Sometimes, people can be pushy. Sometimes it's necessary.

I noted in the post directly below that the reclining gentleman is a metaphor for an attempt at "longer-term" employment. It would be easy to interpret what is portrayed below as one in a long line of "negative outcomes" - and trust you'll find no argument from me - but I have also suggested it is endemic to this particular population. I can live with that fact, and apparently it seems necessary to significantly adjust clinical expectations in relation to a predictably and increasingly morbid process; necessary if you don't want to "melt-down." In my mind, this means that "satisfaction," personally & professionally, is determined by training, self-scrutiny, and integrity. Obviously, I over-simplify an intensively personal process, but is it possible to "get the numbers" and be a slacker at heart? Duh.

I can't imagine anyone enjoys being scrutinized, even knowing that it is the basis of education, skill-building, and practice. And I must admit that, for me, it is next to impossible to separate the personal from the "professional." I believe I have mentioned the violation I filed on a child sexual perpetrator who was screaming "You fucking quack!" at me, without my ever uttering a word, in front of 80 locked-down super-max prisoners. But within the context of education and supervision - and ask anyone who has been in "live observation" or video-taped for "critique" by colleagues - though uncomfortable, is somehow eventually "palatable." But this philosophical license does not extend to employment interviews.

If you have read Snakes in Suits by Dr. Robert Hare, psychopaths should be expected in the workplace. Likewise, I suspect that, with the current "financial scandals," ranging from Bernard Madoff to the AIG bonuses, Dr. Hare's observations have become more poignant. In this context, hiring must be an unusually harrowing task. Gone are the days of simply relying on a resume, personal interview, and simply providing references upon request. Today, Google et. al is everyone's friend and/or nemesis, and HR is trained in structured analysis and parametric testing. Or, if you will,

Returning to the issue at hand, I was one of two viable candidates for a position focusing exclusively on "dual-diagnosis" out-patients, meaning psychiatry patients with a diagnosis of mental illness and a chemical dependency. I digress for a moment to point out that this "buzzword" is annoyingly redundant in that all substance-abuse disorders are contained in the DSM-IV as "mental disorders." Let it ride... Now, the only thing worse than a job interview is multiple interviews that exponentially add persons steps above in the hierarchy. What did I say last time? Am I contradicting myself? My head spins... And now to the actual beheading. At a given point in a very relaxed "conversation," I was asked my opinion of administering psychotropic medication to individuals who continue to actively "abuse" alcohol & other mood-altering drugs. Perhaps it was the "conversational" character of the meeting, perhaps I assumed they really wanted my opinion, and it is here I stepped in front of the bus.

First, I began by expressing my experience, which seemed significant in that, given the limited resources in the county, patients, quite literally, rotate among clinics as if one milling body: it was the rare, statistically insignificant, and anomalistic patient whose cessation of drug/alcohol use could be directly correlated with the administration of a psychotropic med. I could not think of a single example. But most importantly (and you knew this was coming), the literature does not support the practice. Several recent examples:

• 01/09 Of 149 patients enrolled into the open-label [VPA & LICO3] acute stabilization phase, 79% discontinued prematurely (poor adherence: 42%, nonresponse: 25%, intolerable side effects: 10%). Of 31 patients (21%) randomly assigned to double-blind maintenance treatment, 55% (N = 17) relapsed (24% [N = 4] into depression and 76% [N = 13] into a manic/hypomanic/mixed episode), 26% (N = 8) completed the study, and 19% (N = 6) were poorly adherent or exited prematurely. CONCLUSION: A small subgroup of patients in this study stabilized after 6 months of treatment with lithium plus divalproex. [That would be 8 patients]
  
  
• 11/08 While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring substance use disorders [though I cannot locate them], this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic.


• 02/08 Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis... In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak.


• 09/06 Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively.
  

We could go on (and on), and if you'd like citations, ask.

The tension in the room was palpable; eyes were averted; mice were heard sloppily consuming cheese. I then heard the playing of "Taps" and felt the life-raft drifting away. The chief psychiatrist quietly stated, "Prescribing these medications is our practice." Said the program director, "We'll be in touch." The inevitable phone message thanked me for applying and indicated they were "moving in a different direction," but would keep my CV on file.

Factually, have I worked in similar situations where identical treatment philosophies were practiced? Yes. Did I agree with the practice? No. Did I ever resign or quit over such practices? No. Why object now? Because I just felt like it. Because I couldn't take it. Because I'm a dumbass in tough economic times.

Hey! Google my ass. I hope you land on the unconscious fellow below, undoubtedly pumped full of some grossly expensive SGA and who knows what else, which he summarily washed down with a nice chianti.