Grief and Divorce

Grief occurs with every divorce, although grief can promote divorce in a contented couple. Grief is caused by loss, and the loss most frequently thought of, is that of a loved one. Nothing is more difficult than to lose a child. For years there has been recognition by health care providers that often marriages are another casualty of losing a child. Many relationships end in divorce some time after.

It seemed odd to me that when we need each other the most is at times of tragedy, and yet as mentioned previously, there are many relationship terminations. Recently I heard something that may explain this behavior. After a major loss, the parents are in such pain that it is overwhelming. The feeling of not carrying is frequent. Anyone with children can relate to this pain and anguish, although experiencing it first hand must be more intense than intellectual speculation.

This reason for relationship breakdown is as follows. In many parents grieving the loss of children, when the parents or remaining children come together, the pain comes to the surface and the psychological trauma is re-ignited. This pain is understandably avoided. Also, grief is unique for different people and certainly males coping mechanisms differ from females. These different experiences of grief, varying coping styles and pain production in survivors that get close may be the reason people split up. It is terrible to experience another loss in the midst of grieving, yet it is common.

Another factor in loss is anger and even blaming. Both are destructive to relationships although emotions trump logic every time. If we could share a loss by avoiding blame as best we can, accept our feelings (no matter how intense and painful), see others as handling things in their way with respect and understanding, respect the need for separateness, we might regain peace in our lives again. We never get over a loss of this magnitude, although if we did the spirit of the person lost might disappear. Keeping the spirit alive with feelings, memories and any other means, including conversation with the deceased is all worthwhile.

I hope this helps people after their terrible loss and perhaps one more case in family court might be avoided. Tell me what you think as these are just my thoughts.

Fix Health Care With Simplicity

This is a very important and difficult question. My opinion is that the least insurance companies are part of the solution the better. Certainly catastrophic insurance is necessary, although it seems that health care that might be more affordable if the non-catostrophic health insurance was eliminated. I provide halth care for free as does every doctor I know as part of their regular practice. With escalating premiums and shrinking incomes for nurses, other health care professionals and doctors, no wonder people are starting to question the role of health insurance companies.

According to Time magazine, doctor's incomes have gone down every year for the last 15 years. If nurses aren't exceeding inflation, where is the money going that everyone says is increasing health care costs each year? The only people in a position to judge what is necessary are informed health care providers and the subsequently informed people or patients they serve. Of course there are health care professionals that are more interested in money than helping people. I have not met these health care professional yet and I would then assume they are a small minority. This small group is no reason to assume that most health care professionals need supervision from an insurance company that is trying to hold onto your premiums and make it difficult for you to obtain the care you need. Maybe if the insurance companies were not participating other than for catastrophic care, health care costs might not outstrip inflation.

Years ago I saw experts interviewed about the new direction in restaurants. One expert from Manhattan suggested that people are going to demand better food and better service so that higher priced restaurants was the way to go. The second guest owned pizza restaurant's in Southern California and he felt that people were moving toward high quality food in casual environments that were clean and yet not fancy. The last guest owned steak restaurants in Chicago. His perspective made the most sense to me. He said that if any business treated their employees right, then the employees would treat the customers well and make sure they got what they came for. With this simple approach, customers would come back, making for a profitable business that served the community.

If the solution to solve health care in America doesn't include health care professionals being treated with respect and a fair wage for their work, then health care problems will continue. It is a simple yet important idea that I think is right. Let me know what you think, because I care, and I need feedback.

Oprah and Mental Health

Oprah has done more for the mental health of Americans than any other person in the last twenty years. Her shows focus is on what people do, think and feel. This perspective is the exact same as mental health practitioners. Oprah herself is a kind, friendly and empathic person (the ideal of a mental health professional). You do not need to be famous to be on her show, just someone that has a new idea, a new experience or a way of helping people. A major difference with other people interest shows is the lack of ridicule by Oprah. Making fun of people is not something that Oprah does. When Oprah asks questions, she is sincerely interested in the answer, as all excellent mental health care providers are. Her coverage of mental health issues, understanding of people's successes and trials, along with a sense of humor and humility about her own life, enable people to share and talk. When I was a young man studying psychiatry, the advice was to conduct yourself as Judd Hirsch portrayed in the movie "Ordinary People," and you would definitely pass the oral part of the final exam. Years later that advice still holds. Most are more familiar with how Oprah behaves at this time and the same advice applies. Be like Oprah and you will pass your exams in psychology, social work and psychiatry. I am glad to be a psychiatrist in an age when public figures are able to suggest that mental health care is necessary and that it has more to do with growth than anything else. I should not neglect to mention Brooke Shields, Owen Wilson, Robin Williams, Mike Wallace and all the other famous people with the courage to let people know that they aren't perfect and if they need assistance, they go and get it. Oprah is a great American and she should be proud. If you agree or disagree with any of these thoughts, let me know.

Band Wagons or "the latest treatment"

It is reasonable to fear psychiatrists that just prescribe medications and those that won't. Patients deserve to be treated for what works best rather than a psychiatrists therapeutic preference. A recent article in the American Journal of Psychiatry talked about Benjamin Rush, the father of American psychiatry. Dr. Rush was the only physician to sign the declaration of Independence and also the Constitution. He was a great doctor and a great American. During the Yellow Fever epidemic in Philadelphia, Dr. Rush stayed behind to save people's lives. Unfortunately, his primary treatment was a common one of that time called blood-letting. Even though this treatment was ultimately ineffective, Dr. Rush prescribed it even for himself. He survived thankfully although it reinforced his conviction. The point of this story is that after WWII, psychiatry believed that psychoanalysis was the treatment for everything. In the 1950's, we started to prescribe effective medications for many psychiatric maladies. The biological psychiatry revolution has been truly helpful for many patients. Unfortunately, many medications are only effective with some kind of talking therapy. At present, many neuro-scientists are using Freudian insights to guide their biological and genetic investigations. As one of my insightful psychiatry colleagues has admonished, "for all the psychiatrists who proudly proclaim they don't so psychotherapy, shame on you. For all the psychiatrists that proudly proclaim they only do psychotherapy and never prescribe pills, shame on you." Thankfully, most of us do both psychotherapy and medication management or at least insist that patients on medication need the addition of psychotherapy. Band-wagons could be a reasonable perspective for researchers as they need to focus and pursue their ideas with passion. Clinicians need to provide the people who are desperate for help the best treatments available, not what they have the most training in, or their "favorite approach." I get excited about new treatments and always hope they'll work. The ideal care however, is guided by science and at the same time open minded. That is certainly the case in psychiatry and psychology when all the answers are still not in. We know a tremendous amount when it comes to people, although we still have lots to learn, as in every branch of medicine. If you think otherwise or agree, let us know.

Private Practice

Recently I decided to go into private practice. Working for my patients is something I have always enjoyed. Unfortunately in America, you can end up beholden to some insurance company that always wants more information about the people we serve and also to dictate practice. The basic paradigm is that psychiatrists can perform medication follow-ups in 15 minutes or less. This is probably applicable to a group of patients we serve, although it is not enough time for many patients. Rushing people through their care just seems anti-therapeutic to me. I respect all the practitioners that can do it and still have satisfied patients. Unfortunately, I just couldn't seem to rush people through the description of their troubles and not feel like I was being disrespectful. You can ask to see and be paid by an insurance company for more time. Unfortunately the process of obtaining approval is so cumbersome, most practitioners don't even attempt it. I would rather see my patients for the time they need, bill them fairly and not feel like my care always had to be providing the cheapest alternative. I will continue to see severely ill people in a different setting. The great folks at Palomar Medical Center support my ability to help people with little money and yet great need. I felt someone needed to explain the appeal of private practice. It's about some insurance companies policies.
Telling doctors what is appropriate medical care without even having seen the patient is analogous to a back seat driver with a taser. At least it seemed that way to me.

Fear of Psychiatry

I was talking to my new tennis partner and great friend Alan yesterday about my idea of people seeing a mental health professional once yearly for a mental health check up. A preventive helath care idea. Alan told me that people are afraid of mental health practitioners because in part they don't want to be analysed. There are other reasons of course, although I wanted to address this specifically.

The fear is even greater of psychiatrist's as we can hospitalize against one's will and medicate also. All of these perspectives are the same fear and I hope these comments help. It is my opinion think that to be "analysed" is to be judged. This is something we as mental health professionals try to avoid in fact. Our job is mostly to understand, which as a technical term is to be "analysed" after Freud's psychoanalysis treatment. We do judge behavior that is harmful to anyone however. If I was in a session with a patient, and they informed me their young child had been left in the car, I would immediately stop the session and insist they attend to their child. That is judgement of one's parenting skills and necessary for a childs safety. It is rare in our business for this to occur (it has never happened to me) as the overwhelming majority of people we see, are especially careful and cautious. We are often trying to promote some fun in life and being less harsh in one's views as a frequent intervention. First and foremost, we want to treat people with respect and consideration, invite them to share their thoughts and feelings in a safe place where there won't be an automatic response of censure or disapproval.

Most of the people I have seen in my career have been treated as people that matter, people with courage to carry on in the face of adversity. Of course we judge, although it is rarely necessary. Almost without exception, judging is ultimately appreciated by the person we are serving if judgement is required, as it can involve saving their lives. I know that people have been treated harshly by mental health professionals in the past and I only hope that was not the intention, as it has certainly never been mine. Thanks for the insight Alan. I hope this helps and let me know what you think.

Health Insurance

My new practice does not take health care insurance. I have spent the last two years taking health care insurance and in a word it has been mostly demoralizing. The expectation by insurance providers (or maybe a better word is demand) is for psychiatrists to see patients for subsequent visits in 15 minutes or less. This is a unrealistic and apart from saving insurance companies money for services needed, it is ridiculous. I have prided myself in spending as little time with patients as necessary for their care to reduce costs. It has almost never been less than 15 minutes unless rare circumstances occur. Years ago while doing research into Seasonal Affective Disorder, our rating scales to assess progress or not in patients, took at least 20 minutes. Our research was to measure receiving a specific intervention for the condition or not. I did my best to not provide talking therapy in those studies so the patient didn't receive two interventions at the same time, confounding the results. Unfortunately, it became abundantly clear to me that physicians with expertise and patients with problems that went beyond medication or light therapy in this example, would still receive it. Confronted by a person who's dog had just died, needed the support required and I did my best to help the person first, even though it confounded the research to some extent. It is impossible to just provide medication or surgery without the talking therapy, even for health care professionals that don't realize how helpful their comments are. The same is true of psychiatrists writing prescriptions for patients with mental health problems that are also being seen by a talking therapist or not. Something comes up in the persons life since the last visit and it can't be ignored by the doctor. When it's ignored or referred elsewhere, it is seen by the patient as insensitivity or lack of caring. Neither augments the doctor patient, the foundation of all interventions. Research is clear, the more a person seeing the doctor trusts and likes the doctor, the more likely they will comply with other interventions like taking medication. 15 minutes is simply not enough time for a therapeutic exchange to occur and that is why I don't work with insurance companies in my new office in Rancho Santa Fe. Some people may have to pay more up front, although the more effective treatment is worth it in the long run. A small increase in time with a person in need, provides more comprehensive care and ultimately costs less in the long run. If you think otherwise or agree, let me know by posting a comment. Thanks.

Optimalpsychguy origin

Why did I pick Optimalpsychguy as my address? Because Optimal Performance People is mostly what I have seen in my 22 years in practice as a psychiatrist (the psych part of the address). My book Optimal Performance, Without Killing Yourself, The 6 4/4 Steps describe my alternate view of who we see struggling with depression and anxiety conditions. A very close friend of mine, who has been as much a brother to me as one could ask for, started calling me psychguy years ago. It is a good description of me. I am a psychiatrist with a sense of humor and humility. In many ways, just another guy though. I created this blog to complement my interest in human behavior and perspectives. My patients have taught me a tremendous amount in my career and I hope this blog will be an opportunity to share ideas and critique my view. Please share your thoughts with each blog I write. Thanks.