'Shrink Rap' Gets Psychiatry Up Off The Couch

Drs. Annette Hanson (left), Dinah Miller and Steven Roy Daviss are the authors of Shrink Rap and the co-hosts of a psychology podcast. i i

Drs. Annette Hanson (left), Dinah Miller and Steven Roy Daviss are the authors of Shrink Rap and the co-hosts of a psychology podcast. Kery Hummel hide caption

itoggle caption Kery Hummel
Drs. Annette Hanson (left), Dinah Miller and Steven Roy Daviss are the authors of Shrink Rap and the co-hosts of a psychology podcast.

Drs. Annette Hanson (left), Dinah Miller and Steven Roy Daviss are the authors of Shrink Rap and the co-hosts of a psychology podcast.

Kery Hummel

For a profession devoted to dialogue and understanding, psychiatry is awfully misunderstood. You know the familiar stereotype: the long couch, the dim lighting and the soothing voice asking, "And how did that make you feel?" But the reality is much more complicated, and in their new book Shrink Rap, Drs. Dinah Miller, Annette Hanson and Steven Roy Daviss describe what psychiatrists really do every day.

Daviss is a hospital-based psychiatrist. Early in the book, he describes "Oscar," a fictional patient he uses to explain facets of the psychiatric process. Oscar is going through a divorce, Daviss tells NPR's Neal Conan, and has been brought to the emergency room by police officers who charged him with a DWI. When Oscar told the police he wanted to kill himself, they brought him in, against his will.

Cover of 'Shrink Rap'
Shrink Rap: Three Psychiatrists Explain Their Work
By Dinah Miller, Annette Hanson and Steven Roy Daviss
Paperback, 272 pages
The Johns Hopkins University Press
List Price: $19.95

Read An Excerpt

Co-author Dr. Dinah Miller works in private practice in Baltimore, Md. She describes another fictional patient, "Melissa" — a pediatrician with "classic symptoms of major depression," says Miller. "She stops doing the things she usually does, her sleep is disturbed, her appetite is disturbed, sometimes while she's seeing patients, she leaves the room to cry." She's a doctor, and the child of someone with depression, so Melissa knows she needs to get help.

Through the stories of Oscar and Melissa, Daviss and Miller explain the different ways patients get help. Melissa seeks out a psychiatrist for therapy and receives medication. Oscar, who was admitted against his will, goes through the prison system of care. When he's discharged, Miller explains, he looks at the various options available to him on the outside: a community mental health center, an out-of-network psychiatrist and an in-network psychiatrist. "We use them to exemplify the different aspects of what we do," she says.

In the hospital, Daviss sees patients in the psychiatric unit, in the emergency room and on medical floors. "I would say the lion's share of patients who come in to be admitted to a psychiatric unit are coming in from the emergency room — like Oscar did," he says. At his hospital, he says 10-15 percent of those admittals are involuntary, which he thinks is typical for the state of Maryland.

One of the challenges in modern medicine is the coordination of care. A patient may be seeing multiple specialists — say, a cardiologist, a psychiatrist and a dermatologist. "The medications that are used can interact," says Daviss, so it's critical that the doctors communicate well to best serve the patient.

Psychiatrists and other doctors also have ethical constraints that can make it tricky to treat their patients. Clinically, it's important for them to share stories with their colleagues, to confer and share expertise at conferences and in journals. But they have to protect their patients' anonymity, too. Miller says they have ways of obscuring patients' identities, but are especially "tormented ... by this question of how to write about patients."

"One day I picked up The New York Times," she remembers, and thought an article a colleague wrote about a patient compromised confidentiality. That's why she and her co-authors decided to use fictional patients in their book. It allowed them to walk Oscar and Melissa through the process of seeking help without worrying about revealing specifics of their cases. Though the scenarios were true-to-life, the patients were comfortably fictional.

As for the real world, when people ask Daviss casually — that is, not in the office — if he's analyzing them, he's always ready with a glib response: "Only if you're going to pay me."

Excerpt: 'Shrink Rap'

Cover of 'Shrink Rap'
Shrink Rap: Three Psychiatrists Explain Their Work
By Dinah Miller, Annette Hanson and Steven Roy Daviss
Paperback, 272 pages
The Johns Hopkins University Press
List Price: $19.95

What are the different types of mental health professionals? Which pro­fessional should someone go to for treatment? And what exactly is a psychiatrist?

When a person thinks about a dentist, a specific image comes to mind. Perhaps it is of a man in a white coat standing over a patient in a reclin­ing chair, and perhaps the dentist is saying, "Open wide." The image of an architect may be of someone hunched over detailed drawings of a build­ing. What comes to mind when a psychiatrist is mentioned? Oscar Ford pictured a bearded man smoking a cigar, sitting behind a patient who is reclining on a couch. He was thinking of Sigmund Freud. Melissa Adams thought of a red-haired doctor in a white lab coat. She was thinking of the psychiatrist her father had seen at the university hospital for his de­pression. Both images may be accurate.

Psychiatrists may work with patients, or they may be involved in teaching, research, administration, or some combination of these. In this book, we are limiting our discussions to the clinical psychiatrist: one who works directly with patients for the purpose of providing treatment, rather than as part of a research protocol or for teaching purposes.

Psychiatrists are medical doctors (M.D.s) who specialize in illnesses that affect thoughts, emotions, perceptions, and behavior. These are brain-based disorders, but psychiatrists are not neurologists. Like all medical doctors, psychiatrists complete four years of college and four years of medical school. The first two years of medical school include two years of basic science followed by two years of clinical rotations through a variety of specialties, though the past decade has seen many programs develop a greater integration of clinical experiences within the initial basic science years. Every medical student does clerkships in medicine, surgery, pediatrics, neurology, obstetrics, and psychiatry. These clerkships last from one to three months, long enough to give each doc­tor a little experience in a range of specialties. After graduation from medical school, doctors train for several additional years as residents. A general psychiatric residency lasts four years.

Sub-specializations can be earned with further training during fellowships, which are typically one or two years. For example, child psychiatrists spend an additional one to two years in fellowship training. Other common fellowships include ge­riatrics, addiction, research, and psychosomatic medicine.

Psychiatrists diagnose and treat mental illnesses. They have the train­ing necessary to make medication decisions and to prescribe medica­tions, and although they are trained to perform several types of psycho­therapy, they may or may not choose to focus on this. Some psychiatric residency programs emphasize psychotherapy training more than others, and factors that determine if a psychiatrist practices psychotherapy in­clude the work setting, personal preference, and reimbursement issues. We talk about all these things in much more detail later.

Psychologists do not have medical training. They may have either a master's degree, in which case you'll see the initials M.A. or M.S. after their name, or they may have a doctoral degree, indicated by a Ph.D., Psy.D., or Ed.D. after their name. Only psychologists with doctoral de­grees are called "doctor," though anyone with a doctoral degree in any subject can be called doctor. This is often confusing to many who limit their use of the term doctor to refer to medical physicians, such as psy­chiatrists and cardiologists.

Clinical social workers complete two years of graduate-level training to obtain a master's degree, or M.S.W. To receive the designation of li­censed clinical social worker, or L.C.S.W., the therapist must have a period of clinical supervision and then pass a national exam. Social workers have no medical training and are not allowed to order diagnostic tests, administer psychological tests, or prescribe medications. In addition to therapy, the education of a clinical social worker involves learning how to provide for the financial and emotional needs of families and indi­viduals by helping them obtain the programs and services they need.

While this seems clear enough, the distinctions can get very confus­ing. Some people have more than one degree, so that one person can conceivably be both a nurse and a social worker. Or a nurse can get a doctoral degree in nursing and be called doctor even though he's a nurse. Nurses can obtain a master's degree to provide psychotherapy, and in many states, licensed nurse practitioners and physicians' assistants can prescribe medications under loose supervision — "loose" meaning the supervising physician does not have to actually see the patient. A few states permit these health care providers to practice independently. The terms counselor, therapist, and coach may sometimes be used generically and not require any specific educational degree or licensure, though every state does things a little differently, so your mileage may vary. Being "certified" usually indicates less rigorous education and experience than being "licensed." The term therapist can refer to a psychiatrist, psycholo­gist, social worker, nurse, or pastoral counselor.

In case that's not confusing enough, we'd like to mention psychoana­lysts, mainly because they are the image that the media (and Oscar) hangs on to for its icon of psychiatry. Psychoanalysis is a very specific type of psychotherapy where the patient lies on a couch, facing away from the doctor, and talks about whatever comes to mind, a process known as free association. Therapy is conducted for three to five sessions a week and takes several years.

Psychoanalysis is the origin of all modern psychotherapies that base technique on the importance of unconscious thought, feelings, and inten­tions. The unique aspects of psychoanalysis include the frequency of the sessions, the importance of childhood experiences, and the focus on the patient's relationship with the psychoanalyst as a mirror of past relation­ships, a process called transference. The goals of psychoanalysis are an in-depth understanding of the unconscious experience and a greater flex­ibility in self experience that enables the patient to make more adaptive choices. Psychoanalysis is used both to treat mental illness — oft en anxi­ety, depression, and personality disorders — and for personal growth and awareness. Most analytic patients also take medications to address spe­cific symptoms.

Psychoanalytic training typically takes five, or more, years and is done part time while the trainee works. It includes a personal psychoanalysis for the therapist. Traditionally, psychoanalysts have been psychiatrists, but that is no longer the case. Although the analytic couch is the image we often think of in connection with psychiatry, very few psychiatrists practice this form of treatment, and very few patients are treated with it. We mentioned the image of a bearded psychiatrist who smokes a cigar and sits behind the couch, but this is a caricature — we don't actually know of any doctors who still smoke while they see patients!

Excerpted from Shrink Rap by Dinah Miller, Annette Hanson and Steven Roy Daviss. Copyright 2011 The Johns Hopkins University Press. Excerpted by permission of The Johns Hopkins University Press. All rights reserved.

Books Featured In This Story

Shrink Rap

Three Psychiatrists Explain Their Work

by Dinah Miller, Annette Hanson and Steven Roy Daviss

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