Across and Inside my Universe

The Cheapest Care Possible

I don't want to offend any nurses out there, especially the ones who can prescribe.

BUT, when you have as many co-morbid (proper term?) psychiatric conditions as I do, AND especially when you have as many chronic physical health conditions as I do, you really would feel most confident having a psychiatrist, an actual DOCTOR, prescribe your psych meds, since you have so many conditions and medications that can interact with each other.

Now, as I'll apparently be seeing an A.P.R.N, which is a psychiatric prescribing nurse? I'm sure that they have extra education for that, and plenty of experience since they are working for the county's behavioral health system, and see the most disabled and/or severe cases, since they only serve those with Medicaid/Medicare. Lots of people on disability with either of those insurances, so this would be where they go . . . the LCSW I saw for intake interview went out of her way to reassure me that the nurses see severe cases and are very capable (does this mean she thought I was a severe case, or just that knowing they treat severe cases all the time means they are competent to treat anyone?). I got the impression that seeing a nurse instead of a psychiatrist for meds is something alot of people aren't the happiest about.

Anyway, while I'm sure these nurses are capable in many cases, I just feel like I have so much going on both mentally and physically that I'd only be really comfortable knowing a doctor was seeing me; how can I know that these nurses know enough about all the physical health stuff besides the mental health stuff to be able to manage all the issues?

Then again, who WOULD be happy that they'd be seeing a nurse for what they've traditionally thought is a doctor's role . . . I think this is partly based on that, but still . . .

There is part of me that feels like, because this is a government-funded mental health care system, as well as government funded reimbursement for them, that this is why they use the lowest-level providers possible; I was told that they do have ONE psychiatrist, but I'm guessing he only gets sent the most complex or resistant of cases. I was told I'd be seeing a nurse.

I feel like, because I am dependent on government assistance for this, that I will be receiving a lower, cheaper (not necessesarily incompetent) level of care than I would if I had private insurance. I don't think you can argue that these nurses AREN'T less expensive than psychiatrists, which means they are cheaper (although I am not trying to imply that their care is valueless or without dedication, expertise, etc. - it costs less and is less educated than a doctor/psychiatrist, though, is all I'm saying). This makes me feel like I am a second-class citizen, but then, without regular insurance, I kinda feel that way anyway.

I'm sure if something like this was posted over at Shrink Rap, there'd be an outcry from prescribing nurses, and maybe even non-prescribing ones . . . the thing is, though, I feel that prescribing nurses should SUPPLEMENT what a doctor does, not REPLACE them, and it feels like in this case they are being used as replacements. THAT is what feels wrong to me, what feels like I am being given the least expensive care they can get away with.

I'm also annoyed at all the hoops and forms I have to jump through and deal with just to see a nurse . . . I'm sorry if that offends anyone, nurses are very valuable, but I do NOT, I definitely do NOT see them as the primary provider of the medical side of my mental health care. I do not think that is appropriate.

I'd prefer something like initially seeing a psychiatrist, or a psychiatrist with the prescribing nurse present (they'd never do that last, too expensive) for the first couple of appointments and then see the nurse the rest of the time, with maybe a twice yearly check by the psychiatrist; more often if moderate to high problems come up. THAT seems like it'd be more, well, working with both a doc and a prescribing nurse . . .

I guess this post is amounting to a big whine, that might affront a variety of nurses . . . but it's how I feel, and I don't think REPLACING psychiatrists with prescribing nurses is a good thing for mental health care. Supplementing, okay, I can work on getting used to that . . .

I'll have to get used to seeing just a nurse, I guess, but I will not be happy about it. And here I thought I'd come to a new, more open mind about my next shrink, about being more open-minded, more open to different personalities and learning whatever comes to be learned from them. Turns out, I don't get a shrink at all. I'm feeling like I, and other Medicare/Medicaid people, must not be worth it, in the eyes of the government and the people who vote in the people who fund or restrict how such places are staffed.

 

What You NEED Isn't Always What You WANT

So, a while back I posted for a heat-themed Grand Rounds blog carnival that was being hosted at/on Shrink Rap. http://sarebear.typepad.com/blog/2011/06/when-the-doctorpatient-relationship-becomes-heated.htmlUgh, I tried to insert a link the regular way, and it wouldn't.

This last week, for no reason I can figure out, I was thinking about that post, and how it led me to compare my first and third shrinks, and then further led me to realize that I could stand up to my first one (male) and not my third one (female). They were both strong, intimidating personalities. My second shrink was very laid back and mellow.

I thought to myself, "WHY could I stand up to Doctor Number One, and not to Doctor Number Three?" (Names changed for obvious reasons.)

Within about 10-15 seconds, a quiet, deeply felt thought came to me in response, even though I wasn't expecting a response . . . . "Because it was standing up to your mother that got you on the receiving end of her fist." I instantly felt the deeply personal TRUTH of this, and it felt like I'd connected up an essential puzzle piece.

I pondered then, though, that, "Didn't I already "know" that my problems with her were because she raised the same feelings of fear in me that my mother did? That I had already connected up what my mother did to me, with why I was afraid of Dr. Number Three?" What I realized was, I had intellectually realized the connection between #3 and what my mother did, and I'd even told #3 that I was afraid of her because my mother hit me; however, I'd never FELT this inside. It just made sense to me knowing how transference has shown up in the last 7 years of therapy, it just made SENSE. Yet I didn't FEEL it.

THAT's what the difference was when I had this response, this realization this last week. I FELT the truth of this, and it connected everything up on an emotional and other deep levels. It's one thing to KNOW something with your head; it's another to know it in your heart, in the depths of your being, not to get overly dramatic about it . . .

So, it's been a week since that realization, and I've come to another one because of it, and that is that I can now use the word "abuse" to describe the physical, well, abuse that my mother heaped upon me when I was a young teenager (and maybe pre-teen, but that part's fuzzy). Before this, I said in therapy that I just couldn't approach that word because it felt like it was too big, too painful, that the meaning of what she did to me would crash down on me and I couldn't . . . . I tried the word on, especially after my therapist asked me if I would think what my mom did to me was abuse if I heard of someone doing the same thing to their kid, and I said yes, at first, but after that session, I realized I'd HAVE to say NO, because I couldn't, just couldn't, approach the meaning of the word "abuse" and all the pain denying it was "abuse" was holding back.

I did try to cut through the bull a few days after that session, and say, "Really? Your first instinct was to agree that yes it was abuse for someone else, isn't it just you dancing around what's going on, to later say No?" And I thought, maybe it was, but it just felt too dark and horrible . . . this was about two months or so ago (not counting the first times I avoided approaching "abuse" several years ago when I first brought it up in therapy in more than passing.)

Back to the main point(s) of this post . . . Today I was thinking that I am actually quite GRATEFUL to my most recent psychiatrist, much as I dislike her, for helping me (not consciously on her part, as far as I can tell, given her objection to the notion of transference) to make more progress on a difficult, painful issue than I've ever had. For being what I NEEDED, even if it wasn't what I WANTED.

I realized, and I never thought I'd feel or say this about her, that I am GLAD she was my psychiatrist at this time in my life; things just came together to help me learn from her, and I can take what I've learned and appreciate both it, and the fact that she taught me, willingly or not, something that I'm not sure I'd have learned any other way.

Now, I am moving on and finding another psychiatrist. Could I perhaps have learned further from her, in dealing with her and processing my reactions, about how I feel about what my mom did to me and perhaps some measure of how to get over it? Perhaps. The thing is, I also NEED a psychiatrist I can trust, and I can't trust her to be emotionally safe, or to treat me and my feelings with respect. At this point, I think the "what if" of what I could learn from her is outweighed by my need for a safe psychiatrist; that, and it's an hour round-trip to see her and since I need to ask congregation members for rides to get to appointments sometimes, I really need a closer shrink. This next one is about 15-20 minutes away, which isn't as close as I'd like given I'm asking for rides, but it's better.

I am also quite grateful to the part that Shrink Rap played in my coming to these helpful insights and things; if it weren't for them hosting Grand Rounds, and picking the theme they picked, I'd not have come up with that blog post during the writing of which I realized the things that started off this chain of realizations. So, while they may have played a small part, it is an important part, nonetheless, and I am grateful to them for it. It also teaches me that maybe I should put myself out there more and participate more in things like this . . . Anyway, thanks guys (not that I know if they read my blog or not lol.)

When The Doctor/Patient Relationship Becomes Heated

I don't pretend to be an expert on this, or that what I have to say is, in fact, all that earth-shattering on this or any matter.

Still, ever since the Shrink Rappers announced a "heated" or "hot" theme for the upcoming Grand Rounds to be hosted on their blog very soon, I have NOT been able to get the above-titled topic out of my head . . . and so, I will get it out of my head and onto my blog, no matter any reservations I have about being so forward as to submit something for Grand Rounds . . .

I have had two different heated exchanges (actually, they were alot more one-sided than exchanges, with the heat all coming from the doc) with doctors, both of them psychiatrists. One male, and my first psychiatrist, and the other female, and my third and current psychiatrist.

I think it is a negative thing for ANY doctor to yell at or harangue/browbeat their patients, but I feel that with psychiatrists, even when seeing them just for medication management, that since it is usually expected that psychiatrists be sensitive to one's feelings etc., that when they act disrespectful and "heatedly", it's even a bit MORE jarring than it would be from another medical profession.

Now, doctors are human. They are not perfect; they have feelings and good days and bad days and life crises all happening just like the rest of us. I can understand this, and, in fact, in one of the two cases I mention above, it really helped me deal with the episode. The other episode, with my current, female psychiatrist, is harder for me to deal with, and in fact it still bothers me a great deal.

Before I get into specifics, let me say that as a patient, when you are sitting there on the receiving end of some "heat", or ire, or intense aggravation, or anger, even, it is shocking, bewildering, and causes you to wonder what is wrong with you or what you did wrong, as the patient, to deserve what is happening. You are shocked because, if you've had enough dealings with this doctor (about a year, in my first psychiatrist's case, when this happened) you know that he normally conducts himself much more professionally; to see and FEEL such unfettered, intense, unpleasant emotion, directed at YOU . . . well to say it is bothersome is an understatement.

It directly impinges on trust; you wonder, as you get past some of the shock, if you can trust this professional with the most intimate things that you think and feel, things that are necessary for them to diagnose and treat you correctly. If you HAVEN'T had enough dealings with the doctor to know that they usually act more professionally, OR if some of your dealings with them have been laced with discomfort from feeling they are forcing their agenda down your throat, then as you sit there feeling the "heat" you may also end up in "survival mode", doing your best to survive what feels like a verbal assault, trying to get through it as best you can. In my case with my current psychiatrist, this "survival mode" kicked in without conscious thought, and I didn't identify it until later that day or the next day.

I guess I'm trying to say that perhaps some of the difference in how I feel about, and how I handled, the two different incidents, is based, in part, how my usual interactions with that doctor go; how much a partner in my treatment I feel I am with each particular practitioner, and perhaps partly based on my past history, in the female's case, with a dominant, physically abusive woman.

So, here's what happened. With my first psychiatrist, well, he's definitely a Type A personality as they say; very strong, very opinionated, but rather intelligent, always acting in a professional manner, even though he frequently had things to say to me that were difficult to hear. I didn't always agree with those things, but the times I did, were very profound. I don't believe the times I didn't meant he was right, I was wrong, and just wouldn't see it. I really felt that sometimes he didn't listen to me and would come to his conclusion before hearing everything he needed to to come to the most informed conclusion.

This became the basis for his going off on me, one day . . . he spent 25 minutes in angry discourse at me about how I go on too much and waste his time by taking up so much time. After getting over some of the shock, I thought, wait, isn't this the pot calling the kettle black? Who is taking up a bunch of time now? Wouldn't this time be better spent working out our apparent communication problem?

Basically, I sat there and quietly listened until he was done. The appointment ended very soon thereafter, and I was rather upset, although in some ways not . . . . because it was SO UNLIKE him. I also had reason to think that he might be personally going through some emotional difficulties, because the previous summer he'd been suspended by the, whatever the Psychiatric Board or authority is that disciplines psychiatrists. I believe it was an unfounded charge, based on a random meeting long after he'd stopped treating someone, but then, he COULD be rather aggressive in his opinions and ways of interacting (nothing inappropriate, just very assertive) and someone could easily resent that and want to punish him for it.

Regardless, after I went home that day I wondered if he was still dealing with the fallout from his suspension; I imagine it's not easy to get a substitute to cover your practice for 3 months, nor would it be easy to deal with the opinions of your colleagues once they found out you'd been suspended, and even harder, dealing with your patients' feelings about it. So that is what I suspected was going on, so I had an easier time dealing with this.

Still, at the next appointment he apologized for his behavior, saying something about he'd been going through something at the time. I accepted his apology and we moved on, though I did still continue to have problems with him not listening to me enough (yes, I could keep appointments to the 15 minutes, I didn't always go over.)

Eventually, he decided to close his private practice and become a consultant-liason psychiatrist at a local hospital; the timing of this decision was such that I knew he had to have been mulling it over that fall when he ripped me a new one. The deed was done less than 6 months after the harangue.

The second, more troubling to me incident, happened in January of this year with my third, and first female, psychiatrist. I'd been seeing her since the previous March, with a break at the end of summer into late fall. She has a very different philosophy, is an "integrative" psychiatrist, is Buddhist, and is a strong, dominant female personality. At various times I've felt like she's trying to shove some random agenda of hers down my throat . . .

In January, I had finally decided to tell her I was afraid of her. This is a good thing, no? Then the doctor can understand why I seem hesitant or other things . . . Well, apparently my "mistake" was in the type of insight that had led me to realize this; I had realized that because my mother used to physically abuse me, I was afraid of my psychiatrist since she was a strong female, with dominating characteristics. To me, the connection of the two seemed like a no-brainer . . . if one woman in your life beats you and tries to dominate you (there were reasons behind the hitting), then it may make you wary and even afraid of other strong, dominating women.

BIG mistake on my part. I told her straight out, "I'm afraid of you because my mother used to hit me.", figuring that psychiatrists are extremely familiar with the concept of transference . . . . She was instantly OUTRAGED upon hearing this and so angry it took her a few moments to be able to speak and then she assaulted me with angry questions about things like, was she my mother, what does one thing have to do with the other, and eventually she asked me if she was being scary right now . . . . by this point I had unconsciously retreated into "survival mode" and really could not identify ANYTHING I was feeling at that time; I tried, and couldn't feel anything, so I said "No.".

Well, HELL YEAH she was scaring me! Once I'd had some time and space between her and I, oh boy could I identify my feelings . . . . she was proving how RIGHT I was to be scared of her. She FORCED me to answer every question, in a way that made me feel stupid and insignificant, staring me down until I answered. "Do I LOOK like your mother?" "No . . . " "AM I your mother?" "No . . . " and she asked me some other things but honestly I was too traumatized to remember it all. I just remember feeling so verbally assaulted . . . .

In thinking about it now, I feel that she really missed an important opportunity, as a doctor, to connect with her patient and deal with an issue that would interfere with the doctor/patient relationship if left unaddressed. EVEN if she couldn't recognize the validity of the transference principle as something that could fit with her very strange and different philosophies, why throw the baby out with the bathwater and not stop to consider that I said I was scared of her? If she could have set aside the philosophy she couldn't stand, and seen the very real issue between us, then she would have done what was best for her patient, in that situation, in my opinion.

But, as I say, doctors are human too, and when one REALLY objects to a particular school of thought or psychiatric philosophy, perhaps that invalidated to her everything else that was attached to it in the statement I had made. I've often wondered if I had just said, "I am afraid of you", if the reaction would have been much different.

Perhaps, but perhaps not. I suspect she would've assaulted me with questions like, "Do I look frightening?" "Am I scary?" "What, specifically, scares you about me?" and when I couldn't come up with an answer, she'd satisfactorily verbally beat me down with the fact that I couldn't possibly be scared of her, just like she did this last January. But I may be being unfair; perhaps it really WAS the "unacceptable to her" psych concept of transference that was the basis for her going off on me. Perhaps she WOULD have listened if I'd put it differently, but you see, she's the doctor, and I'm the patient, and no matter what "could have" or "should have" been done differently by me, she acted unprofessionally and unacceptably towards me.

Why do I find her behavior so much less acceptable than my first psychiatrist's? Perhaps it is because she had a history of forcing her way on me . . . but then I think, didn't Psychiatrist Number One also have a strong way about him, where he tried to get me to think along his lines of thinking? Yes, he did . . . Then again, he'd never given me an ultimatum, like she had. He'd never tried ramming wierd goals for me down my throat, like she had . . .

In the end I think I can safely say that part of the difference in how I reacted to the two incidents is, indeed, related to my fear of strong, dominant women based on how my mother treated me. Part of it, though, I think is that I had more a feeling of being a partner in my treatment with the male psychiatrist; I wouldn't hesitate to stand up to him, which was saying ALOT for me, because I usually shrink from such things, and he had VERY strong opinions. Still, since I really wanted him to understand me, I knew I had to press for standing up for my view, or my experience, or my thought process that I wanted him to UNDERSTAND before coming to a conclusion.

I guess, after writing that last paragraph, it's easy for me to see now that my mother IS a big part of it; I could stand up to HIM, but not to HER.

Six months down the line from the "heat" I received from my current shrink, and I am still having trust issues, and definitely fear issues. I finally may be getting up the courage to bring up the issue with her again (sans mother), but I am not sure if I have the courage. I do hope that if she gets angry again I can tell her what I think of her unprofessional behavior . . . and lack of insight into the issues that can interfere with a good doctor/patient relationship.