Bipolar, You & Your Psychiatrist
Is your relationship with your psychologist, psychiatrist or therapist all that it can be? Here’s how building a productive partnership can be a team effort.
If you have a psychiatrist on your treatment team, ask yourself this: Are you making the most of your relationship?
Do you come prepared for your appointments with solid information on your recent symptoms and other issues? Are you honest and forthcoming? If not, you’re losing out on the benefits of this professional’s expertise.
“When people need to see psychiatrists, it makes sense to make the visit as productive and helpful as possible,” notes Kevin Turnquist, MD, a consulting psychiatrist for the state of Minnesota who has written extensively about “humanistic psychiatry.”
On the other hand, do you feel that your opinions are respected? Is your psychiatrist responsive to your concerns? If not, there’s work to be done in forging a more constructive partnership.
In the best-case scenario, you and your psychiatrist are allies in the campaign for recovery. Collaborators who each contribute to a successful outcome, as defined and dictated by you. That’s the model for “person-centered care,” which has gained traction in the mental health field in recent years.
“The idea that patients should somehow be less than equal partners in a relationship designed to affect the quality of their own lives is pretty silly when you think about it,” points out Turnquist, who practices at Touchstone Mental Health in Minneapolis.
“The idea that patients should somehow be less than equal partners … is pretty silly when you think about it.”
The idea of an omniscient practitioner handing down pronouncements about what’s best for you is now old school. But that’s not the only positive trend in psychiatry.
The profession began as a form of talk therapy (picture a pipe-smoking Freudian presiding over the outpourings of a tortured soul). A split occurred in the 1970s as science discovered more about the biological roots of mental illness—and developed pharmaceutical options to do something about it.
Over time, the psychiatrist’s role shifted to prescribing doctor, stereotypically doling out scripts in a blur of 15-minute appointments. Talk therapy became the province of various mental health counselors, who are not empowered to deal with medication.
But the pendulum has been swinging back toward reintegrating pharmacotherapy (treatment with pharmaceutical drugs) and psychotherapy (addressing emotional, cognitive and behavioral issues).
That’s the ideal, says Maria A. Oquendo, MD, president-elect of the American Psychiatric Association and residency training director at the New York State Psychiatric Institute and Columbia University.
“Although [mood] disorders are biological conditions, the environment and your interaction with it has a profound impact on how symptoms evolve and develop,” notes Oquendo. “In terms of how well they’re controlled, having the same person manage both aspects is a critical thing.”
The realities of the health-care system, at least in the U.S., pressure psychiatrists into “only doing medication management—not that they prefer it,” she explains.
Despite the limitations imposed by insurance reimbursement, many psychiatrists manage to work around the “meds only” model.
“It’s never just about pills, even if someone is on medications, or changing medications. If you’re not thinking psychotherapeutically as a clinician, you risk undermining the entire process,” says Sonu Gaind, MD, president of the Canadian Psychiatric Association and chief of psychiatry at Humber River Hospital in Toronto.
‘A good vibe’ with your psychiatrist
Of course, it’s still common to have a psychiatrist whose focus is adjusting your meds and another practitioner who handles psychotherapy. In this division of labor, the psychiatrist has been likened to a car’s mechanic and the therapist to the driving instructor.
The setup works for Holly of San Antonio, Texas, who sees a psychiatrist every three months to monitor her meds—checking in more often if medication adjustments are needed—and a therapist at least once a week, “mainly for [emotional] ‘upkeep.’ ”
“It’s really important to me to have this structure, which includes a good support network,” the 26-year-old says.
Holly says it’s not so much about who you see as about how well you get along with them.
“When finding a psychiatrist or a therapist, it’s so important to make sure they have a good vibe with you. You have to feel like they’re not judging you, that they’re trying to understand you and not just looking to slap a label on you and call it ‘done,’ ” she says.
“You have to feel like they’re not judging you, that they’re trying to understand you and not just looking to slap a label on you …”
That’s not to say finding a psychiatrist is an easy task, especially if you live outside a major metropolitan area.
According to the Canadian Psychiatric Association, the country has about 4,770 psychiatrists and that’s nowhere near enough to meet demand: “Many areas of the country lack adequate psychiatric services. Shortages are especially acute in rural and northern areas, even in Ontario.”
The psychiatrist shortage has been making headlines in the U.S. While New York state and New England count more than 15 psychiatrists per 100,000 people, the Associated Press reports, other parts of the country—including Wyoming, Iowa, Mississippi, Indiana and Nevada—have fewer than 6 per 100,000. In Texas, three-fourths of the state’s 254 counties have no psychiatrist in residence.
In the best-case scenario, says Oquendo, people “should feel empowered to select someone who they feel confident and comfortable having back-and-forth interactions with and selecting the next steps for treatment. … Some regions don’t have all that many choices.”
The squeeze looks to get worse as more psychiatrists near retirement age. A recent survey by the Association of American Medical Colleges (AAMC) found that 59 percent of psychiatrists are 55 or older. And there aren’t enough medical students going into psychiatry to make up the shortfall. Renee Binder, MD, current president of the American Psychiatric Association, told the AP that medical students are migrating to higher-paid specialties such as surgery.
Building an alliance with your doctor
From the psychiatrist’s side of the office, treating someone with bipolar can be complicated by the fluid nature of the disorder—not only in terms of mood cycling, but also because of how the illness unfolds over time.
“Because you’re not dealing with something constant, it’s sometimes difficult for clinicians to figure out what’s going on, and for the person to actually get a sense of what the problem is,” Gaind points out.
Then there are the shifts from visit to visit. If you are depressed during a session, you may be withdrawn and uncommunicative. If you’re hypomanic, you might dismiss the idea that you even need treatment.
“That’s one of the particular challenges of bipolar for the psychiatrist—maintaining that therapeutic alliance to stay with the person through their cycling,” Gaind says.
Sometimes, that alliance evolves along with the individual. When Jacques of Toronto first started to see a psychiatrist, it was because his family doctor felt he needed more specialized help with medications to control his bipolar symptoms.
Both he and his psychiatrist have changed their attitudes over time, he says, enriching the relationship and creating a more productive partnership.
Jacques began to bring what he calls “narratives” to his appointments—summaries of things that were happening in his life and things he hoped to change. In response, he says, his psychiatrist transitioned “from the traditional white-coat decision-maker to a trusted mental health advisor.”
He still creates a narrative before each session for their discussions about what he wants in life, what is going well, and the obstacles he’s facing.
“I know what I want to tell him, so I have more control over the conversation,” he says. “I set the tone and I set the direction.”
“I know what I want to tell [my psychiatrist], so I have more control over the conversation. I set the tone and I set the direction.”
Shame, secrecy, and timidity do nothing but waste time, he adds.
“If you don’t tell them what you really want and need, the doctor will have to start probing, and we might end up talking about something that is just not that interesting.”
There are two parts to the successful partnership that Jacques describes. First, your time and effort to assess your current status and figure out your agenda for the future. Second, a psychiatrist who is ready to listen to what you have to say—“someone who will honor the job,” in the words of Philip R. Muskin, MD, a distinguished life fellow of the American Psychiatric Association.
Muskin, a professor of psychiatry at Columbia University Medical Center, talks about the trust required to share sensitive information. Getting to that place isn’t easy, he admits.
“Everybody censors what they say in therapy, until one day you slip or you realize you have to say something,” he says. “Then the process moves forward.”
If you’re thinking about seeing a psychiatrist who does psychotherapy, Muskin suggests asking yourself the following questions: Can I talk to this person? Do I feel comfortable?
And here’s a doozy: Am I willing to hear what needs to be heard—even if unpleasant—and to work on it? Having a psychiatrist who hesitates to tell you hard truths won’t do you any good in the long run.
“It’s important to feel you’re getting something out of the appointments, something more than you would from chats with your hairdresser,” Muskin says.
“Is your hairdresser going to tell you you’re manic? You hire me as the psychiatrist. I work for you so you can engage in a unique kind of relationship you won’t get from anyone else.”
Although the standard advice calls for interviewing practitioners to settle on the best fit, sometimes you take what you get and work toward mutual respect. That was the case for one Pennsylvania man.
“For me there’s no interviewing,” Brian says. “It’s about who can give me what I need for the lowest possible price.”
Financial reality also means he tries not to see a separate practitioner for cognitive behavioral therapy.
“When I meet with my prescriber, our talks often become mini/micro sessions,” he says. “We talk about medication, but all but one prescriber I’ve had since diagnosis in 2012 has also asked me how my life is going.”
Brian considers himself an “informed consumer” and advocates for himself when necessary. He recalls one doctor who dismissed his firsthand input about a prescription they were trying.
“I complained of side effects of a medication that was ineffective for me at the new dose. He said, ‘This should be working,’ and I said, ‘But it’s not.’ After going round and round I ended up at the same dosage I had started off in the past with a different doctor,” he recalls.
“The most important thing for me is that the psychiatrist is not a ‘know-it-all.’ ”
“The most important thing for me is that the psychiatrist is not a ‘know-it-all.’ ”
Brian now has an excellent match for both his budget and his preferences as a person and patient.
“I was very blessed to find someone who didn’t want so much to switch from medication to medication, but had an acute sensibility to modify medications before giving up on them.”
When the partnership just isn’t working for you, what to do?
“If things are diverging—when the patient or clinician thinks it’s not the right direction for the patient—then communication has likely broken down in the therapeutic alliance,” Gaind says. “I like to ask, ‘Are we on the same page?’ ‘Do we have the same understanding of what the issues are, and how they should be addressed?’
“Remember we are both there for the same reason. We’re there to help the patient who wants help—or they wouldn’t be there.”
Rather than simply jumping ship, Muskin says, open up a dialogue and “be prepared to say why you think things are not going well or what you’re unhappy about.”
For example, “Maybe your doctor is always changing appointments now, or wants to see you after work when you can only see him mid-day. You can say, ‘I don’t think this is fair.’ “
The bottom line is this: You owe it to your well-being to find a psychiatrist with whom you work well.
“Ask yourself, ‘What do I need and what do I deserve?’ When you contemplate subjects like medication or therapy, remember that we all have to make hard decisions,” Muskin says. “Do that with your life because you deserve this.”
By Stephanie Stephens – BP Magazine