Too Little, Too Late?

Closed Sign

At the end of a very long day I sat down to read the local newspaper online. I was disappointed to see a major provider of mental health services in the area  is closing leaving 170 patients to find services. The agency had provided care in the form of case management for 27 years. A little longer than me being back in Portland.    I am disappointed  each week when I read of more  and more agencies having to close their doors.  I actually have as much work as I feel I can safely provide.  This work is very strenuous at times so I know my limits. I do feel badly when a colleague will want me to see a patient and I just don’t have the time to take the patient on.  Sometimes things will open up briefly in my practice, but those appointment times  fill quickly.  I also don’t want to take on a new referral if I could not give appropriate followup appointments in a timely manner. Could I add a day a week to my schedule, sure, but then my own self care would be compromised.  In my opinion, no one would benefit from an over tired doctor/therapist. I am adding to my psychotherapy practice but that type of work is weekly for a 50 minute hour and I get to know my patients very well. Although it can be strenuous at times, it is entirely different from working in community mental health. Patient’s have to be much more independent and able to manage symptoms with little involvement from me outside of the office.

I would say that 90 percent of my practice is providing therapy.  It is the work I truly love and why I went into Psychiatry in the first place.   While there is a part of me that feels helpless when I see another agency close. I know that I am only one small piece of the puzzle.  I never quite understand why the “bigger players” don’t step in.  

I hope that reimbursement improves which seems to be the driving force behind the closures. That would mean that the State would have to allocate dollars toward caring for these patients and I know it has been an uphill battle the last eight years. I am hopeful things will improve over time. I just hope it’s not too little too late!

I have a name.

In life there will always be things that bother us.  For me one of my biggest pet peeves came when all of a sudden I went from being a Psychiatrist to becoming a “behavioral health” provider.  I personally can’t stand it.  I feel like it lessens my training as a Psychiatrist.  I am a Psychiatrist not a behavioral health specialist.  I think what bothers me more is that we didn’t fight the name change of the field.   Did surgeons become cutting specialists???   I think I detest it so much because I know how hard I worked to become a psychiatrist.  Now to call me “a behavioral health specialist” takes away from the field of Psychiatry.  There is no such thing as a “behavioral health” residency.  Psychiatrists as a group should have said,”no” when it was implemented by hospital administrators.  I don’t know what drove the decision to change the name of the department.  I see it more in hospitals that don’t have Psychiatry residencies.  I think because all hospitals are required to meet every patient’s mental health needs they came up with a way to offer mental health services that was less stigmatized which gets me onto another topic for another day as to why we still make it a “bad thing” to seek out mental heath care.

Should I stay or should I go. The Re-union Tour.

Packed Bags

This is a post I wrote almost two years ago.  I thought I would repost it because I had some things I wanted to add.  I will add them at the end.

All therapy comes to an end. The question is what to do when the therapy ends abruptly or the patient has been wanting to leave for a while. But what if it is the therapist who wants out of the relationship and does things unconsciously to get the patient to end the relationship? Like missing an appointment, double booking or even being hostile to a patient. It is always unconscious.  Therapist’s are people too. They have their own psychological wounds.  Sometimes a therapist will tell a patient they don’t need therapy anymore. I believe, it is always up to the patient to decide that.  If a patient seems to be coming less and less I might bring up the idea of working toward an ending. 

I think a proper termination is always the best way to end. However, it doesn’t always go that way. When patients leave abruptly and give a reason it is rarely the reason given.  They may blame it on parking, money or even “ not getting anything” out of therapy any longer.  Or because of schedules the therapy may evaporate. Either way, exploration for the departure is always best. Maybe the work was getting to deep.  Maybe my patient felt uncared for.  Maybe an addiction had resurfaced and she was too ashamed to bring it into session.

I have come to understand that patients leaving abruptly or starting with a new therapist before our work is completed can be from something unaddressed between the me and my patient.    The decision to leave can can arise out of their anger that the therapy isn’t bringing them the happiness they thought it would.  The patient will blame me most of the time. They might say something like “I have been doing this for a few years and I am not getting any better.” They usually say something to me  like “ you  are a nice person or I really like you, but I don’t think it is working” which translates to it being my fault. It is my fault in that something I said has made her feel like she can’t talk to me about her feelings. It is not up to me to “make them better.” It is up to me gently listen and hopefully we can repair our relationship. 

When I was neophyte psychotherapist,  I would have tried to convince my patient to stay. Now I know better. If she really wants to leave I will say OK.  I usually will leave the door open for her return.  

When People Betray Us

When we let ourselves be vulnerable we do it at the risk of being betrayed.  It happens in friendships and most often in love relationships. Betrayal can show up as an affair, lying and addictions. There are other ways  betrayals can present but I will focus on the bigger ones here today.  

Betrayal is a funny thing. I believe the reaction mimics a grief reaction such as one similar to death. Because with a betrayal,  comes a huge loss.  The relationship that one thought they had has really suffered a death. I have been watching the show Ozark, on Netflix. The episode I just watched is where the daughter wants to go back to Chicago. Her mother intercepts her in St. Louis.  The daughter says she  wants to go  back to her old life.  The mother responds with, “that life no longer exists.”  The characters parents have betrayed her due to their own greed and bad choices.  The daughter suffers the betrayal.  Her old life has died. But so has the relationship she thought she had with her parents.  Can she ever really trust them again?

Betrayal can be too big to overcome.  Sometimes it can be worked through in therapy and other times it cannot.  It is important to talk about it and honor feelings.   I never assume a betrayal is too big for my patients. It is really up to her to decide what she can or cannot live with.

Losing Your Creative Fire aka as The Little Match Girl

In an effort to be more creative I decided to write in a purple ink and change up my font. Last week one of my patients told me I wear a lot of purple. I was surprised.  I guess she sees something I hadn’t myself.  What was she seeing in me? Something creative?   As women it is important we remain creative in our lives otherwise we can die.  Not physically but emotionally.  Women who are involved in relationships whether it be friends or lovers must never stay if those people try to “put out” her creative fire. It may sound extreme, but it is reality. The reason it has to happen is her life can depend on it. If her psyche dies, it will not be long before her physical body will break down.   In the story of the little Match Girl,  she dies from living in fantasy rather than figuring out how to warm herself. Her creative energy dies.  She also dies in the cold but the important piece is she loses herself in fantasy rather than warming herself.  Something that would have saved her life.  One part of the version I read is that no one will help her.  She accepts less than she deserves.   Many times a woman in “bad” relationships will “ warm”  herself with a fantasy that she  is in  a good relationship.  However, she may be put down, told her dreams are unimportant or  held back financially by her partner.

If I stay with  a partner who puts down my creative efforts, because of his insecurities,  than I am in a sense allowing myself to freeze in the cold.  It is not his fault he is insecure, but it is mine for allowing him to be unkind.  In my office, frequently, women will blast the men and women of their failed relationships.  I tell them it is ok to be angry at them, but lets also look at why you stayed, which is of far more importance (to understand) for their emotional growth.

It s hard when we discover we may be “a little match girl.” However, it’s what we do with the information that matters the most.