[chaotic13]

This post is a follow up to a response I made in the ADHD thread and now a bunch of residual thoughts are bouncing around the synapses in brain. In writing my earlier post I started reflecting on the care I’ve been receiving for my ADHD and …. whatever it is that I am being treated for in psychotherapy. I work/teach in an allied health field and I have some fairly strong opinions about what constitutes quality health care. I find it ironic that I’ve ignored some of these beliefs and standards in my own health care. With regard to the diagnosing and managing my ADHD, I’ve become quite complacent about PLAYING MD. Now I am wondering… should I be the one directing and assessing the efficacy of my treatment plan?? After all what are my qualifications? Would I recommend myself to others? What actually constitutes “quality” ADHD care or “quality” psychotherapy for depression, anxiety, general malaise? Hell, I don't even know what I have??? Is any one else in a similar situation?

Like I said in my own field, I have some very clear criteria for judging the quality of care I render my patients. The clinical decisions and judgments I make are influenced by many different things. However, If a patient or student were to ask me, “Why did you choose this treatment approach over another one?" I would be able to confidently explain my rationale and could likely dig up at least some evidence support it. I don’t know the more I reflect on the treatment I’ve received over the past year, more with regard to the ADHD but also the psychotherapy to some extent, I realize I AM TOTALLY CLUELESS about what I am doing! I have very little information on how pharmacological & clinical decisions are made (or should be made) and then assessed for efficacy in mental health care. For example is it standard procedure for a neurologist to determine medication dosages by simply saying to the patient, “How do you feel, do you want to experiment with increasing your dosage of … Adderall?"

I know in this psychotherapy thread we have discussed characteristics of good therapy a few times. My questions today are:
1) If you were asked if you thought you were receiving the BEST possible care available for your pathology (illness), how would you answer?

2) What criteria do you think are important to consider when judging the quality of your overall mental health care? (pharmacology and psychotherapy) Look deeper than just whether you like or dislike your therapist-- Is just being licensed, nice, and a good listener enough to all it quality care?

3) Do you have the same quality standards for your personal treatment as you do for others (i.e. your children or other family members)?

McKell,
Good question.
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If you were asked if you thought you were receiving the BEST possible care available for your pathology (illness), how would you answer?

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I would have to say yes, because my Pdoc and T work closely together. They are both very knowledgeable, which gives me peace of mind.

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2) What criteria do you think are important to consider when judging the quality of your overall mental health care? (pharmacology and psychotherapy) Look deeper than just whether you like or dislike your therapist-- Is just being licensed, nice, and a good listener enough to all it quality care? /quote]

I think you know it when you have it. Yes, my T and Pdoc both have Doctorate's, which I think helps. However, they both are very empathic and listen to what I have to say. My Pdoc used to be a pharmacist and knows a lot about pharmacology. And my T has been in practice a long time. You can tell that this field comes naturally to them.

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3) Do you have the same quality standards for your personal treatment as you do for others (i.e. your children or other family members)?

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Well, as far as Ts and Pdocs go, yes. I also have the same standards that I hold for my general practitioners.

Hope that helps

[Perna]

From: http://www.who.int/mental_health/res...en/Quality.pdf

For me, I check every now and then that I'm feeling better, gaining self esteem and behaving in my world in a way that makes me more comfortable/happier with the fit between me and my world.

[sunrise]

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mckell13 said:
Now I am wondering… should I be the one directing and assessing the efficacy of my treatment plan??

</div></font></blockquote><font class="post">It depends on what your philosophy is. My primary care physician believes in the team approach--doctor+patient--to medicine. I like that too and so I give input to my doctor on what I want my treatment to be. She may offer options, I tell her what does and doesn't appeal to me, what would not work for my situation, etc., and she takes that into account in our decision making. I may do some independent research and reading in the medical literature. She may veto my suggestions and explain why. Some patients, for example my parents, prefer the "top down" approach and never ask questions of their doctor at all and do not want to be part of any decision making. That's fine too. What approach do you prefer, McKell?

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is it standard procedure for a neurologist to determine medication dosages by simply saying to the patient, “How do you feel, do you want to experiment with increasing your dosage of … Adderall?"

</div></font></blockquote><font class="post">It seems this is fairly standard practice in many areas of medicine. The doctor prescribes a drug and then checks back with the patient to see if the drug has relieved the symptoms. If it hasn't, he may change the dosage or change the drug. That is how my doctors have assessed whether my prescriptions for acne (antibiotics), high blood pressure, and anemia are working. For the anemia prescription, the doctor may ask, "do you feel less tired?" Similarly, for an antidepressant prescription, the doctor might ask, "do you feel less depressed?" or "do you feel better?" The thing is, each of our bodies has a unique biochemistry due to the interaction of our unique genetics with the environment. There is often no way to predict whether a med (or a certain dose) will work for a particular person than to simply try it.

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1) If you were asked if you thought you were receiving the BEST possible care available for your pathology (illness), how would you answer?

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Well, I actually don't believe I have an illness. I approach my mental state from a position of health rather than one of pathology. I believe there is a wide range of what is "normal" in mental health. I don't believe we all need medical treatment to make us fit into one narrow definition of mentally healthy. The mental health care I am receiving is from just one practitioner, my therapist. I do believe I am receiving outstanding care from him because he is getting results and we are making progress. I had a previous therapist and she did not get the results he is, so I have a point of comparison. My PCP has prescribed for me for anxiety, using the team approach, and I was happy with how that went, even though the drugs weren't terribly effective, and when I declined further meds, she didn't badger me into making a choice that was not the best for me. So, yes, overall I am very satisfied.

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2) What criteria do you think are important to consider when judging the quality of your overall mental health care? (pharmacology and psychotherapy) Look deeper than just whether you like or dislike your therapist-- Is just being licensed, nice, and a good listener enough to all it quality care?

</div></font></blockquote><font class="post">For me, an important criterion is if I am making progress. Am I feeling better? Am I coping with life better? Am I making progress on solving my problems? Do I feel more hopeful? Am I learning more about myself? Am I able to apply what I learn from the therapeutic relationship to other relationships in my life? Have I made positive changes in my life? If the answers to these questions are yes, then that is pretty dang good!

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3) Do you have the same quality standards for your personal treatment as you do for others (i.e. your children or other family members)?

</div></font></blockquote><font class="post">Yes. My daughter has a therapist, and I was very careful about choosing her. It is harder to assess the answers to my criteria above though, as she doesn't share much from her therapy with me. So it's harder to answer the question "is therapy working?" when it is not yourself.

[MissCharlotte]

McKell,

These are all thought-provoking questions:

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1) If you were asked if you thought you were receiving the BEST possible care available for your pathology (illness), how would you answer?

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I suffer from depression caused by a combination of genetics and life circumstances. There are also ongoing family issues and illness for which I need support. I think of myself as more than an illness. I don't define myself by my illness. So, I think I have to answer yes. I do believe that I am receiving excellent care that is the best possible for my pathology (depression) and for ME (my SELF)!

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2) What criteria do you think are important to consider when judging the quality of your overall mental health care? (pharmacology and psychotherapy) Look deeper than just whether you like or dislike your therapist-- Is just being licensed, nice, and a good listener enough to all it quality care?

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Again, I think this is a very individual question. As for pharmacology, I take anti-depressants and my p-doc is a psychopharmacologist. It is important for me that I work with someone who has this added credential because I am extremely sensitive to medications of all kind. He is also very experienced treating depression and is an EXCELLENT listener. So, he does not dismiss my experience with a medication and is very responsive. I think it's worth noting here that I think it's a good thing that your doctor asked how you felt about the adderall. He cannot feel what's going on in your body but depends on you to tell him. The experience is yours.

As far as T is concerned, I think his background, experience and training are a good fit for me. There are so many possible permutations and types of psychotherapists. For me, it is important that I work with a man, that I work with someone who has a fair amount of experience and can understand the background I grew up in. His level of empathy, ability to stand still for me, and his overall lived experience is almost more important than his license. However, I would probably not work with someone who didn't have a license. I tend to be suspicious by nature! It is also important to me that I feel like my T is an intellectual match and who is an analyst as well as a therapist. These combinations are important for my well being and my mental health.

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3) Do you have the same quality standards for your personal treatment as you do for others (i.e. your children or other family members)?

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You know, I have to say yes to this one. If nothing else, I have always insisted on the absolute best in healthcare for all of us, including me!

[Razzleberry]

I have had issues getting quality care too. And it really amazes me how bad the system really is. It's no wonder there are so many people with untreated mental illnesses in this world...

If I ever fix myself, my "dream" is to try and fix the system. More accountability for therapists and psychiatrists. Easier access, and shorter wait times for the first appointment. Nation-wide database with ONE phone number to call or ONE website to go to to find the help you need - instead of so many different places all leading you to nowhere.

Sorry you had to deal with this. To me...this side is the worst part of mental illness.

If someone got cancer, and the doctors waited 2 months to get an appointment, then just decided "oh, we don't like to treat THIS kind of cancer" and left you without a referral (but a hefty bill!)...there would be malpractice suits like crazy. But for mental illness, it is not the same. This type of treatment is somehow acceptible.

It's like we have to kill ourselves just to get help.

It's stupid.

[chaotic13]

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1) If you were asked if you thought you were receiving the BEST possible care available for your pathology (illness), how would you answer?

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I don’t know if I am getting the BEST or most effective treatment for either my ADHD or my… malaise. I have not discussed an actual diagnosis with my T, so to avoid pretending to be an MD or Psychotherapist I will for go diagnosing myself and just call it “malaise with life”. Since this is my first experience with the mental health care system, I have no way to directly compare my treatment with others. What I can say is that I am not receiving poor or ineffective treatment for either condition.

Regarding my ADHD I have some serious concerns with the quality of care I am receiving for this condition. I would rate my therapist care in addressing my ADHD as FAIR. As for the care being provided by my neurologist, the 5 minute follow-up visits are a complete waste of time and money. I would have to rate this care as MARGINAL/POOR. My GP has shown much more interest in my specific responses to the medication, my perceptions on therapy, and the impact of these on my overall health. I would rate my GP’s role in caring for my ADHD as GOOD. I think I am responsible and actively involved in my own care. I read a lot about ADHD, monitor my response to the medication, and actively seek potential alternative/augmentative treatments. I rate the quality of my efforts as GOOD.

Regarding my “Malaise with life” condition, I judge my overall treatment quality to be GOOD. I have made significant progress and my therapist has repeated demonstrated her ability to provide meaningful insight to facilitate this progress. Unfortunately after 10 months of therapy, I sat on the ugly couch yet again last week and insisted that what I was feeling was wrong, abnormal, unjustified. I find it very alarming that I have still not grasped the basic concept that feelings and emotions are not right or wrong. This is knowledge is disheartening but simply where I am.

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2) What criteria do you think are important to consider when judging the quality of your overall mental health care? (pharmacology and psychotherapy) Look deeper than just whether you like or dislike your therapist-- Is just being licensed, nice, and a good listener enough to all it quality care?

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1. Improvement in symptoms. This includes not only perceiving myself as having improved; but actually demonstrating real improvement. I not only want to feel or perceive myself as being a better parent, I want to actually BE a better parent. I don’t want to just think I am more compassionate/empathetic, I want to ACT more compassionate/empathic

2. Efficient: I think quality care means that the treatment approach is effective and well matched with the individual. This to me means that measurable progress should occur in a timely manner. There should be a built in process for continually assessing the plan of care and making minor modifications to improve progress and identify problems.

3. Evidence –based: I think quality care should be consistent with credible standards and supported by evidence. I don’t think a good therapist haphazardly uses trial and error to find what works and what doesn’t. There should be some type of systematic (but flexible) way of determining a course of action.

4. Professionalism: Quality therapy is consistent with ethical practice guidelines, adheres to recognized professional standards, puts the patient’s needs and well-being above the needs of the therapist, business, insurance companies etc.

5. Collaborative: Therapy should be a collaborative effort between the patient and the therapist. Sometimes depending on the patient's mental state, the therapist may play a role in leading the course of treatment. Other times the patient should be empowered to direct the course of therapy.

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3) Do you have the same quality standards for your personal treatment as you do for others (i.e. your children or other family members)?

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For me this response is NO. I would never allow a family member to be place on a medication without being absolutely sure that 1) they were comprehensively evaluated and 2) properly followed using a systematic and logical assessment procedure for determining its effectiveness and proper dosage. Would I allow my children to be treated by my therapist? Yes, provided that she clearly stated her diagnosis, outlined treatment plan, and periodically reviewed their progress with me. My treatment is missing the diagnosis and general treatment outline. This leaves me feeling like I am progressing too slow, off on a tangent, or always wondering if I am going to hear… ’So are you sure you want another appointment?’ I understand the nature of my therapy may warrant this level of uncertainly, just on days like today I am craving a clear purpose and a way of measuring where I am in the overall process of achieving joy/happiness.