As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician.  I’ve also written in prior posts about my concerns with modern psychiatry.  I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor.  At the very least, such an understanding takes time.  It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias.  Finally, it takes a certain amount of intelligence.  Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.

I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly.  I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.

On the other hand, if one has the time to sit and share small talk, then review the important issues occuring in a person’s life, and then discuss the problematic symptoms that the patient is experiencing…. then ask questions that provide context for the symptoms, and perhaps make a small suggestion or two in order to provide outside insight into the cause of the symptoms…then present the different medications sometimes used for the person’s symptoms, after first discussing whether the person would prefer medication over working on the problem through more ‘mindful’ approaches… then discuss the different side effects possible with each medication, and the likelihood that the medication chosen would be helpful…

If one does all of these things, psychiatry can actualy lead to profound improvement in a person’s symptoms.

I thought about this situation recently, after paying over $500– my deductible– to repair my car, after hitting a deer.  The cost had to be paid, and I found the money and paid it.  I’m not a ‘rich doctor’ for reasons that I’ve discussed elsewhere, so the expense was significant– but I need a car, and it had to be paid.  Likewise, I had to come up with $3000 to repair my septic tank this spring, since the alternative– having disgusting liquid bubble out of my lawn– was not an option.  I had to pay my speeding ticket– I’m trying to slow down now, by the way– and I had to pay for my own health problems.

If I need surgery, the cost will likely run in the tens of thousands of dollars.  Heck, having a couple warts removed ten years ago cost $400, and the doc was in the room for about 5 minutes.  My auto repair bill, paid graciously by my insurer, amounted to $11,000.

Then there is the cost of psychiatric care.  For reasons I alluded to in the first paragraph, I have rejected the insurer’s model of psychiatric care– the 4-6 patient-per-hour, 10-minute med check.  I spend 90 minutes on the first appointment– often more.  And follow–up appointments last at minimum 30 minutes, and for more complicated cases, 60 minutes.  Because I see only a third as many patients, I do not accept the dramatic discounted fee offered by insurers, and patients are required to pay something.

For patients with a deductible, their cost is essentially the same as for an in-network doctor.  For others, insurers pay some portion of my fee, and for some, insurers pay nothing, leaving the burden of the full cost of an appointment– $199– on the patient.  For that $199, the patient receives 30 minutes of my attention, based on an education that cost me over $100,000 (not counting college), and 16 years of my life to complete– not counting grad school.

I see people who are truly suffering;  people with significant anxiety, depression, addictions, phobias– problems that cause much greater disability than would a torn ACL.  So here (finally) is my question.  Why is it that people will roll their eyes and pay their $2000 deductible for the torn ACL, as their insurer pays $20,000 more, yet refuse to spend anything to treat their depression?   Given the effect of social anxiety on a career, why will people pay $3000 for a septic tank, yet consider $400 unreasonable if spent to improve their ability to interact with others?

We all know the importance and value of a close relationship with a friend or spouse;  we all fear being alone at the end of our lives.  So why do we consider a $1000 plasma TV a ‘steal’, yet consider the same amount, if spent to solidify a marriage, a huge expense?

There is so much good that psychiatry can do.  But I am not impressed by the value of fast diagnoses, and rapid-fire medications.  On the other hand, a limited series of visits, to treat targeted symptoms, is one of the most cost-effective areas in medicine.  I often think to myself, ‘I can FIX this person’s problem– but not in 30 minutes!’  I’ll be frustrated that a person does not consider treating their psychiatric symptoms as valuable as purchasing a new car, or a larger house.  Gosh– my entire cost of treatment– enough for plenty of visits– can be covered by ONE monthly mortgage payment.  And while the mortgage bills keep coming, the benefits of treating one’s symptoms can become a gift that keeps giving, month after month and year after year.

Please help me out by answering the poll below– I’ll try to discuss the results on my radio show in a few weeks.  Thank you for helping me understand an issue that’s had me a bit frustrated!

Today on my radio show I mentioned my frustration with being ‘in my 50′s’, and the injury to my knee that happened while stowing stuff in the garage last night. She sent me the video below– and I got a kick out of it!

I have been kicking these observations around for the past year, and have been unable to find a big fish willing to ‘bite’.  I truly believe that the observations below have the potential to dramatically change the approach to opioid treatment of chronic pain.  Since I have a blog, I have a soapbox– so I’ll share the idea, and welcome comments in return.  I do ask that proper attribution be provided if this article is shared.

Introduction:

Long-term opioid analgesia without tolerance, respiratory depression, or euphoria?  Introducing the Holy Grail for chronic pain treatment!

Premise:

The miracle of opioid pain relief is fatally limited by tolerance, addiction and respiratory depression. Buprenorphine, when combined with a mu agonist, results in game-changing effects. Patients experience potent, dose-related analgesia from the agonist, but have NO euphoria. The therapeutic window is widened. Patients unable to control their use of a mu agonist alone gain that control when on buprenorphine. And most exciting, buprenorphine indefinitely anchors tolerance, maintaining analgesia WITHOUT DOSE ESCALATION. This finding offers huge implications for pain management.

Discussion:

Use of opioids for chronic pain has severe limitations. Tolerance removes the benefits of opioid analgesics over time. Worse, tolerance is associated with dependence and withdrawal. Many patients use additional doses of their prescription early in the month, then suffer through withdrawal while awaiting refills. Others find opioids through less-reliable, non-clinical sources.

At the same time, addiction to mu opioids is a nationwide epidemic. Reformulation Oxycontin has pushed many opioid users toward diacetylmorphine—brand name Heroin. Some physicians recommend avoiding mu opioids altogether for chronic pain (e.g. Physicians for Responsible Opioid Prescribing), while pain treatment advocates argue to ease narcotic restrictions.

Over the past six years I have treated over 500 patients using buprenorphine, mostly for opioid dependence. Buprenorphine, a partial mu agonist, is the active ingredient in Suboxone, a medication used for treating opioid dependence. The majority of my patients began their addictions with narcotics prescribed by doctors for back pain, knee pain, shoulder pain, fibromyalgia, chronic headaches, and other conditions.

Many of my patients found their pain reduced or gone after stopping mu agonists and substituting buprenorphine. Buprenorphine has the mu activity of 40 mg of daily methadone, but this activity is unlikely responsible for significant analgesia, since patients rapidly become tolerant to the agonist actions of buprenorphine. Instead, their pain while on mu agonists was likely maintained by psychological forces.

Patients on buprenorphine occasionally need opioid analgesia, just like other patients. My patients have had knees replaced, gallbladders removed, hysterectomies and c-sections, rotator cuff repairs, and in two cases, cardiac surgery. In all cases, sufficient analgesia was provided by maintaining daily buprenorphine at 4-8 mg per day, and using potent mu agonists, usually oxycodone, in doses ranging from 15-45 mg every 4-6 hours as needed.

Several patients have severe chronic pain from avulsion of the brachial plexus, failed spinal fusion, or other conditions, where prior opioid use resulted in rapid tolerance that prevented effective analgesia. These patients are now successfully maintained on combinations of buprenorphine plus mu agonists.

The combination of buprenorphine plus mu agonists has provided perioperative analgesia for patients on buprenorphine. Patients universally describe adequate pain relief, even after major surgeries. They also described the absence of euphoria, and to their surprise, the ability to control their use of pain medication—something impossible before taking buprenorphine.

But it is the effects on chronic pain that suggest a ‘game-changer’ for pain treatment. Even after over a year on combination buprenorphine/oxycodone, my patients 1. have no euphoria; 2. are often able to manage their own narcotic medication; and most important, 3. describe stable analgesia WITHOUT agonist dose escalation.

The ability to treat pain long-term without tolerance or dose-escalation is as exciting a development as was the initial discovery of opioids for pain relief!

Properties of a combination agent

Buprenorphine is administered sublingually, and could be prescribed as a separate medication, and use verified through urine monitoring. But greater safety benefits would come through regulations requiring buprenorphine (or a similar partial agonist) to be an inseparable part of every opioid prescription. Such a policy would dramatically lower the addictiveness and reduce the respiratory depression of mu agonists WITHOUT removing efficacy. The most obvious formulation would be a transdermal system that delivers buprenorphine and fentanyl, since both are already available in separate transdermal systems.

There may be situations, for example hospice care, where euphoria would be a desirable part of opioid treatment. But for other cases, analgesia without euphoria has obvious benefits.

I have written to several pharmaceutical companies with this idea, and have heard back that while the idea is interesting and scientifically sound, the generic nature of the component medications reduce the potential for profit that would motivate development. But given the potential value of this approach for multiple problems– addiction and chronic pain among them—I have to think that there is money to be made—not to mention the advances in treatment that the approach offers.

Reference:

Some supporting background information can be found in: Alford, D., P Compton, and J Samet, Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med. 2006 January 17; 144(2): 127–134.

I also discuss this approach to pain treatment in my ‘Users Guide to Suboxone’, sold on Amazon and at bupeguide.com

Jeffrey T Junig MD PhD

Please do not reproduce without attribution.

Universal healthcare sure sounds appealing. I resent the high price that my family pays for our health insurance, and my deductibles prevent the policy from paying anything toward the occasional minor surgery or consultation. But one thing is apparent for anyone who opens a newspaper this summer– the US is struggling to pay the bills. While we once gazed at Canada or the Brits with condescension, we now look with envy at the relative soundness of their economies. Canada balances their budgets in part by tapping their large oil reserves– while the US reserves at both coastlines are buried much deeper in regulations and prohibitions than in seawater. And Great Britain has found the courage to reduce government spending to a much greater extent than even the most ‘severe’ proposed reductions in the US.

Seniors Suffer in the UK

Even though Canada and Great Britain are on more sound financial footing than the US, both countries have struggled under the weight of their own healthcare programs. For many years both countries have rationed healthcare to an extent that would shock US health consumers. In Canada, the process is called ‘queuing’, which refers to long wait lines for procedures– sometimes longer than the life-span of the person in line. A patient recently complained that his MRI for his sore knee couldn’t be done for several weeks at his local US hospital; in Canada, the same test would be done after a period measured in years, and would include travel to a regional medical center– not the trip to the local hospital as in the US.

Limitations on care in both countries are minimized by the governments, although the press, save for the most liberal publications, frequently describe the dire circumstances for anyone unlucky enough to need surgery, a catheterization, or any other procedure. As the US chooses to step closer to the British model, we should take a look at the ‘future of US healthcare’ if that model is firmly adopted.

From the UK’s Independent:

Cataracts, hips, knees and tonsils: NHS begins rationing operations;   Almost two-thirds of trusts affected as cuts bite

Anne Ball, 71, a retired business consultant: ‘I have bilateral cataracts and under the original NHS criteria I was entitled to have at least one of mine treated – but then the West Sussex health authorities decided to change the threshold level to save money’

Hip replacements, cataract surgery and tonsil removal are among operations now being rationed in a bid to save the NHS money.

Two-thirds of health trusts in England are rationing treatments for “non-urgent” conditions as part of the drive to reduce costs in the NHS by £20bn over the next four years. One in three primary-care trusts (PCTs) has expanded the list of procedures it will restrict funding to in the past 12 months.

Examples of the rationing now being used include:

* Hip and knee replacements only being allowed where patients are in severe pain. Overweight patients will be made to lose weight before being considered for an operation.

* Cataract operations being withheld from patients until their sight problems “substantially” affect their ability to work.

* Patients with varicose veins only being operated on if they are suffering “chronic continuous pain”, ulceration or bleeding.

* Tonsillectomy (removing tonsils) only to be carried out in children if they have had seven bouts of tonsillitis in the previous year.

* Grommets to improve hearing in children only being inserted in “exceptional circumstances” and after monitoring for six months.

* Funding has also been cut in some areas for IVF treatment on the NHS.

The alarming figures emerged from a survey of 111 PCTs by the health-service magazine GP, using the Freedom of Information Act.

Doctors are known to be concerned about how the new rationing is working – and how it will affect their relationships with patients.

Birmingham is looking at reducing operations in gastroenterology, gynaecology, dermatology and orthopaedics. Parts of east London were among the first to introduce rationing, where some patients are being referred for homeopathic treatments instead of conventional treatment.

Medway had deferred treatment for non-urgent procedures this year while Dorset is “looking at reducing the levels of limited effectiveness procedures”.

Chris Naylor, a senior researcher at the health think tank the King’s Fund, said the rationing decisions being made by PCTs were a consequence of the savings the NHS was being asked to find.

“Blunt approaches like seeking an overall reduction in local referral rates may backfire, by reducing necessary referrals – which is not good for patients and may fail to save money in the long run,” he said. “There are always rationing decisions that have to go on in any health service. But at the moment healthcare organisations are under more pressure than they have been for a long time and this is a sign of what is happening across many areas of the NHS.”

According to responses from the 111 trusts to freedom-of-information requests, 64 per cent of them have now introduced rationing policies for non-urgent treatments and those of limited clinical value. Of those PCTs that have not introduced restrictions, a third are working with GPs to reduce referrals or have put in place peer-review systems to assess referrals.

In the last year, 35 per cent of PCTs have added procedures to lists of treatments they no longer fund because they deem them to be non-urgent or of limited clinical value.

Some trusts expect to save over £1m by restricting referrals from GPs.

Chaand Nagpaul, a member of the British Medical Association’s GPs committee, said he was concerned about PCTs applying different low-priority thresholds and rationing access to treatments on the basis of local policies.

He said the Government needed to decide on a consistent set of national standards of “low priority” treatments to help remove post-code lotteries in provision. “Patients and the public recognise that with limited resources we need to make the maximum health gains and so there needs to be prioritisation. What is inequitable is that different PCTs are applying different thresholds and criteria,” he said.

A Department of Health spokesman said: “Decisions on the appropriate treatments should be made by clinicians in the local NHS in line with the best available clinical evidence and Nice [National Institute for Health and Clinical Excellence] guidance. There should be no blanket bans because what is suitable for one patient may not be suitable for another.”

Bill Walters, 75, from Berkshire, recently had to wait 30 weeks for a hip operation instead of the standard 18. “I believe that the Government is doing this totally the wrong way,” he said.

Case study: ‘They changed the rules to save money’

Anne Ball, 71, is a retired business consultant who used to work in electronics

“I have bilateral cataracts and under the original NHS criteria I was entitled to have at least one of mine treated – but then the West Sussex health authorities decided to change the threshold level to save money.

“It’s like looking through gauze. Everything is foggy, and I’ve got quite a large ‘floater’ in my left eye. The consultant was as distressed as me, having to tell me, and he thought with my eyesight he wouldn’t be able to function.

“I’ve appealed because the cataracts are having a significant impact on my quality of life and it’s left me depressed and fearful about my low vision, which will continue to deteriorate. The new guidelines mean that people who fall below the standard set by the DVLA still do not qualify to have surgery. My vision is not good enough to drive at night.

“I’m not a cranky old lady. I’m the chair of a local village charity and I do a lot of computer work that is affected.

“It will just store up costs for future years, putting a strain on resources as more patients will end up in falls clinics. The longer you put it off the more complex the operation becomes and the riskier it is for the patient.”

I’ve described my approach to psychiatric care throughout my web pages. In case you’ve missed those comments, I’ll briefly summarize them below. I’m writing this post primarily so that I will have a web address to give people who ask about my practice.

Some background for the goals I’ve set for my practice:

- There are times when medication is a Godsend for psychiatric illness and symptoms, for example in treating moderate to severe depression, REAL bipolar disorder (i.e. not the bipolar label that is tossed on to every teen who is acting out), psychotic disorders, and moderate to severe anxiety disorders. Children and adults with significant ADD also do much better with medication than with treatments that do not include medication.

- On the other hand, there are many cases of over-reliance on medications. Studies have established that the best treatments are those that combine medication with attempts to improve insight into problem behaviors. Recent studies suggest that antidepressant medications do little for mild depression, and that at least some of the benefit comes from the patient feeling understood, cared for, and reassured that things will ultimately be OK.

- I find the practice employed in some psychiatric offices to be utterly deplorable, where people are seen for very limited periods of time, diagnoses are assigned, and potent medications are prescribed– without taking the time to understand ALL of the factors involved in the patient’s symptoms, and to explain all options for treatment– including the risks of each option.

- People do well when they are treated well. People want to be ‘understood’ by their psychiatrist, and that cannot happen if an appointment begins with a 30-minute wait! How, in such cases, can the psychiatrist claim empathy for the patient’s feelings– right after demonstrating the opposite? And how can someone accurately assess the personality traits of a person who has just been forced to go through a dismissive, frustrating experience?

- It takes time to understand a person– for many reasons. When I begin treatment of a person seeking help, I want to know that person’s strengths; not just the strengths that the patient knows about and describes, but the strengths that I witness and hear about as the patient settles into a long discussion. I also need to know the things that threaten the patient; those that the patient is aware of, but more importantly, the things that the patient does not yet recognize. And again, that takes time. People have a way of acting when meeting a person for only 15 minutes, that disguises how that person truly feels inside. It takes time for a person to let go of that presentation, and settle into being him/herself.

My practice

- With these principles as background, my practice is designed create an environment where people feel relaxed, respected, and understood. I set aside at least 30 minutes for every appointment, allowing time for us to truly understand each other. My appointments start on time. My patients wait a couple minutes for a 30-minute appointment– rather than waiting 30 minutes for a 5-minute appointment!

- I provide formal psychotherapy, usually with hour-long appointments that are scheduled for a predefined period of time, in order to tackle a predefined problem. My approach is ‘psychodynamic,’ meaning that I assume that we all have an unconscious part of our minds, where we repress painful and frightening feelings.  I sometimes use tools from cognitive behavioral therapy as well, depending on the particular symptoms and on the patient’s style of interaction and comfort level.  Beyond formal psychotherapy, I use every visit as a chance to understand the person seeking help, and to help that person understand their symptoms and options. Having a full 30 minutes for a ‘medication visit’ allows us to get things right the first time, instead of random trials of medication after medication.

- I do not belong to insurance panels. I realize that by not contracting with insurers, some patients may pay more for care than they would from a participating doctor. Unfortunately, insurance is set up to pay for ten-minute med checks– a form of psychiatry that I find to be worthless, in cases where it is not actually harmful.  I wish that I could be flexible, and accept insurance in some cases, but the insurance industry does not allow that situation.   I encourage people to consider the ‘big picture.’  Recent articles in the Wall Street Journal and the New York Times have decried the loss of traditional psychiatry as a result of the pressure by insurance companies.  The articles describe the problems with the ’15 minute med check’ in a field as complex as psychiatry.

- I do submit to all insurers, and many do cover non-participating doctors, at least in part.  If you have a high deductible, my relationship with panels may have no relevance to your costs.  I do accept charge cards for payment.

- I ask that people consider a couple of factors when choosing a psychiatrist.  You will not wait more than a few minutes in the office when see me, meaning that your time away from work or from home is more predictable.  I answer e-mails, so that I can answer the short questions that invariably come up when starting any new treatment. But most of all, I believe that my approach is more likely to reduce your symptoms, and more likely to prevent recurrence of your symptoms.  Working together we will improve your insight into the causes of your symptoms, helping you become more proactive in maintaining good health.

- The kind comments that I hear most often from my patients is that they feel that they can ‘be themselves’ with me; that I do not judge them, and that I act as if I have been where they are.  Those comments are accurate;  I have been there.  Life is sometimes very difficult, and I have had times of great struggles, as well as times of success.  I make no secret of my own experiences, hoping that my own openness will help to reduce the stigma that people continue to feel and experience when dealing with psychiatric symptoms.

That is my practice, in a large nutshell!  If you have any questions about my practice, feel free to write to me drj@fdlpsych.com .

JJ

The following article is from Psychology Today, written by psychologist Douglas LaBier PhD. As I read the article I realized that he is describing the type of psychiatrist who I would like to be, and the type of work that I hope to be doing with my patients.

I am sad that many psychiatrists choose to focus their attention only on medication, at the expense of trying to understand what people truly want and need from their psychiatrists. Even as more studies come to the fore showing little benefit from medication for ‘mild’ depression– i.e. the type of depression that the vast majority of people struggle with– psychiatrists continue to shorten their appointments, leaving the doctor/patient relationship outside the door! There are times when medications are important, and I provide the additional time for appointments so that in those cases, we get the right medications started the first time. But medications are always only part of the answer, and if you have never had the type of relationship with a psychiatrist where you have time to feel relaxed and understood, I encourage you to give my practice a try.

I cannot say that I am the psychiatrist described below all of the time, every appointment, and every day. I have my own bad days, just as everyone else does! But I can promise ALL of my patients present and future that I will always do my sincere best to understand whatever led you to seek help, and I will provide the time and energy to help you find answers, to get relief from turmoil, and to help you understand that I ‘have your back.’

Why Psychotherapists Fail To Help People Today

Many people who enter psychotherapy today aren’t helped at all. Some end up more troubled than when they began treatment. And ironically, some therapists are examples of the kinds of problems they’re trying to treat. In this post I explain why that is and how to become a more informed consumer when considering psychotherapy.

The popularity of the TV show “In Treatment” is one indicator that there’s a large, market for psychotherapy, today. Despite the decline of the more orthodox psychoanalytic treatment – the kind that Daphne Merkin described in a recent New York Times article about her years in treatment – people continue to seek competent professional help for dealing with and resolving the enormous emotional challenges and conflicts that impact so many lives in current times. Beyond healing, they want to grow their capacity for healthy relationships and successful lives.

Many skilled and competent therapists are out there. (I use term “therapist” to describe psychologists, psychiatrists and clinical social workers – professionally trained and licensed practitioners.) Moreover, research shows that psychotherapy can be very effective. Either alone, or sometimes in combination with the judicious use of medication.

Yet so often practitioners don’t help people very much. Some struggle for years in therapy with one practitioner after another, and never seem to make any progress. Others resolve some conflicts, but then are hit with others that hadn’t been addressed.

I see three reasons for this situation. One is rooted in the kind of people therapists tend to be today. Their personal values, social attitudes and how they relate to conventional norms and behavior contrast in several ways with those of the “pioneers” from Freud’s era. That contrast impedes effective help.

Then there are the kinds of problems that people experience. They’ve evolved over the decades, but especially since 9-11 and the near-depression that began in the fall of 2008. But many therapists aren’t in synch with the impact of that shift. They fail to understand how 21st Century conditions impact emotional lives and conflicts. Many are clueless about how life in today’s world interweaves with the dysfunctions or family conflicts that patients bring with them into their adult lives.

The third reason is the therapists’ vision of the goals of treatment; what a healthy outcome or resolution of conflicts should look like, and how to get there. Many remain stuck within an older model – helping patients better manage, cope with or adjust to change and traumas; build resilience and restore equilibrium. But that’s no longer possible: Our new environment is one of “non-equilibrium” and unpredictability. That creates new emotional and life challenges across the board — for intimate relationships, careers and for engaging with a changing society – the “remix” that America is now becoming.

The Psychotherapist – Past and Present

The early analysts were pioneers, adventurous explores of uncharted terrain. They were trying to uncover how human personality and unconscious passions evolve within people to create symptoms and dysfunctions. They courageously risked their careers when they called attention to the impact of repressed sexuality. Aside from the accuracy of early theories about the causes of emotional disturbance, the practitioners’ aim was to reduce suffering. They wanted to help people develop more love, reason and independence – albeit within the context of the norms of their era that they, themselves, accepted.

Moreover, most were well-read in literature, history and culture, more so than today’s practitioners. That gave them a broad outlook and perspective on life. For example, Freud’s writings are filled with references from Shakespeare, Goethe and other great works of literature, drama and mythology. He drew on their themes, plots and character portrayals to help illuminate and understand the motives and moral dilemmas underlying his patients’ emotional problems.

Most contemporaries and followers of Freud possessed a radical spirit. They wanted to uncover the truth beneath patient’s symptoms; see beneath the surface. They shared the view that successful treatment was based on a love of the truth; that is, emotional reality. And that it must preclude any kind of sham, deception or illusion.

Of course, Freud and his contemporaries interpreted their patients’ problems in many ways that were flawed. They made assumptions about psychological health that were part of the prevailing values and norms of post-Victorian, early-20th Century society – a largely patriarchal culture. For example, most assumed that a normal, successful life derived from being well-adjusted to those norms.

Nevertheless, their spirit of truth-seeking, rooted in broad understanding of human culture, literature and history, has become lost. Today’s practitioners tend to be technicians, looking for the right technique that will treat the patient’s symptoms. Many tend to be cautious, often disengaged and detached people in their manner and interactions with patients. They are largely ignorant of philosophical, religious, cultural and socio-economic forces that shape people’s psychological development, especially those in non-Western societies. And yet, all of those forces in all parts of the globe profoundly impact how and why we learn to think and behave as we do. Much current world conflict reflects those differences that define what we think in “normal” or “disturbed.”

Many therapists today simply assume that adjusting to prevailing values and norms reflects psychological health. Now that’s desirable for those whose conflicts have disabled them from minimally successful functioning. But it misses the mark for those whose conflicts are linked with their successful adaptation to begin with. The therapist then fails to explore their patients’ definition of “success” – how it’s shaped their career and life goals, their conflicts and disappointments.

Some therapists will spend inordinate time ferreting out tiny truths about the patient’s family and childhood, without figuring out which have relevance to the person’s conflicts today, and which don’t. They may ignore the impact of trade-offs and compromises patients made as they created their sexual and intimate relationship patterns

Overall, today’s practitioners tend to share in, rather than critique and examine, the social norms, values and anxieties of today’s world. Too often, they uncritically accept good functioning per se, and conventional values like power-seeking, as psychologically healthy. This blinds them from recognizing that “normal” adjustment can mask repressed feelings of self-betrayal, self-criticism, and the desire to be freer, more alive. All of those longings can conflict with or oppose parental expectations or the pressures from social class membership.

Emotional Conflicts In Today’s World

People’s problems have evolved. Up through World War II and into the 1950s-early 60s symptoms that were more typical of Freud’s time — hysteria or specific phobias, for example – diminished. People wanted help for fitting in with the apparent paths to success and happiness and for dealing with conflicts that interfered with or limited it. Therapy often addressed things like guilt, inhibition, the need for approval, and dealing with the conflicts generated by defined, rigid roles for men and women. Desires or longings that deviated too much from the prevailing norms were troublesome and created conflicts, often unconscious.

The popular TV show “Mad Men” is a good portrayal of conflicts of that era, especially issues of identity, longing for an authentic self and gender roles. At the same time, the men enjoyed the surface appearance of power and control. And women chafed against the limits imposed by gender roles, as the women’s movement began to arise.

The period of social upheaval of the late 60s and 70s created more openly conscious conflict and struggle for many people. The theme, here, was seeking more freedom from oppressive relationships and social constraints. Some therapists were able to address these issues in helpful ways. But others were bound by their own uncritical embrace of the very norms their patients wanted help to free themselves from.

Partly because of that disconnect, many psychotherapy patients were attracted to the vision of personal development offered by the rising “new age” movement, although its gurus generally lacked any depth of understanding about emotional conflicts or psychological development.

Then, from the 1980s to about 2000 more men and women sought help to create more personally fulfilling, engaged relationships, and more personal meaning from their work. The costs and limits of success became visible in patients who wanted help to create greater work-life “balance” while preserving their relationships and their upward climb in their careers. Dealing with the emotional fallout of the dot-com bubble burst added another dimension to these stresses. During this period of greater fulfillment-seeking, more people turned to spiritual development as a companion to or substitute for traditional therapy, especially via older traditions like Buddhism and other Eastern practices.

And now, in the current era, emotional conflicts spring more from the psychological impact of our nonlinear, unpredictable, highly interconnected world. For example, financial and career uncertainties. Changing practices in romantic/sexual relationships. Facing one’s responsibilities to fellow inhabitants of the planet, and for sustaining the planet for future generations. The psychological impact of these issues interacts with the legacy of family conflicts and their dysfunctions that people carry with them into the adult world. It’s a new universe of potential pain and confusion that people are now struggling with.

What Helps?

Therapists need a vision of what healing and emotional health looks like, today, and how to help the patient achieve it. And therapists must engage in self-examination about their own values and attitudes. That’s one safeguard against rationalizing failure to help their patients examine these same issues within themselves. Otherwise, the therapist may collude with a patient to avoid confronting issues relevant to both of them. Then, it becomes like a Shakespearian play where the motives of the characters are visible to members of the audience, but the characters themselves remain oblivious to their unconscious motives that propel them along.

Therapists bear a responsibility to help patients uncover the deeper truth about their life dilemmas – not just continue to detail all of its manifestations. Like the branches of a tree, all of them spring from the same trunk, the same roots. For one person, that might be a deep, unconscious desire to remain protected and secure like a baby. Or a desire to destroy one’s father or mother. It could be intense lust for power and domination. Exposing and confronting that core of truth can be liberating, like in fairy tales when the power of the evil spirit is broken when you can call it by its name. At least you then have an opportunity to do something about it.

Being a more personally engaged therapist is also important today. People are increasingly turned off by therapists who maintain the old manner of silence and detachment. Or whose rigid focus invokes in patients the same unmet longings for nurturance and acceptance that patients may have experienced in their families to begin with.

The traditional practice is for the therapist to divulge little or nothing about him or herself. That’s been fading, especially in a Google world. More are drawn to people like the psychiatrist played by Gabriel Byrne on “In Treatment.” While that TV show has elements of a soap opera and the therapy sessions often sound like “life-management” discussions, the psychiatrist shows more openness and flexibility with his patients.

The viewer sees him as a human, himself, struggling with his own personal issues. People like that openness. It’s more consistent with psychoanalyst Steven Kuchuck’s comment about Merkin’s article in The New York Times. He described the greater appeal and benefit of practitioners who emphasize “…greater patient-analyst collaboration, the analyst’s selective self-disclosure and other techniques designed to address many of the concerns and limitations Merkin has experienced…”

In addition to personal qualities, therapists who are familiar with the broad impact of our post-9-11, post-economic meltdown world on people’s mental health are better positioned to help their patients. In addition to knowing that people’s emotional issues are tightly interwoven with global political, social and economic forces as I described above, it’s helpful for therapists to be tuned-in to demographic and other changes that are pulling many in our culture to move beyond motives of purely self-interest, and towards serving the common good.

Similarly, too many practitioners tend to be sadly uniformed about the realities of life in business and career world — the political realities, the politics and conflicting agendas; the challenges of transparency, collaboration, and innovation — all needed for success. Without that awareness it’s hard for them to differentiate problems that people bring with them from in their attachment issues and family relationships, from those that are reactive to confusing, demoralizing, non-linear challenges and constantly shifting goal posts in their workplace.

It’s also valuable for therapists to be current with new research relevant to dealing with today’s conflicts. Two recent examples: One finds that people who maintain a long-range perspective of their past, present and future are better able to navigate through turmoil or setbacks and maintain greater well-being. Another study finds that some adversity in life actually contributes to mental health and resiliency.

The upshot of all this is that you need to be an informed consumer of therapy. To aid that, here are some useful questions to ask:

About Your Therapist:

Does the therapist seem to enjoy his/her work? Sound bored or depressed?

Does he or she convey a sense of humor?

Does he or she seem to have a broad, understanding perspective about the variety of human lives?

What experience and knowledge does he or she have regarding the impact of work and careers on people’s lives? Be wary if the therapist indicates that such familiarity is irrelevant to treatment.

About Yourself:

Do you feel challenged by your therapist to look at yourself, but within a safe, respectful, non-judgmental environment?

Do you feel the therapist is capable of “seeing” you; your hidden truths?

Do you think the therapist is engaged and interested in helping you, as opposed to treating a diagnostic category?

Keep in mind that everybody has some barriers to facing and dealing with unpleasant truths about themselves. You might rationalize your own and conclude that you’re dealing with a bad therapist. Try to be open and honest with your perception. Use your intuition, but in consort with your reason. Don’t’ hesitate to discuss these questions and your response to them with the therapist.

I receive updates from the American Psychiatric Association about new findings related to psychiatry and addiction.  I thought that the following article about a connection between video games and psychiatric conditions, notably depression and anxiety, is worth sharing.

I find it interesting (and worrisome) that we tend to move forward with technology without ever a pause to consider the long-term impact of our inventions on our mental health, not to mention our physical health.  We act as if every bit of progress is ‘good,’ just because it is more advanced, smaller, faster, and more interesting.  I’m no technophobe;  I love using my iphone, and appreciate being able to share my thoughts with whoever stumbles across my blog, regardless of the reader’s nationality.  But it does not take a great deal of insight for those of us older folks to see what the younger generation has given up, in return for all of their amazing gadgets.  I have certainly seen individual students and young adults who would benefit from fresh air.  And I have worked with people whose marriages suffered and failed, in part because of the easy escape from engaging conversation to mind-numbing fantasy games.

The article, complete with links to more extensive information:

Bloomberg News (1/16, Lopatto) reported, “About nine percent of children play such long hours of video games that they are pathological gamers, increasing risks of anxiety, depression, bad grades and social phobia,” according to a study published online Jan. 17 in the journal Pediatrics. In a two-year study encompassing some 3,034 youngsters in third, fourth, seventh, and eighth grades, researchers found that “the compulsive gamers played for a weekly average of 31 hours compared with 19 for kids not deemed pathological.” For study purposes, “gamers are considered pathological when their playing interferes with everyday life, and their behavior is described as being similar to that of gambling addicts, according to background information in the paper.”

“Over a two-year period about 84% of those who started out as excessive gamers remained so, indicating that this may not simply be a phase that children go through,” the CNN (1/17, Wade) “The Chart” blog reported. “Boys were more likely to show symptoms of excessive gaming.”

HealthDay (1/17, Gordon) reported that pathological video gamers appear to “have trouble fitting in with other kids and are more impulsive than children who aren’t addicted.” And, “once addicted to video games, children were more likely to become depressed, anxious or have other social phobias. Not surprisingly, children who were hooked on video games also saw their school performance suffer.”