When a Doctor has to Fire a Patient

TRANSCRIPTION:

Many doctors and counselors are often faced with the difficult decision to terminate a patient’s care or fire the patient.  During the process of treating a patient several factors contribute to the counselor or doctor having to terminate the relationship.  In this week’s video, Healing Path Recovery’s Dr. Beheshti discusses the reasons and gives examples of situations where she has fired patients and the reasoning behind making this tough choice.

 

What is your interpretation of the Doctor Patient Relationship?

The doctor patient relationship is a sacred relationship. When a patient comes in to see me we sign a contract where the patient says they allow me to diagnose and treat them as their psychiatrist as their treating physician and in return I promise to do my best to treat them in capacity of a psychiatrist and a physician. In Most cases this relationship works real well because there are very strict boundaries between a psychiatrist and a patient that protect both parties. In that framework there is a safe environment where the two of us can work with each other.

What do you mean by fire a patient?

Every once in a while unfortunately, I end up having to terminate the care that I provide.  It’s is always interesting to learn about the conditions in which I end up deciding I can no longer treat a patient, or any doctor ends up deciding that about a patient. The fundamental philosophy that this termination of care is based on is the belief that every person is ultimately the first person responsible for his or her own care.

What are some examples of these condition?

When you go to see a doctor, you give the doctor permission to do their best to help you take care of yourself.  This is the case with any doctor, whether it’s a heart doctor, or a doctor that works on gastrointestinal systems, an eye doctor.  You are the one that initiated the call with the eye doctor, and then the doctor makes recommendations for you whether its medications, or change in lifestyle, it is up to you as the patient to follow the recommendations.  One of the cases in which the patient does not follow the doctors the recommendations, is of course, not taking the medication(s).  So for example when a patient comes to me, and I believe that they suffer from let’s say Bipolar disorder and I tell them, “Alright, you need to be on a medication that helps you with this disorder,” and I write them a prescription, They may go away and start taking the medication or they may go away and not even fill the prescription.

Well in the case of not filling the prescription, and it’s been two weeks to a month and they are telling me they feel worse, I really cannot help them, because they never started the medication or followed my directions, of course, just because one incident, didn’t go well, I do not terminate the care, I talk to them about the reasons they did not take their medication.  Was it fear?  Was it a financial issue?  Was it a certain belief that they should not be on medication, and we try to work with each other?

And find out what recommendations are reasonable to the patient and reasonable to the doctor.  And if the patient and the doctor can agree on the course of treatment then they can work together.

On the other hand , I f I have a patient who continues to come to me, month after month, and tells me they haven’t been following my recommendations, at some point probably by the second or third time, that I find out that they haven’t been following my recommendations, we talk about perhaps finding them another doctor.

Another example and this is a big one. Is showing up for your appointments.  I cannot help you, if you do not come to see me. And I f I need to see you every two or three weeks, it is important to not only come to your appointments but come on time. I have patients that miss appointment after appointment and then they call and are upset because they can’t get into see me right away.  Or because they run out medications and I don’t refill it.  My policy is if you miss two appointments with me without calling ahead or without a good reason, I terminate care.

 

Any Closing thoughts?

In conclusion, It is really important to remember that you are ultimately your number one care taker, see your doctor at regular intervals, make sure you take your medications, and make sure you are in constant communication with your doctor.  That is the best way to get a complete care between you and your doctor

Lessons for Parents- Don’t Bail Your Child Out

Transcription:

Over the years when I work with addiction and alcoholism many times patients have been arrested. They may be arrested for possession or driving while under the influence. In most of the cases they typically call their parents. And the parents rush down to the jail to bail their son or daughter out.

Now the question is whether or not that’s a good idea.  When your children were little you must have had consequences for the actions they did. When they got older there were consequences to their actions if they didn’t finish their homework or for them not studying for tests.

Now when your children venture out into the real world, actions have consequences.  Why is it when the consequence is going to jail we jump and think we have to save our children from the consequences of their own actions?  It just doesn’t make sense.

It’s typical if your son or daughter is caught driving under the influence, they are going to call you and ask you to bail them out.  Tell them, “I am sorry. But you did something and you made a decision, as an adult, to use drugs, or use alcohol, and then drive.”

That was a decision you made, and these are the results of that decision.  I think it is best for you to face that decision.  This position is extremely important because when parents run to bail their children out of jail, they are telling the kids that it is ok they can get away with bad behavior every time.

And that is incredibly wrong. What would you do if the child was dead in the car accident?

Consider things before acting. You may be doing more harm than good.

My Soul-Changing Steps to Quitting Alcohol

Thoughts and Feelings About Healing Path Recovery (HPR)

Overall

I think if I truthfully wrote what I think about HPR, it would be dismissed as the hyperbole only generated by a paid endorsement, or a three A.M. infomercial. I’ll leave it at: Soul-Changing.

One of the very best parts of HPR is the treatment customization that allows the client, over time, to select those therapies that work for him, and for Dr. B to customize medication to the client’s needs.

Having been to AA meetings and talked with many members of AA, over several years, I’m virulently opposed to the AA treatment model of alcoholism, and I don’t attend HPR sessions that are led by proponents of AA.  But, one of my best friends has been sober for 22 years with the sole help of AA. HPR recognizes that each client is unique and the program allows for many different points of view: AA, non-AA, spiritual, secular/scientific, artistic, nurturing, confrontational, help for those with difficulty with boundaries, those with unresolved trauma, etc.

I think clients should come to the program with an open mind and, barring decisive past experience with a particular type of help, try all of the various classes and then work with Dr. B and Ali to fashion a program best tailored to their needs.

Having a psychiatrist involved personally with each client is a giNORMOUS benefit that allows clients to be prescribed appropriate medication without having to look outside the program, i.e. pharmacological help isn’t separated from psychotherapeutic help. I think at least 80 to 90 percent of my progress in HPR has been due to proper medication. The other parts of HPR are equally as necessary, but without the pharmacological piece of the puzzle, all the other work I’ve done would not have been possible.

Describing my overall thoughts and feelings about HPR would not be complete without mentioning Dr. Beheshti, Ali, and Aunique.

Having “sampled” multiple psychiatrists in Michigan, San Diego and Orange counties, I can say from personal experience that finding a psychiatrist who is not just a scrip generator disguised as a human being, that is not only technically competent, but warm and caring, with an empathic understanding of her clients, (who accepts insurance, no less!) is something I have never seen. To have such a psychiatrist AND support staff like Ali and Aunique, would previously have been some sort of absurd make-a-wish, like time travel, or for hot dogs and buns to be sold in matching quantities.

Last, whatever vetting process Dr. Beheshti and her staff use to select their eclectic group of HPR therapists seems like magic. More about their classes below.

Classes

Mindfulness: My favorite class. My prior experience of more than ten years of daily meditation moved me forward quickly in this class. That, combined with having heard Eckhart Tolle speak before coming to HPR, has motivated my to return to this way of being (as I’m able of course) and to meditation. Kudos to Colleen for her warm, nonjudgmental, open-hearted approach.

Boundaries: This class is offered in a deceptively simple format (much as focusing on the breath is deceptively simple) that yields great rewards. Dr. Pusateri is the only therapist I’ve seen within HPR who lays down clear guidelines for client behavior. When a client behaves in a passive aggressive manner, she doesn’t just let it slide but calls attention to it in a firm but still very warm manner. Likewise for clients who fall asleep or are not participating. A true example of metta in action. Although each therapist has her own style, I would appreciate it if more of them had Dr. Pusateri’s ability to, well, draw boundaries.

DBT: DBT offers an excellent set of lifeskills. The format is a bit rote. I feel that these skills are so valuable that they deserve some practice, perhaps during the class or as homework. The skills are extremely practical in nature and should be rehearsed multiple times so that they become second nature. These skills can’t be acquired through reading alone.

Seeking Safety/Trauma: Terayn brings a welcome lightness and humor, without ever being flip, to this topic. She reminds all new members that she is still under supervision but her therapeutic skills convey a warmth and caring equal to, or better, than many other HPR therapists. Polar opposite to Process, below.

Process: As ambiguous as its name, this class turns the vibe of other HPR classes (warm, nurturing, safe, nonjudgmental) on its head. Deliberately confrontational, this class would require a very strong and stable personality to benefit from the somewhat abrasive style. Unfortunately, I did not see anyone in the class that fit that description, including me. If you are OK with walking the high wire without a net, or are so lacking in boundaries that you will go along with the process without critical thought, there’s the potential to do deep work and then maybe work on your boundaries later. I feel that a perceived lack of safety is the very last thing I needed fresh out of detox. I feel that this style of therapy (I’ve heard other therapists describe it, not with approval, as old school) is appropriate, if at all, for those who already have high levels of self-esteem, who are comfortable with verbal confrontation and outright judgment.

Art: A fun, positive class that is great for the right brain. I’ve already taken multiple art as creativity classes and felt that this class, while fun, was not therapeutic for me and I have even more fun things to do with the time. A great, nonjudgmental attitude permeates this class and makes making art a comfortable experience for the otherwise self-conscious.

EMDR: NOT my favorite, but the most therapeutic. With the exception perhaps, of brief periods of meditation included within other HPR meetings, no other therapy has given me the direct contact with my unconscious (or whatever you want to call it) as has EMDR.  EMDR is psychological weight loss. For those with a lot of trauma, until you’ve lost 10, fifty or a hundred pounds, pound by pound, memory by memory, you can’t understand the full significance of the weight you’ve been carrying around in your head.  Of course you’re only losing psychological fat, not the entire memory, just the trauma piece of the memory. For a truly palpable experience of what EMDR results feel like, try wearing a fifty pound weight vest for two hours during your normal daily routine. Then take it off.

Not part of HPR but please encourage HH detox to increase the wholesomeness of their food and to get the mold out of the bathrooms. I’ve mentioned both of these to Michelle.

Take my feedback as the opinion of one person. Unless you receive multiple complaints or negative feedback from many, I would ask you to please keep doing exactly what you’re doing and take my feedback with others to improve the program….if you can J

Best,

Scott

An Addict’s Brain: The Great Manipulator

TRANSCRIPTION:

A lot of people have a hard time understanding alcoholism and or addiction. They believe that it’s a choice.  And they continue to tell the person who is suffering from alcoholism or addiction, “To just stop.”  As if they could. if you look at people who suffer from alcoholism and addiction they’re no different from other people. They didn’t grow up thinking “oh when I grow up, I want to be an addict or when I grow up I want to lose my job, my wife my children to addiction.  Addiction is a disease, and what happens in the process of addiction, the brain, basically becomes the addict’s or the alcoholic’s worst enemy.

There is a part of the brain that learns to reward itself. And learns to repeat behaviors that help the brain feel that reward.  Alcohol and drugs puts this reward system into overdrive, so that when the brain gets the alcohol or the substance that its addicted to , it rewards itself highly, more than any other mechanism or any other thing that the brain would get. It’s the alcohol or the substance. That rewards the brain.

I have patients that would tell me that the fix they got from the drug of choice was a thousand times better than sex.  That is the difference that the brain feels. And once the brain gets used to that level of reward.it decides. Want anything else. That this is the thing that brain wants. So the brain of the addict becomes his other worst enemy.

So for example let’s say that John is an alcoholic and his wife has threatened to leave him and take the children if he continues to drink. John would feel a lot of shame and guilt about his alcoholism he would feel a lot of stress over what he put his family through.  So John decides that we won’t drink anymore.

But that’s when the brain gets into its manipulative mode. It starts telling John, it’s OK, just this one last time.  Why don’t you drink in the car your family won’t notice?  Why don’t you drink when your kids are in school?  And your wife is at work. It starts coming up with ways for john to drink.

When John is unhappy or something bad happens, the brain says oh you poor thing. This is awful you deserve a drink.  You should drink another vodka and then you can always clean up tomorrow, you can stop tomorrow.  When John is happy and is having a good, the brain says “Your earned this drink, you can always quit tomorrow.”  So John ends up repeating his pattern of drinking even though understands how important his wife and children are to him

Or consider the case of Julie.  Let’s say Julie uses heroin, the brain will make Julie get heroin at any cost.  For example, Let’s say Julie is renting a home and she is spending all her money on so her landlord is going to kick her out. She wants to pay her rent. Her next check comes in she thinks, “I better use this to pay my rent.”  But then the brain kicks in and starts telling her, oh its ok, your landlord is horrible any way and you shouldn’t be living in this dump.  You should go get heroin with this instead. Julie goes and gets her heroin. And then the landlord gets upset and calls her all angry. Then the brain says “ you poor thing your landlord yelled at you lets go get you some heroin.”

People get to a point where they face death and are willing to face death to get their fix and this is not a choice. When a person gets heroin, from another person in a syringe, and the other person they know has aids, and they still choose to use the syringe, it is not them making a choice it is the brain manipulating them, either saying , “Its ok you’re not going to get AIDS, that’s really not possible, or its saying “it’s OK if you get AIDS you deserve it.”

Either way the brain manipulates the addict.  Addiction and alcoholism are diseases and are serious and are potentially fatal.  They destroy people and their families.  If you or someone you know suffers from addiction or alcoholism, don’t wait. Get them help immediately.

The Addiction is “Just a Phase” Myth

TRANSCRIPTION:

A lot of times when I talk to parents of alcoholics and addicts they tell me about, how they first found out their child was using drugs or alcohol.  It is one of the most tragic things I hear is “Oh I thought it was just a phase and it was going to pass”   he/she has friends who are bad influences, and it will pass, and I always wonder, what would be different in this person’s life if at the first occurrence or alcohol or drug use if a parent had stepped in. I believe there is no drug and alcohol phase that a child goes through. If you have a 14 or 12 year old who is smoking pot and using cocaine here and there.  That is not a phase that is a drug abuse problem sooner or later that is going to have fatal and or serious consequences. Get them help right away.  With the First occurrence of drug and alcohol use, especially if it’s inappropriate.  Make sure you get them help. The sooner the problem gets under control the better.

Think about it would you rather get your child help when they are drinking alcohol and smoking pot or do you want to wait until they are injecting themselves with heroin?

Getting help sooner than later is important in the case for younger children. Let’s say you have an adult son or daughter that’s abusing substances.  Again it is not a phase.  For example, if your son loses his job or your daughter can not get into the school she wanted to or cannot get the job they were looking for and they start drinking on a nightly basis.  Then there’s an increase in their drinking. Then add on the occasional cocaine or meth that is not a phase that will pass.  Get them help right away.  With older children it is a bit more difficult because you cannot take them to a program against their will.

Once the person hits the age of 18 they are considered an adult and can make their own decisions.  You however are not powerless as a parent of an addict. You may be helping your children financially. You can cut them off financially unless they get help. You may be helping your children raise their children.  You have to position yourself in a way that they understand that unless they get help you will no longer be able to assist them.

Addicts and alcoholics rarely get better on their own.   They get worse and the sooner they get help the better the outcome will be. Again if you have a son or daughter of any age who is using alcohol or drugs.   Please don’t hesitate to get them help. It is not a phase that will pass.  Do not take that risk. The consequences can be severe.