How We Heal and Grow: The Power of Facing Your Feelings by Jeffery Smith, M.D.

How We heal and Grow : The Power of Facing Your Feelings by Jeffery Smith, M.D.

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How We Heal and Grow: The Power of Facing Your Feelings by Jeffery Smith, M.D.

I was recently asked by my colleague and friend Dr. Jeffrey Smith, to write the Foreword for this new book that he has written. I was pleased to find it an excellent book. He offers a fresh and sensible way to look at how people develop dysfunctional patterns and facing feelings that have been avoided is the pathway to healing growth. He covers the full range of human problems from quirks to serous personality issues. He discussed the work of Freud, Mahler, Kernberg and many others including his own work. Interestingly the book is directed towards the lay public and I am sure will be received. However it really also belongs in the hands of therapists and any mental health professional who is involved with therapy. Dr. Smith has been teaching this subject to psychiatry residents and other psychotherapists for many years and is always very well received. He approaches the subject from a developmental point of view. He points out how most of us have pockets of immaturity and how to outgrow them. Dr. Smith  discusses how and why the minds resist change. One of the central themes of Dr. Smith’s explanations is the phenomenon of catharsis where our underlying raw unprocessed feelings emerge and lose their power over us and are transformed when we share them with a therapist in the context of connection and safety. He describes this process and how it brings about an almost immediate change to the pathological emotions. I tend to look at the need for catharsis as something that has to occur over and over again which we often refer to as working through process. We do both agree that catharsis is an ongoing part of therapy. While this therapeutic work does require the empathic presence of the therapist. Dr. Smith also examines how some of this work may be able to done singularly when the person is trained in mindfulness in the Yoga and Buddhist tradition. The range and scope of the book is quite wide. He includes discussion of anxiety symptoms, trauma and depression although I felt he was little light on this latter subject particularly in regard to the role of loss. There is fascinating discussion on the dynamics of Multiple Personality Disorder in which he is a one of the few therapists with significant experience treating patients with this condition. Dr. Smith also brings his rich  experience in treating addiction into the book. He shares where dynamics and developmental experience is important and where the here and now social interaction is crucial. Included in the book is one of the best discussions of conscience and superego that I have ever come across. There is also and excellent section on the narcissistic personality and a description of how to understand a parent who had this condition and how to deal with important people in your life who have it. This is really a unique book that should have great appeal to therapists, students learning therapy and people interested in understanding their own emotional issues as well as those around them. I can also picture how this book may be very useful for people entering therapy, It will alert them to what to look for in themselves. It may very well facilitate the therapeutic process. In fact, I plan to give a copy of it to some patients who enter therapy with me. I am very pleased to conclude that Dr. Smith has made an outstanding contribution to our profession as well as to the education of the public about mental health and the therapeutic process.

 

Anatomy of a Psychiatric Consultation For Depression

When a psychiatrist does a consultation for depression, many things have to be considered. Ultimately the psychiatrist needs to decide whether to recommend medication, psychotherapy or a combination of both.

THE REFERRAL OR CHOOSING THE PSYCHIATRIST

Let us look at typical situation where a person comes to a psychiatrist for evaluation because of depression. The most common sources of this referral would probably be from one of the following (or a combination )

1- Primary care physician refers the patient
2- A non psychiatrist mental health professional who is treating the patient in psychotherapy refers the patient for medication
3- The patient is self referred either finding the psychiatrist at the recommendation of an acquaintance or the patient finds the psychiatrist through the Internet

The referral might be influenced by finances and by insurance considerations. The patient may be going to a low cost clinic or they may need to find a psychiatrist who is on a particular insurance panel although insurance companies will often allow their subscribers to see an “ out of network” doctor and will cover part of the fee. Many private psychiatrists have either opted out of the Medicare program or are not accepting Medicare patient so this will also have to be determined before choosing the psychiatrist.

The patient calls the psychiatrist and makes the appointment. The initial appointment is usually 45 minutes – 1 hour. It is perfectly appropriate to discuss the fee and any questions about insurance coverage on the phone

THE INITIAL PRESENTATION

The psychiatrist would take a careful history and look at the reason that the patient is coming ( in this case depression ) and examine the development of this symptom and circumstances around it. Similarly the presence of any other symptoms, problems or difficulties would be carefully examined.

After looking at any of the issues which the patient brings up, the psychiatrist would ask about many other symptoms which may not have been mentioned by the patient such as anxiety, phobias, obsessions and compulsions, sleeping difficulties, appetite or eating difficulties, sexual problems, paranoid thoughts, auditory and visual hallucinations, suicidal thoughts and actions, anger, irritability, racing thoughts, grandiose feelings, short term and long term memory problems, confusion, tiredness, excess energy, dreams, nightmares and a bunch of other things. There would be questions about a history of traumatic events, recent loss and grieving as well as any history of substance abuse including alcohol. The psychiatrist would ask about a history of previous treatment for mental disorders and any psychiatric hospitalization. There also would be a review of any family history of psychiatric disorders. Also, not necessarily in this order the psychiatrist would learn about the patient’s interpersonal relationships with the people in his or her life. This would include getting some preliminary understanding of the patient’s childhood and relationship with close family members. It would also be important for the psychiatrist to understand about the existence of any medical problems, previous medical treatment as well as any medication that the patient may be taking .

WHAT CAN THE PSYCHIATRIST CONCLUDE?

Most of the time at the conclusion of the first interview the psychiatrist will have at least a tentative diagnosis related to the depression and any other condition that the patient may have. It may be that the psychiatrist feels that some medical tests are in order such as a test for low thyroid functioning which can cause depression. The psychiatrist may want the patient to have a neurological consultation or even some brain imaging to rule out something like a brain tumor although that would be quite rare. The results of a physical exam and lab tests may be useful in making the diagnosis and in determining which medication can be utilized if that is being recommended. Most of the time a tentative diagnosis and a recommended treatment plan can be instituted before all the results of any requested medical consultation or tests are received.

For the this discussion, let us assume that the patient doesn’t have any other major psychiatric disorder other than a major depression. There is no substance abuse use, schizophrenia or bipolar disorder or underlying medical problems. Let us also assume that at the time of the consultation the patient does not require hospitalization for suicidal or other dangerous behavior including needing treatment for substance abuse. If the patient was having a first major depressive episode or if it were a repeat episode it would mean that he or she were having significantly depressed mood with possible problems in sleep, appetite, concentration as well as diminished interest and pleasure . The patient may be feeling worthless, guilty and having thoughts about death and suicide even if they didn’t have an active plan to kill themselves. There are other symptoms also and they all don’t have to be present. Most likely the patient isn’t functioning well socially or at work . Even if most of these symptoms are not full blown, it has the potential to get worst and the fact that patient has sought out help indicates that he or she is having a difficult time.

ANTIDEPRESSANT MEDICATION

Anti-depressant medication may well be the treatment of choice to alleviate many of these symptoms. It is most likely going to take at least 4 weeks to get a significant improvement if this medication is going to work.
The dosage may have to be adjusted and the patient will have to be monitored for side effects and possible worsening of symptoms including the potential of becoming a serious suicidal threat. In some situations more than one medication may need to be utilized.

PSYCHOLOGICAL FACTORS

Thus far we haven’t factored in how important are the psychological factors in the patient’s life. Self image, personality, realistic issues in the environment, interpersonal conflicts, failure to achieve goals in school, work and in love can all be an important part of the equation. While improvement in the patient’s mood may very well occur with medication, this is no guarantee that these other issues will improve. Therefore psychotherapy should be considered as the main treatment recommendation. It is true that when a depressed mood lifts, a person is often better able to deal with certain problems. But on the other hand a antidepressant is not going to change deep seated neurotic symptoms, self image and serious relationship problems.

COMBINATION OF MEDICATION AND PSYCHOTHERAPY

Even objectively looking at basic depressive symptoms there is a lot of research that shows that some form of psychotherapy with medication is better that either one of these modalities when the problem is depression.

Of course the recommendation for treatment will also have to take into account, the age of the patient, life circumstances, social supports etc. However in most cases a combination of psychotherapy and medication is often the treatment of choice in the above situation. In cases of a recurrent depression, it may be that the person has previously had psychotherapy and a reinstitution of medication is all that is required or that the patient has done well on medication alone in the past.

WHO DOES WHAT ?

Many psychiatrists such as myself do psychotherapy and also can prescribe medication. Ideally many prefer to do both with a patient when it is indicated. Some psychiatrists only do psychopharmacology and would refer the patient to someone who does psychotherapy. If a patient is referred to a psychiatrist by a non-psychiatrist therapist, then the psychiatrist would prescribe the medication and the original therapist would usually continue the psychotherapy. This requires collaborative therapy in which the patient gives permission for communication as needed between the two health professionals. The psychiatrist would have to decide on the frequency of follow-up visits to adjust medication which can usually be done in time limited visits and the two professionals may have to talk periodically to decide if the treatment needs further adjustment. On some occasions, the psychiatrist may feel that the depression does not or may not require medication but rather there should be a trial of therapy first. This means that if there is a non psychiatrist therapist who referred the patient to the psychiatrist, that person would have to be comfortable in continuing the therapy without medication. Medication could always be reconsidered at a later date.

Another variation would be a trial of medication perhaps with continued psychotherapy and then perhaps a trial off the medication as the psychotherapy continues. Sometimes a non-psychiatrist physician will be comfortable in prescribing medication but might periodically want a to consult with a psychiatrist who would see the patient for an occasional visit.

NO SIMPLE ANSWER

It would be nice if there were a simple blood test or MRI to determine the best form of treatment or even a simple test to determine whether psychotherapy will be successful. While psychopharmacology and psychotherapy techniques have come a long way in the past 50 years, there still needs to be good clinical judgment and a working alliance between the patient and any professionals working with them.

Comments are welcome from both mental health professionals as well as patients, potential patients and anyone else.

Discussion of the Patient Who Slapped a Child

During a recent blog , I presented two case histories which I thought might stimulate different points of view on how to react to the situations described . I asked two  colleagues if they would respond . Today I will restate the first case and then I will present their views. I will also print comments from readers  I encourage anyone therapist or not to weigh in on these cases in the comment section .

Case #1

The patient is a 26 year old young women who came into therapy because she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child and when she was older she would visit him and his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs. She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and she had 2 or 3 brief trials of therapy in the past 3 years including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically oriented psychiatrist who has decided not use medication at present. She has been coming for 4 months 2x/week ( Tuesday and Friday). She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?” The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s 15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it and slapped him real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the legal and therapeutic implications ?

Response from invited discussant Myron L. Glucksman, M.D. Dr. Glucksman is a psychiatrist and psychoanalyst practicing in Redding Connecticut and New York City. He is a Clinical Professor at N. Y. Medical College and a training analyst at the Psychoanalytic Institute at N. Y. Medical College.

In my opinion, the therapist has no legal obligation to report the slapping incident because, so far, it is an isolated episode and apparently did not result in a serious injury to the child. The therapist should explore the patient’s feelings about her behavior; in particular, her angry feelings when she feels disappointed. I suspect that her anger is, in part, connected to her feelings of rejection and abandonment by her alcoholic mother. Evidently, she was not adequately nurtured as a child, and was exploited by both her parents in regard to having to take care of her mother. As a babysitter, she again finds herself in a similar position and becomes enraged when the child spits on her – re-stimulating feelings of rejection and humiliation. However, I believe the therapist should warn her of the legal consequences of similar abusive behavior toward the child or others in the future.

Response from invited discussant Sheldon Frank. M.D.

Dr. Frank is a child and adult psychiatrist practicing in South Florida.

There is no doubt that the information must be reported to the state child protective services immediately, with, of course, communication to the patient that this is being done. The legal and ethical mandates are clear, regardless of effects on the therapy. The therapy may perhaps be unaffected or strengthened–though not necessarily. Certainly a therapeutic relationship which covers up a reportable abusive act and denies the possibility of future risk to this child or other children being cared for by the patient does not help her in the long run. The outburst of violence on her part was so impulsive, so over-reactive to the baby’s acting like a baby, that even her sincere conviction that she won’t do it again is suspect. In addition to dynamic interpretation, the patient might benefit from other psychiatric treatment tools. Her life pattern, her complaint about not finishing things, and, perhaps, this outburst, may reveal adult ADHD (a continuation of childhood ADHD). (One can’t say from the data in this case, but ADHD children are much more likely to be slapped, neglected, and/or abused than other children.) A trial on stimulant medications is a safe and effective way both of confirming the diagnosis and treating. Alternatively, a search for mood swings and bipolarity might establish a mood-based origin of her action, and a mood stabilizer could help her self-control. We child psychiatrists often confront these diagnostic alternatives, and usually opt to test first the ADHD possibility because of the rapid onset and cleaner side effect profile of stimulant medications.

Since the account came out at the end of the session a day before the next baby-sitting engagement, there is a quandary as to how and when communicating the report mandate to the patient is handled. Some state laws require a report within 24 hours of receiving the information–which is defined as information containing the suspicion of abuse/ neglect. (It is the agency’s job, not the therapist’s, to distinguish between abuse and, say physical discipline.) Hopefully, the child protective agency would act promptly. Professionals have the right to anonymous reporting, so the agency would not tell the patient the source of the report–it could have come, after all, from the child’s parents. Still, the chance of the therapeutic relationship being damaged is greater if the therapist waits until the Tuesday session to deal with this complication. If I were the therapist, I would call the patient and ask her to return the same day to continue the session, and use that extra time (? without extra charge) to communicate to her the necessity of reporting. The therapist didn’t answer directly the patient’s question on confidentiality; if pressed, he could have reminded her that the only exceptions were situations in which there was the danger of harm to herself or others.

Initial comments from readers of this blog :

Well, when you said “dilemma” you meant it. In the first case, it weighs the betrayal of trust of a confidential relationship for someone who appears to be genuinely interested in changing her anger responses, against the safety of a very young child from abuse. My response given the details here would be to file a CPS report, and talk to the patient about the legal reasons why that had to be filed in a candid way and trying to help her see the situation through several points of view. Though it would be tragic if the therapeutic relationship were not strong enough to withstand this, a child’s safety must take precedence.- Heather Fretwell

I certainly agree with Dr. Glucksman in this mater.  Dr. Franks by the book, rather concrete approach is useless and harmful, as long as the patient is cooperative and open to suggestions.  There is a question though of whether the child might need help in understanding and digesting what happened so that a traumatic scar is not left in his mind.  I might have insisted that the patient talk this over frankly with the parents and take whatever steps are needed to protect the child and see to the child’s mental health.
Arnold Robbins MD.
Cambridge, MA

Responses and opinions from any readers of this blog are welcome and will be added as comments. The second case will be discussed in a future blog

 

 



 

 

What Should a Therapist Do in These Situations?

Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas . Two cases are presented below which bring up potential legal and ethical issues as well as technical considerations, which the therapist has to take into account to best help the patient.

These vignettes are based on real cases which I have  either been involved with as the therapist or as  the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision.

In a future blog, I will present further discussion about these two cases.

Case #1

The   patient is a  26 year old young women who came into therapy because  she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents  were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child  and when she  was older she would visit him and  his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs.  She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and  she had 2 or 3 brief trials of therapy in the past 3 years  including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically  oriented psychiatrist who has decided not use medication at present.  She has been coming for 4 months 2x/week ( Tuesday and Friday).   She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?”  The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s   15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it  and slapped him    real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the  legal  and therapeutic implications ?

 

Case #2

A senior therapist  is supervising the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor t have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ? 

Telepsychiatry Today and Tomorrow

Three examples are discussed where he author has become involved in the delivery of psychiatric treatment via telepsychiatry (video conferencing). The first is in a county rural mental health clinic in California. The second is in conjunction with the Chinese American Psychoanalytic Alliance (CAPA) where mental health professionals in China who are in a training program provided by American teachers via SKYPE ( video conferencing) desire to have their own personal one to one psychotherapy by this technique. The third is psychotherapy in the United States for private patients who for a variety of reasons find it more convenient and feasible to have their therapy via telepsychiatry.

A county rural mental health clinic in California is set up to provide  psychiatric  services to the surrounding area but there aren’t enough psychiatrists in the area who are able to travel to staff this clinic morning and afternoons five days per week.

An  American  training program for mental health professionals in China provides classes via telepsychiatry (via video conferencing ) but many of the trainees wish to have their own therapy by experienced therapists who are in quite short supply in China at this time.

There are highly functioning productive people in the United states who are in occupations and jobs which often take them out of town or have long commutes to work with irregular work hours. This situation makes it quite difficult for them to arrange  psychotherapy with experienced psychiatrists  which would require them to come for sessions at least once per week.

During the past year I have become involved with devoting part of my practice to telepsychiatry and am now offering therapy in each of these three situations.

When I agreed to provide treatment one morning per week to the above mentioned clinic I already had experience in teaching courses online with video conferencing but I had not treated patients with this modality. I knew that some of these patients might have complicated mental illnesses which would require complex medications and that some might have to be hospitalized. I was aware that certain paranoid patients could be suspicious of electronic communications and some patients might require a translator if they did not speak English. I was pleasantly surprised to find how smoothly everything was able to run. A mental health nurse is in the room with the patient and a translator was available when needed.  The patients understood the concept that they were being seen by a psychiatrist in another city via video communications. We had a clear face to face discussion and the patients seemed as comfortable as in any other setting in bringing me up to date on their symptoms. I had access to a very sophisticated confidential electronic medical  record where I could record my findings and check the observations of any other visits that the patient had at this clinic. I could refer the patient for lab tests as well as to a primary care physician. I also could make referrals to other mental health professionals connected to this clinic who could do individual, family  or group meetings  with the patient. I prescribed medication directly through a very efficient electronic prescribing system, which electronically connects to every pharmacy in the state. If needed I could alternately fax a prescription or make a telephone call directly to the pharmacy. On the few occasions where a patient needed an immediate hospitalization I could arrange that and provide the referral information needed by the admitting doctors. It has been a very gratifying experience to spend this time providing this needed service.

First CAPA Graduation in Beijingi

For the past year I had been teaching as part of  the Chinese American Psychoanalytic Alliance (CAPA),a very innovative program  founded by a friend and colleague Dr. Elise Snyder.This program uses video conferencing mostly by Americans who provides high quality training to mental health professionals in China who previously had very limited access to this type of training. The program has grown and become quite in demand by young Chinese professionals embarking  upon a career in providing mental health treatment in China. One year ago I participated in study tour to China with CAPA where I had an opportunity to give a few lectures and also witness the first graduation from this program which was held in Beijing. In conjunction with such training, it has been common for the trainees to arrange their own personal therapy. Unfortunately for a variety of reasons, there has been a lack of therapists  who could offer such treatment to the trainees in China. Many of the Americans who have been teaching in this program have offered to treat such a Chinese trainee via telepsychiatry ( video conferencing) as did I. Due to the wide disparity in income between Americans and most Chinese, such treatment has to be offered at fraction of the usual fee received by American therapists in the United States. The trainees usually speak English quite well but there are at times interesting challenges related to the nuances of the meaning of words as well as in understanding various cultural differences. The fact of there being a “ one child policy”  in China means most of the trainees have grown up as an only child which has important psychological significance. Most Americans are not familiar with the Chinese concept of “shame” which reassembles but is quite different than “depression” which can be an important part of the childhood experience of growing up in China. Participating in this program as a therapist has also been a gratifying and interesting experience which I am pleased to continue.

The third situation which I described above, reflects an anticipated  shift in the  attitudes of many Americans towards  technology and psychotherapy. This change, I believe, is taking place in both patients and therapists. I practiced psychiatry in Manhattan as well as in a suburb of New York City  and more recently now in Los Angeles. I have seen  many sophisticated patients who chose their psychiatrists by referrals from trusted physicians or friends and would rework their schedules to make regular sessions, often in the early morning or evenings. People tended not to change jobs very often and it was common to have an entire course of  therapy with one therapist. Now days people commonly choose their psychiatrists after a careful investigation of their credentials and background online. Since the Internet is used for obtaining other important information it seems natural for  so many people to rely on the Internet and feel comfortable in evaluating information available on it. It is a known fact that people are changing jobs much more frequently, even in  higher paying positions. Therefore, one can’t be confident that a therapist in one location will be convenient to see at a later date. It seems that time is even at a greater premium than it was in the past. Commuting time is longer especially in a city such as Los Angeles and work environments frequently require people to be quite flexible. This means working at home at times, traveling when needed and irregular hours. Certain occupations such as the entertainment industry in Los Angeles requires long periods of time out of town as does pilots and airline personnel to name just a few. There is  increasing comfort with modern technology illustrated by  the growth of the use of video conferencing in business and education and the personal use of texting, Skyping , Facetime etc. Therefore it is inevitable that there will be a shift in the practice of medicine to use more telemedicine and for psychiatrists to use increasing amounts of telepsychiatry.  Therefore, I was very interested when the California Telepsychiatry Group (also now American Telepsychiatry) ,who were running the services for the mental health clinic described above, asked me if I would be interested in devoting some time to seeing private patients with their group.

I spent some time talking with their Director Dr. John Schaffer and I was impressed how they have arrange their video conferencing, electronic records and electronic prescribing to be HIPPA compliant (meaning state of the art confidentiality techniques) . They had addressed the various legal, ethical and questions of malpractice insurance and were carefully vetting the psychiatrists who would work with them. In addition they set up a very novel and interesting “meet and greet system” where potential patients, at no cost, could have a preliminary 10-15 minute   telepsychiatry meeting with any of the psychiatrists available for treatment . They could therefore review the credentials and experience of potential therapists, as well as meeting them, before they decided to enter into treatment. I am very pleased to now to be connected to an entity which I believe is on the cutting edge of a system for providing quality psychotherapy with this modality.

I suspect in 10 years from now or less,  people will look back on the three examples which I described above and see them all as every day occurrences in the delivery of mental health services in this country and throughout the world.