Why The Patient Care Philosophy Of Psychiatrists Must Change?
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Back when we rode our dinosaurs to the hospital, psychiatrists had one patient care philosophy for treating our patients: To help them live their best possible lives. 

If our patients were schizophrenic, we wanted them to be as psychosis-free as possible. If they were depressed, we wanted them to be happy. If they suffered from obsessions and compulsions, we wanted them to be free of the forces that drove them to needlessly repeat thoughts and actions instead of living their lives.

Today, most psychiatrists are corralled into a fake patient care philosophy that tries to convince us that the only treatment required is to keep our patients out of the hospital. Anything else we can do for them is optional and - most importantly - not reimbursable.

The standard of care has changed since I became a psychiatrist. As long as the insurance companies are protected from having to shell out big bucks for inpatient treatment, the well-being of the actual human beings we are treating is not really important.

We have been indoctrinating young psychiatrists into this patient care philosophy for so many years now that most psychiatrists actually believe it. And this philosophy must change.

There is no magic medication that can give a person a happy life. There is no magic medication that can solve a person’s financial problems, relationship problems, academic problems. There is no magic medication that can address anyone’s existential issues. 

Medications can treat the symptoms of different psychiatric disorders, but they do not treat the person. 

When psychiatry was first developed as a separate field of medicine, the whole premise was that each individual had a unique history, with unique experiences, perceptions, and reactions, that rendered him or her - well - unique. 

The goal of psychiatry as introduced by the father of psychiatry, Sigmund Freud (himself a neurologist) and later refined by generations of other psychiatrists, psychologists, and neurologists, was to tailor treatment to each individual patient.

The original philosophy of patient care was that each person who suffered from some psychic pain could be helped to recover and live his or her best life and go on to achieve all of his goals and dreams, free from the burden of mental anguish.

So what have we accomplished today, in the twenty-first century? We have developed a bunch of medications, many with a plethora of side effects. We have created a pretend treatment called “medication management.” 

I often have students in my office. They are usually surprised to hear that I never ask my patients “how’s the medication?” That is because I am one of the few psychiatrists left in the world who knows that no patient has any idea how their medication is! 

Would you go to your internist for your blood pressure and expect to hear “how’s the medication?” How about for your gout, or your ulcerative colitis? No? You might be asked, “how’s your pain?” or “have you been checking your blood pressure?” 

Psychiatry has become so marginalized despite its quest for parity that even psychiatrists now believe that “how’s the medication?” is a legitimate question.

Let me tell you something: It’s not. I ask my patients how they are doing. There are specific questions I ask to find out if the medication is working the way it’s meant to. But that’s only a start. 

Medication is like the sanding and spackling a good painter would do to a wall before painting on the color of your choice. It’s the base layer. After that needs to come the real work - the therapy that will help the patient become the true person he or she wants to be.

So why does the patient care philosophy of psychiatrists need to change? Why isn’t it enough to ply the patients with all our new miracle drugs and send them on their way? 

One reason it needs to change is that the true, adjusted suicide rate today is about twice what it was only fifty years ago. Despite the availability of all the magic medications, people are killing themselves at unprecedented rates. I believe it is because we are asking pills to do the work of people. 

We are over-medicating people who actually need to learn self-love. Self-love is the sanding and spackle. We live in a society where we are taught that we are only lovable if we look a certain way, dress a certain way, and spend a certain way. We are constantly bombarded with information on a million different platforms all designed to show us how we don’t measure up because we are not as good and worthy as the fake people we see on the screens surrounding us anywhere we look. Instead of bringing us closer together, social media is creating isolation and loneliness. 

The biggest irony I learned about the history of media is this: Right after Sigmund Freud, the father of psychiatry, discovered that we all have a basic need to love and be loved, his own nephew, Edward Bernays, moved to the United States and figured out how to monetize this concept. Edward became the founder of public relations and advertising. 

So what can we do to go back to basics? How can we serve our patients’ need to love and be loved? 

In my own personal quest to learn how to better serve my patients, I discovered the field of life coaching. Life coaching is not yet standardized, so certification can be hit or miss. 

But the philosophy is fairly standard: We focus on the patient’s, or client’s, goals and desires, rather than patching up the problems in order to keep people out of the expensive hospital. This philosophy is suspiciously similar to the original goal of Dr. Freud and all of his followers in the first hundred years of psychiatry, before big insurance took over!

I carefully evaluated a great number of programs and decided to train as a life coach. I’m no stranger to hard work, and I found that my understanding of neuroscience and medication has been a great help and foundation. 

Now my patient care philosophy is this: We conquer our past and we create our best future. Sometimes we might need some medication, and that's okay.

We can all create a life we love living!

Until psychiatrists move their philosophy away from keeping patients out of the hospital and toward creating a life they love living, we will continue to have both unhappy, dissatisfied patients and unhappy, dissatisfied psychiatrists. 

I invite every single one of you to consider working with a life coach to create a life you love living. And a psychiatrist who is also a life coach? Few and far between, but definitely available! Sign up for a free vision workshop or a free strategy session for more information! Spackle up your wall, and paint it any color you want!! The time is now!!

Vivian Shnaidman
WHAT COUNTS AS A MENTAL ILLNESS?
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Many people identify as having some sort of mental illness. Rock stars sing about mental illness. Writers write about it. Characters are described as being “ADD” or “OCD” as if these descriptors are adjectives. 

In some cases - even in many cases, I’ve heard people identify as actually being the mental illness: “I’m ADD.” “I’m OCD” “I’m bipolar.” People who actually suffer from these conditions are the first to tell you: Stop it! 


Nobody is served when people make fun of a mental illness or diagnose themselves. What counts as a mental illness? What makes someone really count as mentally ill, in need of treatment? Or able to respond to treatment? 

The simple answer is that we have some books, compiled by a bunch of self-proclaimed experts, which define mental illness. These are the DSM-V and the ICD-10 which describe, in meticulous detail, the requirements for each of the latest incarnations of every defined mental disorder. 

Of course, some of these include things like nicotine addiction, and some of them are speculative, and some of them are disorders that are so severe that anyone who suffers from them would not even be aware that they are ill, because they would be unconscious or relatively unaware of their surroundings. 

So let’s get started. Does your potential mental illness fall into one of these groups?

MOOD DISORDERS
Mood disorders include all disorders of mood. There are big mood disorders, where the sufferer loses contact with reality. My first patient, as a medical student, had depression. But not any old depression. He had psychotic depression and believed that all his clothes had been stolen and he was being held prisoner. 


In learning his history, I discovered that he had a history of bipolar disorder. He’d had previous manic episodes where he’d believed he was the owner of some sort of business and had millions of dollars. In reality, he was a retired low-level civil servant who’d had multiple previous psychiatric hospitalizations. 

There are smaller mood disorders, that include milder forms of depression, or more serious depression that never swings to mania. Mood disorders can hit anyone, at any age, at any time.

The most important thing, though, is to make sure that your mood disorder really counts as a mental illness and is not a psychiatric manifestation of a medical problem. For this reason, it is very important to see a medical doctor, such as an actual psychiatrist, for a good differential diagnosis. You don’t want your thyroid disorder or your brain tumor misdiagnosed as depression.

ANXIETY DISORDERS

All disorders that present with anxiety are filed under this heading. There are many. 

Obsessive-compulsive disorder (OCD) is probably the most famous one which people self-diagnose when they like things to be tidy. Actual OCD is an often-devastating mental illness which can affect people’s lives so severely that they become unable to leave the house. 

I’ve had patients who cannot finish school, are unable to go to work, and who essentially become invalids because of this devastating disorder. Yet so many people who come in for other reasons casually mention: “I’m OCD” as if it is a joke. It’s not a joke. It’s a horrible mental illness. See the diagnostic criteria I mentioned, above. One Quora user wrote very poignantly about her experiences with OCD and I up

Anxiety, too, can mimic medical disorders, and vice versa. Your thyroid, again, a small gland in your neck, could be responsible. So could any one of a dozen other organs in your body, including your heart. 


Posttraumatic Stress Disorder (yes, that’s how it’s spelled in the DSM) is another anxiety disorder that must be diagnosed according to specific diagnostic criteria. You don’t get to say you have PTSD because you were upset when someone yelled at you. 

You must have a qualifying event, which must be outside of the realm of normal, everyday, human experience. If it’s just a normal upset (up to and including sexual harassment and bullying) then it’s a plain old Adjustment Disorder, a disorder that gets its own category, but still counts as a diagnosis.

SUBSTANCE ABUSE DISORDERS

Speak for themselves. They count as mental illness. Interestingly, the better part of the money spent on mental illness in this country goes toward substance abuse treatment. There is a huge overlap, also known as comorbidity, of substance abuse and other types of mental illness. 

In other words, people who suffer from one psychiatric disorder often also suffer from a substance abuse disorder. These individuals are often best treated in dual diagnosis or co-occurring diagnosis programs.

NEUROCOGNITIVE AND DEVELOPMENTAL DISORDERS

This category includes the famous Attention-Deficit Hyperactivity Disorder, as well as Attention Deficit Disorder without Hyperactivity. These are the same disorder. The distinction about whether or not hyperactivity is present is important mainly to the observer. Teachers and parents are more likely to be annoyed and to notice if someone is afflicted when hyperactivity is present. 


Autism and Autism-Spectrum disorders are in this category. So are intellectual impairment that children are both with and, at the other end of the life cycle, the ones that people acquire later in life, like Alzheimer’s Disease. 


Confusingly, the DSM has lumped all of these under the label of Major and Minor Intellectual and Cognitive Impairment, doing away with the older names of mental retardation and dementia, so finding a specific diagnosis, such as Fragile X syndrome, Lewy Body Disease, or something else, might be a longer time coming. And a traumatic brain injury can occur at any time during the lifespan. Still, if your brain is literally not functioning properly, you get a DSM diagnostic code.

PSYCHOTIC DISORDERS

The most famous psychotic disorder is Schizophrenia. There are various sub-forms of schizophrenia, and other disorders which can include psychosis. The one criterion required for a psychotic disorder is a thought disorder. If you have a thought disorder, you won’t know it, and other people might not realize it either. 

News flash: Believing that everyone in a school deserves to die because you were unhappy when you were a high school student is actually a thought disorder. It’s not a motive, as the news media would like for us to believe. A thought disorder is when your thinking is - disordered. Illogical, makes no sense, messed up. 

The concept of a thought disorder is one that many people, including mental health professionals, often have difficulty understanding. We can all understand hallucinations, and we can understand bizarre delusions (“the satellites are controlling me.”) But many, if not most, patients will never share these thoughts.

Many people who hallucinate are never aware that they are hallucinating. They “hear” words that others speak as if others are really speaking those words. They believe things as if they were actually true. Every day I hear (for real) medical students ask patients: “Do you hear or see things that other people don’t hear or see/that aren’t really there?” If you know that those things are not really there, you are in luck, my friends! You might have some other problem, but you are not psychotic. 

Psychotic people, with their thought disorders and hallucinations, have a profound lack of insight. They are not aware that their delusional worlds are not real. This lack of insight is what makes treating them so difficult, yet so rewarding. If you are suffering from living in a secret world where you get special messages from the TV, where you have been chosen by G-d for a special mission, where you control all the money in the world with your mind, where nanobots have been injected into your body while you sleep, or some other special thing like that - well, it might not have really happened. You might be psychotic. And if you are planning a mass shooting, I promise you - no good will come of it. It’s a terrible idea. Please go to your nearest psychiatric emergency room right now. There is help for you.

SO WHAT COUNTS AS A MENTAL ILLNESS?

We’ve only touched on the biggies - there are many more categories, disorders, and syndromes that we psychiatrists treat. Here’s the take home message. If your thoughts, feelings, and emotions are bothering you, a psychiatrist can help you identify if a mental illness is brewing, and if it is treatable, and how to treat it.

There’s also another perspective. There’s a Russian proverb that goes something like this: If one person at the party tells you you’re drinking too much, well, he’s probably not having a good time. But if two people tell you, maybe it’s time to go home and go to sleep.

In other words, when you see that your life is not going well, when you keep getting fired or your relationships keep failing, or your family situation is going badly, or problems keep happening to you, then it might be worth it to check out the common denominator - YOU! Sometimes figuring out what you are doing at your own party might be a huge help in resolving your problems.

We all deserve to take care of ourselves and have the best lives possible. Call a psychiatrist or a psychologist. The right help is available for you, from medication to therapy to life coaching. I’d love for you to visit  my website at http://www.shnaidman.com for more information.

Vivian Shnaidman
Overcoming Bipolar: Rohan’s Story

Rohan’s journey with mental illness has taken him from Medical School to prison. He is now managing his condition with both medication and therapy. This is a story of recovery and of perseverance. Rohan: I can’t forget to thank Dr. Vivian Chern Shnaidman for going above and beyond for me during this especially difficult time; you’re the proof that there are doctors who truly care about their patients, and for that I am so grateful.

Vivian Shnaidman
Hostile Work Environment/ Sexual Harassment
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Recently one of Fox News’ television anchors asserted that her boss created a hostile work environment due to unwanted sexual advances. What exactly is a hostile work environment?

Hostile environment/sexual harassment occurs when the plaintiff employee’s work environment is made intolerable by sexual misconduct, or the work environment is permeated with unwelcome discriminatory intimidation, ridicule, and insult, based upon sex, that is sufficiently severe or pervasive to alter the conditions of the victim’s employment and create an abusive working environment. Unwelcome sexual conduct that interferes with job performance or creates an intimidating, hostile, or offensive working environment creates a hostile work environment.

How is a Hostile Work Environment Proven?

The plaintiff need not show that the harasser knew that the conduct was unwelcome, just that it was in fact unwelcome. In other words, the plaintiff doesn’t not have to tell the harasser to stop or notify him that his comments and actions are upsetting.

In order to allege a hostile work environment, it is not necessary to allege any sexual advances whatsoever. Nor does the conduct have to be stamped with explicit signs of overt discrimination, or be explicitly sexual in nature. It just has to relate to sex or be part of a course of conduct tied to evidence of discriminatory intent. Sexually harassing conduct that sufficiently offends, humiliates, distresses or intrudes upon its victims so as to disrupt their emotional tranquility in the workplace, affect their ability to perform their job as usual, or otherwise interfere with and undermine their personal sense or well being, constitutes a sexually hostile environment.

Hostile Work Environment Evaluation

Determining whether a given situation constitutes a hostile environment is a “fact-based inquiry into the severity and pervasiveness of the conduct…the jury looks at all the circumstances supported by credible evidence.” However, a single incident of sexual assault sufficiently alters the conditions of the victim’s employment to create an abusive work environment.

Evaluations of whether a hostile work environment exists are based on 1) the nature of the unwelcome sexual acts (considering that generally touching is more offensive than verbal remarks); 2) the frequency of the offensive encounters; 3) the total number of days over which all of the offensive conduct occurs; and 4) the context in which the sexually harassing conduct occurred.

Vivian Shnaidman
Female Sex Offender Evaluations
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Female sex offender evaluations, as with males evaluations, is predominately driven by the need to establish the likelihood of future recurrences of sexual offending behavior and to identify interventions that would reduce their risk of recidivism.

In order to make a determination of risk of sexual recidivism, one must consider the individual characteristics of the offender that increase or decrease the probability of recidivism. These are referred to as static and dynamic factors. Dynamic risk factors are amenable to change and the elements that are addressed in treatment and in the management of sexual offenders in order to reduce the risk of recidivism. Risk factors may indicate a higher risk of recidivism than other female sex offenders.

Static risk factors for female sex offenders include:

  1. A prior criminal history;
  2. Number of prior convictions;
  3. Number of prior sexual offense arrests;
  4. Number of prior child abuse offenses (non-sexual);
  5. Number of prior drug arrests.

Dynamic risk factors for female sex offenders include:

  1. Denial and minimization of the offending behavior;
  2. Distorted view about the sexual offending and sexual abuse in general;
  3. Problematic relationship (e.g., characterized by abuse) and intimacy deficits;
  4. Use of sex to regulate emotional states or fulfill intimacy needs;
  5. Desire for intimacy with victim or co-defendant;
  6. Wanting revenge or wanting to humiliate;
  7. Antisocial attitudes or attitudes tolerant of sexual offending;
  8. Antisocial associates;
  9. Substance abuse;
  10. Lack of an adequately supportive social network.
Vivian Shnaidman
Fitness to Proceed | Competency to Stand Trial
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At times a forensic psychiatrist may be called on by the court or one of the parties to evaluation a defendant’s competency to stand trial. This evaluation involves a comprehensive assessment of the defendant’s mental status, the defendant’s understanding of the nature and objective of the legal proceedings, and the defendant’s capacity to assist in his or her defense. A competency to stand trial evaluation may also involve the administration of specialized psychological tests, depending on the particular clinical issue at hand (e.g., mental retardation, malingering).

When a Competency to Stand Trial Evaluation is Necessary

When a legitimate question arises as to competency, the defendant has a right to a hearing to determine fitness to stand trial. All trial courts have authority to order psychological evaluations of defendants, and in many states, an evaluation is automatic once a party raises the competency issue. Judges are to give great weight to the results of an evaluation, but can consider other factors, too, like the defendant’s demeanor in court. Among the points a court should consider are whether the defendant can:

  • adequately communicate with defense counsel
  • understand and process information
  • make decisions regarding the case, and
  • understand the elements of the charges, the gravity of the charges, and the possible penalties.

A defendant’s lack of intelligence, education level, language difficulties, and challenges communicating are generally insufficient to support a finding of incompetency.

The Court & Fitness to Proceed

The determination of whether a defendant is competent is left to the judge. The judge must decide competency before trial, as soon as reasonably possible after it comes into question. The prosecution, defense counsel, and even the court can raise the issue at any time. Competency usually comes into doubt when the defendant’s behavior indicates a lack of understanding.

Vivian Shnaidman
Child Custody Evaluations
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When parents divorce and families break up, the standard for child custody is always the best interest of the child (or children). In order to determine the child’s best interests, a psychiatric evaluation is often used to assess the parents’ and/or the children’s mental statuses, any psychiatric illness or abnormality, the family dynamics, and any conditions or situations which would lead to a better understanding of what appropriate parenting time or custody arrangements would lead to the most psychologically beneficial living situation for the children. Additionally, any treatable psychiatric conditions can be assessed and appropriate treatment can be recommended to ensure the ongoing safety and a good future outcome for each child.

Vivian Shnaidman
Fitness to Return to Work Evaluations
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There comes times when a worker may be required to leave the workplace because of the experience of an extreme stressor on the job, disability, discipline, or concern about threat. That same worker may wish to return to the job, raising questions about whether the worker may effectively resume functioning. At this point there are  several kinds of evaluations conducted by forensic psychiatrists or psychologists to determine if a worker is fit to return to the job. The first, the fitness-for-duty evaluation (FFDE), is a specialized evaluation that occurs in safety-related or “high-risk” jobs such as fire fighting, police work, or security. The second, the return-to-work evaluation (RTE), occurs in more general situations in which the worker has been removed from the job because of disability.

Vivian Shnaidman
Forensic Psychiatry-When is There Need of a Forensic Psychiatrist?
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Forensic psychiatry versus the other side: Why the need for a forensic psychiatrist

Anyone who has ever been to court for any reason knows that people’s behavior in front of judges is not always polite, decorous, or appropriate. We often attribute the anxiety, yelling, or tears to the stress of the high-pressure situation, and many times, that’s all it is. But what about those cases that simply scream “crazy” from the very beginning?

Forensic Psychiatric Evaluations

Psychiatry is a branch of medicine which incorporates biological, psychological, and social information and constructs for assessing and treating patients. Forensic Psychiatry is different. Forensic psychiatrists are trained to evaluate individuals for a third party. Unlike general medicine or general psychiatry, people involved with the legal system generally do not wish to consult a psychiatrist for help with their emotional problems. Of course, there are some applications of forensic psychiatry in which an individual will bring psychiatric information about himself to the court, and we will deal with those specific issues later. However, there are  incidents and eventualities which might require the expert testimony of a psychiatrist, and, most importantly, how to understand, interpret, and utilize the information the psychiatrist brings to the case. After all, an expert might look really professorial in his pin-striped suit, but if he does not really know what he is talking about, neither will rot firm.

Over all, Forensic psychiatry is a sub-specialty of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry. A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment like medications and psychotherapy to criminals.

Vivian Shnaidman
Dead Man Talking: Psychiatric Evaluations of People who are no longer among the Living
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These types of evaluations are among my favorite, although saying so out loud is possibly not quite politically correct. Still, I didn’t kill them, so let us consider what types of evaluations I might be asked to perform, and how these evaluations might be utilized in a court of law.

Testamentary Capacity refers to the ability of an individual to make a will under the law. Sometimes I’m asked to evaluate a still living person, for example someone in a nursing home. But although the criteria are the same, it is fairly easy to evaluate someone who alive. I can ask them questions, we can bring witnesses to the party, and people generally have an idea if the person has an idea of the requirements necessary to write a will, which in virtually every jurisdiction in the United States includes only a few elements: the person must know the nature and extent of his bounty, who his natural heirs are, and to whom he or she wishes to leave his estate. While there are some local additions (in New Jersey, the person is supposed to know in what type of business he or she worked), those additions are minimal and beside the point.

These evaluations become really interesting when a person writes a will, dies of natural causes, and then the heirs and non-heirs start to contest the will. Sometimes only one heir does not like the way the will is written — an heir might not like having to wait until a certain age to get her money, or might not like having to share with siblings. Then the heirs can contest the will, and to contest a will, these heirs must hire attorneys.

Attorneys then look for experts. Often the attorneys hire any random doctor whom they can convince to write something stating that the dead person lacked testamentary capacity on the day he or she wrote their will. Smart attorneys, however, hire me.

In rder to really assess testamentary capacity, we have to recreate the person’s mental status examination as it pertains to the requirements for testamentary capacity on the date of the will writing. A three-sentence letter stating that the individual took medications that might impair consciousness is insufficient. I have seen all manner of ridiculousness submitted in lieu of actual psychiatric expert reports. “Because I said so” is not an expert report. “Because I am a doctor and I said so” is not an expert report. Lawyers need to hire experts who know how to read and understand medical records and apply the appropriate legal standards to them, and then communicate their findings in a way the courts can understand. Otherwise the “expert” reports are useless.

In addition to testamentary capacity, there are other cases in which mental status of deceased people has to be recreated. One example is the psychiatric autopsy, when someone committed suicide or otherwise died and there are legal matters that need to be investigated. Sometimes a wrongful death suit requires information not uncovered in any other investigation. Both civil and criminal matters often require the input of a psychiatrist in uncovering the details of someone’s mental status when that person is unavailable for interview. Those details are important. We do not guess. We reconstruct, based on available information. This work is detailed, painstaking, and challenging. And it is not a letter saying “Because I said so.”

Vivian Shnaidman