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Friday, September 19 2014 @ 02:51 PM CDT

Rethinking Psychiatry

Mental Health

Allan is a new patient at our outpatient clinic. In the space of a month he has lost his job, his health insurance, and after a fight with his wife, his home. He is 32 and is suffering from, he explains, “PTSD, bipolar disorder and ADHD”. He wants me to renew the medications he has been taking for the last few years: a mood stabilizer, an antidepressant, two antipsychotics and one tranquilizer.

Rethinking Psychiatry

Journal of Wild Culture
12/12/2012

A Psychiatrist’s Journey 1992-2012: Award-winning LA-based psychiatrist Bernadette Grosjean on the story of her career, and its implications for the profession.

The Dilemma

Los Angeles, January 2012. Allan is a new patient at our outpatient clinic. In the space of a month he has lost his job, his health insurance, and after a fight with his wife, his home. He is 32 and is suffering from, he explains, “PTSD, bipolar disorder and ADHD”. He wants me to renew the medications he has been taking for the last few years: a mood stabilizer, an antidepressant, two antipsychotics and one tranquilizer.

Option 1: He signs the papers authorizing me to treat him; I quickly read the medical and psychological questionnaire completed by the admissions social worker; I check the absence of major psychiatric symptoms or worrisome side effects; I renew the prescriptions given by my previous colleagues, preferably for three months, and document the visit in my computer. The procedure takes fifteen or 20 minutes; the patient gets what he wants and the administrator is satisfied. All is for the best in the best of all possible worlds in the land of managed care.

Option 2: I try to get a sense of who he is. I explore his history, symptoms, treatments and responses. I discuss medication and the risks and consequences of hasty and simplistic diagnoses and their pharmacological corollaries. The patient is initially surprised and worried that "I would refuse to prescribe”, but then he relaxes. He talks about his "legal" use of cannabis. I ask him what he really wants and where he sees himself in five years. I clarify the difference between bipolar and borderline diagnoses, and their respective treatments. At the same time, I give him the address of a website run by patients. I tell him about our support groups for trauma victims. With his consent, I contact the social worker in charge of emergency shelters and the staff responsible for Narcotics Anonymous. At the end of the consultation the patient says that, in fact, he doesn’t take his medication regularly. Together, we discuss a treatment plan (that he signs) and the part he is supposed to play in it. He thanks me with enthusiasm, explains in detail the medication that he is “really taking” and asks if he can see me in two weeks. The entire encounter takes less than 45 minutes.

I watch him leave, thinking about the psychoanalyst’s neutrality, about so many psychiatric patients in jail and in the streets, about Jack Nicholson in One Flew Over the Cuckoo's Nest, about the role of the psychiatrist in a team, about the changes in cultures and practices...

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