How Do I Know if I Have a Good Shrink?

I work in a university hospital, and most of my patients come to me for a second (or third or eighth) opinion, because their treatment isn't working. Beyond talking to these patients about their problems, I review the notes and records from their treating doctors and therapists, and usually speak with the referring clinician.

When psychiatric treatment fails

Most of the time the treatment of these patients has failed, despite the fact that their clinician has made reasonably good decisions and has provided conscientious care for the patient's problem. But a patient whose treatment has not yet worked does not always see this, and so sometimes thinks ill of the referring doctor or therapist, often unjustifiably.

When this happens, I think it's useful to review the fundamentals of good clinical care with these patients, either to reassure them that their clinician is indeed doing good work, or else to provide with some criteria of good therapeutic practice, which they can then use to judge the effectiveness of their therapist more accurately.

Some criteria I use to measure the quality of psychiatric care

• Availability. If your clinician answers your calls or emails within a day or 2, and finds time for you when things are rough, this is a good thing.
• Efficiency. If sessions seem too frequent or too lengthy, or if they seem to be focused on the wrong thing (e.g., childhood traumas, when your problems are rooted in the present), then the therapy might be going astray, and you should discuss your concern with the therapist.
• Humility. Any clinician who sends a patient with a difficult problem for a second opinion gets a plus mark in his or her favor because this indicates a willingness to consider other people's opinions about the course of treatment.
• Pharmacologic skill. Any doctor can prescribe the latest medication on the market; a psychiatrist, however, shows an advanced level of skill if he or she also considers the older and well-established meds. A superior therapist will also be sure to use the least amount of medication necessary to resolve the problem and enhance the patient's function.
• Flexibility. Not too many of today's psychiatrists use only psychotherapy and no medications, but many use medications and little or no psychotherapy. In all but the easiest-to-treat cases, medications alone can restore only the capacity for recovery; recovery itself tends to require some attention to psychological adjustment and functional rehabilitation.

One last thing to bear in mind

Your clinician may have good skills and the best of intentions but be constrained by insurance companies that pay only for such brief and infrequent visits that the therapist only has time to manage symptoms and write prescriptions. If you are financially able, you might have to consider paying part of the fee out of pocket so you can have a clinician who can afford to integrate all these good qualities into the practice.

A discussion about how to find a psychiatrist can be found here.

The website of the National Institute of Mental Health has links to information about psychotherapy, psychopharmacology, and other treatment modalities.