January 31, 2007

When Your Patient's Parent Is A Psychiatrist and A Patient and You Just Want To Go To Bed

If you want to test the faith of a psychiatrist in their "science", present them with one of their own.

In my career I have treated a few dozen children/spouses of doctors, and about a dozen of psychiatrists.  Treating patients with these connections is difficult, if we are to be honest, for two reasons: 1) a lot of the trickery and hand waving we use on regular patients won't work with them, because they know the game.  2) we feel tremendous pressure to do a good job, because we feel that we are being graded. 

The result is we almost always do an inferior job. Notwithstanding the admonition against treating family, the reality is that if they knew what to do, they wouldn't be referring them to you.   And the trickery and bs are vital parts of the dance: these say you have really no idea why this works, but you're optimistic, so you are offering a framework to think about how it could work. The framework doesn't have to be "true"-- it has to be internally consistent. 

But the countertransference towards the patient and his family is so strong that we do things we should not, think things we should not.    

Treatment is even harder when both the patient's psychiatrist-parent/spouse is also a psychiatric patient somewhere.  If you want to see an entire department blow an aneurysm simultaneously, say, "I'm getting X as a patient, and X's mom is a psychiatrist-- and a patient in the Bipolar clinic!" 

In any other scenario, a mom in the bipolar clinic would suggest that the child had a similar disorder, by virtue of being a first degree relative.  But in these cases, psychiatrists read it differently: it means the mom made the kid insane.  It was the mom's fault.  Not genetics, or biology, or even shared environment: specifically bad parenting.  And not bipolar-- personality disorder.

I can make a statement that is completely unqualified, without exception: never, not once, has anyone hearing of this scenario said to me something like, "bipolar in educated families is difficult to treat."  In every case, again without exception, every single person who has heard of the situation has said the same exact thing: "Oh my God, she's a borderline, and the mom is even more crazy."

What's interesting about this, to me, is two things.  First, how immediate, reflexive, and certain everyone is of this assessment-- given even before they ever see the patient, only hearing that the mother of a patient is a psychiatrist.  "Mom's a psychiatrist..." Boom.  Case closed.  Out the window goes diagnosis, biology, serotonin,  kindling, TSH, whatever-- it is immediately predicted to be personality disorder due to an unhealthy relationship between parent and child (or spouses).  Overinvolved, underinvolved, abusive, manipulative, whatever. 

Medications are inevitably thought of as band-aids-- likely to be changed thousands of times over the lifetime-- or proxies for therapeutic maneuvers ("I will nurture you by giving you extra Klonopin to get you through the holidays, but then I will be a disciplined parent-surrogate and reduce it in January.")  A family history of CNS lymphoma is less telling than a Dad who is a psychoanalyst.   The adult child is crazy because the parents made him crazy.

That's the first thing.  The second thing is this: they are almost always right.

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