April 2008 Volume 1 Issue 1
In this issue
- Who we are
- How we do it
- Owen
- Joining with Us
Welcome! We are pleased to have you with us. We hope you
will enjoy our newsletter. We welcome your communications
and suggestions.
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Who we are
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Diane Engelman and I direct the Center. I am a psychiatrist,
board certified in both Child-Adolescent and General
Psychiatry. Diane Engelman, Ph.D. is a neuropsychologist.
Our associates are quite distinguished. Philip Erdberg, Ph.D.
is our psychological assessment guru, Rick Mendius is a board
certified neurologist and a regular contributor at Spirit
Rock where he confronts the spiritual dimension of our fields,
and Paul Gilbert and myself are both board certified in child
and adolescent and general psychiatry. Given our backgrounds
with children and adolescents we are quite comfortable working
with families and couples. Paul and I are also psychoanalysts,
albeit eclectic and practical in our orientation.
Backing us up are a sizable group of experienced, independent,
therapists who we have participated in our consultation groups.
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How we do it
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It makes sense to begin by illustrating the multifaceted
approach to doing psychotherapy and monitoring its efficacy
that we have evolved at the Center. Please note that each of
us practices independently, and that the Center itself is
devoted to research and training in the models of
psychotherapy we have evolved.
We call our model of treatment "collaborative psychology
and psychiatry." As you might expect, collaboration occurs
between therapist and patient, and in the case of children
and adolescents the therapist and parents. According to
this model, as possible there is another, integral, member
of the therapy team, a psychologist. That person does a
psychological and at times neuropsychological assessment
of the patient, repeating a convenient version of this
assessment at intervals to measure the patient's progress.
I can imagine that the word "cost" is circulating furiously
in your mind. "All well and good, that's the way in an
ideal world, but which of my patients could or even would
afford that kind of enhancement to the treatment?" But,
the real question, I submit, is: how can they not afford
it? I will elaborate later. The second usual concern is
that bringing in a third person will interfere with the
therapy alliance. Further, what if the patient, as a result
of the assessor's findings, begins to become skeptical of
the therapist's assessment of his or her needs. Worse,
what if the patient decides that the assessor is their
real savior? In that case isn't introducing a
psychologist-assessor to the therapy field likely to
disrupt rather than enhance the treatment. And those
things happen.
The short response to that concern is based on our
experience. In the more than sixty cases we have done
at the Center that person, when properly trained, has
virtually always made the treatment stronger. If the
patient wants to bolt he probably will try to do it
anyway. Having a third consultative presence should
help guard against this eventuality. The longer answer
has to do with whether the psychologist-assessor is
trained in our collaborative technique and is able
to guard against and contain any competition she or
he may feel toward the therapist.
Owen is a case in point.
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Owen
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Owen is 22. Bright, maybe brilliant, but moody and
remarkably stubborn. Lots of potential. Lots of reason
why he has left every situation, including high school,
in a puddle of mediocrity. Other factors are important.
Owen falls in love hard. In high school there was Lilly,
a free spirit who went to Mexico to live with a writer.
Emily from his first two years of college was more stable,
but left Owen because of his moodiness. His parents, two
straight arrow lawyers, had trouble not focusing on Owen's
professional success. After all, his three years older
brother had gone to Harvard and was a model student now
headed for medical school.
It might help if I describe Owen. Awkward and disheveled,
he looked like he belonged in some garret in Paris,
spending his time drinking absinthe and talking philosophy.
Owen was referred to me after quitting college for the
second time in three years. Since he was such a good
thinker he had been admitted to an excellent California
University. He bombed out after getting drunk and protested
a decision by the university affecting his girl friend by
riding his bicycle recklessly around the university police
headquarters while calling out epithets. For the next
semester he transferred to a rigorous private college
where he didn't do his work. By the point of referral
his parent's were so perplexed that they were willing
to let me "do anything to help."
Here is what I did.
I had a phone call with Owen's parents and told them that I
would meet with Owen once, and with his permission I would
then meet with them. I asked for copies of all the school
records and testing reports they had. In conjunction with
taking a history I asked them to fill out an extensive
background form. I explained that the more information they
and Owen could provide in writing the fewer notes I would
have to take and the more efficient the intake.
Owen was as moody and reluctant as his parents reported.
"Nothing was wrong" outside his parents' heavy handedness
and excessive worry. But, he had no choice so he would meet
with me. He was curious, however, and agreed to psychological
testing, then a neuropsychological supplement and a full
neurological examination. In fact, he was having headaches
and wanted to have an MRI of his brain done.
So, the first question is: why go to all this trouble and
expense in assessing this relatively ordinary case? The
initial cost of all these evaluations was to be $3,000.
Let's do some math. Typically someone like Owen would be
swept into a once weekly treatment, possible emphasizing
CBT. The psychological testing without the neuropsychological
component and minus the neurological workup might cost $1,500.
But, think about what you would have with the bare bones
approach?
It would be easy enough to conclude that Owen suffered
from ADD. A stimulant might help, and there certainly would
not be any harm in trying one. But is that the whole picture?
In Owen's case it certainly was not. There was his father's
heart attack when Owen was nine and his brother's perfection.
There was Owen's incredible intelligence and capacity for
creativity. There was Owen's stubbornness and objection to
being scrutinized.
The jump start we got allowed me to begin medication in
spite of Owen's parents' abject fear of it. It allowed Owen
to participate in treatment planning and to set the
frequency of sessions to one and a half hours every other
week. He preferred the infrequency and said the length of
the sessions allowed him "to get into and not resist them."
The extended length of these sessions also helped us to
jointly witness and work with his impatience. In accordance
with Center protocol Owen's agreement to have repeated
"minor versions" of the original testing every six months
assured that we would not slip into any illusions about
whether treatment was working.
The neurological examination was entirely normal as was the
MRI of Owen's brain. Even his cervical spine was within normal
limits, a finding leaving the source of his headaches obscure.
The neuropsychological testing, which in this case was not
done by Diane, underscored the seriousness of what the assessor
called Owen's combined ADD and irritable temperament. While
irritability is frequently associated with both childhood
and adult ADD, personality testing was needed to fill in the
blanks about Owen's diagnosis.
Philip Erdberg, Ph.D. did the personality testing. His unique
take on the situation in contrast to the neuropsychologist's
emphasized Owen's intelligence and, even more, his creativity.
Owen simply got bored easily, excluding him from the class of
people who, like his brother, could sit still for four years
of college. Also, it became apparent in sessions with me that
Owen was remarkably unrealistic. Cheese sandwiches were fine
for breakfast, lunch, and dinner, just so long as no one was
forcing their agenda down his throat. Put in another way,
he craved and needed constant stimulation and excitement.
Owen's propensity set up a vicious cycle. He'd get bored,
move locations to create stimulation, get bored again, and
leave one more time. To make matters worse, in each of these
situations Owen would progressively isolate himself socially.
Even if I could get Owen interested in understanding and
finding alternatives to these habitual patterns, there was
every reason to expect that he would soon become impatient
and quit our work.
So, here's where I had to be especially creative. In spite
of Owen's age, and with his consent, I worked with his parents,
providing guidance on how to manage Owen. That he trusted me
was a godsend, since I didn't have to report back to him at
each point.
The Alternative
Of course, we could have done this assessment without the
bells and whistles, no neurological and no neuropsychological
assessment. But, consider this. Everyone was exasperated with
Owen. He needed a diagnosis and a fix. Maladjustment based on
brilliance and understandable contempt for people he felt
were his inferiors were certainly an important part of the
picture. The diagnosis ADD alone didn't fit, but having that
label made everyone feel purposeful. Owen could see the logic
in the ADD label, but it wasn't the whole picture and made
Owen feel at odds with everyone else. Yes, of course, ADD
was right, and Adderall worked to a point. But, the rest?
There was an interpersonal part to be addressed in the
form of focused, interactive psychotherapy. A
cognitive-behavioral component helped him learn to sit
still and deal with his impatience. Owen agreed to ten
to fifteen sessions of behavior training with a
neuropsychologist who worked particularly with ADD. And
there was the encouragement. The "encouragement" piece
consisted of clarification that indeed he was a fish out
of water and would have to stretch to comprehend and
reach others who were not as smart and rigorous as him.
Since Owen said he wanted to make a normal adjustment
and have friends, he acceded that the stretch should be
worth it. He is now taking classes in computer aided
design, working in that area, and planning to return to
college in the spring.
And the extra cost of the neurological and psychological
workups? My claim is that they were more than justified
by the fact that with them we knew exactly what we were
treating and could tailor the treatment, its interpersonal
and behavioral component precisely to Owen's needs.
No wasted effort or money.
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Joining with Us
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Would you like to know more about the work of Center?
If so you may be interested in reading my last published
book: Making Psychotherapy Work: Collaborating Effectively
with Your Patient, published January 2007. My new book
Evidence from Within: A New Paradigm for Clinical Practice,
will be published by Rowman and Littlefield in May.
Information about how to order either book can be found
on the Center website: collaborativepsychology.com
Again, welcome. Glad to have you with us.
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Thanks for reading,
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