Things to worry about...

This year I will have been doing what I do for 38 years. I started out in community mental health, in the heyday of that movement back in the early 70's, and in those days I worked with young children and their families. My first job was to design and direct a therapeutic nursery school program in Lewiston, Maine. In those days we really embraced the idea of a multi-disciplinary team and on my team, all of the professionals had an equal voice. So the classroom teacher was seen as having the same degree of importance as I, the psychologist, or our consulting psychiatrist. We talked about the kids and families we worked with and developed treatment plans *together*. And we were working with some pretty disturbed kids from very chaotic households. In the nearly 3 years I worked there, I could count on the fingers of one hand the number of children who were placed on psychiatric drugs and none were diagnosed as bi-polar because in those days we did not believe, nor do I today, that such a diagnosis can be made in kids that young. Our operative assumption was that by working in the classroom with the kids, and working with the parents, often utilizing paraprofessionals who spent time in the home, we could make a big difference in the lives of these kids and their families and head off serious problems later. And, we were pretty successful.

The key to what we did was that we really worked as a a team. Three years later, after the first couple of rounds of draconian cuts in funding for community mental health, things changed. And in my next job, in a satellite clinic which was part of a large medical center, there was hardly more than lip service given to the notion of a team of professionals, all with important and unique skills. In that setting, I had to present my cases in staffing conferences each week and get the approval of the psychiatrist for my treatment plan. I still worked with young children and I also did school consultation. This psychiatrist had no training in working with children and knew nothing about school consultation, yet he had to approve any plan I made and he could modify them. I was seen as something of an extension of him rather than as a professional in my own right. That was when I left to enter private practice.

I am a big fan of Ars Psychiatrica. He impresses me as someone who is thoughtful and careful in his work. We don't always see things the same way, but he makes a thoughtful case for what he does, as indeed I hope I do as well.

In his most recent post on antidepressants he says:

But if, as the commenter to the previous post suggested, the primary function of the doctor must be the relief of suffering, what happens when the doctor's tools are in fact too weak to accomplish this, or what is more complicated, what happens when the effect of those tools is owing to their wielders' social power rather than to any inherent properties (i.e. the placebo effect)?

Which I believe gets to one of the nubs of the problems we are seeing in the field today. And some of that is about the hierarchical system which still prevails. In private practice, it is very rare, in my experience and that of therapists I know well, for a psychiatrist to really talk with therapists about what we all do and how we can best, together, meet the needs of our patients. That kind of time is certainly not reimbursable, which is one factor that probably operates against it at least unconsciously. But it is also about how we think about each other and how we see our responsibility to relieve suffering. And then of course there is the influence of insurance companies.

There is another horrific story of over-medication of a preschooler in today's New York Times . Sadly these stories no longer surprise me, though it is interesting to me that it is in the business section, not health. We have heard over the last year or so about the awful fact of high numbers of poor children and children in foster care being on psychiatric medications, and often those medications are atypical antipsychotics. So that fact is not new. But look at what one of the doctors quoted in the article says:

Dr. Edgardo R. Concepcion, the first child psychiatrist to treat Kyle, said he believed the drugs could help bipolar disorder in little children. “It’s not easy to do this and prescribe this heavy medication,” he said in an interview. “But when they come to me, I have no choice. I have to help this family, this mother. I have no choice.(bolding is mine)

and later

“But if you will commit yourself in giving these children these medicines, you have to have a diagnosis that supports your treatment plan. You can’t just give a nondiagnosis and give them the atypical antipsychotic.

The desire to help is certainly admirable but the first intervention is not behavioral; a behavioral intervention came only a couple of years later when this child was on his way to becoming a psychiatric cripple. The behavioral approach was a last resort rather than a first one. 

I am not working with young children any longer. But I worry about them and I worry about us too and what we are doing. And wonder why we can't find a way to talk to each other about how we can help each other in our work. 
© Cheryl Fuller, 2016. All  rights reserved.