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THE UNREAL WORLD

Drawing lines for psychiatrists

When should they prescribe drugs, speak their minds -- and keep their distance?

July 30, 2007

"State of Mind," Lifetime, Sunday, July 22, 9 p.m., episode "Between Here and There."

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The Premise: Dr. Ann Bellowes (Lili Taylor) is a psychiatrist who shares her offices with several other therapists at New Haven Psychiatric Associates. A former colleague she once supervised asks Bellowes to conduct an informal strategy session with her panicked family just before her wedding. During this session, the woman's sister, a transgender, complains that her parents are trying to get her to wear a gown at the wedding. Bellowes offers to meet with her separately and later takes her shopping for a tuxedo.

Dr. Taj Kalid, another psychiatrist in the group, is treating a patient who comes in for Viagra, Rogaine and Ativan prescriptions but doesn't seem interested in therapy. He and his wife go on vacation and leave their 15-year-old son David alone. After they leave town, David's growing depression and feeling of abandonment lead him to consider suicide. Kalid discovers this and takes him to a therapy group of troubled adolescents that meets in the basement of his office building. When David runs away, Kalid follows him home and breaks in. David, who had been contemplating shooting himself, points a gun at him. Kalid persuades him to give up the gun, calls his parents and, when the father seems reluctant to cut short his vacation, yells at the man. Finally, Kalid arranges for David to be hospitalized.

The medical questions: Is it appropriate for a psychiatrist to meet informally with a troubled family and take one of its members shopping? Should a psychiatrist fill a patient's prescriptions without talking with him first? Is group therapy adequate for someone who is severely depressed and troubled? Is it ever OK to yell at a patient? Is it justifiable for a doctor to break into someone's home if he believes that person may be in imminent danger?

The reality: Dr. Paul Applebaum, former president of the American Psychiatric Assn., says psychiatrists need to maintain professional boundaries. "When relationships are blurred like this, it compromises the ability of a patient to obtain good care. Potential patients seeing this portrayed on a TV show may find it off-putting," he says. Dr. Gary Schoener, executive director of the Walk-In Counseling Center in Minneapolis and a national expert on professional boundaries in psychiatry, agrees, saying that in such a situation as Bellowes' -- being approached by a former colleague to help her sort out problems -- a psychiatrist should not agree to see the family but should immediately "consult with a colleague to arrange a referral."

Regarding the sister, Schoener adds: "Therapeutically intervening with the transgender sister is bad judgment, and no therapist should accompany someone shopping as a form of intervention. That job should be left to professional shoppers."

But Amy Bloom, the show's creator and a practicing psychotherapist and faculty member for many years at Yale University, disagrees. Although she has never shopped with a patient, Bloom says that Bellowes' character wasn't involved in a formal doctor/patient relationship but was instead trying to help a colleague out in a pinch. Bloom insists this was "simply someone offering bright ideas to a family in crisis."

Like Dr. Taj Kalid, many psychopharmacologists I have encountered are quick to prescribe medications without a well-developed relationship with their patients. The show accurately portrays this problem. Bloom acknowledges that David would have done better if his problems had been discovered by someone with more skills than Kalid, someone who could have found a way to respond sooner and more effectively. But Bloom is attempting to portray her characters as true-to-life doctors, she says, whose choices are not always ideal.

Schoener says Kalid's use of family information gained from David's father is by extension a doctor/patient relationship with the son and justifies his setting David on the right track to emergency treatment. Although group therapy in the basement was far from an ideal choice, Kalid unwisely saw it as the only initial option after deciding David was too young for him to treat.

Dr. C. Scott Saunders, director of trauma psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA, agrees with Bloom that there are "no set rules" for a psychiatrist's degree of involvement or personality and that psychiatrists can "speak their mind for the therapeutic goals of helping their patients." But Schoener says there is never a good excuse for yelling at a patient. "Therapists should ventilate such feelings with colleagues," he says.

Finally, it is against the law and strategically unwise for Kalid to break into David's home rather than call 911.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. He is also the author of "False Alarm: The Truth About the Epidemic of Fear." In The Unreal World, he explains the medical facts behind the media fiction. He can be reached at marc@doctorsiegel.com.

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