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Articles    H3'ed 9/7/11

Reflections upon transitioning to private practice

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Just over two months ago, I left the community mental health center where I worked in New York to begin private practice in Vermont.   I wanted to reflect upon the differences I am finding between a private practice model and the community mental health center model.   Of course, New York and Vermont are very different places.   One feels this on crossing the border.   Suddenly, everything is organic.   Even the gas stations present fair-trade organic coffee and have a section of Vermont products, from maple syrup through beer and wine.   This morning I stopped at a gas station in the small town of Hartland, Vermont, which offered up a dazzling array of organic Vermont products including locally brewed beer.

A short story will explain this well.   A man came to see me who was feeling like killing himself.   He was sad all the time and short-tempered.   He claimed that he wouldn't act on his wishes, because of his son, for whom he was the sole parent.   I believed him and we made an agreement that he wouldn't attempt to harm himself.   He had already wisely given his hunting rifle to his brother (this is an important question in Vermont; whereas in New York, it was more about the hand gun!).   I started him on two medications -- 25 mg of desipramine and 2 mg of aripiprazole.   I chose the desipramine because he showed elements of difficulty paying attention and concentrating, and this drug had once been used for Attention Deficit-Hyperactivity Disorder.   He also was not sleeping and desipramine is known to make people sleep, at least until they adjust to that particular side effect.   He was 40 years old and athletic and I wasn't worried about any of its effects on the heart as I would have been with an older person.   I chose aripiprazole because he was excessively fearful and suspicious.   He thought people were whispering about him when he left the house, so he avoided leaving the house.   He worried that someone was inside the house at night, so he compulsively checked under all the beds and looked in every closet before lying down to sleep.   He heard buzzing voices but couldn't make out what they were saying.   He had a tremendous sense of impending doom, thinking that at any minute something terrible would happen and he would be struck dead.   He worried that this would be at the hands of someone he had wronged, though he couldn't imagine who that would be or that it would be a random act of nature, such as a lightning bolt or a tree falling on his head. I also chose aripirprazole because gaining any weight was unacceptable to him given his athletic tendencies, and most of the other similar drugs result in weight gain. I gave him his prescriptions and made an appointment for one week later.

What's different about this scenario?   In New York, he would have waited for several weeks to see me.   He would have had to have an interview with a social worker first and would have then been sent to me for medication management.   I would have had 15 to 30 minutes with him instead of the hour that I spent.   I could not have seen him again for two months and would have had to have him see a nurse in several weeks for follow-up.   In New York, private psychiatrists are paid $7 per visit (so I was told by a private psychiatrist in Rochester) by New York Medicaid, which makes them unwilling to see Medicaid patients.   The community mental health center, in contrast, because it is a designated facility by the Office of Mental Health, receives $172 per visit (according to one of the administrators there).   Vermont Medicaid, in contrast, pays about $110 for the first visit.   Afterwards, it pays about $60 for a medication visit and up to $110 for medication management combined with one hour of psychotherapy.   I could afford to see him every week.   In fact, I make more money in private practice from Vermont Medicaid than I made working for the community mental health center and I get to see people for an hour instead of 15 minutes and the State of Vermont actually pays less overall than the State of New York did to care for a similar man.

I saw this man every week for three weeks.   We adjusted him medication to a dose of 50 mg of desipramine and 5 mg of aripiprazole.   He is feeling much better.   This is a "born in the hills" kind of man.   He had never been exposed to psychotherapy.   He probably didn't know we were doing cognitive behavior therapy (what I call Buddhism 101).   On the MYMOP2 scale (My Medical Outcome Profile) which I use to track improvement, his level of distress had dropped from the top number of 7 to a number oscillating between 4 and 5.   At the next visit, he asked me if he could come every other week.   "So long as you're not thinking of killing yourself," I told him.

"I'm not," he replied.

"Well if you start thinking that way again," I said, "you'll have to go back to every week."  

"That's a deal, doc," he said.

In relatively short order, we had moved him from crisis level to a more mundane level of psychiatric urgency.   I would argue that this was much more cost effective and health effective than what could have been done within the constraints of the community mental health system in New York.   He has my phone number and can call me if problems arise.   I could work him into my schedule the same day if need be.   So why wouldn't New York want to encourage private practice?

Since I didn't know the answer, I asked a number of New York psychiatrists and mental health providers.   The most common initial answer was that the State of New York doesn't trust us not to "rip them off", to say that we're providing care, and not do it.   With the community mental health system, they can come anytime and audit charts and demand money back.   The volumes are sufficient that the money they get back is substantial.   With private practitioners, the volume would be lower and auditing visits would be less cost effective.   So New York is willing to waste money in order to get money back at the cost of less effective care.   There may be other reasons, too, and those I do not know.

I have noticed another difference between New York and Vermont medicine.   In Vermont, family doctors are readily willing to take over prescribing psychiatric medicine for patients if they know they have support and can call when there is trouble.   In New York, I could only convince one family doctor to do this, thereby resulting in a slew of 15 minute appointments every three months for people who were stable and could have seen their family doctor.

Personally, I do not believe that this man's improvement was all medication.   I believe that our relationship played an important role, including his knowing that I was there for him, that he could call me and I would respond.   I "held space" for him, which is radically different from what happens when a patient sees a different practitioner on every visit.   The theory is that all doctors should practice the same and that relationship shouldn't matter compared to the powerful drugs.   But most of us know this isn't true.   Psychotherapy outcome shows that relationship is crucial and that it does matter very much in outcome, perhaps being the primary factor.   I completely believe in the power of placebo, or what Herbert Benson of Harvard calls the "self-healing response".   Perhaps placebo is our most powerful medicine, but placebo operates best in the context of a relationship.   It's harder to believe that a mental health center cares in the same way as it is to believe that a single human being (me in this case) cares.

My client lives with his new girlfriend and some of his distress relates to their relationship.   In time, I hope to convince him to bring her with him.   I hope to engage them in learning how to dialogue with each other.

I am convinced that healing occurs through dialogue, through the kind of dialogue that he and I had and through the kind of dialogue that he and his girlfriend could learn to have.   Currently, I suspect that they talk at each other and not with each other.   Hermans and Hermans-Konopka have written a powerful book on Dialogical Self Theory in which they explore these concepts more fully than I could have articulated them prior to reading their book.   They have spent more than one life time (combined) studying dialogue and have come to an understanding that dialogue changes each participant in a conversation.   Monologue does not .   Mostly I fear we talk in order to make our point and not in order to share with another.

This idea was very apparent to me at a weekend conference I just attended -- the 28th International Conference for the Scientific Study of Shamanism.   I watched people interact in the "discussion" sessions held after each series of talks.   Mostly people asked questions in order to state a point.   The person asking the question did not really want an answer from the presenter and the presenter had a point to express that often ignored the gist of the question.   I thought that we need dialogical sessions rather than questions and answers, which is part of the old paradigm in which an expert knows something that we need to absorb.   Having read Hermans and Hermans-Konopka's book, I am trying even harder than before to listen carefully and to find what points of agreement even with those who disagree with me.

My talk at the conference was about the healing power of community and particular the role of the shaman (I call them intercessors, since shaman is a Telengit word from a particular people in Siberia that translates as spiritual healer).   I talked about how we couldn't heal by ourselves if everyone around us believed that we couldn't get well.   We needed to convince all those around us that we can heal and that we will heal and perhaps are even already well.   This is what a good intercessor does, I said. He or she convinces others that the patient can get well.   These others include spiritual beings as well as actual living relatives and friends.   This is what I tried to do for my client, though indirectly, for he has not brought any of the members of his social network to my office.   A Buddhist scholar took issue with me.   He argued that people can change all on their own with enough work, though slowly.   I completely agreed with him.   I just made the point that many of my clients are ill with life-threatening illnesses or serious psychological suffering and don't have the time to retreat from life or to learn the contemplative paths, though that would be wonderful for them and very healing.   He was satisfied and we could continue to find more points of agreement.   I learned through self-reflection that our first impulse (mine, at least) is to listen for how we disagree than to explore how we can both be right.   I wish New York would do that -- would explore how private practice and community mental health could both be right.   I think everyone would benefit were that to happen.

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