Author

freudandfashion

I'm a newly graduated psychiatrist who believes it's stylish to talk about mental health. Welcome to my diary, Freud & Fashion, created in 2010 to document my life as a psychiatrist-in-training and share knowledge and psychotherapy pearls that I learned along the way.

Personal

Mother’s Day Note

written by freudandfashion

{Napa, California}

Oftentimes, I observe my mom and wish that I could match her levels of energy, thoughtfulness, and ability to multi-task. Fortunately, some of her traits were passed on to me, though I still hope for late-onset development of her culinary skills. Even as an adult, if I’m ever out of line or “misbehave” in any way, my mom is the one person whom I will always fear to put me in my place! But seriously, she embodies all the qualities I’d hope to possess when I have my own children. I love you Mom, Happy Mother’s Day 🙂

And to all the wonderful mothers and mother figures — hope you have a well-deserved, enjoyable & relaxing day!

May 10, 2015 5 comments

Psychiatry

Trapped In A Role

written by freudandfashion

I met some of my most memorable patients while moonlighting on an inpatient psychiatric ward during my final year of residency. One of the patients I was assigned to was labeled as the highest-risk for agitation (he was restrained and placed in seclusion two nights prior), so the staff warned me, remained on standby, and closely monitored the cameras as I approached the patient to conduct my first interview. Instead of standing during the meeting, I sat in a chair to take a more submissive stance. After all, I am the doctor and patients with chronic mental illness and histories of multiple involuntary hospitalizations understandably perceive psychiatrists as possessing the power and ability to determine their length of stay and which medications they must take. Sitting in a chair below his eye level demonstrated my attempt to even out the perceived sense of power and control.

He remained standing and proceeded to yell at me: “You’re the psychiatrist?! You don’t look like a typical psychiatrist! Are you going to ask me if I’m suicidal ‘cus I’m not. Are you afraid I’ll hit you? I don’t want to talk to you!”

I wanted to bolt out of the chair immediately, but instead remained calm and allowed him to scream his frustrations, for he was likely projecting onto me a build up of anger based on past experiences with psychiatrists. I assumed psychiatrists kept interviews brief and never asked in-depth questions beyond those pertaining to his psychotic symptoms. As a medical student, I observed meetings that lasted as quickly as one minute, which usually consisted of the standard questions: Are you hearing voices? Are you suicidal? Do you want to harm others? Did you take your meds?

Once he finished yelling, I told him that I read his chart, but emphasized that I wanted to hear his side of the story. After a few minutes of allowing him to talk without interruption, he eventually sat in the chair across from me. He paused a few times with suspicion, but when he saw that I remained engaged with the conversation, we later moved on to discuss topics such as his hobbies and interest in art. When I asked about medications, he told me that his antipsychotic made him tired during the day, which tends to make him angry. He tries to fight the sedation side effect in order to stay awake, so he often refused to take it (patients get marked as “noncompliant” when they refuse their meds). I asked if he’d be willing to take the med if switched to nighttime dosing in order to help with sleep. He agreed. I slowly got up from my chair and thanked him for allowing me to speak with him. As I extended my hand out to shake his hand, I caught a look of shock on his face (perhaps doctors never shook his hand?), then he informed me that he doesn’t like shaking people’s hands. I told him, “no problem, I understand” and we both left the room.

When I returned the following day, the report from nursing staff was that my patient willingly took his medications and there were no reported issues with agitation. One staff member even said they were able to have a short and pleasant conversation with him for the first time. I was pleased, though I also felt bad because I was his psychiatrist temporarily for the weekend only. Later that day, I told him that another psychiatrist will be seeing him tomorrow. He proceeded to scream obscenities at me, but this time I ran into the medical room and slammed the door shut. I was scared, but not upset with him the slightest bit. My intuition told me that in that moment, I became just like all the other psychiatrists who proceeded me, who made headway only to leave him in an even more vulnerable state. When the nurses asked whether or not they should give him a PRN (a medication given “as needed,” in this case for agitation), I quickly said “no.” He allowed himself to open up to me and in a sense, I abandoned him. Based on his history, he has experienced abandonment from several others throughout his life.

I can’t automatically change a patient’s pre-existing, negative perceptions of psychiatrists, but he changed my perspective of patients labeled as “agitated.”

Total Time for my first one-on-one session with him = 13 minutes + a sense of feeling heard + a developing therapeutic alliance.

Total Time to call security, obtain back-up staff to restrain the patient, and monitor the patient while placed in seclusion = several hours + long-lasting, negative, traumatic experiences that the patient will forever associate with psychiatrists and the psychiatric ward.

Photo by Marlon Santos

May 7, 2015 10 comments

Personal

Home Sweet Home

written by freudandfashion

{Fairfield, California}

As a fledgling adult who moved away from home for college then medical school, my family often made trips to visit me, especially to drop off or prepare a home-cooked meal (I lived 30 minutes away from home for college and 7 hours away for medical school). Now that I’ve completed all my training, I return the favor for all the support I received and visit them in northern California as often as I can (except I’m not the best cook, so my family probably prefers that I NOT make the home-cooked meals). I am currently staying at my parents’ place this weekend for a mini family reunion and feel pretty excited that I get to reunite with family members visiting from the Philippines whom I haven’t seen in years (and apparently there’s a boxing match everyone’s watching tonight). We all have our own priorities in life and at one point my education and career took precedence over family, but I learned my lesson after missing out on numerous momentous events. Having a lucrative career can bring a sense of satisfaction, but true happiness can’t be attained unless balanced with those who support you the most.

I hope you have a balanced weekend!

May 2, 2015 11 comments

Medicine

What Being a D.O. Means To Me

written by freudandfashion

When approaching the door leading to my office, patients often look at the signage and proceed to ask one of the most frequently asked questions I receive: “What’s a D.O.?”

Several books and articles exist on explaining the background, history, and differences between being a D.O. (Doctor of Osteopathic Medicine) versus an M.D. (Doctor of Medicine). Also, debates on which degree is better persist, though I personally find the feeds quite annoying and amusing at the same time (mostly because I remember diligently reading these forums before applying to medical school, which were predominantly biased towards M.D., but I’m able to confidently say that myself and all of my classmates/colleagues that I know of from my D.O. program turned out just fine). So let me be clear that my purpose is NOT to exacerbate the debate between which degree to choose, but rather convey what being a D.O. means to me.

But first, let’s get the basics down regarding the two degrees (if you’re already aware of the basic similarities/differences, skip to the next paragraph):

What’s the same:
- both undergo four years of medical school education (some schools actually offer both MD and DO programs where students attend the same lectures/classes, such as Michigan State and Rowan University).
- both undergo the same amount of residency training depending on the program
- both are fully licensed to practice medicine in the United States
What’s historically a bit different:
- Different licensing exams: DOs take the COMLEX while MDs take the USMLE
- DOs receive > 200 hours of osteopathic manipulative medicine training; MDs do not.
- DO programs are historically known to accept the non-traditional applicant (for example, the average age of students are a bit older, may be non-science majors, or seeking a second career)
- In 2008, 7% of practicing physicians in the U.S. were DO graduates and 68% were graduates from a U.S. MD schools (I tried to find more recent statistics, but couldn’t find an accurate source)
- Osteopathic medicine is distinct in its philosophy that “all body systems are interrelated and dependent on one another for good health” (American Association of Colleges of Osteopathic Medicine)

I applied to both MD and DO programs for medical school and remained open to attending either one. I interviewed at both types of programs, but only received acceptance letters from DO schools. Perhaps I didn’t have the highest MCAT scores, GPA, or my interview responses weren’t impressive enough? Well, whatever the reason, I was just happy that the DO admissions committee gave me the chance to prove that I’d make a good doctor.

The whole concept of a more holistic approach to medical practice offered by DO programs sounded ideal to me, yet at the time I was more focused on getting through school and graduating rather than on how the philosophies would impact my practice as a physician. After graduating from medical school, I had the option to apply to either DO or MD residency training programs. I applied to both, yet decided to pursue the osteopathic route when I heard about the opportunity to be a part of the first osteopathic psychiatry residency on the west coast. As the oldest of 33 grandchildren, it was inherent of me to jump on the opportunity to help trailblaze a new program (my program director nicknamed me Hiawatha). I knew that my decision posed potential limitations in obtaining a future job since a few organizations still don’t accept psychiatrists certified under the osteopathic board. However, I took the risk because I saw more value in being the first to graduate from and help shape a new, developing program.

For me, being a DO fits my personality and what I’ve grown to stand for in my practice: being integrative, holistic, and preventative. I truly believe that without such an emphasis on integrative medicine as one of the main tenets of the program, I wouldn’t be the physician that I am today. Therefore, it’s no wonder that 50% of the graduates from DO programs become general practitioners (family practice, internal medicine, emergency medicine, etc). I initially despised having to attend osteopathic manipulation classes, and even failed my very first practical exam. Yet, the hands-on approach made me unafraid to touch my patients. Each psychiatrist is different, but for the most part human touch provides a sense of comfort and connection. A few of my patients politely ask for a hug, and if appropriate, I unhesitatingly oblige.

And in some unique way, I feel that being a DO caused me to work harder in a field predominantly filled with MDs to make my presence and way of practicing known. When a large, metropolitan county declined to consider me for a job due to my credentials, I utilized the rejection as motivation to persevere rather than a barrier.

And most importantly, I used to feel bombarded by the numerous, large framed portraits of osteopathic medicine’s founder, Andrew Taylor Still, MD, which hung in almost every corridor of each osteopathic institution. However, after feeling frustrated with several aspects of current practices in medicine, I’m undoubtedly far more appreciative and understanding of AT Still’s motivation in the 1800s as an MD to create a method of practice that rose from adversity (he lost 3 of his 12 children to viral meningitis with no method of saving them even as a physician himself) and frustration (an over-dependence on medications and the sometimes harmful medical practices of the time). I actually wish his story was more widely publicized because he epitomizes successful individuation from mainstream medical practices amidst much scrutiny and opposition.

In the field of psychiatry, where Western medicine can’t always explain nor provide the most adequate treatment via pharmaceuticals, wouldn’t it be great if we had more modern day AT Stills to branch off and create a newer system of viewing and practicing mental health? I’m truly frustrated with the current practices particularly the overemphasis on medications alone. The number of overdoses (100 people die from drug overdoses everyday in the U.S.), medicated children as early as infancy, continue to rise. Medications are only one component of treatment, but greater emphasis should be placed on developing resiliency, acknowledging the individual’s unique traits, and treating the person holistically rather than symptomatically.

AT Still put it best when he said the following:

“An absolute demand for revolution is before us at this date and time, for there is a demand for a progressive step in the line for treating disease. For a number of days I have been haunted by the feeling that we are in danger of getting into a rut unworthy of higher consideration than should fall to mere imitation. Let us not be governed to-day by what we did yesterday, nor to-morrow by what we do to-day, for day by day we must show progress.”

April 30, 2015 23 comments

Personal

Something New

written by freudandfashion

{Upland, California}

My life throughout medical school was pretty monotonous: wake up, attend lecture, eat, go to anatomy lab, study, eat, sleep. I started to exhibit more signs of life once residency started, though limitations to participate in enjoyable activities always existed. I could never rid of feeling guilty each time I did something other than study because there was always an upcoming crucial exam (licensing exams, PRITE, etc) to prepare for. My cognitive distortion was that I’d perform terribly unless I spent every waking hour reviewing for the test, therefore I rarely experienced a day where I felt totally relaxed and present. Fighting the little voice in my head telling me to do something more productive, I’ve been giving myself permission to do more fun activities and am amazed that the self-critical voice is starting to diminish.

So, in continuation of my New Year’s resolution to be aware of my need for self-care, I took a break from paperwork this week and joined my cousin and friend on a trip to their local rock climbing gym. I completed a couple routes belaying for the first time and rediscovered how much I enjoyed the adrenaline rush. It was so much fun!

Therefore, I’d like to encourage all the students and any slightly rigid readers out there (like myself) to try a new activity this coming week. Anything from taking a different walking path to trying a new coffee shop, or avoiding the couch after work/school (seriously, anything to break the monotony is worth something and brings you a little bit out of your comfort zone). If you’re open to sharing or maybe you already participated in something new this week, post in comments below!

Have a wonderful weekend!

April 24, 2015 15 comments

Psychiatry therapy

Choose Your Therapist

written by freudandfashion

The one thing that has made me the most self-aware, insightful, and empathetic towards others, especially my patients? Psychotherapy. Everyone can benefit from going to therapy. I probably refer 80% of my patients to a psychotherapist, especially since I believe that the best treatment plans consist of more than just medications (or may benefit from therapy alone, depending on the case). When choosing a therapist for myself, I was fortunate to have a trustworthy former supervisor refer me to two great therapists since I first started therapy during residency, though I realize that most people don’t have the luxury of having a go-to person to help them navigate their local mental health resources. I pride myself and put effort into referring my patients to therapists whom I believe will be a good fit. If you’re wondering whether or not you’re ready for therapy, I wrote a previous post that addresses that question here.

The following are some guidelines/tips that I use when choosing a therapist for my patients or suggestions I would give friends/relatives if they were looking for one themselves:

Keep in mind that the most crucial factor for effective therapy is the connection you have with your therapist. The connection is important for feeling safe, developing trust, and creating a mutual understanding of your goals in therapy. Even if the therapist listed trained at the most elite programs or was Dr. Phil himself, if the connection doesn’t develop over time, then it’s best to move on to a different therapist.
If you see a psychiatrist and feel that he/she knows you pretty well…Ask them for a therapist referral based on your history and goals in treatment. Note: if your psychiatrist does NOT know you very well and solely focuses on medications and symptoms, then see bullet points below. I work part-time for a Health Maintenance Organization (HMO) where we have designated therapists/case managers (who may or may not know the patient/client) make the referral, yet I’ve made efforts to connect with the contracted therapists so that I have a sense of their therapeutic style to gauge which therapists would work best with my patients.
If you have a friend or family member currently in therapy…Ask if they’d be open to inquiring with their therapist to provide any recommendations for you (Note: make sure your friend/relative actually likes their therapist and trusts their recommendation).
Nuts & Bolts:
- if it’s important to see a therapist who accepts your insurance:
  - take a look at the in-network provider list, or search online directories such as Psychology Today (there’s a section under the profile of accepted insurance plans) and research information on the therapists online. I recently gave a close friend the gift of psychotherapy sessions as a birthday present (yes, I try to be both creative & meaningful with my gift-giving ideas) and since I didn’t live in the area, I resorted to an online therapist search.
- Whether or not you need to see an in-network provider, when narrowing down your list, consider the following:
  - Gender preference
  - Photograph – this is not intended to be superficial. Since having a connection is important, you’d likely want your therapist to appear like someone you can feel comfortable sitting across from and opening up to.
  - Location – if transportation is a crucial component, then limit your search to local therapists. I personally drive one hour to see my therapist in Los Angeles, but I’m okay with the distance because I’m willing to drive further in order to see my therapist, who came highly recommended, versus seeing someone questionable, yet closer.
  - Cost – if on a budget, there are several therapists who offer discounted fees on a sliding scale dependent on your income. If you’re a student, be sure to look into your school’s counseling and psychological services (usually covered if you pay for student health benefits). If you work for a large employer, they may have Employee Assistance Programs (EAPs) that provide confidential counseling services for their employees. However, if choosing to pursue out-of-network providers, mental health professionals in private practice may charge anywhere from $50 to over $200 a session depending on location, credentials, and experience, though cost can be greater in larger, metropolitan areas (for example, in Los Angeles, a psychiatrist who provides both medication management and psychotherapy may charge around $400/hour).
When in doubt, try it out. Yes, I’ll admit that some of my referrals haven’t worked out, but for the most part, the initial experience may solidify even more which qualities you prefer in a therapist. I’ve even had a few patients request to see a a different psychiatrist other than me for specific reasons (usually because I look too young) and that’s okay because this is your treatment and we each have our preferences. When you meet for the first time, take note of how you feel while interacting with the therapist (do you feel invited to share, does the therapist have a genuine interest in understanding you, does the therapist seem invested in working with you to help determine the issues impacting you the most?). Keep in mind that just like any relationship, building the therapeutic relationship may take some time, but as long as there’s forward movement in the process, then I hope you commit and stick with it!

Any other comments or suggestions?? If any of you are in therapy, I would love to hear of tips/information you found helpful when choosing a therapist, or, if you’re a mental health professional, I truly welcome your thoughts on how to choose a therapist as well!

April 22, 2015 13 comments

Personal

Lessons of the Week

written by freudandfashion

{Playa Del Rey, California}

If you read my last post, you’ll know that my mood has been a bit off this week. Yet, now that it’s Friday, I can reflect on the positive lessons I learned from the experience.

1. Be cautious of making any crucial decisions when you’re feeling emotionally off. Let’s just say that losing control of my emotions led to an impulsive desire to regain control, which manifested as having the urge to make irrational decisions (regarding my job, therapy, and relationships). Fortunately, I gained enough insight and control of my emotions in time before committing to anything!

2. No matter how stressed, angry, or upset you may be, if possible try your best to remain present for others. I felt exhausted during clinic yesterday. Then, one of the last patients on my schedule tells me that I’m the only doctor she has who listens and doesn’t make her feel as if she’s being judged. I was touched by her comment (and I also thought, “wait shouldn’t every doctor be that way?”). I don’t suppress my feelings of lethargy (in fact, if my patients ask, I’ll be honest and tell them if I’m feeling a bit more tired), but I make sure that my energy levels and mood don’t interfere with the connection I have with my patients. If it does interfere with my interactions, then it’s a sign that I’m in need of a vacation!

3. Grief is tough and very confusing. Period. If support is available, please utilize them. It took me awhile to reach out, but I’m glad I did. And I appreciate all of you for reading, commenting, and helping me realize that I’m not alone.

April 17, 2015 6 comments

Personal therapy

Grief In Repeat

written by freudandfashion

{Upland, California}

Upon driving into my garage coming home from work this evening, I suddenly burst into tears as the garage door slowly closed behind me. I haven’t felt like myself at all this past week. I tried my hardest to discern the reason for my melancholic mood and pinpointed a series of events that occurred after the subject of death was brought up during my therapy session this past weekend. The subject of terminal illness and inevitable death is never an easy one, even as a physician who had to pronounce deaths in the hospital wards and was educated on how to talk to patients about advance directives (Do Not Resuscitate/DNR), hospice, etc. We all have triggers that may occur randomly during our day that may unleash suppressed feelings that go deeper beyond whatever triggered us in that present moment. A patient once told me that hamburgers made her sad because her deceased father cooked them all the time at family gatherings. For others, something as simple as a hamburger triggering profound emotions may sound ridiculous, but we must be empathetic to each individual because none of us know of the history, context, or meaning that a symbol (such as hamburgers) provided in a person’s life.

My initial trigger was watching the movie Furious 7 last week. Now, I know that millions of devoted Paul Walker fans (including myself) were profoundly impacted by his tragic death, but the uncontrollable amount of tears that I shed was far too disproportionate to the mild attachment I had for the actor. Since everyone I knew who watched the movie admitted to shedding tears, I didn’t think much of my emotional response at the time. But, during my group therapy session, I was extremely angered about an unrelated topic, and again, I couldn’t figure out the reason why. Leaving my therapy session in a pissed off mood, I contemplated quitting group because I didn’t want to be a part of anything that made me feel angry and unsupported. I looked at my phone and started scrolling Instagram to distract myself from my emotions, and stopped incessantly scrolling once I came across the picture below, which my sister posted for National Siblings Day with the following caption:

It was always the four of us. Although we’re all grown up with separate lives, we will always have the same love for each other, and share the same values that our Lola and Lolo (Grandma & Grandpa) taught us. My latepost In honor of ‪‎siblings Day 4/10 and my lolo’s birthday 4/7. I love you all. I miss you Lolo & Lola.

Last week was my grandfather’s birthday. The theme of losing such a devoted and integral part of a family is the theme that resonated most with me about the movie. And watching the ending somehow re-opened the wound in my heart that I experienced when I first received news that my grandfather passed away from cancer thirteen years ago. I continue to re-experience feelings of grief each year around his birthday and this year is no exception. I wrote about my grandfather’s influence and my difficulties coping with losing him in previous blogposts (here, here & here). Last week, a few of my patients discussed their own grief, which is always a hard subject to process. I always do my best to provide them with as much support as possible because I know what it’s like to feel isolated, angered, and confused by a complex mixture of emotions.

I used to want to believe that “time heals all wounds,” but one of my inspiring readers modified my perspective of the statement to make it more accurate: time may help make the grief a bit more tolerable. Grief never goes away, but rather is re-experienced in different, sometimes confusing ways. But, just like the goal of the movie, I try to shift my focus from sadness to embracing my grandfather’s strength and legacy. I can already feel the wound close a tiny bit as it starts to repair itself yet again.

April 15, 2015 16 comments

Personal therapy

Let Go

written by freudandfashion

{Ventura, California}

Several of my readers know how much I struggle with self-care and criticize myself on days that I feel less productive (I wrote about the subject here, here, and here). I’m starting to let go of the guilty, judgmental thoughts, which I’m sure are ingrained in the minds of many others like myself who’ve spent most of their lives incessantly working towards a degree and busy career. Last month, I disclosed to one of my patients that I sometimes sit on the couch and watch tv for hours on days I feel exhausted and overwhelmed. I regretted telling her the information because I realized my attempt to make her feel less guilty about doing a similar “lazy” regimen was really an attempt to validate my own actions of simply resting on my days off. I realized how much I still need to work on letting go. I need to let go of the pressures, demands, guilt, and self-criticism.

Well, I’m happy to report that I went to the beach this week, strolled, and stared out at the water as the surfers rode the waves. The thought of rushing home to answer emails popped up in my head a few times, but I surprisingly allowed myself to let the thoughts go. I’ve been working on this process of self-care for years, but I’m making progress. And that’s all that matters (no self-criticism involved).

What activities of self-care did you incorporate this week? I hope you all have a wonderful, relaxing weekend!

April 10, 2015 12 comments

Psychiatry

Contemplating Psychiatry?

written by freudandfashion

As the 3rd year of medical school approaches, medical students typically narrow down their specialties of choice, and if unsure, feel rather overwhelmed since the decision practically solidifies their field of practice for the rest of their careers (though yes, it is possible to switch specialties during training). Did I know at birth that I wanted to become a psychiatrist? Absolutely not. I went through my first two years of medical school wondering when the light bulb in my head would go off as to which specialty I was destined to go into. Then, it finally hit me — I’m meant to become a cardiologist! Well, that idea was short-lived once I became aware of the required six years of training after medical school (much respect to the cardiologists out there). Fortunately, I discovered Psychiatry, which is the one specialty where I actually felt motivated to go above and beyond to learn more and felt passionate about!

If Psychiatry is listed among your options, then the following are reasons I believe Psychiatry is an amazing specialty to choose:

Psychiatrists are in high demand. There will truly never be enough psychiatrists to meet the current and growing needs, which means more job opportunities and lucrative possibilities to create your own practice.
Psychiatrists in the United States make a mean annual income of $182,700 (US Bureau of Labor Statistics, 2014). Sure, Medscape notes this number ranks at the bottom third compared to the annual income of other specialties, but if lifestyle and job satisfaction are factored in, the ranking can be considered insignificant (see next bullet point). In Australia, psychiatry is found to be one of the best financially rewarding careers.
Lifestyle can be catered to your preference. I currently work part-time and know several psychiatrists working part-time who feel content with their flexible schedules. One of my friends practices telepsychiatry in the comfort of her own home, which has been perfect for raising her growing family.
Establish your niche or dabble in different areas. Several psychiatrists have their own solo practice, yet are able to divide their time into percentages working with other health organizations, academia/teaching, treatment centers, etc. And when establishing your own niche, your expertise working with specific populations can be highly sought after (for example, I was mentored by various specialists including a bipolar disorder specialist, sports psychiatrist, developmental disabilities specialist, psychoanalytic psychiatrist…the list goes on). I’m still trying to establish my own niche (I have way too many interests)!
There are multiple subspecialties (including child/adolescent, geriatric, consultation/liaison, sports, forensic, pain management).
If having a private practice is the goal, then the cost for equipment is minimal compared to other specialties (after all, the main instrument needed to practice is yourself).
Many opportunities exist for research, especially since there is much left to be learned about the brain.
Multiple settings exist for work: outpatient, inpatient, ER psych, community mental health, academia, college/university/student health, Veterans Administration, residential treatment centers, subacute treatment centers, drug detox and rehabilitation centers, consultation, Assertive Community Treatment (ACT) model, telepsychiatry, correctional system, etc.
If your goal is to have an extended career, most psychiatrists continue to work until late in life with only 18% retiring before age 65.
And residency training is only four years!

If you have any other questions or comments about the field, then feel free to post in the comment section below. I would love to hear from you especially since I remember what it was like to reach such a pivotal point in my education/career.

Photo by Marlon Santos

April 8, 2015 15 comments

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