Changing Horses in Midstream

The current changes in medicine are trickling down and showing up everywhere. In psychiatry and mental health, we are not immune.

One of the ways our clinics are changing now is that the approach to initial assessment, triage, and acceptance for treatment is a moving target once again. Basically, anyone can walk through any door and ask for help. He will then be screened by a clinician, then his story will be told in a treatment team meeting designed to decide who would benefit  from the mental health center’s services and who would best be served by referral out to another entity, such as the Department of Disabilities and Special Needs or their own family physician. 

Once the determination is made that the services of the center are right for that particular patient, then he is assigned to a therapist and treatment begins. It goes for ten sessions or twenty sessions or longer, depending on presenting symptoms, diagnosis and the desires and goals of the person seeking help.

Unless it doesn’t.

Sometimes, after six sessions or worse yet, six months, the patient is told that she will have to switch to another therapist or counselor in the middle of the process. This is most likely not something that she will have chosen to do herself, especially if she has developed a rapport with her counselor and feels that she is making good progress towards her goals. 

It is happening more and more because we simply have too many patients and too few providers and need to cover too many bases. A therapist who normally does play therapy with five year olds may have to pick up the slack and see adults with bipolar disorder. A psychiatrist who loves seeing adult patients with chronic illnesses such as bipolar disorder and schizophrenia (raising hand) may find himself a de facto child psychiatrist for a clinic of five hundred patients because his predecessor retired or moved or died. These mandated changes may come from an immediate supervisor or straight from the top. 

If we as therapists and counselors and doctors think this is stressful, imagine what our patients must be feeling.  

They have already told their story, in great detail and with great emoted pain, to one person. Now, they have to tell it again? To start all over? They have finally summoned the courage to talk about sexual abuse that occurred twenty years ago, and now they have to re-live that trauma to re-tell the story to another therapist?

If you’ve been there as a patient, you know how hard it is to do this. You feel lost for a while, adrift, until you re-tether yourself to another port in the ongoing storm. If you’re a doctor or counselor or therapist, you know how hard it is to pick up therapy in the middle of the course, to review what someone else has  already done and try to build on it, instead of crafting the original plan yourself and going forward together. 

In medicine generally, and in mental health specifically, trust is important. Continuity is crucial. Knowing that the person who is trying to help you knows your own individual story, your little secrets, your hopes and fears, is the keystone in the overarching plan for excellent care. 

Disrupting this process at the whim of bureaucrats, legislators and bean counters may be good management, but it is not good medicine. 

11 thoughts on “Changing Horses in Midstream

  1. Mental Health has suffered for many years, the field much the way patients have. In the nineties our clinic was told by the state that we had to suddenly limit sessions–to do only short term therapy– with existing patients as well as new ones. We were off the beaten track and could stretch the rules for a while. I left (because we were moving away) shortly before it was taken over by a private company and all changed again, and for the worse.

    I worked mostly with people with serious mental illness and really loved doing it. But there was absolutely no understanding in the bureaucracies of the needs of these patients. I took weeks to separate from my patients. But later, you just got one session..


  2. My office mate covered for me during my 4 week leave after my mastectomy and during my 7 week leave following my TRAM surgery. No one called her or saw her. She is an excellent psychologist and I did a lot of prep work with patients who I thought would benefit from seeing her. The kids did not want to see anyone else.

    It’s just not the same as seeing another doctor for a sinus infection when your internist can’t see you right away.

    I did keep up with folks via email but I had to keep boundaries around that for my own health and recovery. It was tricky, but so is cancer, and so is life, in general.


  3. Esther,

    Thanks for reading and for the comment.

    Yes, it really bothers me that these decisions to cut services, limit funding and carve out certain diagnoses are made by folks who usually have no or limited clinical experience, do not understand the therapeutic process, and look only at the bottom line.

    I know that we all suffer when this happens, but of course the ones who suffer the most are the patients. I really believe that.

    It’s unfortunate that the folks who pull the strings sometimes have to experience the trauma of mental illness in themselves or their families before the see the necessity of providing these services.

    Please come back and comment again.


  4. E

    It sounds like you did all you could do to prep folks for your very necessary absence. This was not a mandated separation or a permanent state of affairs I suppose, which is different. At any rate it is traumatic for all.



  5. No, it is definitely different. And I know that I did all that I could. I don’t feel guilty about it. Fortunately, I had shifted my practice to emphasize assessment for family reasons. These days, only about 10-20% of my patient load is for psychotherapy. (The kids I see have chronic issues and come back for a series of booster sessions on an intermittent basis. I have a couple of patients who I’ve seen regularly for years and one of them was most negatively impacted by my leave. But he hung in there and perhaps, it ended up being a good learning experience for him in coping with his anxiety. But I must say that ever since I returned from my mastectomy, he gives me a hug at the end of every session. He also invited me to his Bar Mitvah over a year early! So sweet.)


  6. Of course you did, and of course you should not feel guilty!
    Hate to say that there is EVER a silver lining to cancer (a friend of mine just old me three hours ago that he had just been diagnosed and is undergoing extensive treatment-I still haven’t grasped the truth of it yet). That being said, in the case of your young charge, he may have really learned something about how to deal with real anxiety and loss, and then how to really rejoice and revel in having you back! That is very cool and must have made you feel just wonderful.


  7. I’m so sorry to hear about your friend. There can be many silver linings to cancer. I know a lot of people disagree but it has definitely been true for me. I have made many positive changes in my life and feel happier and healthier than I ever have in my life.

    What kind of cancer does your friend have?


  8. That’s really good to hear! I’m glad some positive things have come out for you.
    I hope you understand that I can’t say more about my friend. He has told very few people very little at this point.


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