Finding a competent psychiatrist.

September 30, 2005 4:44 AM

How do I find a psychiatrist that doesn't suck?

I have suffered from depression and anxiety all my life, but it's gotten really bad lately to the point where I am avoiding social contact and have great difficulty carrying on verbal conversation. I've been on and off various medication for years, without much permanent success. Having recently moved, and started a new health plan, I need lots of help from someone competent and compassionate.

Therein lies the rub. Everyone I have been to has, in one way or another, failed to help: invariably I am accused of narcissism, or faking it; get bewildered comments about why I am there in the first place; gotten offended when I requested medication in lieu of talk therapy; been told "I don't really know how I can help you - I only prescribe drugs;" been admonished for not taking responsibility for my own problems; been told to just sit tight for a few months because they don't know how long the medication will begin to work; and generally been made to feel even more out of place than I do in my daily life, which is why I'm in the damn psychiatrist's office to begin with.

Am I being punk'd on a huge scale? Starring unwittingly in Malpractice Candid Camera? Or am I doing something wrong myself? I do not light things on fire, nor do I hurl feces at bystanders, nor do I run naked through parks. I'm a normal, smart guy with a lot of emotional and mental problems that I need addressed before I start my career.

So how do I go about finding someone competent? I have a clean slate now, and need to start over with a person who I can trust and will help me through this compassionately and professionally. I have a list of twenty doctors from my health plan who have offices within a reasonable distance. I have no idea where to start and no peers who I can ask about these specific doctors. My other doctors are useless and just refer me back to the names on the list without any specific recommendations.

Please help me manage this maze and get me started on the path to recovery.

posted by anonymous to health & fitness (15 comments total)

Put your list in alphabetical order. Make an appointment with the first doctor on it. If you're not comfortable with that doctor, don't go back; try the next one on the list. Keep talking to new doctors until you find one you do feel comfortable with.

Keep notes on what the various doctors you meet have to say, and if more than half of them say the same thing, take it seriously.

While you're waiting to meet Dr. Right, you can always try a little self-help.

One stupidly simple trick that's been known to work is to learn to monitor your own thoughts, and when you find yourself setting off once more down one of the all too familiar paths that lead to hell, remember to interrupt yourself and think "that's all very well, but maybe things will work out just fine!" This is in no way a cure-all and does need to be practised a fair bit before it becomes second nature, but it really can take the worst of the edge off a bad day.

Courage, and best of luck!
posted by flabdablet at 5:22 AM on September 30, 2005

Oh, yeah: in case you're not already on to this: going for a brisk walk for half an hour or so every day can work as well for some people as quite heavy medication, and has better side effects.
posted by flabdablet at 5:24 AM on September 30, 2005

Referrals are usually the best way to find a good doctor, but that's problematic in your case. Are there any local support groups or mental health associations that could perhaps give you some advice?
posted by desuetude at 6:37 AM on September 30, 2005

Hmm, I'm actually wondering this myself. I have a friend who is really screwed up and can't even hold down a job. She's in counselling and has been for years, but it doesn't seem to be helping much. I'm trying to figure out how to find her a better therapist, one who will help her work to better her present rather than endlessly rehashing her past and who isn't too prescription-happy. But how do you do that? Don't you need a personal recommendation from someone who actually knows the therapist and is familiar with his or her work? There may be another way, some registry somewhere perhaps, but I don't know of any.

So what I would consider doing, anon, is to post again anonymously, identify your specific geographic region, and ask for recommendations. Perhaps you could set up a hotmail box and invite people to email you privately with names and contact info, because not everyone will want to admit they are recommending their own counsellor.
posted by orange swan at 7:02 AM on September 30, 2005

FYI, one accepted model of depression involves having the belief that "I need help but nothing can help me" with the unconscious need to repeatedly prove it by trying to get help and having it "fail". So, some of the psychiatrist responses you are seeing are their (rather lame) attempts to try and break this cycle.

I personally do not think you need to put your life on hold while you address your "emotional and mental problems". Living is many times the best medicine.

As you're anonymous I can't ask you a question, but try to answer for yourself what you want to have therapy achieve for you. Think of it in positive terms, e.g., "to feel available and energetic to pursue this important part of my life" vs. negative terms, e.g., "to not feel bad all the time". Then as you go to different therapists and talk to them, notice which of them respond to your positive intentions and which relate to the negatives. This will give you a good indication of whether they unconsciously want to take you somewhere new or if they want to hold you (multiple meanings intended). I know which I would prefer, but you have to figure that out for yourself.
posted by blueyellow at 7:14 AM on September 30, 2005

I've had better luck with licensed professional counselors or psychotherapists for the "talking cure." Try the phonebook, under "Counselors," see if they're on your list. I've been to a couple of psychiatrists to try out different meds for social anxiety, but I found them to be cold and too "doctory" for therapy. A lot of practices who do therapy will recommend an MD for medication, or have someone else in-house. I did the double-duty for awhile. Hang in there!
posted by steef at 7:26 AM on September 30, 2005

One more comment, psychiatrists are not better than psychologists, social workers and other types of therapists. It is not uncommon to have a therapist and an occasional psychiatrist if drugs are neccesary.
posted by blueyellow at 7:30 AM on September 30, 2005

Many therapists will also be willing to talk to you on the phone or over email before you set up an appointment. It might be worth trying to phone interview a couple before schlepping all over town, at least to eliminate the immediately incompatible ones.
posted by occhiblu at 7:42 AM on September 30, 2005

blueyellow writes "FYI, one accepted model of depression involves having the belief that 'I need help but nothing can help me' with the unconscious need to repeatedly prove it by trying to get help and having it 'fail'. So, some of the psychiatrist responses you are seeing are their (rather lame) attempts to try and break this cycle."

I've never, ever, heard of this "mode"l of depression, nor have a heard of professionals trying to treat this model. Your previous docs sound like jerks.

Finding a good doc can be hard, and painful. Referrals are the best bet, interviews the next step. You should feel fine about interviewing your doctor, feeling out their bedside manner, figuring out their treatment philosophy, etc. Their ability to form a relationship with you is the most important part of your treatment equation. I kid you not, the most important part. Different doctors rxing the same meds to patients with the same diagnosis have been shown to have very different responses to treatment. Those whose patients get better are those who establish better relationships. This is true for therapists as well.

My recommendation, actually, would be to find a therapist first who will refer you to a good psychiatrist if you still want to go. I'm not making an anti-med argument, but one based on the realities of modern psychiatry. Many, many psychiatrists only see patients for med management, which means short sessions and rushed attempts to connect. It's part of the reality of managed care, among other things. If you have a relationship with a therapist you trust then you may trust them to send you to a doc who cares for you well. Also, it sounds to me as if you've got some questions about what you want and need, questions that might need to be at least fleshed out before you can effectively interview a psychiatrist. We also know that even for severe depression therapy is as effective as medications (this article is a reference, note the last two paragraphs), so seeing a therapist is not a waste of time even if you think meds are really needed.

I've said stuff about what works in therapy in this answer in another thread. My email is in my profile; I will keep any communication confidential; I have professional experience in this area. Feel free to email me if you like and I can help you.
posted by OmieWise at 7:51 AM on September 30, 2005

First, thinking of depression as a kind of addiction may be helpful. You have to struggle against it.

Second, as miserable as this sounds, you are going to have to go on "interviews" to find the right therapist. You have to find someone that talks sense, that you can respect, that uses tools that you think will work for you. The only way to find this person is to make an appointment and see how it goes.

Third, in many cases depression starts with a dysfunctional environment, which creates dysfunctional habits/reactions. Take an inventory of what you do/don't do that "normal people" do/don't do, or do differently. Then, try living life their way. One step at a time.

Ever think about Group therapy instead/in addition?
posted by ewkpates at 8:22 AM on September 30, 2005

One more comment, psychiatrists are not better than psychologists, social workers and other types of therapists.

I would absolutely have to disagree with blueyellow. I have seen 4 psychiatrists and 4 therapists/social workers in my life and they are worlds apart. Like the differrence between riding a bike and standing still.

Every psychyatrist I have seen actually takes an active role in helping me, like actually talking back to me, letting me know how I sound, challenging me, examining fundamental emotional obstacles, real constructive stuff. With the psychologists, wow, I just sat there and talked about my day while they reccommended I listen to some relaxing tapes. I mean real bullshit. I could not believe that there is such a differrence, but all the MDs I have seen have had the same frank, constructive style, while all the psychologists I've seen over the many many years have had the same wishy washy, soft, unfocused style.

While this is just my experience, I really do beleive that an MD is going to be more aggressive with curing your problem.

I always post this, but I found my current doc by asking metafilter. I searched the archives for a strong rec by someone in my area and contacted that mefite. He doesn't take insurance but he's good. The best I've seen. If you're in NYC and want to add another one to the list, feel free to email me.
posted by scazza at 9:39 AM on September 30, 2005

Try using Google to search for the names of each doctor. You may find comments about the doctor or even their website. That information may help you in finding a doctor who fits your needs.

I would also suggest finding two different professionals - a therapist you can talk to (when you do finally feel like talking) and a psychiatrist who can prescribe meds (if needed). Meds are good, but in combination with talk therapy they can be a miracle.
posted by Serena at 9:39 AM on September 30, 2005

anonymous, it's not you. What you've experienced is the way that it is for most people with care for depression and anxiety.

Part of the problem is that what constitutes a solution for depression and anxiety is highly subjective, and that the controlled studies and evaluations for treatment are evaluated mostly on patient reports, which can vary widely based on any number of factors (psychological, physiological or external). Other than gross malpractice, there really aren't objective ways to evaluate whether a psychologist, counselor or psychiatrist is "good."

I too am going to disagree with blueyellow. I saw a significant number of psychiatrists and psychologists when I was younger (I've been generally doing pretty good on the psychological front for years now), and while the psychologists were generally unhelpful, and the talking cure did little for me, and the psychiatrists I saw weren't much better on that front, they were able to do one thing the psychologists couldn't -- they can prescribe drugs. The decent ones were able to evaluate the effects of the drugs in a methodological fashion; the psychologists simply invited me to talk about my problems and generally did not offer anything approximating solutions. There are certainly some people who are depressed or anxious because they're holding something in, and the talking cure may well work for them... but I wasn't one of those people, and it was useless.

Drugs are their own problem, of course -- the most effective psychiatric drugs are blunt instruments that do little more than slow you down or speed you up. The track record of the SSRIs (which have been hailed as being less blunt than the older medications) is spotty, with the undeniable side effects, the controversy over their effectiveness over placebo across studies, and the very real increased risk of suicide (which is now mentioned prominently right on the top of Prozac's prescribing information). However, when you're experiencing severe symptoms (if you're having severe difficulties leaving the house, for example), medication may well be the best course of action just to get you functioning, and you can come up with solutions from there.

My advice, before you sit down with a doctor, is to figure out precisely what you want out of treatment -- create a list and bring it. It should contain the symptoms of depression and anxiety that you want to eliminate (the gory specifics of your difficulty communicating with people -- that's why you type or write it up in advance), what would make you think you were being acceptably treated ("Ability to go out in public twice a day," "no crying fits for several months," "ability to keep from missing work because of anxiety for a period of over three months."), and the course of action you would prefer (behavioral therapy, cognitive therapy, drugs). Schedule first appointments with a few of these doctors, explain that you're having difficulty communicating your symptoms and desired treatments effectively, and hand them your document with the specifics. They'll then give you a once-over on what they typically would feel the best treatment options would be, and if you're not happy with that, you're not obligated to them.

Honestly, though, I had to come up with the answers myself after I got the severe things taken care of. Often, friends can be better therapists than professional therapists when it comes to general coping with life. And often, keeping busy with a satisfying job or good friends is a better way of coping with non-severe depression or anxiety than therapists. Interview the doctors about the severe things, and once those are taken care of, try different ways of life until you find something that works.

Good luck!
posted by I EAT TAPAS at 10:27 AM on September 30, 2005

Finding the right mental health practitioner can be difficult. I believe in shopping around, while at the same time paying close attention to what makes you not like a certain person/therapy. I strongly recommend actually addressing these concerns directly with the person instead of holding them in.

I have suffered from anxiety and depression for most of my life and have been in and out of therapy since the age of 13. In my late twenties I was introduced to cognitive behavioral therapy and medication. The combination of the two has been remarkable; it has been three years since being in therapy (I am still taking the meds) and while I still suffer from anxiety and short bouts of depression, it is not anything like it once was and on top of holding down a job, I can actually say now that I enjoy life and am getting better each year.

In the beginning, I was resistant to CBT because I was used to years of "intellectual" analysis delving into my unconscious motives and desires and was too proud to believe that my thinking was irrational and that that could be a major part of my problem. To be honest, I was so resistant to this therapy at first and if it wasn't for my being so desperate and the therapy being free, I probably would have stopped seeing the psychiatrist. (I am so glad I didn't!) When I actually went along with it and did the exercises, I found they worked remarkably. This is the book my psychiatrist recommended to me at the time.

Also, I did find the right meds, but it took about a year of trial and error to get there.
posted by cardamom at 10:44 AM on September 30, 2005

Here's an earlier thread, and a not as early thread.
posted by daver at 10:51 AM on September 30, 2005