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  1. #1

    I'm OK, therapist is OK, but no integration

    Hello friends,
    This is my first posting and after reading messages and replies from other member I feel very enthusiastic to introduce my case and myself.

    I am a Mumbai based architect and I left my practice three years back in persuasion of administrative career through a competitive exam known to be toughest in country. This year it's my last attempt. When I reviewed my progress and psychological state for last five years I found it necessary to refer the case to psychiatrist to guide me through the gridlock I was facing.

    Accordingly I visited one in a well-known NGO in the city last December '04. In my case summary I mentioned technical details about my deteriorating performance and whatever I could about state of mind. I concluded the summary saying I want to learn to try to try and make better use of capabilities and I have specific deadlines to meet. The psychiatrist lady, an assistant psychiatrist in the organization, referred my case to an industrial psychologist for counseling. In first two sessions only it didn't work out well so she asked me to go through MCMI-II and two day workshop on REBT. The workshop was good but it too didn't help much. In the test results I was diagnosed for mood disorder and a few personality disorders. These results ushered second stage in therapy.

    My case was brought to notice to one of the chief psychiatrists for occasional overview. I was put on lithium regimen and self-observation charts. I followed both religiously and provided as much information as I could. Both the doctors very well appreciated my systematic reporting. During the course I informed them 3-4 times that everything was going well except some efforts towards deadlines I need to meet in month of May '05, October '05 and April '06. Besides medication and self-observation I needed some concrete guidelines to improvise to meet the above. Nothing happened. In April I was put on some additional medication that caused severe side effects to the extent that my already minute working capability was also impaired.

    This was limit to my patience and I registered a strong disapproval towards therapeutic process to my psychiatrist. She appeared sarcastic to my disapproval but still prescribed another medication with a welcome gesture. That too caused another side effect. That was just 15 days before my exams and I felt scared like anything. This time she was on her summer vacation so I contacted the chief myself for help. When I visited him, I realized that she had already reported my disapproval to him internally and he wasn't happy with my intervention too. For the third time cycle of medication and side effects repeated and I discontinued it altogether. My exams went disappointing, but I have no regrets because my preparation was substandard in the first place. But I had complaint about doctors to whom I went when my self-efforts failed and I trusted so much.

    The chief assumed the case to himself leaving me wondering what exactly the assistant doctor informed him. I told him that I wasn't expecting miracles but I would have been happier if we had a single discussion about my main stressor. To be more specific I wrote to him--

    Why treatment procedure is so opaque? Why it appears that nobody has time to understand the case or even when in face-to-face interaction? Is patient's view considered as invalid following his disorder irrespective of the objective assessment? Why structure of organization seems so bureaucratic? Who's truly aware of the case? Who's available when and how? If anybody has time? etc etc

    In his responses he appeared a bit angry about such open questioning so I placed a general query to understand what these people exactly do? In my following letter I requested him to give me some insights in order to develop a positive attitude towards therapy.---

    What kind of roles therapists perform in the therapeutic process? Like Neutral, anonymous, activist, interventionalist, guide, teacher, observer, value neutral, agent, catalyst, etc. In case of multiple roles, what criteria ensure right selection of roles on the part of therapist?

    How far is the therapist concerned with the therapy? I. E. the problem constitutes a whole for the client/patient, but could be a minute fraction of day-to-day work for therapist and hence of minute concern. Is such gap between whole and minute fraction is bridged? If yes how? If no, why?

    Therapist concern with the client/patients problem may not be a good sign in view of attention to rest of the work and a principles governing therapy. Is it possible to put excellent efforts in absence if such concern? If yes, how?

    Therapists concern with his profession instead of the client/patients problem could be the ideal situation. This factor should necessarily relate to therapists personal commitment to his profession. Does this aspect introduce a general subjectivity in the discussion?

    What motive govern job of a psychiatrist? Profession, service, paid favor.

    Is it legitimate to select/shuffle among above motives as a situation warrants?

    For example, a patient seen generally peaceful turns hostile sometime. Here, a psychiatrist needs to do away with service motive (if any) and wear a professional skin to save him from such hostility. But is such conscious shift in attitude perfectly capable of misuse in terms of evading responsibility and masking faults?

    Responsibility for all the real events is solely on client/patients shoulders. But what is the amount of responsibility is advisable to be assumed by the therapist for his help? If responsibility has strong correlation with the success of any given event, does is constitute hallmark in a psychological profession? After all responsibility being a moral trait cannot be enforced in truest sense and remains at the mercy of individual personality.

    What a therapist does -- Enlightens or Makes one work (even when partially enlightened)? In other words, what's sphere of responsibility of therapist?

    Responsibility without authority is dysfunctional and authority without responsibility is destructive. Accordingly, does therapist assume such co- terminality? If yes, what kind of authority he could assume besides authority of knowledge? How undue authority or authority without responsibility is exonerated?

    Accountability, a widely disputed topic about doctors in general. In countries like India, enforcement of accountability is out of question when people are hardly aware of such consumer protection legislations. A patient is expected to remain patient than put himself in the first place being a consumer. Recent public violent outbursts speak a lot about concrete steps need to be taken in this direction in near future. But in view of vacuum of such specialized enforcing agencies even at the base level of physiotherapies, safety net for psychological services seems like a futile expectation.

    Free rein and no misuse is an obsolete expression as it could be!! Laws are external and regulative hence less efficacious. What mechanisms ensure accountability within and specially in constructive manner?

    Looking at the growing complexities of the human problems, most of the pure disciplines are looking forward to alliances with other relevant disciplines to accommodate diverse needs. A multi-pronged approach is increasingly getting popular for its flexibility and high yield as compared to rigidities of a single application. I am referring to environmental but extra-psychological tasks around a particular case, could be of any kind, but requiring expert attention. Does psychiatry/ applied psychology allows such synchronization with a foreign application? If yes how?

    For example, is it possible to synchronize psychotherapy with project management techniques like PERT-CPM? Still further, which one should take precedence in case of a clash? How does psychiatry/psychology regard non-psychiatric emergencies?

    Multi-disciplinary approach is strongly upheld by generalists. It is acknowledged by specialist but not really heeded on account of irrational element or inability. How far this statement seems valid?

    If most problems need practical experience/actual attendance for solution, how therapy devices its solutions? Therapy is like a staff agency that directs from far away in an abstract form not necessarily in consonance with field requirements.

    For example, how a normal therapist counsels a hard-core alcoholic or a top brass manager?

    Rules, regulations, procedures, precedents are generally stated in brief form and observably designed for prevention of possible misuse/chaos. But if basic philosophy of such devices is understood and no chance of misuse is foreseen, a mutual agreement is reached to relax a few rules and seek modification to established procedure to speed up the process. How far psychotherapy welcomes such customization?

    Looking at all the above factors it could be easily understood that entry and performance in second person's mind and life cannot be subjected to technical dimensions alone. Equations of complexity of problem with the responsibility of therapy towards individual life could have great bearing on speed and efficiency of therapy process, generally towards negative end, slowing both. What validity this view holds?

    With the principle of anonymity, therapist is not expected to get benefit from client/patients welfare. It goes for penalty in case of deterioration too. Does this two-way device make therapist part with his creativity and efficiency or interest in general? Are sympathetic initiatives strongly discouraged in psychotherapy?

    Monotony induced boredom, insensitivity are common to most of the professions. But it could have special significance regarding therapists. How a therapist keeps himself in good stead?

    Pioneers, entrepreneurs are more effective/careful/energized than employees. Is it true?

    Most of the theories and practices are developed in western countries with a profound influence of individualistic culture. How an Indian therapist accommodates concerns of transitional culture?[/i]

    No comments about what he felt about this but he told me that all my queries are unrelated to my case and he might answer them whenever he wishes. He left me no room to explain how I arrived to such questions. In clear-cut words he told me not to be over smart. Also he warned me of further deterioration if I continue to behave like this. I agreed that I need to be lot more realistic, but when I asked him how? he told me to do it on my own! Despite of all this antagonism, I feel that he might have something good for me up his sleeve, but in absence of such knowledge I don't want to keep any blind faith. i have already skipped my last appointment with him.

    I am not drawing any conclusions unless I am satisfied with my own clarity of thinking. But one thing is very sure, I feel very tired of everything. Neither in this city there are other options available nor I have energy to go through it all over again.

    Maybe I am not being patient in real sense, but nobody is telling how to be one!!

    Expecting your kind reply. Thanks.
    A L

  2. #2

    I'm OK, therapist is OK, but no integration!!

    I concluded the summary saying I want to learn to try to try and make better use of capabilities and I have specific deadlines to meet.
    What factors made it more difficult for you to be productive at work? Was is depression, anxiety, difficulty with co-workers, etc.? Would you be more productive if you went back to being an architect or doing some other type of job?
    "What lies behind us and what lies before us are tiny matters compared to what lies within us." ~ Ralph Waldo Emerson

  3. #3

    I'm OK, therapist is OK, but no integration!!

    The psychiatrist lady, an assistant psychiatrist in the organization, referred my case to an industrial psychologist for counseling. In first two sessions only it didn't work out well so she asked me to go through MCMI-II and two day workshop on REBT. The workshop was good but it too didn't help much. In the test results I was diagnosed for mood disorder and a few personality disorders. These results ushered second stage in therapy.

    My case was brought to notice to one of the chief psychiatrists for occasional overview. I was put on lithium regimen and self-observation charts.
    This seems very confusing to me. First, in my opinion the MCMI over-diagnoses personality disorders, so I would put much credence in that at all. Second, I wonder about the expertise and training of an industrial psychologist in clinical diagnosis -- that is not usually an area in which an industrial psychologist has much knowledge. Third, if the psychologist felt that you met the criteria for personality disorders (sic) or bipolar disorder (I assume this from the later prescription for lithium), I would question the referral for Rational Emotive Behavior Therapy. Fourth, in my opinion, any mental health practitioner who would state, imply, or suggest that you do not have every right to question or ask for additional information or clarification about a diagnosis or the approach the practitioner is taking to treatment is, in my opinion, unethical and highly questionable.

  4. #4

    I'm OK, therapist is OK, but no integration!!

    Respected site administrator,

    Clarification - the industrial psychologist had no involvement in MCMI diagnosis, he conducted just the 2 sessions. Secondly, the workshop was based mainly on REBT (their printed material says so) and not the full-fledged one, it was group training designed for self-help with other behavioral techniques included. I attended the same before MCMI results were out. I am not aware of technicalities of diagnosis. But about lithium, I don't find myself troubled even when I am not on lithium for last 50 days.

    Respected moderator,

    I can trace this loss of productivity back in my mid-college years since 1998, when I ran into a prolonged conflict with a few college mates only to cause severe dislocations in my personal priorities. Instead of actual description, here is an example substituting a painter for myself and a mad dog for insuperable situation---

    Imagine a painter working peacefully (till 1998). Now set a mad dog free in his studio and see the way he might work, if at all! (1998-99). Then chain the dog but keeping it in the studio only (1999-2001). Next, dog is removed from the studio but painter keeps on thinking that my painting skill is useless if I can't protect myself and paintings from mad dogs, but if I start learning how to tame mad dog then when could I paint? And painter learns to do nothing (2001-today).

    I don't have technical words but it could have been identity crises for a year or so, but my actual efforts reduced drastically since then. I was more blamed for no performance than poor performance in my college assessments. After college my performance improved in professional practice but I never had any real wish to work. I decided a career shift because I needed some satisfaction out of performance and not just plain performance for sake of it.

    Here I need to make an important note about prevalent education/career selection in the society - in majority cases young ones are dependent on parents decision-wise and financially till their graduate studies are over. But decisions about further studies are mostly at individual's own discretion, after asserting some independence of course! If earlier choice is found not satisfying enough then people often go for a major career shift, especially valid for management and administrative careers where they never revert back to their parent discipline. So is my case.

    Results for my exams are due, so I am not at a decision point just yet. Still if at all I revert back to architecture in near future, I shall be productive, but don't know about more productive!!!!

    In case of a failure I don't feel hurt about what I lost, but I do if I haven't tried well, and indulging in this hurt feeling sucks all energy meant for further efforts. I haven't been able to disconnect this circuit yet.
    Besides this central problem I don't know what I should do with therapy
    A L

  5. #5

    I'm OK, therapist is OK, but no integration!!

    Besides this central problem I don't know what I should do with therapy
    Does your graduate school in India provide a mental health counselor that you can talk to? (Mental health counseling is available at most colleges and gradute schools in the U.S., but this is certainly not the case in many other countries. )

    Otherwise, are you sure there are no other counselors in the area that you can talk to? Usually, there are more mental health counselors than psychiatrists in a given area (at least in the U.S.).
    "What lies behind us and what lies before us are tiny matters compared to what lies within us." ~ Ralph Waldo Emerson

  6. #6

    Therapist is not ok

    Fourth, in my opinion, any mental health practitioner who would state, imply, or suggest that you do not have every right to question or ask for additional information or clarification about a diagnosis or the approach the practitioner is taking to treatment is, in my opinion, unethical and highly questionable
    "If you don't risk anything, you risk even more." --Erica Jong
    It was a very bad experience today.

    Somehow I convinced myself that I needed to change my therapist. So called up my psychiatrist an hour back to ask him if I would get back all the information and my personal observations I submitted with him in the course of therapy. He blatantly refused saying that there is no such procedure to return papers even if I wrote them. So all that I managed to write about myself so long has gone to dump. I even cannot use it to present it to somebody else. I cannot figure it out if I encountered a doctor or..!? I have no words to explain what I am feeling at this moment. I am not able to just let go the matter.

    Any help?
    A L

  7. I'm OK, therapist is OK, but no integration!!

    If you do start to see another psychiatrist, the new psychiatrist should be able to obtain your records from your previous psychiatrist. While you might not be able to get them, your new psychiatrist most definitely SHOULD be able to get them.

  8. #8

    I'm OK, therapist is OK, but no integration!!

    I can understand that the doctor won't hand over me my records. In last visit he warned me of possibility of inching schizophrenia. Wonder anybody who knows this would readily trust my decision-making and set me free just like that. I asked for the papers with a partial motive to preserve them with me at least, and not seeing them going to paper recycling shredder when the doctor finds them too heavy for his file. Wrong view, isn't it? (He even didn't know if he had any of my writings with him, forget about the case) I tried to find out a few more

    I think it's also important not to put time limits on things. Each of us is different, and different people require different amounts of time to overcome various problems. When you're trying to work with several problems at once, that only complicates the issue and increases the time frame in which noticeable change can be expected.
    I think he had idea since long about how much I was capable of accomplishing. But giving me precise idea about it might have demoralized me (his possible opinion), especially in view of such a mammoth task. So he kept me working without interfering much and side-by-side continued the long-term standard course of treatment.

    In my second letter to him, I was very much focused on his responsibility towards me. But today I must acknowledge his larger responsibilities giving him a lot of scope to hold a few things/information at his discretion.

    Whatsoever, combining the doc's stand and your postings, I think you want me to have a therapist in any case, at least on records. Hardly matters whether I wish or not. I am not at all against therapy as such, but i think I have valid reason to be this cautious before any next step.

    Somehow I am not able to let the earlier matter go out of head. Neither I find myself willing to embrace anything new in absence of simple assurance I am seeking about psychological professions. In anguish I asked asst. doc lady some day you might have 100s patients per week, how does that matter to you if one perishes? I have just one life to take care of!! sigh. nobody answers!

    I would think that therpists who have experienced the death of a patient by suicide would be more emotional about the issue than they would be otherwise.
    I am just not suicidal, but are they going to wait till then?
    A L

  9. #9

    I'm OK, therapist is OK, but no integration!!

    BTW I don't claim to be dumbo in psychology. I have been going through Intro. Psych. by Baron and another by Atkinson's & Hilgard, Abpsych. by Butcher & Mineka, Psych. Applied to Modern Life by Weiten & Lloyd since January and presently going through Theories and Systems of Psych. by Chaplin & Krawiec. In third week of my treatment I first time told my doctor that I didn't feel like seeing her. And that time I had all the above and more books in my hands with an argument that I had to read because she didn't tell me enough. I have only finished a first reading and understood basics at the best. Half knowledge is very dangerous so I refrain from making deductions on critical issues. But one thing is sure, 99% credit to books for keeping my brains alive & maintain a positive frame of mind and 1% to me for reading them...of course, lol.
    A L

  10. #10

    I'm OK, therapist is OK, but no integration!!

    1. your doctor cannot shred your records - s/he is required by law to maintain them for a number of years.

    2. it is always helpful to get information about yourself and any conditions that might be affecting you but of course that isn't a substitute for expert opinion - doctors and psychologists spend many years in basic training and then years more in internhsips, etc., to get to the point where they are competent therapists.

    3. Thatlady is correct that if you start to see another psychiatrist or psychologist, your new practitioner can request, with your authorization, the records from any previous therapists -- such a request could specify that your writings be included.

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