Psychiatry & Psychotherapy Podcast - Treating the VIP: Physicians and the Famous or Wealthy

Episode Date: September 24, 2021

There is a real danger of medical professionals treating or behaving differently with someone they perceive to be a Very Important Patient, which leads to inferior treatment. In this episode, Dr. Puder and Dr. Heacock discuss the complicating factors of treating physicians, the famous, and the wealthy.   Dr. Heacock is the host of a podcast called: "Back from the Abyss." By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the psychiatry and psychotherapy podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is email to you in seconds.

All right, welcome back to the podcast. I am joined today with Craig Hecock. Dr. Craig Hiecock, he is a psychiatrist working out of Colorado, and we did an episode for his podcast, and I am having them on my podcast, to talk about treating VIP patients, patients that either consider themselves to be VIPs, or maybe as medical professionals, we feel like intimidated or we feel like we're giving them special treatment or we feel like a little bit more pressure. Often it's people that we sort of are unconsciously,

consciously assessing are high up the dominance hierarchy maybe, high up, and this could be specifically the dominance hierarchy of your liking. So if you were into classical music, this could be, you know, yo-yama comes into your office for anxiety and your therapist, and it's like, this is someone you worship, and now he's right there. Obviously, if you don't know Yo Yamah, you don't know classical music, this could be perceived in your mind as someone who thinks he's a VIP.

I don't know Yo Yamah, so maybe he comes in thinking he's a VIP. Maybe he's just acts pretty normal and you don't think he's a VIP at all. So we were talking on your podcast a little bit about how you've treated physicians, colleagues, and there's a kind of unique aspect when we start to see someone very similar to ourselves as well. That's kind of like we can kind of change the way we do things. So I thought that I would have you on and we would have this topic. Yeah. Thank you, David. First of all, I want to apologize. I'm on the front range of Colorado and the smoke here from California has been so severe that my asthma is kicking up and my voice is really scratchy, so I'll do my best to be coherent. But for those of you who haven't

listened, David was on my podcast back from the abyss. We did an episode called The Clinical Moment in Psychotherapy. And I think it turned out, great. And yeah, this was one of the interesting topics we talked about doing therapy, doctoring VIPs. And I guess I really love this topic because we got some training in residency about difficult patients. But I think as you and I talked about in my podcast, some of the most difficult patients are VIPs. And you and I talked a little bit about physicians in particular, because not all of us are going to treat Yo-Yo Ma or, you know, a famous politician, but probably we're going to treat physicians, and because of transference and countertransference issues

and specialty hierarchy in our own stuff, as you just mentioned, just the act of treating another physician as a psychiatrist can be fraught with danger. Yeah, there can be, well, I want to just highlight your podcast back from the abyss. It's psychiatry and stories. It's a much more conversational, sort of dialogue, listening to people than my podcast. I have some of those things, but my podcast is kind of more geared towards the mental health professional. But yours is, back from the abyss, the title of that is this is your journey out of your own sort of abyss that you found yourself in at one point. Is that correct? Yeah. So I had my own really difficult stretched in early in my career with addiction where I just fell into just such despair after a number of

suicides and I was getting increasingly overwhelmed with my practice and then I went into my own abyss and came out and then a few years ago started getting obsessed with podcasts and I started thinking I want to help people tell the story of their own darkness and how they came out and so that was the idea of back from the abyss is this sort of plunge into the psychiatric or psychological abyss and how they got out with a goal of spreading hope and letting people know that even in the worst of darkness that there's a way out. Yeah, yeah.

So you both have treated physicians and are a physician who has been in treatment. I'm a physician who has had my own treatment. When you were receiving treatment, did you feel like the person treated you differently because you were a psychiatrist, because you were someone known in the community as a psychiatrist?

No, that's such a good question. I remember when I went to treatment, when I first was evaluated and then went to rehab, I wanted them to treat me specially. Yeah. Because I was being evaluated by a psychiatrist and addiction specialist, which is what I am. And I wanted them, you know, I don't think I consciously thought that, but I thought, you need to give me some slack. You need to treat me different because I'm clearly different from all these other people. Because I got it together. I know what I'm doing. I'm an expert. And, you know, to her credit, my psychiatrist treated me exactly, I think like she treats everyone else. And I was so, I was furious. Sort of sound like. it took me a long time to really work through this idea that, hey, wait, she just taught me a really valuable lesson. One is a patient, but a bigger thing as a physician, is that people are going to come to us and consciously and unconsciously want to be treated differently for a lot of reasons. And it was interesting to be on the other side of that, to be furious that I wasn't given special treatment or special favors. Interesting. Yeah. So in my role as a psychiatrist, I've treated a number of medical students, residents, physicians.

I've also, like now in my sort of, with the podcast, I don't know, have you found that more people reach out to you than before who might consider themselves VIPs or are VIPs? Yes, yes, for sure. Yeah, it's, you know, it's kind of thrilling to have VIPs contact you. And already I've seen that it's so hard not to bend the rules. people say, oh, would you meet me after hours? Would you do an out-of-state Zoom session? Would you start me on this medication, but then I'll see you later? And others.

And, you know, it's such a mix of knowing I shouldn't do this, but I want to do this. I want to please the person, you know, I think especially with the physicians. You know, physicians, I treat a number of physicians, and they are constantly asking me for special favors. And some of them found me through the podcast. In fact, just the other day, I got a call from a guy in New York City who wanted to see me. But he's in New York City. I said, look, you live in the land of psychiatrists. You should find someone on the Upper East Side.

But he wanted me to treat me, him remotely. And I was really tempted to because he was kind of a big wig. But no, I just had to tell myself the best care he needs to be treated there. It's not like he's in rural Alaska. But when people reach out and ask, it's tempting to say, oh, yeah, for sure, I'll work with you. So I find I'm constantly having to ask myself, wait, is this best for them? Why am I saying yes or no? And what are the motives?

Yeah. So that I've had to kind of check my internal clock as well. And I think that's why this is, it's interesting because, you know, I think that it does affect you. Your countertransference, you know, the total reaction we have. and so I was digging into the literature a little bit, which I'll sort of bring out and ask your comment on these things. So it's kind of been in my mind. And then when the Britney Spears thing came up,

I did an episode on that with a lawyer and with this psychiatrist who's treated baseball players and kind of this VIP topic came up, but I felt like we didn't really flush it out. So I was like, man, I got to talk to Craig and get your take on your experience here. Okay. Because we have you here, man, what is like some of the harder things that have come up in treating physicians?

So, gosh, yeah, I've treated a bunch of physicians. One was a really difficult case. And I'll change some of the details. I'll do that with all these. But this was a very successful physician who had bipolar 1. And mostly did well. But when he would decompensate, he would get psychotic and homicidal. And he ended up losing his medical license.

and he finally got stable after working with me, and he begged me to write a state medical board and to alter the record. And his lawyer had a letter to me that said, if you will change this one thing in the record, he can work again. And he cried and begged me in my office. He was actually younger than me.

He had a family, had children. He said, I can't support my family. All you need to do is write the state medical board and just attest to this one thing that's not true. and I didn't do it, but he fired me. And I still think about him. And that's a more extreme example, but, you know, I have physicians regularly asked me

for controlled substances without seeing them, to see them after hours, to not hospitalize them when they're suicidal. And I really think, at least of, you know, I've seen some famous people and some well-known people, but for me, you and I talked about this, in my episode, doctors are the hardest because we identify with them. You know, they know just enough psychiatry to get themselves in trouble.

And we don't, we see ourselves in them. Or, like, for example, I treat a couple anesthesiologists and a couple surgeons. You know, there's this hierarchy in medicine, and I kind of think, well, you're out like this surgeon. You're anesthetologist. So you're, you know, it's hard as a psychiatrist not to feel like we're kind of outside of the realm of some of those super specialties. And sometimes I find myself deferring to them or even their judgment and having to say, wait, they're not trained in psychiatry. They are incredibly well trained in their specialty. But this is like med student, me looking up like, oh, you're a big deal surgeon or you're this big deal specialist when really like, wait, they came to me because they need help in this area.

But just assuming that they have competence, not just in their area, but competence in psychiatry. You wouldn't actually, usually they don't at all. I imagine it's frustrating for you to then realize like, okay, I'm deferring to them. And it's because I like consciously, unconsciously, like, look up to them or see their work is very important, which kind of almost takes away like your entitlement to your expertise and your years of, you know, like 30,000, 40,000, hours of practice. I don't know, maybe more than that at this point. Yeah. I wonder, I think, at least for me, treating, you know, procedural specialists, for example, sometimes I've had a little existential crisis. Like, what are, what are psychiatrists good at? We don't sew, we don't have

scopes, we don't do funky interventions with stents, we talk to people, we listen, maybe we give them catamine, but we, you know, our skill set is, is deep and rich, but it's hard to put into words. And I I think sometimes when I'm sitting across from a super successful, you know, specialty surgeon, it's easy to think like, oh, like, she's a real doctor. She's the real deal. She's the head of this huge surgical center. And I'm sitting here alone in my office with a couch talking to people. And then, you know, I can talk myself out of that, but it is interesting how,

because I got a lot of messages in my medical school that psychiatry was less than, that if you went into psychiatry, you know, it was like a default for people who don't want to be real doctors. which I couldn't disagree with more. But I do find, you know, sometimes when I'm sitting across from a physician, I sort of go back to that space of like being a third-year med student and having people make fun of me for saying I want to be a psychiatrist. You know, I wonder what kind of mirror neuron stuff you're picking up that would lead to that insecurity.

And so part of my research, I did like this connection index, which looked at the connection that's, residents felt towards their attendings. And in the process of doing that, in one department, surgery or anesthesia, I'm not going to say, I went through and I did all the attendings, and then I met with the attendings and gave them their feedback. And some of them were rock stars, but some of them were interpersonally abrasive and like almost like low EQ, low social EQ, right, needed to improve their EQ, but like maybe their ego got in the way of that or their stress or whatnot. And some of them scored low because they were going through a lot of stuff like a

divorce or child custody battle. There were like reasons that were stressing them out and so they weren't as connected to the residents. But some of them had personality issues. But I'm, I'm wondering if some of the people that you met with, it's almost like you felt their profound insecurity. And then we feel that insecurity. And then we feel that insecurity. that profound insecurity, but then we put our own narratives on it. So the narrative that you put on it is the narratives from the past, right, that related to them and you and your specialty. What do you think?

Yeah, no, I think that's totally true. I mean, that's one of the reasons I think you and I and so many other people just love therapy and psychiatry in the mind is it's never just about what's happening in the room. I mean, it's that, and then it's the past, and it's what's being triggered, and it's the layers. it's the past relationship templates. Like it's so, it's like inception. There's all these layers. And for sure, I think it's very likely

that someone comes in as a little cold or hard to reach or just like restricted affect. I'm thinking like, oh, yeah, you are not thinking I'm competent or you're discounting me or it's because I'm a psychiatrist and you're a specialty surgeon and you already think, yeah,

that I can't possibly help you, because who in your med school class became psychiatrists. And right, that's all me. Like I'm coming up with this narrative. And I think, again, this is with difficult patients, including physicians, we get this stuff triggered so much that just starts flying through our minds and our bodies. And it's hard to give people good treatment

because we're just playing out our own scenarios. So I did this episode with David Burns, and I was vulnerable. And at one point in the episode, I said, I don't know if people want to hear this vulnerability on my podcast. And David Burns is like, all right, guys, if you heard that, if you like this, email Dr. Peter that you liked it. And I got like hundreds of emails.

And I'm thinking about, you know, you're being vulnerable here. And some people might not understand that, you know, like to just put out your insecurities and stuff. But, you know, psychiatrists are real people too, right? So we're sitting there. We're treating people. And we can have these sort of things that we, need to work through and need to be curious about. And I think that rather than have judgment that

we have these thoughts, if you have these critical self-thoughts during sessions, which I imagine a lot of my audience has from time to time, just imagine if you didn't have that in your conscious. And if you had it unconsciously going on and weren't registering it, then you couldn't be curious about it. You couldn't look at the meanings of it. We couldn't like look. and think like, oh, maybe it's this physician's insecurity who's coming in for the first time seeing a mental health professional. Something must really be off, right? Something must really be bad.

Physicians are very resistant to getting treatment. Terrible patients. Physicians, I would say residents actually have lower suicide rates than the general population. Residents have, it's about four per 100,000, whereas in the general population's around 11. or 13. So for that age group, we are more resilient. But then what happens as physicians age is it's like the cumulative burden of stress kind of weighs on us, right? And we have decades and decades of like

patients dying and horrible interpersonal situations in our personal life. And we may have an incredibly busy schedule that it's hard to get in to see a doctor or a therapist or we may not want to, right? So I'm curious, you know, what have you seen as like some of the points of resistance in these VIPs and getting the treatment that they need? I think one of the most common things I see is that VIPs and doctors included can be really resistant to actually come in and see me. Like they want to be treated by phone and text. So I have a number of people who are super successful or a few well-known people and my doctor patients, it's like they say, hey, I'm busy, can you just, you know, do this, do this, do this, but they don't want to come in and sit down

face to face. And, you know, it's kind of exciting sometimes to get a text from certain of my patients. I think, wow, that's cool. They're texting me. Sure, I'll do what you want. But then I think, wait, is that good care? You need to come see me. And then I'd say that you should come see me. Oh, yeah, yeah, yeah. And then I think, wait, would I accept? this from other people, but then you don't want to upset them. And then again, I think if we go back to the physician patient, I recognize how busy I am and how much I can have trouble saying no to taking on new people. And so I could put myself in their shoes. Oh, they're too busy to come see me. I should probably just treat them sort of by a two-minute phone call and text check-in. That's terrible.

So that's the biggest thing I've seen is that docs and some of my other VIP patients, just they they want to have just very remote, like tip their toe in treatment. Okay, now I'm pulled out. Here you there. Okay, we're good. Versus, you know, like sort of face to face that I insist on with everybody else. Yeah. I think we all would like solutions that are very fast,

but often the best solutions are very slow and take time. And I would say one of the difficulties that I see is kind of this commitment to the weekly work of therapy or twice a week. And then it's really management of shame because just because someone is successful doesn't mean they don't experience a lot of shame. And some of the most hardworking people are hardworking because of the shame.

It's like the shame of being found out or the perfectionism that comes with that kind of drives them to these accomplishments. to try to prove against their own sort of inadequacies. I think that's true, David. I think of just off the top of my head three different physicians who pop in my mind who I see who are really phenomenally successful.

And they're driven by shame, trauma, just awful stuff in their early lives. And so what they learned was, you know, succeed, succeed. And, you know, if you run fast enough on the treadmill and you work, work, work, then maybe you can, can run away from your past. And I was just thinking the other day, I see a guy specialist,

really successful, and he deeply needs to see me very often. I saw him the other day, he said, so six months, is that what we'll do? I said, yeah, I'm busy. How about that? I said, how about Nick's week? He said, hmm, how about four months? Yeah.

I know. And, you know, I laughed and he laughed, but that is such a classic, at least what I see. especially with my physician patients. And you think busy business people too. They want this like come in, boom. Fast food, fix it.

Yep. And then we'll just stuff it and make it go away. So one of the fast foods of psychiatry is benzodiazepines. And one of the things they found on autopsy of physicians is that physicians have an odds ratio of 21 that they were taking a benzodiazepine compared to the general population. Wow.

And antipsychotics was 28.7, which may be because they were being treated for something, like bipolar or something like that. I don't know why that's so high that. I'm curious about that. That was in a study, Gold, 2013. A lot, I think, like, there's a, there's a lack of knowledge in a lot of physicians, since we're talking about physicians of the value of long-term therapy, like once-a-week therapy. Like I had this one guy who came, came to the end of our six-month stent of therapy. And he attributed the success of his change to something not therapy. And I was a little bit like, like the word I'm going to use is castrated. It was like, it was a little bit of a jab at me maybe. But it was also like there's some things that are concreted. crete that it's easier to point the finger at like oh i changed my diet or oh i i started um

you know this new medication and then magically after six months of taking it and weekly therapy you know i attribute it to the medication so sometimes there's a lack of understanding of the value of therapy that it's almost like hard to for anyone to really understand but then VIP people people who's maybe they, it might be a harder pill to swallow. How do you get someone to really commit to the weekly therapy who maybe is resistant to it? Yeah. I've used a few different strategies. One strategy I've used is to bring in spouse, if they have a spouse.

And I mean, I usually do that anyway just to get collateral information. But a lot of times the spouse can say, hey, spouse, other spouse, you need Craig. You need Dr. Hickok. please come, like, do this for me. I've actually had that with a few just overall VIP and physician patients where when the three of us met, that was helpful. It's like the spouse could call the bluff because, you know, the physician shows up like, I'm fine, I'm good, I'm handling this well, I'm not really drinking that much, and I'm not

really that suicidal, and I'm doing my job. And the spouse comes in and says, nope, nope, not happening. And I also, you know, I try to make explicit, you know, what this whole difficulty of treating physicians. You know, I'll talk to people early on and say, hey, this is a tricky relationship, both being docs. Like, you know, you would think that this, we would be especially good for each other, but there's some reasons that we might be especially difficult with each other. And we, I'm going to watch for those. I want you to watch for those. And I think people appreciate that.

It's interesting. I often worry that if I bring up those kinds of, you know, countertransference issues with people that, hey, this is going to be hard for me because of X and Y. They really appreciate it. Again, it's sort of like you said, you know, when you admitted, have admitted to vulnerability on your podcast. I know that's true, my podcast. Like our patients, you know, they want to know that we're real, that we're self-analyzing, that we're vulnerable, that we are thoughtful. they don't need us to be perfect. They actually want us to be human. Yeah. I think it can be a skill to know when to be vulnerable with patients.

I think I've heard it go wrong from a number of therapists who I was like, you know, talking to. And they were like, oh, the therapist disclosed this thing. And it's like the first session. So I think I was talking to a resident the other day about this. And I said, you know, maybe after six months, they earn some degree of vulnerability. That being said, if I'm really tired someday and they're picking it up, and if they're someone who would then take it upon themselves,

like, oh, I'm boring, therefore he's tired, I may reveal like, hey, just want to let you know, going through some stuff, and I didn't get quite as much sleep as I normally do. And just to kind of give them the, it's kind of a mentalization type thing where they can mentalize, like, okay, that's why it's going on, you know? But I think ultimately, though,

If we can get people, I'm thinking again, my physician patients, if you can crack through this kind of barrier that they need to look okay and be okay, they can relax, many of them can just relax into this, just deep gratitude for being taken care of. You may have seen this, but some of my physician patients after a while, they come in and they finally just like settle into the couch and just like, and they just relax, and they just let it all. be, and I can tell they no longer have to be the super-achieving specialist. They can just

be real and cry, and, uh, that's so powerful, I think, you know, when we get to that level. Yeah. Yeah. Even our problematic physician patients can get there. And, and I think it's important to say part of the, part of the, part of the reason why they're problematic is because it brings up stuff for us. It's close to home. It's like, when you're treating someone and they have a daughter who's like your daughter who's going through some stuff or they have you know it's like it's like when there's that parallel process which is it increases our empathy but then it also can get us out of their experience and our own experience and we we need to kind of like work through that specifically with physicians i was thinking

there was one study that asked you know about board requirements and you know there's a lot of very invasive, backwards board questions, like when you're applying for a license in a specific state, like have you been under psychiatric treatment or have you taken medications or have you seen psychotherapy? And in one survey, 75% of respondents agreed or strongly agreed that medical licensing board questions about whether a physician has ever had mental health diagnosis or treatment impact decisions about seeking treatment. And so what I found, So I offer like coaching. I have a nonprofit where I specifically offer coaching.

And because of my sort of interest in medical education and some of the research I've done on connection, I run all my physicians not in state through that system. And if they're suicidal and if they need medications, I'll help them get through the resistance of seeking that care, you know, obviously. So there's certain things I won't treat under that coaching relationship. but what I've found is that there are a lot of physicians who are so scared about not being able to work that they will not seek treatment. They won't seek treatment at all, you know, until it gets so bad, right, when like their life is in jeopardy.

So I didn't expect this kind of direction of the podcast, but here we are, you know, and we're thinking, so imagine you're talking to a group of physicians, there's some 30,000 mental health professionals who listen to these things, what do you say to encourage them to not feel shame in seeking the treatment that they might need as a VIP? Yeah. I think one thing, you know,

when I first meet with medical professionals is I talk about my notes because a lot of people are worried about what am I going to put in my notes. And, you know, even as I'm going through the e-val, some of the more sensitive questions, if I sense people, physicians, or other VIPs are really sensitive, I might say,

is this is something I don't have to put in the note if you don't want. Some people really appreciate that, this idea, because I've had people open up to me either initially a hour later, and they stopped. And if I brought up this idea that it wouldn't be in the record that helped them. But, you know, the flip side, I was just thinking, David, of medical professionals reluctant to seek treatment, is, and you and I

talked about, or emailed about this, is this idea that we can be reluctant to ask questions, really sense of questions that we feel that we might have to go to the medical board or report people like substance abuse questions or impairment at work. You know, I think to have a physician, for example, tell us that he or she is, you know,

impaired in some way at work, and then we're thinking we are going to have to report this. and what that might do to the person's career, I think it's, you know, it goes back too to this whole countertransference thing. I think the most difficult people to treat for me of for sure are psychiatrists and physicians who've had addiction.

And you'd think, like, oh, I'd be an expert in that, but they touch so many buttons that I have to just constantly be checking in with myself, like, okay, am I doing everything in the interest of this person and not, like, avoiding things because it's touching painful things in me. Yeah, that was actually, I read some articles on treating celebrities, powerful people,

and one of the things that came up is the danger of not asking questions that the person may feel are uncomfortable or embarrassing. And I think I get it. It's like we, that's a good example of how, when we get impacted as providers thinking about this person, do we get impacted in a way that leaves us operating in a different way than we normally work? Maybe not giving as much empathy, maybe overly letting them run the treatment, not giving them the treatment that's the best treatment for them,

that we would give them under other circumstances. And there is this like uncomfortableness with, with the questions we would ask, you know, like sexual, are you having any sexual dysfunction? Would you ask that to, you know, some person that you look up to for various reasons? Yeah, I think also when you said, what do we document, I've chosen not to do an EMR for that reason.

Because, and not have it in a cloud, right? Document sparsely, you know. And do you tell people that? Do you give them a heads up that, hey, something different about my practice is that this is, you know, your information is not going in the cloud on EMR? I think I mentioned that on the podcast. And so I think, you know, because if you're like a flight pilot, like you may not want any trace record that you've seen a therapist. I think that there is so much stigma about psychiatry, about psychiatry, about. psychotherapy. I don't know if I saw a therapist, if I would want my information on some cloud computer. And so when I started my own practice here in Florida, I was like, you know, I'm just not going to keep records in a cloud, you know? So. Yeah. I would think that would give

your people some comfort. I think so. Yeah. Because, you know, people often ask me, not just VIP patients, but hey, do other clinics in hospitals have access to your records? And I say, no, I'm just, just me and they just great relief people just like oh good yep yep and then i was reading about kind of like do medical directors justify this kind of allowing the VIPs to be in their system and um you know basically getting early treatment is how they they would characterize most of the VIP treatment that they were giving or like quicker treatment um interestingly when I was in California, I was well known in the university, and so I could walk into the ER and be seen within like five minutes.

And I needed to do that one time, and it was very nice. I don't have that privilege in Florida. Or like, I have a list of doctors. I have doctor privilege. I have a list of doctors I could reach out to and ask questions and get an answer. Like, it's a real privilege. Yeah. and um but then you wonder too you know there's then there's the whole kind of um overtreatment

or just uh i've experienced people calling me hey would you see me and you know VIP patient I bend the rules I see them in the evening or at work you know at the end of the day but then I'm tired I'm not I'm not my best me and there have been times when I did you know something special for a quote unquote special patient afterwards I thought they did not get the best of me because you know, I added them on the end of the day. I came in on a day off. I did a video session when it would have been better in person, but they wanted it video because it was convenient for them.

So, yeah, I think it's a double-edged sword to have this sort of, you know, privilege to be able to get in and be seen right away. And people like, oh, yeah, David's going to come see me or Craig. But then, you know, you're going to get the best care. I mean, maybe, maybe not. Yep. So, you know, I think. think it can be sometimes expedited care and sometimes sort of like that special care is not

always the best care, right? Especially like if it's expedited therapy. It's like, okay, you're, you're a very high, highly, oh, I had this patient recently, super high functioning. Like, if you were to read this person's CV, just would blow you away. And this person described going to three different therapists and after one or two sessions the therapists were like hey i think you're doing great i don't know if you need to go to therapy one one of the therapists wanted to be a friend of this person and they became friends and i think because of this it's like because this person is a very high social EQ person they hide their distress so much more but through micro expressions i see it i see it flash on their face, but otherwise, like, the majority of their affect that they sort of put out to the world

doesn't seem congruent to the level of the distress that they describe or that you can pull out. I don't know if you've seen that where, like, because of their high social EQ or because of how they are, it's like almost harder to see the true distress. Do you know what I'm talking about? Yeah. Yeah. I think, you know, part of being successful at anything is being able to, fully step into that position

no matter what's going on underneath. And we all do that. We carry our personas around and you know, I did that when I first got evaluated at rehab and like, hey, do you know, I'm a doctor. I'm an addiction specialist. Can you see me? Can you recognize this?

And, you know, it took her a while to peel back to the me that was not this sort of persona that I was wanting her. I wanted her to evaluate my doctor persona, not what was underneath. Hmm. Yeah, that's interesting. It's like we can as well, like, want people to immediately identify us as like special, which of course we do. Like if you're listening to this and you're like that, it's like, yeah, that's very normal. We want attention. We want to feel special. That's like something all my kids feel, right? And that doesn't really change when you become an adult too much. Maybe you, you, you know, you. you get a little bit more sophisticated on how you communicate it.

Yeah. I once had kind of the opposite experience where I went to see a psychologist. And at the very first session, I came in and she, I think she just didn't put it together who I was or whatever, not that I'm any big thing, but when she figured out within the first couple minutes that, you know, sort of where my position in psychiatry and stuff, she got so flustered. She started saying, I'm so happy you came to see me.

I'm so glad. I'm so, and she kind of, she was just so deferential. And it really turned me off. I never went back. Like, I felt like she tiptoed around.

And actually reminded me, just another thing popped in my head once, is I once went to primary care doc with some pretty terrible symptoms. And not to go into, tons of detail, but really, I needed a rectal exam, and the PA wouldn't do it. I think because of, I was a physician and a male, and I could tell she thought about it, and she didn't do it, and later it turned I had to get one in the ER, but I know she treated me differently because I was a physician, like I got under-treated. And it's much like that psychologist when she thought, oh, Craig Hickok,

blah, blah, blah, she didn't give me a genuine eval. She just kind of fell apart and gave me sort of softball chat session for the first thing. So I didn't get what I needed from either one. Oh. And yeah, I don't even... I think that what you're describing is you want competence and you want to be treated like they would treat anyone else. And my PA listeners will be happy to hear

that you wanted a rectal exam from them. Okay, that... Or at least I wish I got one. Like, yeah. I think it was simply because I was a physician and maybe some other reasons, but yeah, both of them under-treated me. Yeah. I think they're both like, ooh, we should, okay, well, we'll just not really do anything. Yeah.

And I wish they'd treat me like a regular person. Yeah. No, I think we desire to be seen and to be understood. And sometimes I think when people get kind of like this cloud of, wow, this person's really special, then they kind of like maybe exit out of their ability to be present and to do the work that they would normally do. You know, you get like distracted, internally focused, kind of self-critical maybe, and or just like overly, it seemed like with that therapist, congratulatory or like deferential, right?

Yeah, yeah. Where's the psychologist I ended up with after her? he, I could tell he just treated me like anybody. He just treated me. I just felt, he wasn't wowed by that. I was a physician or anything. Or that I was a psychiatrist, he was a psychologist. He just treated me like a patient.

And it was such a relief. I think that's kind of the flip side. You know, some VIP patients want to be treated especially, but others just want to be treated like a regular person. And I think they might worry, am I going to get special treatment? just because of who I am, when I just really want to be seen

and cared about as a person, not because I'm the chief medical officer or because I'm a singer. Yeah, that's what they get a lot of their life, too, is they get this deferential treatment, not because of who they are, not because of their innate gifts and abilities,

or maybe because of their gifts and abilities are, like, if they're an artist or a singer, you know, maybe because of that or their fame. but I experienced that the wealthy people just want to be seen and they don't want to be seen and appreciated for their wealth. It really is a huge turnoff. And so there's kind of like we want to be seen as human. And this is where like kind of working through our own counter transference I think can be so

important. Like, hey, there's this person I'm treating. Like help me work through this feeling that I have with this person, which is different than when I work with most other people. You know, how do I make sense of this? How do I overcome this? I think envy is another experience that famous people that wealthy people get from other people. I've had clients whose brother-in-law, sister-in-law want special treatment.

They want money. They want, you know, and it just drives a wedge in the way. the family and it's envy it's it's essentially envy that's driving it and then the envy and the anger from the envy doesn't get consciously registered in those people and so then they direct that anger at this other person oh this other person is angry at me or you know they label the person as narcissistic when they're actually very gracious and giving and every other domain of their life so sometimes envy an unconscious envy can drive us away from other people. We can't celebrate with them their successes. And I think that's something

to pay attention to as well in ourselves, which is a little bit harder. It's harder work. I think when we feel competitive with another person, I think that's harder work to do. What do you think? Yeah. Yeah. I guess I'm trying to think if I felt competitive with people, no, actually, have kind of had recently sort of the opposite thing where a couple psychiatrist, colleagues of mine have become my patients, and they both just struggled terribly during COVID and burnout and depression. And so I felt like these were two people, they are two people that I really respect and count on, even referred to.

And then to have them kind of, you know, go down, I felt really not competitive, really demoralized. I thought, oh my gosh, like two of the best psychiatrists I know are going down. They're just, and I'm treating them, and that's so scary to me. It's, I felt honored they wanted to see me, but I thought, okay, I feel like mental health often in the last year and a half, a lot of us have felt demoralized. And like, there's just too much pain. And now these two different people are coming to see me for me to try to help them. And I felt like I'm barely keeping my own head above water.

And so it was this, yeah, it felt good to have them want to see me, but I also thought, oh, no. Like, if they were going down, like, am I next? Like, am I, and who's going to be there for me? Who can I go to? Because I feel like the last man's standing. Yeah. Well, I think there's one thought right off the top of my head is we're not going to be envious

of people struggling. The envy comes when they're feeling better or their successes. and or when they come in and they've been very successful in a domain that maybe we want to be successful in. I think what you're describing is also common. It's like these are people that you look up to. And it's like imagine you're in the trenches fighting this battle. And then the people that you expect to be by your side fighting the battle come in and they need, you know, they need you to like pick them up and carry them.

And so yeah, there's like this feeling of like, wow, how are we going to keep going as a profession if like these people who are people I really look up to are struggling so much. You know, it's interesting. I know a person who would come in and probably, you know, voice their struggle. And then when they go back out into life, you would never know. you would just you would you would never know because they cover it so well you know and i think as like there's this thing like the most popular kid in school was probably the best liar and as your social EQ IQ go up like your lies become a lot more convincing and essentially that's what they're that's what we're doing when we put on that very strong social veneer to do the work that we do at times when we're feeling awful is we're putting on that social veneer.

And I think that's why when you humanize yourself and bring them into that where they can be okay falling apart in front of you, I think that's why it's so connecting. And often the people who are supposed to be holding it all together, they don't have that place. They can go to be completely raw and completely themselves. And that's so healing. So I would just encourage you, man.

I think that that is awesome that you are able to provide that. And, yeah, thank you. Have you noticed this, David, in the last year? I've noticed more people, maybe it's just because it's just been such a demoralizing last 12 to 18 months, but more people come in and they check in with me. Like, that didn't used to happen much, but people, how are you? How are you? And, you know, and really wanting to know, not just sort of in a,

polite way, but a lot of my patients have been just genuinely concerned, like, am I okay? Am I going to be there for them? And it's very sweet, but I also think it's maybe a marker of the times. Yeah, yeah, I've had a number of patients who authentically, careingly want and have concern. And this one person I've treated for like six years, like could tell something was off one day, called me out on it. And I was like, you know what? I've been treating you for six years. You deserve to know the real answer to that.

So I told her. And she was more than happy to give me a little bit of therapy almost, you know? Which is unusual. I mean, gosh, six years, right? I think I've, it's like. Yeah, but you help her when you let her help you. What a gift. I think so.

I think she really was honored that I would tell her the real story of what was going on. And, you know, like, these are real relationships, right? So the thing about treating people who are psychiatrists or therapists is they don't want the rehearsed empathic expression. Like, it's almost like their bullshit meter is so much higher, you know? So it's like they're, if you just say something that's like the normal pat sort of could, imagine reading all the textbooks. and now you want treatment and you also don't want someone to say something that's not true, right?

Yeah. It is one of the cool things about seeing therapists. Yeah. And just mental health people, that you, right, the bar is up, but the bar is up for genuineness. The bar is up for just, like, true connection. Because, you know, what are therapists? We're professional connectors.

And when you're seeing someone who's a connector, Yeah, right. You can't fake it. You can't dial it in. So I see a number of therapists. And actually, there's some of my favorite people to see. And they're kind of VIP in a certain way in my mind because I feel like when you help a therapist, you help a bunch of people. It's just a big spilldown effect. So I definitely feel myself kind of raising my own bar for better or worse when I see a therapist thinking like, okay, I need to do everything I can to help this person because this person works with so many other people. Like there's just such multiplicative effects if I can help. that person. I think we have some commonality in our just the connection being the key aspect. It's like you want you want a real connection. I remember with one of my therapists saying to her, you know, I just, sometimes I worry like, are you just saying these things because you've learned how to say them? And she had a really good answer. It's like, you know, she was like, you know, this is a real relationship. and the stuff you bring up affects me

and this is a real relationship and that kind of stuck with me like, you know, this is a real relationship like this is not just, I know I'm paying this person a lot of money and but it was... Go ahead.

I'm sorry, I wish there were a word that we as psychiatrist, therapist, doctors could use to tell our patients how we feel because, you know, it's like, I care about you, I like you. I'm fond of you. But it's different. Like we need a word, like for the people I've worked with intensively

and seen through their own darkness, like I have a love for them. It's not love in the traditional sense, but there's, in fact, my wife's a therapist, she's like, asked me once, do you think you can love your patience? She said, because I think I love a bunch of my patients. And I said, yeah, it is a kind of love.

It's, but it's not, we don't have a word for it. It's almost like the Eskimos, or the Inuit have like 40 words for snow. We need some word for this deep affection, respect, love, loyalty, admiration that we can have for people when we work deeply with them. I wish we could use that word because I'm often finding, like, people are questioning, is this a real relationship? Do you really care? And I'm always struggling for what's the right real way to say that, that they can hear and feel it? Yeah, it's sometimes hard for people who aren't therapists and psychiatrists to understand that, like, we can both be paid for our work, but also do it for free or be doing it for free if we, you know, if we didn't have bills to pay. Like, it's like the work, the therapy, like, I love, I love the connection so much that I would do it for free.

But some people can get fixated on, well, I'm just, you're doing this because I'm paying you. And I think the way that you described right there was perfect. It doesn't need one word. It's like it's that struggle for a word maybe that's good. Right? Freud said therapy is a cure by love in one of his letters. And some of the, my analyst mentor said the patients that did the best under Freud, Freud would have over to his dinner table.

He would go along walks with them, not the normal boundaries we imagine, right? And the patients he would do the worst with are the ones that he would have like, a lot of negative feelings towards. Anna O, right, is a story of like this person that there was this huge connection between the therapist and this person and the therapy was kind of ended and the therapist went on a second honeymoon with his wife, which might have been like a sublimation of sorts. Because there was real love that was forming between these two people. So we're human.

We have love. and yet we have boundaries because we realize that's what's best for the person. And the boundaries are the same for VIPs or normal people. It's like, this is how much I charge. This is how long the sessions are. This is when the sessions take place. This is how I work. And I think staying in that frame allows for us to maintain this is, I'm here for you.

And first and foremost, and my attention, my thoughts are towards you during this time. because it's easy otherwise for us unconsciously to collude with what is best for ourself, I think, which is maybe the darker side. I could read a couple of these stories and see what you think. Michael Jackson's doctor was convicted of an involuntary manslaughter for prescribing propofal at the request of a patient to help him sleep in 2009. Yeah, he had his own personal physician giving him IV propofal in his house. Yeah. And just for those of you who don't know what Propheaval is, it's used for surgery to keep someone to sleep. So the idea is if you titrated someone right, it would put them to sleep no matter what. Yeah. Okay. Here's another one. Joan Rivers Clinic doctor took responsibility in a malpractice lawsuit after the comedian died in a routine procedure due to the doctor's being overwhelmed by the star's presence. I'm laughing, but it's like horrible. It's a laugh of uncomfortableness.

One doctor took a photo of Rivers while she was on the operating room table, which is a major violation of protocols in 2014. Steve Jobs refused to let his doctors remove a pancreatic tumor, hoping to find alternative medicinal remedies. By the time you finally gave into the physician's request, the tumor had spread out of control. So that's an example of not kind of going along. with standard of care

and thinking that you're going to be able to find some super treatment, which I've seen as well. Like, you know, I'm going to spend exorbitant amounts of money to have my brain scanned. And it's like, no psychiatrists across the America or the vast majority,

99.99% of psychiatrists don't do that. And there's probably a good reason why we don't do that. Yeah. Yeah, I don't know what made me just think of this. This is kind of, this is a sad bit telling story. I had a VIP patient years ago, which actually, I'd never thought of her this way, but I'm calling her VIP because she was so unbelievably beautiful and charismatic. She was like a, she was some like superhero, superpower of just like beauty warmth and charm. And I only saw her a few times,

but I remember she came in my office once and she said to me, I need Xanax, two milligram bars, two a day. And I thought, that's insane, because I knew she had a history of addiction. And I ended up writing her the script and she walked out and she left and I remember thinking she's going to die of addiction because she people cannot say no to her and I actually found out years later she did die of addiction she died of an overdose and it was really powerful for me to think like there I was like literally writing her script and thinking this is insane but she was such a powerful force and then me also thinking like this is going to kill her, this superpower she has over people to just, like, get them to give her what

she wants. And, I mean, it's kind of an embarrassing story to share, but I think I'm sharing it because it's going to happen to people who are listening. There's going to be people who come in your office, and whether they're famous or doctors, or whether they just light something up in you, and they're going to potentially ask you to do things or to write things that part of you knows you should not do. And you have to take a deep breath and ask yourself, why am I doing this? Because sometimes people get under our skin or touch things in ways that it's only later, you know, when we're rowing or biking and running and going over the day and we think, oh, that's why I did that. Yeah.

That's that's why. So because you shared that story, maybe maybe the approach, maybe the provider out there will be more consciously aware of how someone's beauty is influencing them or charisma rather than it unconsciously registering, you know, because I think we can be unconsciously driven to things. And then later, when you're like out exercising, you're like, why did I do that for this person? You know, I would never do that. And so I think it's important to tell these stories so that we can think through, well, what would we do? What would we do if we're in that situation with this incredibly beautiful person in front of us. Like how would we treat them differently? Would we treat them differently? And what boundaries are good boundaries? I've had a

couple of patients who have had boundary issues with other male authority figures in their past, you know, because they were beautiful. And it's like, it's almost like they're waiting for you to have that boundary violation with them. And I think the treatment is really powerful when you don't and when you respect, like, hey, I'm providing this treatment for you. Dr. Tar would say, I shake hands at the beginning of treatment and at the end, but between that, we don't touch it all. So having the normal boundaries, not sort of changing the way that we do things with patients

just because they're lighting us up in a certain way. Yeah, it's good reminder. Yeah, it's such, yeah, I think it's so important for all of us to continually remind ourselves. I like that, David, that am I keeping the treatment frame the same? Am I having the same boundaries? And if I'm doing anything different and, you know, all the listeners will be tempted consciously or unconsciously at times to do things differently to ask yourself why. Like, what is going on right now? Why am I doing this?

This is not something I would normally do. Like, what is happening right here inside of me? and that can be great learning point. And it's an ongoing thing. Like, I've been doing psychiatry a long time, and I still find certain people for certain reasons just get me acting in different ways, and I have to stop myself and say,

wait, what am I doing? Like, what is this? Why did I just agree to that? Yeah, and that's the beauty of being interpersonally sort of that sort of questioning of like what is this unique sort of way that this person is influencing me, how do I bring meaning to that, how do I have some compassion for myself in the midst of it,

and how do I sort of come back to be centered in who I am and how I operate? It's good, man. Yeah. Yeah. I think we could wrap this up. Yeah, any sort of final thoughts, final kind of things floating in your mind? to like you want to get out there on this topic, treating physicians, treating famous people, treating VIPs.

Yeah, I guess the main thing I would say is, again, this is such a perfect example of how checking in, not just with yourself, but with other people. Like whenever there's a patient or a session that just you're asking yourself, what was I doing, what happened? It's so great to check in with a colleague, to write about it, to get,

some supervision on it. You know, psychiatry is such an isolated profession. You know, we, most psychiatrists work alone and most of us are seeing people all day alone. And yet we're facing these really difficult situations and things getting lit up at us. And even like we're doing right now, just kind of processing stuff, like this is so great. I think the more we, again, are aware of when we're acting outside our bounds or when people are getting to us, but when we're able to talk about and share it with somebody. Like, this is how the learning happens. Yeah.

Voicing our doubts and, you know, being vulnerable. Right, because I think a lot of people are surprised when someone like Craig talks about these things who's been, you know, very experienced psychiatrist. And they're like, wait, like, what? Like, how does that like, I thought everyone else was different than me. I thought I was the only one with the insecurities. And a lot of my patients feel that way. You know, a lot of my patients feel like I'm the only one with insecurities.

I'm the only one with the imposter syndrome. I'm the only one here. Why am I fighting all these negative thoughts? And I think it can be helpful to hear like, hey, we all have countertransference across the board. Everyone does. And it's through supervision. It's through talking to colleagues that we kind of move out of it.

So I'll call in your Xanax to me. milligram just after this episode. Thank you. I would appreciate you prescribing that to me across state lines as well. Okay. What did you want? Like a, you wanted like five a day? Uh, gosh. I may, I may have catatonia. I may need 20. Okay. All right. Done deal. Oh, okay. And I will, yeah, I don't know what I'll do. This is fun to talk in the middle of the day because our last conversation was like 11 or 12 o'clock at night in my time. Oh, yeah? Yeah. And, uh, and you You were saying, oh, I'm a night person. I'm like, oh, I'm not a night person. I'm more coherent today, even though my voice is scratchy. Okay. So if anyone wants Craig to come back, talk about

his MDMA trials that he was a part of why he left the MDMA trials, are I allowed to say that? Yeah. Did you leave the MDMA trials? I did, yeah. But mostly I left because I just want to spend more time and energy on my podcast. Okay. Because, yeah, because back from the abyss, a lot of time and it's just such a labor of love and it's so meaningful so that's the main reason. So go check out Craig's podcast. If you want us to cover any other topics, let me know. And we'll leave it there for today.