Psychiatry is subjective, and it takes time and trust
The article “How, and why, we’re covering Clancy trial” (Metro, Aug. 9) contributes to a negative view of mental health treatment by stating that if Lindsay Clancy, a labor and delivery nurse, “could not find appropriate care, as she and her ex-husband have claimed in separate civil suits, how might other mothers, especially those less savvy about the medical system, fare?”
I won’t comment on any specific legal case, but I will comment on the field of psychiatry itself. Psychiatry isn’t witchcraft or mind-reading. It is an evidence-based field of medicine. Because the data on which psychiatrists rely is the inner life of patients, psychiatry is also subjective, involving shared reflection upon the thoughts, feelings, and perceptions of patients. Lab testing and imaging can play roles in treatment, but psychiatric diagnoses are based on a patient’s self-report and physician observations.
There are myriad reasons patients are unable or unwilling to verbalize their inner experiences, and this is the very work of mental health treatment. It takes time and trust. During initial visits in my psychotherapy practice, I ask patients to help me understand all the barriers to getting started. Next, I ask that we agree to not allow the barriers from stopping the patient from getting the treatment they deserve.
My reality as a psychiatrist is shaped by the reality that is shared with me. This is different from other fields of medicine but also what makes psychiatry fascinating and completely personal. The truth doesn’t always come out in psychiatric treatment.
In addition to asking about how the system might have failed the Clancy family, it would be a gift to public health for the Globe to examine what makes psychiatric treatment work and to educate readers about how to access the best psychiatric treatment and how to be fully understood and form a trusting relationship with a qualified provider.
Dr. Wendy Cohen
Brookline
The system pushes polypharmacy over forging a therapeutic alliance
As a psychologist with experience in a general health care setting as well as more than 35 years as a provider of psychotherapy to individual adults, couples, and families, including those struggling with postpartum mood disorders, what repeatedly strikes me in the descriptions of Lindsay Clancy’s mental health care is the chasm between the way I was trained in the 1980s and today’s mental health system. Today’s system seems to be dominated by symptom counting, diagnostic labeling, and polypharmacy to the exclusion of forging a therapeutic alliance.
When caring for a patient who returns to me reporting increased distress and fearfulness about the direction of their care, whether my own psychotherapeutic treatment or that of a psychopharmacological provider with whom I am collaborating, I follow my training, which is to prioritize above all else gaining an empathic understanding of my patient’s experience of that treatment.
The capacity to empathically think my way into my patient’s internal world and forge a trusted shared sense of their distress, its roots, and possible roads toward its amelioration is the foundation of a therapeutic alliance. The forging of such an alliance takes a trained awareness of its importance and the clinician’s alarm system when an alliance does not exist or has been broken,
Clancy’s increasingly desperate cries that the multiple different medications she had been prescribed might be making her worse needed to ring an alarm bell for at least one of her mental health care providers. Instead, her cries led to a continuation of prescriptions for more and different medications, repeated monitoring through symptom checklists, and proliferating diagnoses.
The sidelining of the therapeutic alliance reflects a mental health care system that has lost its bearings. I fervently hope this tragedy will be a wake-up call.
Susan H. Phillips
Brookline
The writer currently has a private practice. She holds a doctoral degree in clinical psychology and is a member of the board of the Psychodynamic Couple and Family Institute of New England.
This case is a tragedy, not a crime
It was extremely frustrating and painful to read, in the article “Doctors describe Clancy’s mental state” (Page A1, Aug. 8), the account of the testimony of psychiatrists and others regarding the medications prescribed to try to help Lindsay Clancy. As someone who trained and worked at McLean Hospital 30 years ago, just as insurance-driven managed care paralyzed the health care system and providers within it, I can state that there is always pressure to discharge patients before they are ready (“utilization review” is a presence at rounds), that providers all know that many medications take weeks to have an affect, that hospital prescribers see patients only briefly and do not follow them when discharged, that follow-up communication between inpatient and outpatient providers is spotty, and most important, that mental health care providers and mentally ill patients themselves have a difficult time understanding what is happening to them and how to fix it.
The only thing we all really have to go on — providers and patients — is language. Brain science and the field of mental health is still in its infancy.
This case is a tragedy, not a crime.
Christine Musello
Smithfield, Va.
The writer is a licensed psychologist and holds a doctor of psychology degree.