Some Thoughts on My Psychiatry Practice

post by Laura B (Lara_Foster) · 2019-01-16T23:16:54.264Z · score: 105 (48 votes) · LW · GW · 30 comments

I’ve noticed a marked change in my clientele after going into private practice.[1] Of course I expected class differences-- I charge full fee and don’t take insurance. But there are differences that are not as predictable as ‘has more money’. During residency I worked at a hospital Medicaid clinic and saw mostly poor, often chronically unemployed people. While monetary problems were a source of stress, they were not nearly as present in people’s minds as someone from a middle-class upbringing might think. These people were used to going without. They were not trying to get more. The types of things they talked about were family problems, health problems, and trauma. So much trauma. People’s ego-identity crises centered less on their accomplishments and more on their relationships.

The patients I see now are mostly highly successful, highly educated, weathly people, most of whom care a lot about their careers. Their ego-identity crises center around their work and their position in life relative to others. There is a lot of concern about ‘the path’. ‘Did I go down the right path?’ ‘Did I make a wrong turn?’ There seems to be a great fear of making or having made a wrong decision, which can paralyze their ability to make future decisions. While this group is not without trauma, it is not what they wish to focus on. They will often be dismissive of its effects on them, noting that they clearly got over it in order to get where they are now. Which is, you know, in my office.

Many of my new patients do NOT want to take medication. This is a large change from my patients at the Medicaid clinic who were always requesting more and different pills. And this difference is not because my new patients are less unhappy. They describe intense misery, even a wish to die, going on for months if not years, and yet they struggle through each day in their sisyphean ordeal. They ‘power through’ until they can’t. Until something gives. Then they come to me.

I can think of several good reasons to have concerns about using medication. What are the long-term effects? Could this change my identity? What if this makes me ok with a shitty situation and then I don’t fix an underlying problem? But these are not the typical concerns I hear raised. What most of my patients say is that they don’t want to ‘rely’ on a medication. They don’t want to be the type of person who takes it. ‘That would mean there is something wrong with my brain.’ Even though they are clearly very depressed, clearly suffering and hating every day, so long as they can push through without taking a pill they must be ‘ok’ in some sense. Taking the pill would confirm there is actually something wrong. Taking the pill might mean they are more similar to the patients at the Medicaid clinic than they want to consider.

What struck me about this was how people’s desires to assume a certain identity – that of someone who didn’t take medication – was more important to them than their actual lived experience. ‘This is your life.’ And this is broader than to take or not take medication. People will suffer through horrible work situations in order to be the type or person who has that job. ‘If your job makes you want to kill yourself, shouldn’t you consider quitting it before killing yourself?’ ‘But I’m good at it.’ Identity seems to be everything. Experience is there to tell you if you’re on the right way to assuming the proper identity. If you go through the motions properly you can look the part. What’s the difference between looking the part and being the person anyway?

Now refusing medication would be one thing if they wanted to come for weekly therapy and talk through their problems. But many don’t. They complain they don’t have the time (and it’s time, not money that is the concern). They know something is wrong. They were told by their pmd or prior psychiatrist that they should go on an antidepressant. They didn’t like the idea, they came to me. For what? I suspect they wanted me to identify the one thing that would help them in one 45 minute session and tell them how to fix it. It doesn’t work like that. In this sense, they are not that different from the patients I worked with at the Medicaid clinic. Those patients demanded new meds to fix them, when they clearly had a lot of problems medication was not going to fix. ‘This might make you feel less horrible, but it’s not going to solve the problems with your marriage.’ These new patients eschew being identified in that class, but still in some sense want a ‘quick fix’. They want to feel better but keep their illusion of identity intact.

So what’s the point of these observations? I’m not quite sure yet. I’m still working that out for myself, which is one of the reasons I decided to write them down. I find I identify more strongly with my current clients, which is unsurprising given we have more similar characteristics and backgrounds. I see some of my own identity struggles in theirs, and it makes me reflect how ridiculous the whole identity struggle is. Everyone is Goodhardting it[2]. All of the time. People want to play a part and they want to be the type of person who plays that part, and their lived experience is a frustrating disappointment which doesn’t fit the role they told themselves they have to play. And we live in a society that is vigorously reinforcing ‘identity’ roles. One where 7 year olds are asked to write essays on their ‘identity’. Can we let go of these identity constructs? What is the alternative? Buddhism? Ego death? Self-referential sarcasm? I feel like I’m onto something but not quite there yet. Psychoanalysis is, afterall, an attempt to be more honest with ourselves, and that, it turns out, is much more difficult to do than one might initially think.

[1] * Just noting that I realize that money is not the only factor in the selection process. Patients at the Medicaid clinic were often waiting for months to be seen. A long wait will select against patients that are ambivalent about taking medication. In addition, my website advertises me as being more ‘evidence-based’, which I think appeals to people who are more likely to have a scientific world-view. Another large difference between my current and former clients is belief in God. Almost none of my current clients believe in God, whereas the majority of my prior clients did. Religion does anticorrelate with class, but I think this is more extreme then one would expect by class alone. I also have a large number of people in finance. How many hedge fund managers are there in NYC anyway? I have many first and second generation immigrants, who have ‘pulled myself up by the boot straps’ type stories. The wealthy clients I got are ‘new money.’ Basically I think my advertising captured a demographic that is unusually close to that of my friend/peer group and not necessarily representative of most ‘rich people.’ The factors that caused them to select me might very well be more relevant than rich v poor in terms of their psychodynamic makeup.

[2] * Goodhardt’s law: "When a measure becomes a target, it ceases to be a good measure." In other words – people are optimizing for the superficial qualities by which success is measured, and not the underlying structure of the success.

30 comments

Comments sorted by top scores.

comment by romeostevensit · 2019-01-18T07:40:22.282Z · score: 20 (10 votes) · LW · GW

The meta lesson I learned by squinting at things and holding them at arms distance was this: don't be middle class. Live like a grad student and then retire having never acclimated to consumptive patterns that seem to be more about auditioning to be upper class than about enjoyment of the life material prosperity can provide.

comment by ErickBall · 2019-01-18T18:44:58.362Z · score: 6 (6 votes) · LW · GW

But, like, how do you actually do that? I make three times what I did in grad school, but somehow it doesn't feel like my standard of living has changed much, and I still basically spend everything I make...

I guess the problem is that "consumptive patterns" can be sneaky, and sometimes you didn't notice they were there all along. The rent doubled because I moved to a city, even though my apartment's not much nicer; my cell phone is no longer on a family plan; my parents no longer buy me plane tickets home for Christmas; I take the train to work every day. Maybe the cat gets sick and suddenly there are vet bills. In other words, nothing that feels like much of a change in consumption, yet the expenses keep going up.

And then there are a bunch of little expenditures, each one of which feels reasonable: What's the harm in fresh vegetables, or a gym membership; won't you save money on health problems in the long run? Wouldn't it be dumb to worry about a $10 movie ticket or spend 20 minutes looking for free parking, when you make $30+/hr? I know people who make a lot of money but spend a lot of time and effort trying to avoid small expenses, and that doesn't seem like a good way to live either. Sometimes I think the "save half your income and retire early" crowd is actually just faking it somehow.

comment by ioannes_shade · 2019-01-19T04:26:40.111Z · score: 6 (5 votes) · LW · GW

Just some quick thoughts:

  • Housemates and other group-living arrangements can make living in cities affordable
  • Pets are expensive (though probably worth it for lots of people)
  • Flights are expensive (though deals can be had)
  • Car ownership is expensive
  • The internet can provision almost all media at high quality, low inconvenience, minimal risk, for free
comment by GuySrinivasan · 2019-01-20T09:14:48.593Z · score: 2 (1 votes) · LW · GW

Do you have a way of seeing your expenditures for the past year, categorized and summed? Use Mint or something similar. Take a day every couple years to go through and look at _all_ of them and determine which are simply extraneous, which you don't endorse.

comment by Benquo · 2019-01-18T11:48:31.226Z · score: 6 (5 votes) · LW · GW

I feel like my life would get a lot better if I had a list of these things, so I could reflect on them and see whether I actually like them.

comment by romeostevensit · 2019-01-19T21:55:03.888Z · score: 16 (5 votes) · LW · GW

A lot of the smaller items are covered in early retirement type blog posts such as ERE and MMM. They both also have books out which are organized better than the blogs. The big ones tend to be things like

people not running the numbers on home ownership: After playing a lot with the NYT rent-buy calculator and both current prices and historical rates of housing inflation in major markets (ie the places you'd actually want to live) I found only two scenarios that paid off. Both hinged on being very confident you were going to stay in the same place at least ten years, which given the opportunity costs of not being mobile for the best available job as well as the often underestimated commuting costs to QoL is a pretty high variance bet. The two scenarios were buying a 2 bedroom condo and renting out the 2nd bedroom, and buying a 3 bedroom 2 bath house with a converted garage, living in the garage while renting out the house and then flipping to living in the house and renting the garage when family planning needs kick in down the road. And this was still only beating renting in advantageous markets like Denver, Austin, Raleigh. Terrible in popular places like Seattle, SF, NY, Chicago etc. Assuming you plow a decent chunk of your salary into index funds otherwise.

Not optimizing their career due to short term comfort considerations. The long term impact of optimally switching to advance several times *early* in your career is massive. Most people don't apply often enough to nearly a wide enough range of positions in many different cities with excuses like 'my friends and family are here' and only counting the immediate salary difference rather than the huge trajectory shift.

A general habit of buying stuff, 90% of which sits unused 99% of the time. Which also causes one to rent bigger places on average.

A general habit of not TDTing 'reasonable' convenience expenses and finding more permanent solutions that cost less over a lifetime.

As mentioned in the recent putanumonit post completely insane financial planning folk beliefs. Not parking money in a well run robo-index like Schwab's.

Dating people who reinforce their bad habits, which feels like validation from the inside. Especially in the justification that those living at lower consumptive levels are 'missing out on life' or wasting their time. (They might not be making optimal time-money tradeoffs but the person hasn't actually checked this, it's just a reflexive defense)

Not valuing slack enough to fight tooth and nail for it over the longer run.

I don't know, I'm probably forgetting stuff. The real juice tends to be in stances more than individual decisions. The primary legible stance is something like: once you finish Mario Kondoing your possessions, start in on your processes.

comment by Benquo · 2019-01-17T16:59:09.578Z · score: 18 (8 votes) · LW · GW

This is pretty much what The Last Psychiatrist is about. Nearly all his late blogging is a combination of:
(1) Poor people are assigned disability status and drugged to stop them from rioting because their lives are shitty and society doesn't want to (or perhaps can't) spend the resources necessary to fix the problem.
(2) The rest of us have been raised to be narcissists in a way that would have been genuinely exceptional a couple of generations ago, and are desperate to have our narratives affirmed by someone else with the right to pass judgment.

comment by Laura B (Lara_Foster) · 2019-01-17T17:40:10.768Z · score: 19 (14 votes) · LW · GW

Number 1 is the politically correct thing to say, but was not what I actually observed when working with Medicaid patients. People complained far less about poverty than I (who come from a middle-class upbringing) would have anticipated. People adjust to what they are used to. It's the middle class, with the constant fear of downward mobility, which really suffers from monetary issues. There were some interesting interactions between race and class, which are hard to express without the internet eating me. Being hispanic and poor is very different from being black and poor, which is different still from being white and poor. And I'll leave it at that.

2 just sounds correct. America has reached the apotheosis of individualism. We can't all be the star of the show, and it hurts when you find out you are not.

comment by Alexei · 2019-01-17T06:00:35.763Z · score: 15 (9 votes) · LW · GW

Thanks for writing your thoughts out loud. Curious to follow your progress.

comment by Jacobian · 2019-01-18T18:29:47.040Z · score: 9 (7 votes) · LW · GW

If someone will stay in a relationship or job that drives them to the verge of suicide for "identity" reasons, it means that the person/institution providing someone's identity has almost unlimited power over them.

I'm thinking of something like academia, which is used to dealing with people for whom their identity as an "academic" is the most precious thing in the lives. It's not just internal "culty" things like academics having their own friend groups, markers, and even language. It's also how external society sees them, like academics having special social status and even different names ("My name isn't No, it's Doctor No!") that reinforce "academic" as a precious identity. As a result, academia can impose arbitrary rules on its members, overwork and underpay them, and cause them to be depressed and anxious at 6 times the rate of the general public.

Perhaps the antidote to this is to build up an identity that is self-conferred, rather than being dependent on the approval of other people. You can call yourself a "rationalist truth seeker" for example even if the rightful Caliph thinks you're a moron, so that's an identity that doesn't open you to exploitation.

comment by Jay Molstad (jay-molstad) · 2019-01-19T19:07:15.514Z · score: 7 (5 votes) · LW · GW

Your patients seem to have a problem deeper than depression. They seem to be spending their lives doing things that they hate. Taking a pill to hate it less is probably a sub-optimal solution.

comment by Laura B (Lara_Foster) · 2019-01-20T13:52:31.286Z · score: 6 (4 votes) · LW · GW

That might be true, but it is very hard for people to make reasoned changes when they are deeply depressed. Depression has real cognitive effects, which people frequently complain about. Depressive reasoning often looks like I SUCK I SUCK I SUCK I SUCK Everything is my fault and I screwed it all up, and I can't fix it, and I can't fix it because I SUCK I SUCK I SUCK. Ok - let me focus for a second - If I change this... I SUCK I SUCK ... Ok, if I change this thing then... why can't I think? Oh right I SUCK I SUCK I SUCK... etc, etc. Getting people out of that pattern is very helpful.

comment by Benquo · 2019-01-20T15:21:33.121Z · score: 2 (1 votes) · LW · GW

I think there's a "different worlds" thing going on here that might be impeding communication. My experience of people suggesting that maybe I'm depressed is that they think I'm misguided in focusing on changing the underlying conditions of my life or trying to figure out what's wrong. Maybe this is a deep depression vs moderate/mild depression thing.

It makes sense to me that someone in the condition you're describing would benefit a lot from taking a pill to free up mental space. But, people I know very well have been prescribed pills to alter their mood without anyone checking whether their mental condition was anything like what you described.

comment by Meli · 2019-01-18T07:56:56.565Z · score: 5 (4 votes) · LW · GW

I wanted to respond because your description of the reasons people give for not wanting to take medicine is related to the reasons I would rather not take it, but doesn't include some steps in the decision making process that led me to avoid the medicines. I see the world like this: Suffering increases the chances you will have experiences that are negative and uncomfortable which leads you to be more prone to do things that others don't like. Responding to this reality, psychological theorists have categorized people's responses to suffering so as to separate the acceptable from the unacceptable or the healthy from the pathological. Psychological terminology designates people who exhibit certain characteristic as unacceptable.

I wish that we'd develop a response to suffering which acknowledges that we all suffer and that we all have different responses to suffering and also encourages us to support each as we deal with the pain of being human. People's actions stem from their experiences and once we see the world through this lens we can attempt to understand people in the context of their life stories. If this were the standard approach to dealing with suffering, and if there were a specific and clear result that was expected from taking a medication, then I'd be all for it.

As an example of a what I mean by establishing a direct connection between a medicine's impact and expected mechanism for improving life, I offer this: Setting aside the potential for addiction, if a person was told that they should take a small dose of an anti-anxiety medicine just as they were to starting to panic, that the calming effect of the medicine would be part of a kind of self-study program where you are examining your reactions and by doing so becoming better able to intervene during the earlier stages of a conditioned response that becomes harder to stop the further along it goes, then it would make sense to take the medicine.

My suffering been a barrier between me and the life experiences I believe are important like having a job where intellectual curiosity is an integral part of what I do, which in turn would allow me to interact with others who value using their intellectual curiosity. I have had a persistent sense of my own powerlessness and inability to shape my own life. If I were to turn to psychology, I would feel even more powerless because in order to be helped, I need to be designated unacceptable. I already feel separated from the life experiences that I want to have and so don't want to reinforce the distance between me and those experiences which I believe are worth pursuing. From past experience I know that the medicines available aren't given as part of a process of increasing self-knowledge.

Although the chronically unemployed may not express a desire for more money in their lives, I think that we should keep in mind that they don't represent all those who are poor in our country or in our world. We should also consider the fact that the life experiences of the medicaid patients are surely responsible for their lowered expectations. How can we not want to contribute to a world in which everyone has the opportunity to use their minds and explore their potential, even this world takes several generations to bring into being? Rather than identity, maybe the answer is to value and pursue meaning, the search for what matters, putting effort into ensuring that worldwide everyone's basic needs are met and then into supporting each other as we all explore our unique gifts.

I was so amazed to see that the author responded to some other comments. I am not sure if I will be so lucky because my comment is so long and it is pretty personal.

comment by Sherrinford · 2019-01-17T09:28:17.038Z · score: 5 (5 votes) · LW · GW

Very interesting. May I ask whether by "psychoanalysis" you mean that as referring to the school of thought founded by Freud, or just as a general description referring to a get-to-know-yourself process?

comment by Laura B (Lara_Foster) · 2019-01-17T11:40:05.989Z · score: 5 (5 votes) · LW · GW

The latter. Most 'analysts' today do not consider themselves primarily freudian.

comment by Sherrinford · 2019-01-17T13:22:14.384Z · score: 3 (3 votes) · LW · GW

That's why I am asking. Probably because I am not an American or native English speaker, I assume that "psychoanalysis" is just that school of thought, and the therapists I know really want to distance themselves from that Freud's couch image and just say psychotherapy or CBT.

comment by shminux · 2019-01-17T02:57:57.457Z · score: 5 (3 votes) · LW · GW

A spelling note: It's Goodhart's law. A question: do you come across patients with DID, not "just" C-PTSD?

comment by Laura B (Lara_Foster) · 2019-01-17T11:39:04.991Z · score: 3 (3 votes) · LW · GW

My new practice is only 3 months old, so no one with full on DID yet, though some people have these rando dissociations (which are likely trauma related) I had one patient in my former position with DID. Very interesting case, but hippa lol.

comment by adamzerner · 2019-01-18T23:46:44.211Z · score: 4 (3 votes) · LW · GW

I've been meaning to think more about ego and identity. I also sense that a lot of people have problems where they don't feel accomplished enough, and where they compare themselves with other people. I know that I have those sorts of problems.

On the one hand, it seems silly to compare yourself to other people like that. Especially when it is taken to such an extreme. But on the other hand, it seems like something that is deeply ingrained in us, and that is very hard to avoid. In reality, that sort of thinking is probably establishing a false dichotomy. Clearly there are some people who are more invested in how accomplished they are than others.

The question that I'm interested in is how to change your mindset, such that you retain your ambition, but aren't caught up in it, if that makes sense. Where you pursue improvement and accomplishment either because you are intrinsically motivated to do so, or because you want to do good for the world, but not because you want social status points. And where you see the accomplishment as a "nice to have", rather than an "I'm happy if I get it, and sad if I don't". And especially not where you see it as a "I feel normal if I get it, and depressed if I don't". I find for myself, and sense that the same is true for many others, that a "logical" understanding often isn't enough, that your brain still may act as if it's a necessity rather than a nice to have, even though you logically understand that this mindset is silly. I suppose that this is a much more general problem, and a very important one.

comment by romeostevensit · 2019-01-19T21:59:56.559Z · score: 4 (2 votes) · LW · GW

The aspect of comparison I find useful is less competitive and more in noticing that a lot of people are *quietly* having what I consider some pretty bad outcomes in their career, primary relationship, relationship with family, and personal growth. It has been valuable for me to do a bit of analysis of equivalence classes of these sorts of failures and try to avoid the big pitfalls. A lot of this rounds off to stuff that we might already know about like exercise and sleep actually needing to be major priorities, but the greatly added juice of having a feel for the real consequences in the lives of age peers and older folks is great.

comment by Meli · 2019-01-19T02:35:44.932Z · score: 1 (1 votes) · LW · GW

I think the way we process information of any kind involves making comparisons. We wouldn't be able make any distinctions at all without some sort of internal calculation that allows us to understand where one entity ends and another begins, so advising people not to compare themselves to others strikes me as advice that is meant to be helpful, but that does not address the complexity of the human condition. I also don't think that we can rid ourselves of status concerns-there is evidence to suggest that these have been present in our evolutionary history for a very long time.

It would be nice if a public conversation in the world at large drew people's attention to ways in which we can reinforce the positive aspects of comparison. These might include an intention to value the efforts people at levels of the socioeconomic hierarchy make despite the challenges they face, even if their accomplishments are small or an attempt to pay attention to things people do, no matter how mundane, that are unique to them. I believe it would also be helpful if as a society we encouraged every one to pursue their dreams and not to accept the limits placed on them by historical circumstances. If we did this, perhaps eventually, after a period in which society was reconfigured to allow for a much broader section of people to experience autonomy and fulfillment in their working life, the middle class would not be so terrified of downward mobility because the floor would not be as connected in the imagination to the worst outcomes imaginable as it is now.

comment by adamzerner · 2019-01-19T03:34:19.830Z · score: 3 (2 votes) · LW · GW

I definitely see what you're saying about how we make comparisons when we process information, and that there is a strong evolutionary pressure for us to be concerned about social status. The thing that makes me feel hopeful is that when you look at humans, there's a pretty decent range of how much different people care about social status. Some care a lot, some only care a little. I wouldn't argue if someone were to claim that you can never 100% get rid of the concern for social status, but it does really seem to me that there is room for growth in terms of how much you care about it. Otherwise, what explains the fact that there is a spectrum of how much people care. Unless it is all genetic, it seems that there is a lot of room for people to improve.

I think that's a really cool idea about society moving towards healthier comparisons. Without having thought deeply about it, my impression is that it'd be extremely difficult because of equilibrium stuff. If an individual actor starts to prioritize something like effort instead of accomplishment, no one is going to praise them, and they won't get social status points. It seems like something where you'd need to get a sizable group to all make a change at the same time, which is always tricky to do. Not to say that it isn't worth pursuing though.

comment by AnnaSalamon · 2019-01-19T19:08:16.179Z · score: 3 (1 votes) · LW · GW

Thanks for the portraits; I appreciate getting to read it. I'm curious what would happen if you got one of them to read "The Elephant in the Brain". (No idea if it'd be good or bad. Just seems like it might have some chance at causing something different.)

comment by adamzerner · 2019-01-18T23:58:25.629Z · score: 3 (2 votes) · LW · GW

There's something that I've always been curious about but never had the chance to ask: as a psychiatrist and psychologist, to what extent has your training helped you avoid or solve your own mental health problems? How helpful has it been?

My guess is that it is only somewhat helpful. Many doctors smoke and eat unhealthy foods even though they've spent years studying just how harmful that stuff is. It seems to me that this is an area where "incremental improvements in rationality don't always lead to incremental improvements in winning" is true.

comment by Adam Kritzer (adam-kritzer) · 2019-01-24T05:20:16.476Z · score: 2 (2 votes) · LW · GW

Great article Lara. I think that a form of 'Ego death' is indeed the answer, and I've decided to start a blog to ponder this very subject. I think you've touched upon the fact that for the suffering of most of your patients is rooted in unhealthy identities or self-images, rather than in poor life circumstances. For if people who are well-off and live satisfying lives 'on paper' can't find happiness, that would seem to say more about their lived experiences rather than in their external life situations. Focusing on their resistance to medication is in some ways missing the point; the issue is not so much that they refuse to take medication, but that their identities are so fragile to begin with that they can't even entertain the benefit of trying medication. In the end then, I would argue that overcoming resistance to medication is less important than fixing - or rather discarding - one's entire self image.

My full response can be found here:

http://www.depersonalization-and-enlightenment.com/2019/01/24/mental-illness-and-ego-identity/

comment by Dagon · 2019-01-21T03:07:50.109Z · score: 2 (1 votes) · LW · GW

Tell me more about how I can use self-referential sarcasm to free myself of the identity trap. I definitely see myself as the type of person who's good at that,,,

comment by Gurkenglas · 2019-01-18T04:10:08.621Z · score: 2 (2 votes) · LW · GW

How is this not a problem that's solved by pointing it out? "Trying the pill doesn't cause you to be the kind of person who should take pills. It tells you whether you are one."

comment by Tyrrell_McAllister · 2019-01-19T01:02:47.960Z · score: 6 (3 votes) · LW · GW

Trying the pill still makes you the kind of person who tries pills. Not trying really does avoid that.

comment by Kaj_Sotala · 2019-01-18T14:41:05.726Z · score: 6 (4 votes) · LW · GW

I'd expect the response to be something along the lines of: "But I already know I'm not one! I'm [list of reasons for why this is purportedly the case]."