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Philosophy of Treatment
Philosophy of Treatment? That should be simple and exactly the same for every physician, no matter their specialty: To accurately make a diagnosis and render evidence-base, scientifically sound treatments that are effective for that diagnosis. And that is certainly what I do, but I think we can go into more detail of what “Philosophy of Treatment” might mean.
Unfortunately, in this day in age psychiatrists are often less involved in psychotherapy and many times not at all. In fact, I have sometimes heard psychiatrists defined as “they give out medication and don’t do psychotherapy.” I cringe when I hear this for two reasons. Number one: it is often true. Number two: it is not true of me and I don’t want people to think that way about all psychiatrists.
In decades gone by, psychiatrists were the main providers of psychotherapy. Most of the great names in psychotherapy of the past century were psychiatrists. Over time, that began to change for several reasons. Fifty years ago, we had few psychiatric medications and most of psychiatry was involved with psychoanalysis as the main treatment for whatever your issues were. With the incredible advancements in neuroscience over the past several decades, our understanding of the brain greatly increased and with it more ways to effectively treat depression, anxiety, panic disorder, obsessive-compulsive disorder and others.
If you looked at the table of contents from an issue of The American Journal of Psychiatry in the 1960’s or 70’s, almost every article would be pertaining to psychotherapy. If you look at a current issue, virtually all of the articles will be about biological treatments. This is not all bad. It speaks to the awesome revolution in neuroscience advancements that show no signs of slowing down. This is very good.
However, in our excitement about synapses and brain receptors, we cannot forget and we should never underestimate the power of psychotherapy. During my residency in the late 80’s, there were still many professors who spent their careers doing psychotherapy primarily and I was lucky enough to have received an extensive experience in the practice of psychotherapy in its many different forms.
I have many patients where I do the medication monitoring and I work with a competent psychologist or social worker who does the therapy and we work together as a team. I have many patients where I do the psychotherapy and the medication monitoring. I have patients who are only on medication and don’t need psychotherapy and I have patients who I am doing psychotherapy with and need no medication at all. My point is that everyone is different. One size does NOT fit all and each patient needs a different “treatment plan.”
Let me give you an example. Two patients come to my office with almost identical problems: over the last year or so they have developed a driving phobia that has worsened to the point where they cannot drive to work and are about to lose their job because of it.
The first person is a 35 year old woman who has been rather anxious her whole life and over the past year her anxiety has manifested as a driving phobia. I explain to her
the concept of “exposure therapy.” I tell her she has to gradually expose herself to the source of her anxiety. This will make the anxiety worse in the beginning, but then it will decline and resolve. I tell her that depending on how the exposure therapy goes, we will see if medication in conjunction with the therapy might be indicated.
The second person is a 40 year old male who after taking a thorough history, I learn that he witnessed a horrific car accident where two of his friends were killed. I talk to him about the nature of posttraumatic stress disorder and how his response is understandable. As we process the trauma and come to understand the purpose of the anxiety (perhaps an unconscious desire to avoid driving so he won’t suffer a similar fate) he can learn to master it. We also talk about the role medication can play in the treatment of posttraumatic stress disorder.
In both these examples, we don’t want to use medication to mask the anxiety. We want the person to learn to master the anxiety and in so doing, become a more adaptive person. However, certain medications can treat underlying neurotransmitter imbalances that may be present or if the anxiety is of such intensity that it is making therapy impossible, medication can help bring it down a level.
Again, the point is that every situation is different and every situation needs a different plan of treatment. And that “Treatment Plan” is developed with a team approach between professional and patient. That is my “Philosophy of Treatment.”
In all of medicine, no matter the specialty, the patient’s world affects the illness. If you have asthma, what happens if you get anxious? If you have hypertension, what happens if your job suddenly gets more challenging? Especially in psychiatry, how can you treat the biological factors of the problem if you don’t attend to everything else in your patient’s world? I don’t think that you can.
Sometimes it is simple: A person will come into my office with major depression and I will put them on an antidepressant and in 2 weeks they will be better. Great! But, as we all know, it is usually not that simple and sometimes it is incredibly complicated.
After taking an initial history, I may learn that my patient’s marriage is in trouble, that he may be getting laid off from work, that his daughter is not doing well in school and his son may have a drug problem. He tells me that he is not sure if life is worth living anymore. I will try to communicate this message: “This is overwhelming. We are going to look at this and you and I are going to put a plan together. We can do this and we will take one step at a time.” Just an offer to help and an indication that help is there, can be most reassuring.
This is my “Philosophy of Treatment.”
In the following pages under this heading, I will discuss some topics in psychiatry. My brief descriptions may lead to more questions than answers. That’s not a bad thing. I would welcome you to contact me to discuss those questions.
We do not see things as they are, we see them as we are.
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