Go Retire Psychiatrist

Reblogging The Good Enough Psychiatrist Latest Post, “How to Love”

I haven’t seen any posts from The GoodEnoughPsychiatrist in a while. This one was posted yesterday-just in time.

How to Love

Dirty Dozen on Interpersonal Psychotherapy in WordPress Shortcode

Hey, because May is Mental Health Month, this is another one of my Dirty Dozen lectures. It’s on Interpersonal Psychotherapy.

It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size. If you see weblinks, right click the links to open them in a new tab.

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Dirty Dozen on Interpersonal Psychotherapy by Jim Amos, MD

Definition of IPT

–Time-limited, dynamically informed therapy.

–Goals are to relieve symptoms and improve interpersonal functioning and social support.

–Focuses specifically on interpersonal relationships to bring about change.

Applications for IPT

–Major Depression

–Postpartum and peripartum Depression

–Dysthymia

Essential Characteristics of IPT

–Focuses specifically on interpersonal relationships as a point of intervention.

–Time-limited when used as an acute treatment (12-16 sessions).

–Interventions used do not directly address the transference relationship.

Premises of IPT

–Interpersonal distress closely associated with psychological symptoms.

–Helping people improve communications in relationships or change their expectations about those relationships relieves symptoms.

–Helping people build or improve social support network improves ability to cope with crises that precipitated distress.

IPT Contrasted with CBT & Psychoanalytic Approaches

–CBT focus is on cognitions.

–Psychoanalytic focus is on understanding contributions of early life experiences.

–IPT focus is on improving interpersonal communications in the present.

Theoretical Framework of IPT

–Attachment Theory

–People are driven instinctively to form attachments to get and give care.

–Hallmark of good mental health is ability to form flexible attachments.

Theoretical Framework of IPT cont.

–Communication Theory

–Securely attached persons able to communicate needs effectively.

–Insecurely attached persons communicate in an indirect, ambivalent way that may elicit neutrality or hostility.

Problem Areas of Focus for IPT; Conducting IPT

–Grief

–Interpersonal Disputes

–Role Transitions

–More important than technique is the focus on extratherapeutic interpersonal relationships and fostering of productive therapeutic alliance.

Conducting IPT

–Opening Phase: diagnose, frame the treatment, relieve symptoms.

–Middle Phase: develop strategies for problem areas: identify situations which elicit feelings, validate feelings, explore and role play options, summarize sessions.

–Conclusion and Maintenance Phases: reinforce independence.

Conducting IPT cont.

–Communication Analysis and Interpersonal Incidents (accurately describe in detail).

–Use of both content and process affect (what happened outside and inside).

–Observe transference but don’t comment on or interpret it.

IPT References and Links

–Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004

–Stuart, S. (2012). “Interpersonal psychotherapy for postpartum depression.” Clin Psychol Psychother 19(2): 134-140.

–Interpersonal Psychotherapy Institute

Dirty Dozen on Cognitive Behavioral Therapy in WordPress Shortcode

In keeping with May being Mental Health Month, here’s another slide set on psychotherapy. This one is on the basics of Cognitive Behavioral Therapy. Once again, it’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.

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Dirty Dozen on Cognitive Behavioral Therapy by Jim Amos MD

Origins of CBT

–Psychoanalytic theory dominant in 1960s

–A. Beck, the creator of CBT, was trained as a psychoanalyst

–Conducted experiments in late 1950s and early 1960s intended to support psychoanalytic constructs-found the opposite to be true

CBT Definitions & Assumptions

–Focused therapy based on model that psychological disorders involve dysfunctional or unhelpful thinking

–We often feel what we think and behave accordingly

–Assumes that modifying dysfunctional thinking improves or resolves symptoms

–Modifying dysfunctional beliefs that underlie dysfunctional thinking produces more sustainable change

Overview

–Pragmatic, action-oriented treatment approach

–Initially developed for depression and anxiety

–Empirically validated brief psychotherapy shown effective in over 350 outcome studies

–Effective in treatment of many medical and psychiatric conditions

Examples of Automatic Thoughts

–I should be doing better in life

–I’ve let him/her down

–I can’t handle it

–I feel like giving up

–Something bad is sure to happen

–I’ll never be able to get this done

Examples of Maladaptive Schemas

–I must be perfect to be accepted

–I’m a fake

–I’m unlovable

–I must always be in control

–Other people will take advantage of me I’m stupid

Key Behavioral Concepts

–Depressive behavior can be modified with behavioral techniques

–Exposure therapy and related methods can be effective interventions for anxiety disorders

–Behavioral interventions can be useful for helping patients improve coping, social, and problem-solving skills

Principles of CBT

–Overall goal is to help achieve remission of disorder by solving problems and relieving symptoms.

–Achieved through collaborative empiricism

–Approach which teaches patients to view reality more clearly by examining their distorted cognitions

–Correcting faulty ideas leads to improvement in mood and function

–CBT is educative in nature; it teaches patients to be their own therapists. CBT is goal oriented.

CBT Methods

–Socratic questioning

–Stimulate curiosity to engage in learning, less didacticIdentifying cognitive errors

–Thought change record

–Guided discovery-series of inductive questions to reveal unhelpful thought patterns

–Examining the evidence

–Generating rational alternatives

–Role play and rehearsal

Behavioral Methods Used in CBT

–Activity and pleasant event scheduling

–Graded task assignments

–Exposure and response prevention

–Relaxation training

–Breathing training

–Coping cards;example: suicide safety plans

References

–Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.

–Garland, A., R. Fox, et al. (2002). “Overcoming reduced activity and avoidance: a Five Areas approach.” Advances in Psychiatric Treatment 8(6): 453-462.

–Temple, S., PhD, and S. Stuart, MD (2010). Psychotherapy for the hospitalized medically ill patient. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 242-248.

References cont.

–Whitfield, G. and C. Williams (2003). “The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings.” Advances in Psychiatric Treatment 9(1): 21-30.

–Williams, C. and A. Garland (2002). “A cognitive–behavioural therapy assessment model for use in everyday clinical practice.” Advances in Psychiatric Treatment 8(3): 172-179.

–Williams, C. and A. Garland (2002). “Identifying and challenging unhelpful thinking.” Advances in Psychiatric Treatment 8(5): 377-386.

The Most Interesting Thing About the Svengoolie Movie House of Frankenstein

We saw the movie House of Frankenstein last Saturday night and, spoiler alert, everybody dies!

Anyway, the main impulse we had when listening to Boris Karloff (who played Dr. Gustav Niemann) was to think of something I’m not even sure I can say on this blog due to the strict copyright laws governing even the utterance what I’m going to call NAME. I’m using only the word NAME because I’m afraid Dr. Sues Enterprises will track me down and sue me for copyright infringement if I actually say NAME.

Yes, Dr. Sues Enterprises is intentionally spelled that way because I’m not even sure I can say their name without getting slapped with a lawsuit.

No kidding (and this is no joke by the way), I read a lot of scary stuff on line about how NAME is not in the public domain and what can happen to you if you even say it out loud.

I think I can get away with saying that Boris Karloff was 79 years old when he voiced NAME in the movie which I guess will have to remain nameless.

There are people who get away with it, though. Maybe it’s because they pay for the privilege of uttering NAME.

Here’s an interesting thing. Pixabay has a lot of pictures that are royalty-free. You want to guess what I found there? Pictures of NAME! I don’t know how they get away with it. OK, so maybe it’s because they don’t charge a fee for use.

On the other hand, there’s this guy who wrote in to some kind of ask-a-lawyer website that he sells a tee shirt that has NAME printed on it. He got a copyright infringement notice and asks why he can’t get away with it. All the lawyers who answered said he can’t sell shirts with NAME on it because Dr. Sues Enterprises has a federal trademark registration on NAME.

Anyway, that’s the most interesting part about the movie House of Frankenstein.

Submitted My Two Cents on Centers for Medicare and Medicaid Services Proposal to Minimize the Importance of the Delirium Diagnosis Code

I found out that the Centers for Medicare and Medicaid Services (CMS) is planning to reclassify the diagnosis code for delirium, making it less serious than encephalopathy. Many clinicians are challenging it and organizations of consultation-liaison psychiatrists and the like, including me, don’t understand or agree with the plan.

Even though I’m a retired C-L psychiatrist, I put my two cents in as a comment. I told them what I used to tell others who were either my colleagues or my trainees—that delirium is a medical emergency. I support classifying delirium as a major complication or comorbidity (MCC).

Since CMS asked for supporting documents, I included a pdf of Oldham’s article:

Oldham MA, Flanagan NM, Khan A, Boukrina O, Marcantonio ER. Responding to Ten Common Delirium Misconceptions With Best Evidence: An Educational Review for Clinicians. J Neuropsychiatry Clin Neurosci. 2018 Winter;30(1):51-57. doi: 10.1176/appi.neuropsych.17030065. Epub 2017 Sep 6. PMID: 28876970.

As the authors say, “Delirium always has a physiological cause.”

Big Mo Pod Show Theme: Subverting Expectations

I want to give a shout out to the Big Mo Pod Show Subverting Expectations that aired on May 11, 2024 following the Friday Big Mo Blues Show on May 10, 2024.

What impressed me most and puzzled me a lot was the tune that Big Mo didn’t talk about on the podcast. The tune was a dazzling guitar performance called “Hot Fingers” by a duo called Lonnie Johnson and Blind Willie Dunn. Big Mo said it was recorded in the 1920s.

I looked for a video of it and could find several with the picture of what looked like a Caucasian guitarist and nobody else. I also saw one picture with the Caucasian guitarist and what looked like a cut-and-pasted photo of a black guitarist.

Because I couldn’t tell who was who, I googled their names. It turns out that Lonnie Johnson was a well-known blues guitarist. He was black. Lonnie Johnson recorded “Hot Fingers” with another famous jazz guitarist named Eddie Lang, who was white. Eddie Lang used the alias of Blind Willie Dunn in order to hide his race while performing with Lonnie Johnson. I’m not sure how Eddie Lang could pass for black, an interesting twist in the late 1920s. I’m not saying either was racist. Why would they have performed together if they were? And why would Eddie Lang have adopted the black-sounding pseudonym?

So that brings me back to the title of the Big Mo Pod Show which was Subverting Expectations. The expectation that gets subverted had to do with a tune I don’t remember hearing on Friday night. It was “That Lovin’ Thang,” by the group Tas Cru, with which I’m unfamiliar. Big Mo remarked that you could listen to the blues as played by Tas Cru with an expectation that they were going to make mistakes in their performance—which never happened, attesting to their talent.

On the other hand, it strikes me that the story behind Lonnie Johnson and Blind Willie Dunn (Eddie Lang) does create its own sort of subverted expectation, in a different sense. I know Blues music experts already knew that, but it was news to me.

FDA VRBPAC Meeting on Covid Vaccines Postponed

The May FDA VRBPAC meeting on Covid vaccines, originally scheduled for this month has been rescheduled to June 5, 2024, 8:30 AM-4:30 PM EST.

Guys and Gals Birds

The other day we went birding on the Terry Trueblood Trail. You couldn’t ask for better weather. We saw a lot of birds paired off and checking into the nest boxes or building from scratch.

I don’t know how we got so lucky. We saw male and female red-wing blackbirds, tree swallows, sparrows, and goldfinches.

The difference between the guys and gals is that the female birds tend to be drab. It’s mainly for protection. The females don’t want to attract attention from predators. The males tend to be flamboyant, as if you didn’t know that from your own experience with humans.

The red-wing blackbird male has stunning red and yellow epaulets on its wings. The female is mostly brown.

The tree swallow male is startling bright greenish-blue. The female is a bit duller.

The goldfinch male is a loud yellow while the female is kind of drab olive.

And so on.

Dirty Dozen on Common Elements of Psychotherapy in WordPress Shortcode

In observance of May being Mental Health Month, this is one of my Dirty Dozen lectures. It’s on the elements that are shared among some of the important psychotherapy methods.

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Dirty Dozen on Common Elements of Psychotherapy by Jim Amos, MD

What is Psychotherapy?

-Change facilitation

-Self awareness development

-Doesn’t necessarily have to occur in formal therapy encounters

-Can happen between patients and a wide range of professionals

Patient Variables and Relationship Factors

-Ability to relate, psychological mindedness

-Therapeutic alliance

-Readiness to change

-Respect, listening for understanding

Placebo, Hope, and Expectancy Effects

-Power of providing a “treatment experience”

-An emotionally charged relationship in which therapy instills hope for change

-A particular set of procedures that enhance belief in the therapist’s competency

-A therapeutic explanation of the problems that fits the patient’s belief system

Motivational Interviewing

-Intended to raise patient’s awareness of ambivalence between opposing thoughts and behaviors

-Accepts the “yes, but” responses without confrontation

-Emphasizes validation, reflection, reframing

-Source: Miller, W. R. and S. Rollnick (1991). Motivational interviewing : preparing people to change addictive behavior. New York, Guilford Press.

Motivational Interviewing cont. Stages of Readiness to Change

-Precontemplation

-Contemplation

-Preparation

-Action

-Maintenance

-Termination

Cognitive Behavioral Therapy (CBT)

-Foci of treatment are internally based cognitions and challenging, unhelpful or harmful thoughts and behaviors.

-Time limited

Interpersonal Therapy (IPT)

-Focus on interpersonal communications with others

-Focus on helping improve communication and social support in the present

-Time limited

Psychodynamic Psychotherapy

-Focus of treatment is on understanding contributions of early life experiences to psychological functioning and unhelpful or harmful behaviors

-Can be lengthy or open-ended

Essential Operations of Psychodynamic Psychotherapy

-Accepting: Therapist affirms the patient’s past and present subjective experience

-Understanding: Therapist appreciates both the conscious and unconscious contributions to the patient’s emotional problems

-Explaining: Therapist expresses, through interpretations, his or her understanding to the patient

Integrating Therapies

-Skillfully staged combinations of approaches may be more successful than one used alone

-Cognitive behavioral or interpersonal approaches first for more immediate symptom relief

-Psychodynamic approaches first for increasing self-awareness and exploring the need for change

References

-Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.

-Miller, W. R. and S. Rollnick (1991). Motivational interviewing : preparing people to change addictive behavior. New York, Guilford Press.

Big Mo Pod Show 006 on KCCK Radio Iowa!

I got an update to the Big Mo Pod Show on Iowa’s only jazz and blues radio station KCCK 88.3 in Cedar Rapids (translator 106.9 in Iowa City). Last Friday on the Big Mo Blues Show, host John Heim (aka Big Mo) played a lot of tunes, which he gets quizzed about a day or so later on the Big Mo Pod Show.

He gets quizzed about the name of that tune, the artist, and why he picked that tune for the show. He got them all except for one; he said “East Coast Blues” instead of “West Coast Blues” as the song by Blind Blake. He was almost perfect.

I was listening that night, but the Seasick Steve number I missed. It’s misspelled on the KCCK website on May 5, 2024 as “Internet Coyboys,” but it’s “Internet Cowboys.” Maybe by the time you read this, it’ll be corrected. It’s all about spending too much time on the internet. We need to disconnect. I’m sort of a fan of Seasick Steve, ever since I heard him do “You Can’t Teach an Old Dog New Tricks.” It means something special to old dogs like me.