Heather Clague on Psychiatry, Psychotherapy and Working with Society's Most Marginalized Populations

Heather Clague on Psychiatry, Psychotherapy and Working with Society's Most Marginalized Populations

by Deb Kory

Psychiatrist and psychotherapist Heather Clague offers reflections on the difference between private psychotherapy practice and working in the psychiatric emergency room, how prescribing medication broadens psychotherapy, and the joy and heartache of working with those society is "happy to ignore."
Deb Kory: One of the reasons that I wanted to interview you for Psychotherapy.net is that you’re one of the only psychiatrists I know who both works in a hospital setting and also sees private clients as a psychotherapist. You are the medication-dispensing therapist that so many of my clients wish I were—though I’m so grateful not to have prescribing privileges. It would freak me out.

Since we’re releasing a video this month about working in hospitals and treatment centers, I thought you would be a great person to shed some light on that world. You are in private practice in Oakland, California, and you also you work at John George psychiatric hospital. What is your job there?
Heather Clague: John George is a public psychiatric hospital in San Leandro, California, and I’m an attending psychiatrist in the psychiatric emergency room (PES). It’s the 5150 [California law allowing involuntary psychiatric hold] receiving facility for Alameda County, so anyone who is put on a psychiatric hold in our county will come to us to be assessed for that 5150.

Our model is known as the “Alameda Model,” and it’s a way to reduce the length of stay for psychiatric patients in emergency rooms. In other counties that don’t have psychiatric emergency services like we do, people with psychiatric emergencies are taken to medical emergency rooms and then await an inpatient bed somewhere.
Methamphetamine accounts for a shocking amount of our services. Meth makes you really, really crazy.
And since there are so few psychiatric inpatient beds, they can wait days and days, often strapped to a gurney, ignored in a corner. Medical ER boarding times are significantly shorter in our county than those without a PES like ours, because as soon as the patient is medically cleared they can send the patient to us.
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“We have just allowed ourselves not to see them”

DK: Dr. Heather Clague, thanks so much for taking the time to speak to me and our Psychotherapy.net readers today. Truth in advertising: you were my supervisor at Berkeley Primary Care, a community health clinic, where I did a practicum my third year of graduate school at the Wright Institute. These days we sometimes share clients and we also did improvisational theater together for a while. We’re both believers in the therapeutic value of improv
HC: Indeed.
DK: Let’s say someone is having a psychotic break and they go to a regular medical hospital and they get discharged to John George—what then happens to them?
HC: Then they come into our facility and they get an evaluation.
DK: Would you do that evaluation?
HC: I would, yes. We have a doctor-centered model where each patient will get seen by a physician once or twice, or sometimes even three times, and an assessment is made. The idea being that it should be a rapid assessment, that patients are not supposed to be held there more than 24 hours, at which point they will either be admitted to the hospital or released to the community.

But the reality is that our service can become overrun. There can be long delays and patients often still have to wait days and days to get an inpatient bed—although they are at least waiting in a psychiatric emergency room as opposed to a medical emergency room.
DK: Feeling hope and joy in this work really matters.
HC: It matters to me and I think it matters to the people that I work with. I also think there’s something about midlife where one has to reconcile reality with ideals.
DK: It’s humbling, isn’t it? Finding peace in our little slice of the pie, much smaller than we might have once hoped.
HC: But without becoming cynical.
DK: Is that why you only work there one day a week?
HC: For me it’s the threshold. Below a certain amount, I have a very good sense of gallows humor about it. The people I see who work there full time struggle a lot more with the despair and a very grim feeling that comes from working in a dysfunctional system.

The other way the system is broken is that there is a population of maybe 100, maybe up to 500 high users, people who are chronically calling 911. If they were given apartments, free taxi vouchers—just find out what they want and give it to them—it would cost vastly less than the impact that they have on the medical system. And I’m not just talking about the financial cost, but the burnout and wear-and-tear on the people who work in the system. I think there’s pretty good data on this.

If you need to go to an emergency room and you wait a long time, that is a direct result of this problem.
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“The overwhelming burden of the radical not-enough-ness”

DK: You would have to retain some sense of hope to do this work. Both of us, really, but I’m quite comfortable in my cozy, private psychotherapy office, whereas you are much more in the trenches of human suffering, where I think hope is often in short supply.
HC: Or, less charitably, I think I’ve got strong internal boundaries. When I was working at Berkeley Primary Care, where you and I met, I had a population of patients that I saw as part of my ongoing caseload, and I ultimately left that environment because it was too dispiriting for me. I followed those patients long term and I think I felt too responsible for them, just this overwhelming burden of the radical not enough-ness. At least in emergency room settings what I’m supposed to do is so tiny, I can do that tiny piece really well and cheerfully and with compassion and humanity so that I don’t have solve everyone’s problems. If I can give them a moment of feeling seen as a human being, that works for me. I think it would be grandiose to suggest it really has a radically long-term effect on the patients that I see, but it allows me to sustain and feel hopeful and to enjoy what I do.
DK: That must be awfully dispiriting.
HC: Well, I can handle it when I work there one day a week.
DK: Wait, so you’re basically also a homeless shelter?
HC: We’re basically also a homeless shelter. And we are emblematic of societal dysfunction. If Alameda county would invest some money in opening up some shelters, the number of patients coming to us and medical emergency rooms would drop. There is no drop-in women’s shelter in Alameda County. There is one drop-in men’s shelter in Alameda County and it costs $5 a night, which is $150 a month, which most people can panhandle if they’ve got the wherewithal to panhandle $5 a night, but that’s a giant chunk of what General Assistance [Alameda county aid program for indigent adults and emancipated minors] gives you.
DK: Because our culture has become immune to it?
HC: Yeah, happy to ignore psychotic people. We have just allowed ourselves to not see them.

We have a large population of homeless people who use us a shelter. And almost all of them are also using drugs, but some of them will just come in and know that if they say the magic words—that they’re suicidal and hearing voices—they’ll get to spend the night. Some of them first present to the nearest medical emergency room, which amps up the expense because there are ambulances involved and there is a medical ER evaluation involved.
DK: So part of your role then is educating them about the dangers of meth?
HC: We do a little scaring them straight. “There are dangerous consequences to continued use, you could lose your teeth”—that type of thing.
DK: Is it?
HC: It’s like Altoid’s, strangely addictive.
DK: Otherwise you’re kind of on automatic pilot?
HC: Well the productivity expectations have gone up and up and up. When I started in 2001, if we had 20 people it was off the hook. Now, if we come in and there’s fewer than 50 we’re like, “easy day!” At the peak this weekend we had 86. I’m just waiting for us to hit 100. It just keeps escalating, and the population of Alameda County has not grown that much.
I think what we’re witnessing is the degradation of the mental health system—the ongoing defunding of the community mental health system and the social system.
I think what we’re witnessing is the degradation of the mental health system—the ongoing defunding of the community mental health system and the social system.

They just keep slashing money from community mental health, caseloads go up, there are fewer case managers and fewer psychiatrists. Services are getting cut or just not growing proportionate to the need.
DK: Wow. I had no idea there were so few shelters around.
HC: There are some other shelters around, but none that you can access on a drop-in basis. It’s an appalling lack of care that our county pays for through the nose, but those who pay for it are not necessarily in charge of fixing it, and so the problem doesn’t get fixed.
DK: Say more about that.
HC: It’s a high-energy place—there’s always a lot of work to get done. It’s very satisfying. There’s all these people that need to get seen and you make a lot of people happy because you send them home.
DK: Do you feel a special affinity with your colleagues there?
HC: Absolutely. The nurses and social workers who work there are fantastic. The people who survive in that environment develop certain social skills and have a certain philosophy of life—
DK: A sense of humor would be paramount.
HC: It’s so important. If we aren’t overwhelmed with patients one day, one of our social workers will say, “Well, we had a mental health outbreak today!”

Also, there’s no calls, there’s no voicemail.
DK: You get to leave it behind when you go home?
HC: Exactly. I have a very intense experience when I’m there and then when I’m done I can let it go.
DK: And do you?
HC: Yeah. I would say I do. Actually, I find it important not to let it go too quickly. Part of the problem of working there is it’s so fast-paced, it’s easy to do it a little mindlessly. So when I’m working in the hospital, it’s actually good for me to tell my husband some of the stories of the day so that I can actually take in that, “Wow, I just had a brush with someone who is having a much deeper, more complicated experience, and I got to bear witness to a small piece of a much bigger story.” It’s important to be able to sit back and reflect on what that story likely looked like.

It’s easy to let my impressions of people fall into stereotypical typologies, so it’s important to pull back from that and realize that there’s a very interesting three-dimensional person behind what looks like “just another meth addict.” This person had a mother, this person came from somewhere, they have a very specific story that brought them to this point.
DK: There’s obviously a deep level of dehumanization that has brought them to this point, and I think you’re saying that it’s difficult to yourself not become dehumanized in that environment.
HC: Exactly.
DK: So you have to find creative ways to stay present and to rehumanize these people.
HC: And oneself.
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“People don’t have beds to sleep in”

DK: One thing that’s very noticeable about the Bay Area when you move here are the number of mentally ill people living on the streets. Do these folks make their way to you?
HC:
In our culture, you have to be pretty smelly or lying in the middle of the street or obviously bothering people with your lack of self-care before anyone will really take action.

There are people with chronic psychotic illnesses who become agitated or have such radically poor self-care that they come to attention of the people around them. In our culture, that has to be pretty radical—you have to be pretty smelly or lying in the middle of the street or obviously bothering people with your lack of self-care before anyone will really take action.
DK: Do you see a lot of addicts at the psych ER?
HC: Substance abuse is huge. My impressions aren’t necessarily accurate, but it feels like at least 20% of the people we see are having paranoid delusions because of methamphetamine use. Methamphetamine accounts for a shocking amount of our services; methamphetamine makes you really, really crazy.
DK: It sure does.
HC: And very aggressive.
DK: So what would you do with a meth addict who came in?
HC: Give some Ativan. Let them sleep. Feed them.
DK: Detox?
HC: We can refer to a detox facility that’s right near us, though there are shockingly few detox facilities available.

I think there should be a public health announcement in the Latino community because I see these higher functioning men working two jobs to support their families, who start using methamphetamines to increase their productivity, and then they get psychotic. I don’t think they know how dangerous it is.
DK: That people don’t have beds to sleep in and aren’t being properly treated for their addictions and poverty-related problems?
HC: People don’t have beds to sleep in, which is an easily solvable problem that would not cost that much money. It also would not cost that much money to give some intensive case management to this particular high-using group. Perhaps they are a fairly cynical, seemingly undeserving group, but it’s a funny kind of justice that would create a system like ours to punish them in the way we do. There’s this feeling that if we give those people taxi vouchers, then other people are going to learn that if they spend all their time in emergency rooms pretending to be suicidal, they’ll get taxi vouchers too. But I don’t think the population of people willing to spend all their time at the hospital pretending to be suicidal is that high.
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“Well, it is fun”

DK: That’s a really good point. So if you’ve had to keep your workload down to one day to stay sane, why do you work in the psychiatric ER at all?
HC: Well, it is fun.
DK: How long is a typical stay for a patient there?
HC: I’m not sure what the average is, but it’s probably too long. It can range anywhere from a half hour—we get a quick evaluation and realize you don’t need to be there—to 18 to 36 hours. So, a night or two.

If we’re backed up on beds, or there is a placement issue, patients can stay for a number of days. That’s not ideal and everybody in the system tries to keep that from happening.
DK: Why?
HC: Because it’s a rough experience for the patients. It’s a hard place to have to hang out, especially if you’re in psychiatric distress. We have nurses and doctors rotating every shift. We are able to make some limited interventions—start medications, family meetings, have patients participate in some group therapy, but it’s primarily a facility designed to collect observations, make a decision, and move on. It’s clearly a giant step above waiting for days in a medical emergency room, but it is not equal to a good inpatient experience.
DK: Say more about the types of people you see.
HC: The 5150 is applied for danger to self—someone who is acutely suicidal; danger to others—so someone may be homicidal; and grave disability—someone who is unable to provide food, clothing, and shelter for themselves. We see people with chronic psychotic illnesses having a decompensation, people with bipolar disorder who have become manic, people who have a depressive illness and have become acutely suicidal. We’ll see people who aren’t necessarily mentally ill but they just had a breakup and have became suicidal and texted someone they were going to kill themselves.
DK: Are you only involved in the initial assessment, or are you involved in ongoing care?
HC: My general schedule is to work one day a week, so normally I would just do a one-time assessment and would see them over the course of the day if they have needs during that day. Sometimes I’ll work two days in a row and if a patient is still there then I see them again. I can do small interventions, but we’re not an inpatient service.
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Bringing Grit to the Comfortable Place

DK: Without becoming cynical, right. Do you feel like your ER psychiatrist role is a separate identity from your role as a psychotherapist in your private practice Oakland?
HC: Yeah, I do.
DK: In a never-the-twain-shall-meet kind of way?
HC: Well, not entirely. I’m me. I’m the same person. But, my role is quite different. They are two ends of a spectrum: Long-term/short-term, higher-functioning/lower-functioning. But obviously the two inform each other. I think it’s good to bring some grit into the comfortable space and compassion into the gritty space. And I definitely feel like using my empathic skills in the emergency room is effective and incredibly rewarding.
DK: Speaking of which, psychiatrists are not often thought of as empathic. It’s all anecdotal, but I’ve not had many people come into my office reporting positive experiences with psychiatrists. Why do you think that is? And why don’t more psychiatrists do therapy?
HC: Well, it’s not as lucrative. If you see three medication patients per hour, you can make a lot more money than seeing one therapy patient per hour.
DK: So it’s purely financial?
HC: Well, also, in order to do learn to do therapy well, you have to feel safe and have time to empathize and mentalize, and I don’t think the medical model facilitates mentalizing.
DK: Because doctors are trying to squeeze in as many patients as possible?
HC: You’re not trying to form a model of the patient’s inner experience, you’re trying to make a diagnostic categorization and then select a medication.
If I can give them a moment of feeling seen as a human being, that works for me.
I think skillful pharmacologists obviously do need to understand the target symptoms, what the side effects are, what a particular person’s concerns about taking medication are. Obviously having empathic skills helps with prescribing medication, but I think it’s treated as icing on the cake. I think that’s true in most medical settings.
DK: When you went through UCSF Medical School, were you given any proper therapy training?
HC: UCSF did a reasonable job of training people how to communicate effectively with patients. I also went to UCSF for residency and that program was very strong in training. But I think that’s not typical for psychiatric residencies. They tend to be more biologically oriented, and I personally feel a bit skeptical about the biological approach of psychiatry. There are obviously illnesses like schizophrenia and bipolar disorder and severe depression that look like medical illnesses. They look very biological. But the human condition does not want to easily fit itself into DSM V diagnostic categories, and there’s a lot of politics behind why we shoehorn them in there.
DK: Our last interview was with Gary Greenberg, who recently wrote The Book of Woe: The DSM and the Unmaking of Psychiatry, and in it he talks a lot about how inappropriate the medical model is for maladies of the mind. How do you use the DSM? How do you view diagnosis?
HC: I hold it lightly. I have to put some code down there, and I choose from a handful of codes.
DK: Do you have a favorite?
HC: Well at the hospital, we’re allowed to use more of the bullshitty codes, the “NOS” codes. Of course, we can’t put substance abuse as a primary diagnosis because we don’t get paid.
DK: Why not?
HC: I don’t know, actually. The stigmatization of substance abuse? Insurance companies don’t want to pay for addicts who end up in the ER? Perhaps it’s viewed as an issue of volition rather than biology?
DK: Though there’s plenty of evidence for a genetic predisposition toward addiction.
HC: Well, the reason we call it volition is that we don’t have great treatments for it, so it’s blamed on the patient.

But the DSM doesn’t turn me on. I do what I have to do. Probably the biggest diagnostic question that I face is, “is this unipolar depression or bipolar depression?” I don’t want to give a bipolar patient an antidepressant and cause a manic episode, so that is an important practical diagnostic question.

Or “does this person have OCD as opposed to other forms of anxiety?” because that has treatment implications. With OCD, we’ll want to use higher doses of SSRIs and encourage therapies such as exposure and response prevention.
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There is No Truth

DK: Well, if I were struggling with the Bipolar 1 or Bipolar 2 question, I’d just send them over to you to figure out.
HC: And I would tell you that there is no truth.
DK: And that would be annoying.
HC: Do you want to hear my rant about bipolar disorder?
DK: Yes, please.
HC: Bipolar got really trendy right around the time that Lamotrigine was being marketed.
DK: Which is Lamictal.
HC: Right. And the evidence for its efficacy is actually pretty weak.
Bipolar got really trendy right around the time that Lamotrigine was being marketed.
People who responded to Lamotrigine who went off of it were more likely to have a depressive relapse than people who stayed on it, but there is no control trial of people having acute depressive episodes on Lamotrigine doing better than people who took placebo. And there are all sorts of methodological issues around discontinuation studies. Even the data on lithium and Depakote is actually quite thin. And if you really want to get paranoid about it, the reproducibility of psychiatric trials is also quite weak.
DK: Because it’s too hard to control for variables? Or is it just that the nature of the mind is still so mysterious? It’s not like measuring the size of a tumor or drawing blood to see if a disease is still present.
HC: Well, we take a cluster of symptoms and we describe them and we put a label on them. Some people are probably very obsessively good at asking really detailed questions—“How many days did that last?” But I can tell you in practice I don’t have the time or the interest to go through it with that fine grain a comb. I screen for things that sound like classical bipolar symptoms, but what is ultra-rapid cycling bipolar disorder and how does it differ from the psychiatric effects of trauma? I mean, does pediatric bipolar actually exist? Kids who are beaten and raped and emotionally abused are going to have rage outbursts and sleep problems.

I saw this young man last week who was put in foster care at age 4, so who knows what kind of horror show was happening in his life before age 4. He’s been in and out of foster care. He’s been in juvenile justice since age 12, and he’s been shooting methamphetamine, and he’s telling me he has bipolar disorder. You grow up that way you’re going to be traumatized. Maybe there are people who have resiliency factors who don’t become mentally ill, but he didn’t look like he had bipolar disorder to me. He looked like someone very, very traumatized, but I’m going to giving him Zyprexa?! That just did not feel like the right solution.

The next guy who comes in, I ask, “Have you ever made a suicide attempt?”

“Oh, yeah, a bunch of times.”

“Oh, what have you done?”

“Well, I swallowed glass and I swallowed razor blades. I drank bleach.”

“When was the last time?”

“Five or six months ago.”

He’s got scars all up and down his arm and all up and down his neck. This patient did not want to talk to me about what happened to him when he was young, but in my mind, his diagnosis is trauma until proven otherwise. But this guy is not carrying a trauma diagnosis, even as a rule-out. He’s only carrying a psychotic disorder diagnosis. That just feels very wrong to me.

I’m partly on a kick because I saw Bessel van der Kolk at a conference, and what he says makes so much sense to me. He put together a diagnosis called “developmental trauma disorder,” which is obviously a trauma-based diagnosis, and one of the major cons of including developmental trauma disorder into the DSM is that it would wipe out a bunch of other diagnoses. It wipes out a lot of ADHD. It wipes out oppositional defiant disorder, borderline personality disorder, a lot of bipolar disorder.
DK: So it wipes out a lot of money?
HC: It wipes out a lot of things that people want to treat with medication. There’s compelling epigenetic research about the way that experience and trauma gets incorporated into your biology and passed on to your offspring, and it doesn’t necessarily mean that the primary solution should be to take a pill.

I’m not anti-medication. I think there’s definitely a role for pills, but the fact that psychiatry has put all of its eggs in that basket is appalling to me, especially when there’s a lot of exciting research about non-pharmacological treatments, such as EMDR, neurofeedback, hypnosis, and paradoxical motivational techiques.

How is it that we help our patients? How do we train ourselves as therapists to be highly effective on a kind of session-by-session basis? What did I do in session today that was actually effective? I think we should be collecting a lot more data, both as a profession and also individually. Our impressions are so misleading.
DK: Scott Miller has done a lot of research on what works in psychotherapy and what doesn’t. I think he reported that something like 75% of therapists think they’re better than average, which is, of course, statistically impossible.
HC: That is healthy narcissism. I would want to know what is up with the 25% that thinks they’re below average. I wouldn’t want to see them. I think it’s okay to think you’re somewhat more effective than you are.

Does pediatric bipolar actually exist? Kids who are beaten and raped and emotionally abused are going to have rage outbursts and sleep problems.
But we also need to be willing to take that confidence in ourselves to the next level, so that we can look at ourselves critically and separate out what we do that is effective from what isn’t. I was really intrigued when van der Kolk talked about doing EMDR with a patient who was very hostile toward him. He was asking the patient to be with this traumatic memory and he says, “So tell me what’s going on.” And the patient says, “It’s none of your fucking business.” And van der Kolk says, “OK, go with that,” and he completes the session and the guy tells him nothing about what he was thinking about, but at the end says, “Thank you, that was very helpful.”

So it’s not always clear how the patient liking or attaching to us predicts the kinds of changes they want or that we think they should want. I’m not saying we should encourage our patients to hate us, but I think a lot of us think we’re more effective than we are.
DK: We just recently interviewed Bessel van der Kolk as well as Francine Shapiro, the originator of EMDR, so you are in good company here. They are both big researchers and into collecting data on the efficacy of their work. Do you collect data from your clients?
HC: I’ve started to. I’m training in the David Burns TEAM model of cognitive therapy, and it asks the patient to complete a symptom rating scare before and after every session. So after every session they fill out a feedback form and they evaluate you based on how well you empathized with them, how well they felt that they were able to talk about what was important to them, whether they learned new skills and whether they’re going to do their homework, and then it lets them give a little narrative write up.

It’s very, very humbling. And it has transformed my therapy practice. You have a session you thought was great and then learn that patient didn’t think so! You’re able to come back to the person and say, “You know, it sounds like I wasn’t really getting this. Can you fill me in? How was I off track?” It’s an incredibly therapeutic moment. We’re inviting patients to criticize us and then taking that non-defensively. How many people have that in their lives where they get to actually say to someone, “that kind of sucked,” and to have that received that lovingly and non-defensively?
DK: And with curiosity.
HC: It’s incredibly hard to do. And we’re only human. But I think that having the right kind of training can make it possible.
There is a lot of narcissistic support built into our field for embracing failure.
Allowing ourselves as therapists to really take pride in our failures is what allows us to be non-defensive and to receive critical feedback from patients in an open-hearted way. For example, it turns out my grandparents were right, I really do talk too fast. I’ve heard that on enough feedback forms. That’s humbling, but at least I know I have that tendency, and when it comes up I can validate the patient’s experience. And actually, now that I think about it, I haven’t gotten that feedback as much lately, so maybe I’m actually doing better at slowing down!
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To Prescribe or Not to Prescribe?

DK: Do you generally try to do psychotherapy first for a while before prescribing?
HC: So much depends on what the patient comes in expecting and wanting. It’s really interesting, because some people are very clear: “I don’t have the time and energy for CBT. I want a relatively straightforward, easy solution to my chronic anxiety, and I’m willing to take the risks that come from medication. And I only have to see you every six months if I’m stable.” And that works for me. CBT is hard work. Actually, most psychotherapy is hard work and that doesn’t fit for everybody.

And then other people feel like, “I don’t want to take a pill. I don’t want to take medication. I don’t want to be labeled and stigmatized and reduced to that. I want to explore and understand.” It’s a tremendous privilege as a clinician to be able to work with people in such a broad way. The danger is that I’m a little jack-of-all-trades, master-of-none. I’m not the most hotshot psychopharmacologist. I’m not up to date on all the latest meds. But I’m really good at SSRIs.
DK: Speaking of SSRIs, given that they work slightly better than placebo, do you tend to psychoeducate people about that, about all the risk, the fact that we don’t even really know why they work?
HC: No. I don’t. Because I want to maximize the placebo response. I give them every testimonial I can. Because they’re not just getting the pill, they’re getting me prescribing the pill. They’re getting the experience of having a relationship with me and so to whatever extent taking that pill is internalizing me, I want that to be a positive experience.

Now, I’m not going to shine them on and say that SSRIs always work or are completely benign, but as drugs go—certainly compared to the mood stabilizers or heavens, antipsychotic medications—I think they’re relatively benign. They’re not so benign for people who might be bipolar, since they can bring on severe agitation or even manic episodes, so I have to be careful there, but otherwise they are relatively benign.
DK: If somebody is clearly suffering with chronic depression, they are in therapy, and they’re open to getting pharmacological help, how many SSRIs are you willing to try on a person before you give up?
HC: The data shows that the chance of it working goes down with every trial. But, again, they’re not getting a pill, they’re getting the experience of paying a fair amount of money to come sit in my nice office, to sit across from me, and have me listen to their story, and then to have a conversation with me about what it means to take medication. And then to have customized dosing.
DK: So it may be that they’re getting the therapeutic effect of seeing you rather than from the pill.
HC: Right. I had a client some time ago with a lot of trauma who had bad experiences with antidepressants, and we shifted him to Prozac and it was going well and I remember him saying to me in session that he was feeling much better, but also sometimes feeling really sad and that it was scary for him.
The expectations of psychiatrists are so low....I get a lot of credit for having kind of average social skills.
I was able to tell him that the fact that the sadness came up right when he was feeling better made me think that maybe his body was realizing it was safe to feel his feelings. I pointed out that he’d had a lot of trauma in his life and lives in a high-pressure culture with a high-pressure career as a high functioning person and that it’s easy to become phobic about feeling sad. And I said, “What do you think about the idea of just allowing the sadness?” And he was so visibly relieved by that.

I think there’s something very powerful about having your prescriber license your sadness instead of pathologizing it. Of course your therapist can do the same thing, but some of what I do is help support therapists whose clients I share. They want to know that they’ve done everything they can in the therapy setting and I can validate that and help them feel less alone in their treatments.
DK: It makes everybody feel more confident, including the clients who feel like, “I have a team working with me.”
HC: Which is why the current model of overburdened, non-psychologically-oriented psychiatrists handing out pills and not calling back therapists probably isn’t the most effective. The expectations of psychiatrists are so low.
DK: No kidding.
HC: I can walk on water because I return phone calls. I get a lot of credit for having kind of average social skills. Very privileged place for me to be in. I will not complain.
DK: Because you’re not a complete weirdo.
HC: There are a lot of very weird therapists out there, too, though.
DK: We are a strange subculture. Or maybe everyone is strange but the standards are higher for us because we’re supposed to be helping people with problems in living?
HC: Well, when you’re vulnerable and need help, you’re really sensitive to the weirdness.
DK: Well, on that note, I want to thank your only modestly weird self for participating in this interview.
HC: It’s been a pleasure.

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Heather ClagueHeather Clague, MD, trained at UCSF for medical school and psychiatric residency and currently has a private practice in Oakland, California offering psychotherapy and psychopharmacology for adults. She also works part time in the Psychiatric Emergency Service at John George Psychiatric Hospital in San Leandro, California. She lives in Berkeley with her family and is an enthusiastic member of The Berkeley Players improv theater group. www.heatherclaguemd.com
Deb Kory, PsyD, is the content manager at psychotherapy.net.  She received her doctorate in clinical psychology from the Wright Institute and has a part-time private practice in Berkeley, CA. She loves both of her jobs and feels lucky to be able to divide her time between therapy, writing and editing. Before deciding to become a psychotherapist, she worked as the managing editor of Tikkun Magazine and published her writings in Tikkun, The Huffington Post and Alternet. Currently, she is working on turning her dissertation, Psychologists: Healers or Instruments of War?, into a book. In it, she describes in great detail the historical context and events that led to psychologists creating the torture program at Guantanamo and other "black sites" during the War on Terror.
Refreshingly frank and open discussion of a challenging enterprise - being a psychiatrist. Thanks to Drs. Clague and Kory for a lively and engaging interview.
David Bullard, Ph.D.
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CE credits: 1.5
Learning objectives:
  • Describe the role of psychiatric emergency services in the mental health system.
  • Illustrate the types of disorders that are most highly represented in the psychiatric emergency room.
  • Discuss how the psychotherapy process changes when the therapist has prescription privileges.
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