some of the same patients.  The perception is that the dual roles of patient and professional colleague do not conflict.

Psychiatry has been different, particularly during the era when traditional ("psychodynamic") psychotherapy was the field's main tool.  In such therapy, the relationship is not incidental to the treatment provided.  It is the treatment provided.  The relationship-in-the-room takes the place of blood tests and brain scans in collecting data, and the place of medications and surgery in helping a person change.  Mixing this essential relationship with other types of roles — colleague, family member, golf buddy, or worst of all, lover — simply ruins it.  It also opens the door to unethical exploitation, as the therapist may unduly influence the patient in this other role.  Professional codes of ethics for psychiatrists and other therapists condemn dual-role relationships for this reason.

But what about medication management?  Most psychiatrists do little, if any, psychotherapy anymore, leaving that to psychologists, social workers, marital and family therapists (MFTs), and others.  When psychiatric treatment is medication and not the relationship itself, then the usual situation in medicine seems to apply.  Couldn't my colleague, the psychotherapist who called, see me for a medication evaluation just as she could a dermatologist or internist with whom she shared patients?

Although she only sought medication services from me, I can't help but think like a therapist.  I imagined the awkwardness of later speaking with her about a shared case if she divulged strong feelings related to her job.  I imagined I might expect less of her as a colleague if I knew her inner pain, yet this could shortchange the patients we shared.  I was concerned I might treat her differently as a patient, since I already knew her as a colleague.

I politely declined, and suggested ways for her to find a psychiatrist she doesn't work with professionally.

The reverse situation of "patient first, colleague second" has also come up.  A few patients of mine are themselves therapists, and occasionally ask to collaborate on a case.  I invariably decline, citing the dual-role concerns above.  It feels less clear when ex-patients later become therapists, and then refer their own clients to me.  Any word-of-mouth referral is a compliment, and the truth is, I have accepted such referrals.  But I still wonder about the potential clash of roles.