Mohammad-Arefnia-150x150 2Mohammad: February 21, 2011

Hi Every One,
As you may know I work in a Community Psychiatry Program. The model of the program is such that psychotherapists essentially work as physician’s assistants. The calls for renewal of prescriptions from pharmacies for instance come to me. I sit in all medication reviews and may indeed participate in the discussion about the medication. I am the person who speaks with the psychiatrist when renewal of prescriptions are necessary and update her about the status of the patient and provide background information for her to decide on the need to continue with the course of chosen medication or that change in either reducing the medication’s dosage or increasing it may be necessary, and if another medication perhaps should be considered. When a patient has been stable for a while and is in the “maintainance phase” I might even write the prescriptions ahead of time and bring them to the psychiatrist to verify and sign to save time, because we are very busy!

One thing is that we have a large number of psychiatrists on staff at the clinic and for that we can tend to the needs of our patients rather quickly.
The wait time for most clinics is much longer. We have a number of very skilled psycho pharmacologists with a lot of experience in dispensing the right dosages of the the right medications and I would say that all of them have their hearts in the right place, that is they intend no harm and wish to be helpful to those who come to them with their troubles.
However, some of the medications are made out to promise far more than they can deliver. There are plenty of studies showing that anti depressants for instance are not as affective as psychotherapy and coupling them with psychotherapy does not necessarily make significant difference in the outcome. Both the physician and patient, however, would prefer the pill cure as it is much easier-this is also preferred of course by the insurance companies and the makers of the medications. The pill for one helps psychiatrists allay their anxieties that what they are doing is not effective. The more inexperienced the more change of medication prematurely as they feel the need to fix and there are plenty of folks who show up for the fix. In that sense the patient and the psychiatrist end up in a collusion, each giving credence to the other.
For some medication can make a big difference right away. The fears of a psychotic episodes for instance can be quelled and likewise the anxieties of those in acute stages of trauma can be lowered with the fast acting but addictive anti anxiety medications that may then provide for entering another phase of recovery. In the long run, however, certainly in case of trauma, since medications lower the cognitive acuity/sharpness they will actually impede the progress toward learning and development. Other means of managing anxiety that are generated from inside are more helpful than medications-outside objects to be ingested- for those who are trying to get around the legacy of the trauma.

Going back to the person that I shared a bit about her valiant efforts with you about, the anti depressant, in my opinion is nothing but a prop, placebo, something to hang on to in the face of fear. Because her difficulties are not necessarily about depression the need for such medication is not supported. For the most part it seems we somehow believe anti depressants as harmless and using them for assurance more than anything else.

Primary care physicians are the primary prescribes of anti depressants, thanks to well organized campaigns that began several decades ago by the pharmaceuticals that first established depression as a disease and then argued for the need for their product. An indispensable agent in this campaign has been the very interesting creature of the “drug rep”, usually young, good looking, healthy and rather friendly with a bag full of goodies and presents-dinner invitations, cash for talk and Caribbean getaways, some of which are getting some limits imposed on but the impact has already been made. Most primary physicians were long time ago brought into the fold and to change course will take a lot of doing.
All said, awareness is shifting and we can only hope for moderation!

Peggy-Sax 2Peggy: February 22, 2011

Hello Mohammad, Kevin, Mary & Ítalo,

Just a quick reply to say how much I am enjoying listening in on this conversation. For me, this exchange is like a dream come true – how you each draw from both professional and experience knowledge in the quest for understanding, consulting not only with the books but with each other. Knowing we can together hold the complexities in facing these huge systemic challenges to mental health/psychiatry, to remember we can lean on each other and think together …this gives me such hope for our global at a time when there are so many invitations to despair. Thank-you!

JamesPhoto-150x150 2James: February 22, 2011

Hi everyone!  It’s been a while since I’ve been in the conversations, but I am very pleased to start again on this one.  Mental Disorders are a very interesting topic to me, and my current position focuses my work with people who have been diagnosed with early and ultra-high risk forms of Psychosis and the various so-called mental disorders that Psychosis is associated with.  So much to say about this… where to start?

I have been afforded the opportunity since last Fall to participate in a interdisciplinary study group that has specifically been discussing the nature/social construction of mental disorders; the “what are these things, really?” question.  The group is a mix of psychiatrists, philosophers, sociologists, political scientists, psychologists, and social workers (of which I have been educated and trained as).  Of all of the readings we have completed and discussed, George Graham’s “The Disordered Mind” has been most interesting to me.  The reason being is that he has done a very good job of covering the Cartesian and Biological/Neurological view of the Mind, the Socio-cultural and “Post Modern” view of the Mind, and then formulates his own original position that I think fits more closely with the “Modest Realism” philosophical school.  In that position, Graham states that he believes Mental Disorders are indeed very “real” occurrences in so much as they gum up the works of the Mind in a harmful way, but that the harm and “gumming-up” is contextual and closely associated with culture and social position.  Furthermore, he states that Mental Disorders are “biopsychosocial” such that they can manifest themselves in all spheres of functioning and be susceptible to change from all spheres, but that by the assessment of them being “mental” they are psychological primarily.  I do not entirely agree with his assessment (I think “conditions” are very much “biopsychosociospiritual” and just because we call it “mental” does not make it justly so in all cases), but he does approach the matter in a very holistic way that is hard for me to find much disagreement with.

My notion about why it is important to think and talk about models of this phenomena of “Mental Disorder” is that because it is such a currently highly diagnosed phenomena (and if it weren’t I worry about what Western culture may be calling it… “witchery” or “demonic possession” or worse… and what can that lead to?), and our ideas about this guide how we treat these problems and the people who live with these problems.  I would highly recommend Chris Beels’s “A Different Story… the Rise of Narrative in Psychotherapy” for a variety of reasons, but I was really drawn to something he writes in a chapter:

“A successful psychotherapy

[I would add any ‘therapy’… not just the psychological variety] is a piece of negotiated truth, involving contact between an illness [or problem] as a patient/client experiences it and the powers of healing [or solution] provided by the patient’s/client’s culture.”

Having been educated/trained as a social worker, this idea makes a TON of sense to me.  I was very much drawn to Helen Perlman’s Problem-Solving Approach to Social Work Practice that says that most of human life is problem-solving.  I think this fits with Narrative Approaches that help to identify and separate these problems from people, and open space so that people can use their resources (inner and outer) to develop solutions that work for them (not always the way treatment professionals think it should).  Am I digressing here? Hmmm… ah, no.

Back to the issue of Mental Disorders being “real-kinds” or “socially-constructed-kinds” (Ian Hacking has written extensively on this idea… and he takes a “Either/Or” position), I will invoke the powers of Narrative Practice and pluralism and say why not a “Both/And” position?  Can they not be both “real” and “socially constructed”?  Using Chris Beels’s quote, can a person not do what makes sense according to their culture (both personal and larger) to help them solve a problem as personal as a “mental” one?  That may include medications or not; may include psychotherapy or not; may include exorcism or voodoo or santeria or faith-healing or not; may include hypnotism (Chris Beels also writes a very interesting set of ideas about hypnotism and narrative in that book) or not.  Would that be a problem?  I ask those questions purposefully, because I do not know the answer to them and would like your thoughts on that.

I suppose the problems I encounter in my own life and work is when a person’s narrative about the “Mental Disorder” strips them of hope, dignity, and self-worth, or when someone else imposes a narrative upon them that they do not agree with.  I see quite often a very confusing scenario where a young man or woman is presented to us by their family for a “Psychotic Episode” and the young person says “There is nothing wrong with me” and the parents say “There is clearly something not right here”.  For example, I met with a young man who had problems with catatonia, isolation from friends and family, and self-injury (trying to circumcise himself).  Prior to the development of these problems he was a bright, artistic, sociable young man who was very close with his mother and father, and now refuses nearly all contact with friends and family, does not eat except when encouraged by his mother, and acts strangely such that without assistance he could end up street homeless or worse.  He says that there are no problems and that his parents are controlling.  I think it is very easy to jump into such a situation with a “either/or” position and say that “he has a psychotic disorder” or “his parents are controlling” or something else… and for insurance reimbursement in this country sometimes we do have to put a diagnosis down even if a person disagrees with it, but in my sessions I have been very open about not calling it a mental disorder except for helping this young man understand what it is the psychiatrists are talking with him about and understanding their research on the matter (who knows, it may be helpful for him some day).  I instead try to remain pragmatic and focus on first what makes most sense to him and his parents together (they appear to be the only people who would care for him in his current state outside of the hospital… and although he is angry with his parents, his anger tells me that what they do is important to him) and how they can join in a fight against what it is that is affecting their relationship first.  We haven’t gotten to a clear, agree-upon collaborative definition of the problem yet, but it’s a process.  He may decide that “Psychosis” fits or not… he may decide that medications fit or not.  My hope is that he, along with his parents and treatment providers and community of care, will negotiate a truth that makes the most sense so that they can problem solve together.  Regardless of where it resides, inside or outside of a person, the “Disorder”, the “Illness”, the problem can be solved best by a solution that he and his community find most appropriate and correct.  What other ways might you all want to approach this collaborative effort or help this young man and his family address these problems?

A note on efficacy of treatment of “mental disorders”:  Multiple meta-analytic research studies have shown, in US culture anyways, that problems of “Mental Disorder” respond about as well to medications as they do psychotherapy (where Depression is one that responds better from psychotherapy, and Psychosis and Bipolar Disorders better by drug therapy).  Improvements by medication only account for 30% of what is going on, with about 30% because of placebo effect/belief in treatment, and 40% is extra-therapeutic (i.e. social support… which is perhaps why family psychoeducation works so well for people with psychosis).  Improvements by psychotherapy technique account for 15%, 15% placebo/belief effect, 30% common factors (i.e. empathy, alliance, warm regard), and 40% extra-therapeutic.  Could it be that Narrative Approaches do work so well because they tap into belief/placebo, the common factors, and supporting the development of extra-therapeutic effects?

What you say, Mohammad, about the risks of psychotropic drug use and the influence of the lobbies and market on what gets peddled and prescribed concerns me as well.  There are new studies coming out all of the time by the neuroscience disciplines that are showing that SSRIs and Antipsychotics are actually creating neurological dependencies much the same as does taking a decongestant too long or using alcohol/opiates/stimulants too long.  Our brains are incredibly sensitive, and the chemicals being prescribed are incredibly powerful.  I wonder if the drug companies are “firms” or if there are people in those companies who have some degree of “social justice and sustainability” in their ethical compass.  Our systems of business and professional domination (particularly that of the profession of medicine) are concerning and confusion indeed.

I think Anorexia Nervosa and Encopresis are two of the greatest examples of where medications fall short, diagnosis and prescribed treatment from the standpoint of objectivity falls short, and collaboration and creativity stands tall.  More mental health professionals and human service workers should read the stories you all have about helping people solve those problems.  What other stories do you have about those you’ve treated? I’d love to read those.

Kevin, I, too, feel ambivalent at times about working a position where I am making diagnoses.  My graduate education and training did prepare me for the task of understanding and using the DSM, but I don’t think I was prepared to realize how much power I had in that circumstance and the far reaching effects of my actions in using that power.  Irving Yalom had a great bit of wisdom for everyone that has that authority/power: only give a diagnosis when insurance requires it or when a client asks for it (and find out why before handing it out).  I wonder what possibilities that sort of stance implies to our work.  I wonder how possible that is for you in your new position.  I wonder if others run into that same predicament and how they handle that.  I wonder if my open discussions with my clients about what the risks and benefits of a diagnosis are seem helpful and empowering, unhelpful and oppressive, or moot.

Good to be back in the conversation!  I hope our friends around the world are safe.  So much turbulence occurring… earthquake in New Zealand, revolts and violent oppression throughout North Africa and the Mid East, oppression in China, disempowerment in the US.  Sigh…

Mohammad-Arefnia-150x150 2Mohammad: February 23, 2011

Hi James, Hi Peggy, Kevin, Mary & Italo,
And Hi Every One,

I began reading Beels’ “A different Story” a while back while on the plane heading to Oklahoma. It had been sitting on the shelf for some time and I just grabbed it at the last minute and when I began reading I knew why. Christian grew up in Oklahoma and I too began my journey on this side of the Oceans there, just one small hint at how much I felt like I could identify with in his description of his journey.  His book, I agree James was enlightening for me as well. The way he explained how the audience also shapes the discourse and about Hypnotism. I am seeing it more and more as I lead my patients through guided mindfulness meditation. It is hypnotic to notice one’s breath!

The bit about anti-depressants not being so harmless after all has been something I have been concerned about for some time and comparing them to decongestants resonates with me. I recall how after a while of using spray decongestants if I did not use them I would be congested.

There is solid evidence now how the antidepressants will lose their effectiveness after a while and need to be exchanged for another because the “dependency” is there. At the same time I have a number of patients who have stopped taking medications-mostly SSRI’s- and have done so with ease and no difficulties and are managing rather well.

About diagnosis I don’t pay much attention to them and like Yalom I would just go ahead and put something down for the insurance companies and so forth. One good thing about the clinic I practice in is that diagnosis is done by the psychiatrists- upholds the hierarchy but that is a related but wholly other conversation.

And one more thing about the narrative discourse. One thing I am doing these days is help with deconstruction of sentences and influencing a shift from referring to oneself and viewing oneself as a passive object- a victim- that is acted upon and things are done to, to an active agent who steers her own life toward a another vision of her own choosing. “Anorexia almost killed me” is transformed to “I employed anorexia to help me take a stance for that which is important to me: justice!”

“Once I recognized the tyranny of anorexia, my old friend, I took a stance against its tyranny, the illusion that it was creating around me, and managed to loosen its hold”. “I recognized that I needed to eat, to fuel my body to stay alive so that I could go after my dreams.”

A rich discussion ensues about food and “addiction”-her word, how not eating gains momentum and becomes “addictive”, the 100 push ups and laxatives all implements of anorexia’s tyrannical rule. But, never taking a position that she needs to eat. That is her decision and her personal agency. What is important is the utterance of her appreciation of life and wanting to live and to what end and how! Mohammad

Italo-Latorre-Gentoso 2Ítalo: February 23, 2011

hi Mohammad, James, and everybody,

I am trying to read your post’s but because my difficulties with fast lecture in English, I take more time and effort. Despite this, I want to write this to let you know I am very excited knowing the interest for these theme, and I will continued my lecture also posting.

Thanks, Ítalo

JamesPhoto-150x150 2James: February 24, 2011

Italo,  I appreciate the effort you put in to these conversations.  I wish I could read/write/speak another language than English so I could join your efforts.

Mohammad, I’m drawn to your stance towards helping people see problems as employed functions rather than totally oppressive forces.  It sounds like that opens up other spaces in the work for people to see their power and action in relation to problems.  I wonder how you would do this with someone struggling with Psychosis or Mania.  This is an area of debate in my mind about “Mental Disorders”: do the effects of these things serve some function?  Psychoanalysis posits that yes they do (i.e. the aggressive “drives” are turned inward and attack the self, the executive functions, or even literally the organs, all in order to save the caregiving object from the rage of the inevitably frustrated person… interesting idea, but the only good I find that can come of this idea is that it means, in my opinion, that we should be open to our clients’ anger and rage towards us and not shut that part down if it comes out).  My clients, I think, would rather think that “Psychosis” and “Mania” serves only to destroy their transition into independent adulthood.  I’m interested in everyone’s thoughts on this.

Speaking of executive functions, I am really striving to organize my life such that I can dedicate one evening a week to get back on here and read/write regularly and maybe even do a Skype call with those who are interested.  I am amazed at how busy my life has remained since being in NYC… perhaps busy-ness is serving some function I don’t quite understand fully.  Have any of you dealt with a consuming busy-ness in your life, and how have you kept it at bay?  And how are you all organizing your time to get on the group regularly?


Mohammad-Arefnia-150x150 2Mohammad: March 1, 2011

Hi James, Peggy, Everyone,
James you wrote:
‘I suppose the problems I encounter in my own life and work is when a person’s narrative about the “Mental Disorder” strips them of hope, dignity, and self-worth, or when someone else imposes a narrative upon them that they do not agree with.”

In all all our lives a claimant on an authority of some sort is going to try to impose a defintion that may be different from what we may choose. The dance of respectfuly asserting one’s vision is the challenge we all face.
To claim one’s voice is the so sweet!

Mohammad: March 6, 2011

Hi Everyone,
Here is an article from NYTimes this weekend. It says a lot about the state of affairs here in the states and also a lot about a couple, a psychiatrist and his wife a social worker, both giving up being therapists, and turning to psychopharmacology. The wife in essence becoming the office manager and the husband an alchemist, coming up with the proper mix of medications in 10 to 15 minutes and avoiding like hell to listen to the stories people have to tell primarily in order to maintain their desired level of income and their standard of living. Of course they do not have to make this choice but the system does promote making such choices based on economical imperatives and many are making them. Note that the investment bankers can still enjoy boutique psychiatrists that do still do therapy at the tune of $600.00 per hour. But others have to go onto the other side of the tracks and access care from the other tier of our two tiered system. In my opinion it could take far less training to become a good psychopharmacologist choosing the proper mix of medications for someone than it is to become a decent therapist. And in all fairness the pay should reflect that and be in fact the other way around. But for the sake of weeding out those who become therapists or psychopharmacologists to become “rich” the pay should be the same and the relationship with the number of patients seen in a day and the level of income would need to be severed in order to preserve quality of care. Otherwise a provider will see as many people as humanly possible and cut every corner that can be cut to make more money as the 11 hour day here in the story bellow speaks of.

Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy

New York Times
March 5, 2011

Peggy-Sax 2Peggy: March 8, 2011

Hi Mohammad et al,
Thanks for posting this NYT article. It really captures the current state of psychiatry in USA even here in small town Vermont. It’s both sad and disturbing.

Right now, I’m reflecting on another perplexing trend in my state. Sometimes medicine is indeed helpful in conjunction with therapy. I believe medicine has literally saved people I’ve worked with. In Vermont,  the primary care physician usually does the prescribing because it is extremely difficult to get a consultation with a psychiatrist. When the situation is complicated (someone experiencing psychosis, suicidal depression, acute anxiety, etc. ), we really try to find someone with particular psychopharmacology expertise. However, there are very few psychiatrists in this state to whom I would refer clients.  And when we do try, often they do not have room. Besides, the psychiatrists often want to do the therapy as well –  and most commonly from a psychoanalytic approach. I remember one client who was told she would need to stop seeing me if she works with the psychiatrist. Needless to say, I think the medical model places psychiatrists at the top of the therapy hierarchy, and does not teach collaborative skills. Ironically (but not surprisingly), I hear that psychiatry as a specialty is now one of the least favorite choices in medical school. Even less preferred than primary care!

Lately, I’ve been referring to a group of psychiatric nurse practitioners in Burlington, Vermont. They TALK with their patients. And  they seem more open to helping people decrease medication. But now I hear their practice is filling up. The word is out.

A couple of years ago, I had a memorable conversation with a psychiatrist who has the well-earned reputation as being one of the best psychopharmacologists in Vermont. She confirmed my impression-  she is one of the few psychiatrists she knows who is primarily interested in medicine vs therapy – and at the same time, when she takes someone on, she really devotes herself to the mystery of medicine. She engages in conversation with someone who consults with her, and works with the therapist as well. As a physician, she prides herself on keeping on top of cutting edge new discoveries in medication, mixes, etc. Her patients benefit as well – she also works slowly to help decrease overmedication (SO COMMON these days). And guess what? Her schedule was CRAZY with long 12-14 hr days, on call on the weekend, etc. And for surprisingly little money (because she was not doing the fast med checks). She had a disabled partner, and was having trouble paying the bills. Guess what now helps her make a better living? She goes around the country giving talks on depression for drug companies!!!!!!!!

What a mess!

Does anyone have a psychiatry story of hope and possibility to share? I think I need one.

Margaret Wells: March 8, 2011

I don’t have a happy story that comes to mind just now (it’s nearly midnight here) but thanks for appreciating the work of the mental health nurses and celebrating the things we can do well.

kevinN-150x150 2Kevin Nielsen: March 8, 2011

Hello everyone,

I have been reading with interest these posts.  I really appreciate them.  I have been waiting and wanting to write a reply that would capture all that I have been thinking of in regards to this.  However, it often feels like I never have enough time.  So, instead, I’ll put in short comments.  First, James I have been thinking about the study group you were involved in and the book you read, The Disordered Mind.  I will remember that.  I just bought Ken Gergen’s book, Relational Being.  It has really got me thinking about the implications of the “bounded being” and how we construct the meanings of things, such as psychiatric disorders…Got to run.  More later.  Thanks to everyone who is making this such a stimulating conversation.


Mohammad-Arefnia-150x150 2Mohammad: March 8, 2011

Hi Peggy and Everyone,
I try to make this short as my shoulder cannot take much typing.
Deep from within the medical establishment, I work closely with a number of psychiatrists. I am made well aware of the hierarchy that medical model somehow needs to have. My theory is that it seems that the white lab coat somehow claims a status that is even hard to believe by most physicians- the healer, the life saver, the preserver of life, the fixer. So, in order to help allay the anxiety of taking on such impossible posture, and to justify the enjoyment of the compensation ratio that is well over others who also have a claim to being a healer, a whole host of characters would need to be recruited to agree and reflect back the image of the healer to counter the pangs and worries of being an impostor.
I think were it not for the compensation and the social status we have chosen to attach to the profession of medicine, one that is often readily claimed by most physicians and felt entitled to, were it not for the promise of making big bucks after getting the degree, most of those who would take on such responsibility would be more like your friend who would have difficulty paying bills like the rest of us but still would spend the time needed to get to the bottom of someone’s story to provide for healing.

The allure of big bucks, one that attracts many to lawyering also, brings to the field the “best and the brightest” and not the most compassionate or the one who wants in his or her core to care for others.
I do hope for the day that there is pay equity amongst all of us care providers and then I imagine we would see more of the very wonderful human beings who are doing great psychiatric work.
I can right away count about seven psychiatrists that I closely work with who are decent human beings, who know their craft, who care about the welfare of those who come for consult, who are humble enough to speak to the limits of the medical cure, and who are willing to yield to psychotherapy as the most important part of the treatment. When the trophies are being handed down, would they jump to say oh it was not the prozac, I don’t know, but it is quiet possible.

We are a nation of number ones. We have a problem with being number two or three…

We are taught to think of ourselves as exceptional, superior, and the best. Would we have the courage to say well this stuff we are handing out should take the back seat to psychotherapy? Some do sometimes!
There is hope, even for the pill cure and certainly for those who dispense it!

kevinN-150x150 2Kevin: March 9, 2011

Mohammad and others,

I really appreciate hearing your comments about the complexity and relationship between working in the medical establishment where
prescriptions are usually valued more than talk therapy.  I am a little more than one month into my new job working at a federally qualified health center.  It’s a medical model that has a commitment to a social mission (and will help pay off my student loans).  There is so much I want to write about all of this, but for now just want to say, what has been said by others, on the journey of working collaboratively with people in a setting that sets one up in a hierarchical, expert position.  The psychiatrist and DSM can seem like the priest and holy bible.  I have found many committed people and in the actual practice there seems to be space for more than one way.
This gives me hope.


Mohammad-Arefnia-150x150 2Mohammad: March 11, 2011

Hi All,
I attended a three hour lecture yesterday by three leading psychiatrists, each taking up an hour to speak about the complexities of humanity.
The chief psychiatrist at Hopkins spoke about the absurdities of diagnosis and the diagnostic manual and his hopes as to how the new DSM5 may be more in tune with how people are all unique and we are not really talking about disease. He is on the 161 member committee and doing his part to bring some sanity to the final document. Though he cautioned it will not be what we hope for and further efforts will be necessary.
Another speaker’s perspective was genetics and his hope along with others to find genetic markers.
Yet another spoke about Mood Disorders from the neuroscience perspective and how is it that we have accidentally stumbled on antidepressants and reviewed the evidence for their efficacy.
One word they all used, specifically in terms of genetics studies, was Collaborative.

The recognition is there that without collaboration with other disciplines and amongst the members of the same discipline there may not be any move toward meaningful understanding. I can only hope for humanity to get around greed and fear and begin to relinquish attachment to power.

Though as you can see in Libya, Egypt and elsewhere, it is rather difficult for man to give up its hold on power. One thing about yesterday worth noting is that all three were white male. For whatever is worth one of them is gay, which means a shift from the past when he would have had no place at the table.

Let’s hope for a place at the table for all of humanity with all its complexities and colorful faces.

With Love and Light and Unyielding and Reasonable Hope,

Peggy-Sax 2Peggy: March 11, 2011

Mohammad, this is exactly the kind of hopeful story that I/we need to hear!While there are many reasons to worry about the future, there are also reasons to be hopeful.

I love knowing the chief psychiatrist at Johns Hopkins (one of the best teaching/research hospitals in the USA) is speaking publicly -and to  professional audience – about the absurdities of diagnosis and the DSM. Maybe this new DSM will make some changes in the right direction?

Good to to hear there are hopeful new developments in research with genetics and mood disorders. Judging from other medical discoveries  such as in oncology and cancer treatment, I know science has tremendous potential – as long as combined with understandings about the complexities of humanity.

Speaking of complexities of humanity….I’ve been thinking about the complexities that contribute to the domination of the medical model/ medical establishment over other ways of thinking/working/seeing. What keeps physicians at the top of the hierarchy? I know there are many factors.

Mohammad, I’ve been thinking about what you said about the lure of big bucks and assumption that keeps the psychiatrists at a higher compensation ratio:

I think were it not for the compensation and the social status we have chosen to attach to the profession of medicine, one that is often readily claimed by most physicians and felt entitled to, were it not for the promise of making big bucks after getting the degree, most of those who would take on such responsibility would be more like your friend who would have difficulty paying bills like the rest of us but still would spend the time needed to get to the bottom of someone’s story to provide for healing.

The allure of big bucks, one that attracts many to lawyering also, brings to the field the “best and the brightest” and not the most compassionate or the one who wants in his or her core to care for others.

I do hope for the day that there is pay equity amongst all of us care providers and then I imagine we would see more of the very wonderful human beings who are doing great psychiatric work.

I totally agree that we need more pay equity. It is appalling how little social workers make in relation to other medical providers.

I also want to share an inside view of the making of a physician, and some of what contributes to the sense of deprivation, vision of delayed gratification and sense of deserving more compensation than others. This perspective comes from my experience of watching my son Jordan who as you know is also at John’s Hopkins, now a second year resident in emergency medicine.

I think you know I am a hard worker. “To Be of Use” by Marge Piercy is one of my favorite poems: Here is the first stanza:
“The people I love the best jump into work head first without dallying in the shallows and swim off with sure strokes almost out of sight. They seem to become natives of that element, the black sleek heads of seals bouncing like half submerged balls.”

To read the entire poem, click here.

However, everything I have ever done pales in comparison to Jordan’s training to become a physician. I can honestly say I have never worked as hard as Jordan, nor carried the weight of as much responsibility (decisions/interventions carry the urgency of life and death).

Medical school was extremely demanding beyond anything  I have ever experienced in graduate school (as student or teacher). Unless someone comes from a wealthy family,  medical students in the USA accrue significant loans over the 4 years of med school – in the 100,000s of $$. Then comes residency (Jordan’s residency is 4 years) where you make about $40,000 a year, for working CRAZY hours with little room for any other kind of living. So while your friends and family get together, you work. For example, yesterday Jordan finished a month long rotation on the “shock trauma” unit where he worked 32 hour shifts, most of the time fueled by an adrenalin rush. Then there is a short break before you go back again. When I was just in Baltimore visiting, the best way I could enter his life was  to show up at his apartment during a window of time when Jordan wasn’t working or sleeping- we had thought we would go out, but instead spent a wonderful day talking while cleaning up his apartment – the messes that  built up while he has been basically living at the hospital.

I am not sure how the making of an emergency physician compares to the making of a psychiatrist, but I imagine there are similarities.
All of this hard work, responsibility and deprivation  – combined with intimidating loans to pay back – sets ups physicians to believe they deserve extra compensation for about a decade of putting the rest of their lives on hold.  Again, I’m not suggesting that others don’t work hard. And I believe fully that we need more equity. But I also think it is important to understand some of the pressures that contribute to the making of a physician.

What are your thoughts?


Mohammad-Arefnia-150x150 2Mohammad: March 13, 2011

Hi Peggy and Every one,
This may be my last post for a while. I will fly out of DC tomorrow night and arrive in Qatar Monday evening and then fly out of there early the next morning and arrive in Tehran at 4:00 AM Tuesday. I will be entering a new world, one that is far from the world I grew up in and put behind me when I was eighteen. I don’t know what to expect. I do hope to be able to post from there but at the moment I know I will not have daily internet access as the old house I grew up in is not equipped with it. But there are internet cafes and I will be making my way to them when I can. In any case you will be in my thoughts and my heart!
Peggy I cherish hearing about the makings of a physician from a mother’s perspective, especially from yours. I entirely agree. Medical training is grueling and most oppressive and in many ways inhumane. Such test of endurance, to pull those long shifts with so little sleep and compensation, supposedly designed to prepare interns to make accurate diagnosis and deliver proper care in the face of adversity. It is years of hard work, memorizing exactly the acceptable treatment and practicing it accurately. I imagine psychiatry is not any less demanding. Though in the hierarchical world of medicine psychiatrists, I am told, are lower in rank than most and in some cases are not considered “real doctors” and their pay, unless they are very well known, is lower than other specialties. I hope all physicians are well compensated for all the years of hardship, self denial, and great effort. And my hope is that the compensation does not have to do with the number of patients they get to see in a day, as I think that is where we all run into trouble. The connection between the number of patients seen, the number of procedures done, and the pay can be corrupting. I see it in my own practice. In our clinic we have minimum quota of patients wee need to see, “volume of service” that we have to maintain, other places call it “productivity”. For us the minimum is 50 percent, that is out of a 40 hour week needing to bill twenty hours of direct contact, which we are told is far less than most other clinics where the expectations are higher. When a therapist maintains 55 percent or 60 percent productivity for three months then he or she receives an incentive, a bonus, respectively. That is what I find troubling. The possibility of cutting corners to make the bonus at the expense of those who are most vulnerable and needy. And or pressuring patients to come in more often than they would want to in order to maintain the minimum, double booking, etc. to not be at the least nagged at for not being more productive. In our case we simply get more patients assigned to us. Let’s say I have patients who demand a lot of my time through phone calls, visits while they are in the hospital, or work with other care providers and family members but not have direct contact with them in my office. That is not taken into account, indeed it may be considered as too giving and for that I will be urged to cut these things short and see more patients “efficiently”. Once I am assigned more patients I will have to limit my time with each or else I will be at the clinic a lot more than my typical 45 to 50 hours a week. I do need to have a life after all.

I had a conversation with my primary care physician a while ago, a wonderful, compassionate and funny man who spent many years toiling at the same hospital I now work. He typically spends one to two hours with me when I go to see him, asking about all aspects of my life. He looked up the address of the old house I grew up in on google map when I told him where I was going and showed him a picture of it. He explained that one week’s earnings out of the month goes to overhead expenses for his private practice. I don’t think he is wealthy by any means and I am not sure if that is important to him. He seems to love his work and love people. I do hope that he is well compensated for his great work now and all those years of sacrifice he has made. I do hope that he can continue to spend the time that each of his patients need with them without feeling the pressure that he has make his quota for the day. I do hope that his life is comfortable. That he feels well cared for so that he can continue to care for others the best way he knows how. I do hope that for all of us, to be paid well, reasonably, and the level of pay having to do with our training, the years we have spent studying and also how proficient we are and that be regardless of how many people we see in a day. A dream I suppose!

I need to disclose that when my family sent me out of Iran their hope was that I would become a “doctor”. At one point I hoped that too. It was indeed a way to move upward in social status, class and income, while at the same time it was to respond to a calling that I felt inside of me. The fact that I did not make it to medical school in part gives credence to the presence of “the not good enough” and how I look down on myself while at the same time can be so critical of the medical profession. In Freud’s words it would be a case of “doctor envy”.

During the 1979 revolution I was in college in Maine, majoring in chemistry, pre-med, and taking a whole lot psychology, and English and creative writing on the side, and though far from where it took place, much in my life was impacted and drastically changed. Others experiencing the same events may have survived through the storm differently, and most certainly did. I, however, experienced a crisis in my life and went on to toss out the whole of idea of “hard sciences” as I found them cold and not rewarding. One statement by a psychotherapist I consulted, a social worker, has stayed with me. That he “would have hated to have been one of my patients had I become a physician.” I very much agree with him. I would have made a horrible physician and I am glad I am not. I was not cut out for that work nor did I want it. What I wanted, though I did not know at the time, is the work I am doing now. I know I could not do the work that physicians do. I just simply do not have the discipline and do not have the skills in categorizing and memorizing lists of symptoms and treatments, nor do I want to. I think much more globally and often make mistakes and leave things out. I think like a poet, hint at things that are out of grasp and feel my way through. Knowing is not my specialty. I am rather more comfortable, if that is entirely possible, with not-knowing.

When I am off balance in the session then I resort to knowing. But, when I am non anxious and can sit with the discomfort, I simply practice not-knowing and that is when I get a glimpse at the glory of my calling. Curiously asking, co researching, paving the way for discovery of somethings but more importantly influencing others to also accept and be comfortable with not-knowing. As so much is unknown.
I leave you with the last portion of Sengstan’s “Verses on Faith-Mind”:

“One thing, all things:
move among and intermingle,
without distinction.
To live in this realization
is to be without anxiety and non-perfection.

To live in this faith is the road to non-duality,
because the non-dual is one with the trusting mind.

The Way is beyond language,
for in it there is
no yesterday
not tomorrow
no today.”

With Love and Light and Unyielding and Reasonable Hope, I do look forward to joining you again on this island of belonging!


Peggy-Sax 2Peggy : March 13, 2011

Hey – I love the story about your physician. He sounds extraordinary. And so much more to say – but all can wait until your return.

Mohammad, I can hardly believe you leave tomorrow on your journey home to Iran. Please do write if you can from one of those Internet Cafes. And if not, we’ll be eager to hear more upon your return. I cannot imagine what it might be like to return home after 33 years!~ I know you have been planning this trip for many years. So many stories to tell and to hear! May your shoulder be sufficiently healed, your heart open and your relatives and friends greet you with loving embrace. No matter what, remember you have an island of belonging here with us.

With Love and Light and Unyielding and Reasonable Hope,


Mohammad-Arefnia-150x150 2Mohammad: March 13, 2013

On the plane! Taking off soon!
This island is in my heart!
Talk soon!