What to Expect From a Psychiatric Consultation:
General areas of work: general psychiatry; psychopharmacology; psychotherapy; family, marital and couples counseling
I have been involved in the teaching, practice and study of psychiatry, psychoanalysis, and couples and family therapy for over 30 years. In my practice, I see patients ages 18 to over 90. They are typically referred to me by medical doctors, friends, and family members with whom I’ve worked. Common reasons for a consultation and treatment include depression, anxiety, family and relationship issues, work crises, and stress.
After taking a careful history and collecting relevant outside reports and laboratory studies, I tease apart three separate but overlapping factors: 1) the biological, 2) the situational and interpersonal and 3) the intra-psychic or psychodynamic roots contributing to the patient’s problem. Some of these will be more relevant than others for the issue at hand. Each factor would be addressed slightly differently in treatment. But it’s the purpose of a good consultation for the patient and doctor to come away with an understanding of how each contributes to the presenting problem, and what that means for the therapy.
As a result, for the initial visit I allocate extra time. In my experience, most people who come for a consultation have been struggling with their condition for some time. They may have already tried and failed at treatments. There may be a lot to cover. It’s important that we be thorough and review everything that has been tried, what’s worked, what hasn’t and benefit from all the prior experience one may have had at attempting to solve their problem. This enables us to pull together all someone has gone through into a diagnosis of the problem which he or she can understand. The treatment options will flow from that.
Tremendous strides have been made in the treatment of depression and anxiety – both psychopharmacologically and psychotherapeutically – over the past two decades. We, in the psychiatry field, have high therapeutic expectations. Clinical depression is not the normal state for any condition or circumstance in life. Mourning yes, but depression no. In fact, people who are depressed can’t mourn. They are stuck ruminating over the same thing, while mourning involves working through a situation. These conditions frequently need to be differentiated in treatment.
In addition, for people who have concurrent medical problems, the treatment will need to be carefully coordinated with one’s general medical doctors.
Most people come to consultation in the midst of a crisis. In the course of getting that under control, sometimes issues that have been dormant or festering from a long time ago may surface. Exploration of these issues can lead to surprising additional insights into what makes one “tick,’ which can be beneficial in handling relationships at home and in the workplace. Once depression and anxiety have been treated biologically, people often find themselves acting more assertively at home or on the job. They and the people in their lives may not be use to this. There is a settling in period during which one is learning how to ‘use’ this newfound strength. What words or phrases to say to get out ones point without feeling one has been too assertive or aggressive. As one patient said, ‘it’s like learning to walk all over again.’
As coping skills change, it may happens that the medications one is taking may be capable of being reduced, sometimes eliminated altogether. There is a fluid interplay between the psychodynamic changes in one’s personality and the pharmacologic part of treatment.
There is a lot more to be said about this fascinating interaction between treating biological conditions and how people change. But that is best left to the specifics of one’s individual circumstance.
In 1987, I co-authored one of the first book on the developmental transition to marriage, now in it’s fifth reprinting, The First Year of Marriage: What to Expect, What to Accept and What You Can Change. It covers the tumultuous issues newlywed couples often experience and guides them so they are able to approach conflict and deep-seated fears and doubts so they can grow as individuals and as a couple. It’s been excerpted by dozens of books and magazines and translated into multiple foreign languages, as well as featured on many TV news shows. I have also taught courses on couples therapy and have seen many couples in consultation and treatment over the years.
Couples may come to treatment at any time in the life of a relationship but in particular when a certain kind of logjam occurs in their relationship. For problems where only one partner’s anxiety is raised, the other can be the calming influence. But where both are being made anxious, neither can be the reassuring one, and the anxiety can spin out of control. This is especially true if it requires some kind of compromise which causes the other anxiety. For instance,A: “I have to visit my parents, I feel so guilty we haven’t seen them in so long.” B: “You know I can’t stand how critical your mother is of me, why do you always side with her…” Etc.
You know the kind of situation. Couples begin to go in circles. There is a failure of ’empathy’ as neither feels they can accommodate. A seemingly trivial issue can blow up. A mole hill can be made into a mountain. Other grievances can come tumbling into the hole being dug. As a colleague of mine use to say only half facetiously, “couples break up over how to roll the toothpaste”. The fact is that this may be the ‘straw that breaks the camels back’. The sign that empathy has been so drained, that each feels they are living not just with a stranger, but an enemy. The toothpaste becomes a weapon.
Needless to say these are nuclear situations. The irony is that these situation are not as difficult to dig out of as couples often fear. In consultation I will hear the couple together for a period of time. I’m not in general interested in having fights in the office. Rarely does serving as a referee help. What the couple really need is someone who can listen emphatically to both. At some point I will ask one or the other to step out, and speak to each individually for a while. Then switch. That way they can unburden themselves, express their fears, hurt and anger without having to inflict further pain, or do further damage to the injured relationship.
This model, of seeing each separately for the beginning of sessions then coming together at the end is a model that is frequently useful in the case of these ‘negative feedback loops’. We can explore ways to recognize the dynamic and what to do about it. If the couple truly still want to be together, but stumbled into their own personal ‘black hole’, then a lot of progress can be made over the first few sessions. Rebuilding trust and love may take longer. And that’s a longer story, more appropriate for the specifics of an individual treatment.
So the above are some brief indications about how I work at least initially in individual and couples consultation. Psychiatric consultation, at least the way we still have the ‘luxury’ of practising, meaning really gearing it towards the specifics of the individual or couples presenting for treatment is art and science. The art is in the ‘feel’ which a practitioner has about how to proceed. It can’t be coded. It can’t exactly be taught. It can be mentored.
I’ve been fortunate to have had some wonderful mentors and been trained at a time when doctors were still being trained to be, well, doctors.
Treatment is truly integrative these days. It is never about just medication. There are many kinds of talk therapy approaches—some insight-oriented, some very practical and problem solving. My counseling also takes into account the importance of healthy living in general, as we explore the benefits of exercise, nutrition and spiritual disciplines including tai chi, yoga and meditation – all of which are important additions to the therapeutic mix for those who are open to engaging in them.
Faith, psychiatry and healing:
Regarding my research interests on other pages of this website: Earliest in my career, I was involved in the issue of Traumatic Stress experienced by hospital staff working in high-stress settings. Also, I have done, as mentioned above, a lot of work regarding couples.
In addition, I have been very interested in the overlap of psychoanalysis and issues of faith and belief. When people are severely depressed they have a total lack of faith that they can be healed. They also lose faith in themselves. These can be very dangerous states. Frequently, it is only the conviction of the doctor that ‘you can get better’ that gets someone through the first couple of weeks that it takes for medication and treatment to work in severe depression. This has led to a long interest in matters related to psychiatry, psychoanalysis, religion and spirituality in general. These are not things we learned much about in medical school. Traditionally, science, religion, and spirituality have spoken very different languages and held each other at arm’s distance. Yet for many people these are extremely important sources of solace and meaning in times of difficulty.
If you would be interested in discussing a consultation, please call. If I am unable to accommodate you I have many excellent colleagues I can refer you to.