Our Work at the CCPPM

Who we are
Diane Engelman and I (Steve Frankel) direct the Center for Collaborative Psychiatry, Psychology and Medicine. I am a psychiatrist, board certified in both Child-Adolescent and General Psychiatry. Diane Engelman, Ph.D. is a neuropsychologist.

Our associates are quite distinguished. Philip Erdberg, Ph.D. is our psychological assessment guru, Rick Mendius is a board certified neurologist and a regular contributor at Spirit Rock where he confronts the spiritual dimension of our fields, and Paul Gilbert and myself are both board certified in child and adolescent and general psychiatry. Given our backgrounds with children and adolescents we are quite comfortable working with families and couples. Paul and I are also psychoanalysts,  albeit eclectic and practical in our orientation.

Backing us up are a sizable group of experienced, independent, therapists who we have participated in our consultation groups.

How we do it
It makes sense to begin by illustrating the multifaceted approach to doing psychotherapy and monitoring its efficacy that we have evolved at the Center. Please note that each of us practices independently, and that the Center itself is devoted to research and training in the models of
psychotherapy we have evolved.

We call our model of treatment “collaborative psychology and psychiatry.” As you might expect, collaboration occurs between therapist and patient, and in the case of children and adolescents, the therapist and parents. According to this model, as possible there is another, integral, member of the therapy team, a psychologist. That person does a psychological and at times neuropsychological assessment of the patient, repeating a convenient version of this assessment at intervals to measure the patient’s progress.

I can imagine that the word “cost” is circulating furiously in your mind. “All well and good, that’s the way in an ideal world, but which of my patients could or even would afford that kind of enhancement to the treatment?” But, the real question, I submit, is: how can they not afford it? I will elaborate later. The second usual concern is that bringing in a third person will interfere with the therapy alliance. Further, what if the patient, as a result of the assessor’s findings, begins to become skeptical of the therapist’s assessment of his or her needs. Worse, what if the patient decides that the assessor is their real savior? In that case isn’t introducing a psychologist-assessor to the therapy field likely to  disrupt rather than enhance the treatment? And those things happen.

The short response to that concern is based on our experience. In the more than sixty cases we have done at the Center, that person, when properly trained, has virtually always made the treatment stronger. If the patient wants to bolt he probably will try to do it anyway. Having a third consultative presence should help guard against this eventuality. The longer answer has to do with whether the psychologist-assessor is trained in our collaborative technique and is able to guard against and contain any competition she or he may feel toward the therapist.

Owen is a case in point.

Owen
Owen is 22. Bright, maybe brilliant, but moody and remarkably stubborn. Lots of potential. Lots of  reason why he has left every situation, including high school, in a puddle of mediocrity. Other factors are important.

Owen falls in love hard. In high school there was Lilly, a free spirit who went to Mexico to live with a writer. Emily from his first two years of college was more stable, but left Owen because of his moodiness. His parents, two straight arrow lawyers, had trouble not focusing on Owen’s professional success. After all, his three years older brother had gone to Harvard and was a model student now  headed for medical school.

It might help if I describe Owen. Awkward and disheveled, he looked like he belonged in some garret in Paris, spending his time drinking absinthe and talking philosophy.

Owen was referred to me after quitting college for the second time in three years. Since he was such a good thinker he had been admitted to an excellent California University. He bombed out after getting drunk and protested a decision by the university affecting his girl friend by riding his bicycle recklessly around the university police headquarters while calling out epithets. For the next semester he transferred to a rigorous private college where he didn’t do his work. By the point of referral his parents were so perplexed that they were willing to let me “do anything to help.”

Here is what I did.

I had a phone call with Owen’s parents and told them that I would meet with Owen once, and with his permission I would then meet with them. I asked for copies of all the school records and testing reports they had. In conjunction with taking a history I asked them to fill out an extensive background form. I explained that the more information they and Owen could provide in writing the fewer notes I would have to take and the more efficient the intake.

Owen was as moody and reluctant as his parents reported. “Nothing was wrong” outside his parents’ heavy handedness and excessive worry. But, he had no choice so he would meet with me. He was curious, however, and agreed to psychological testing, then a neuropsychological supplement and a full neurological examination. In fact, he was having headaches and wanted to have an MRI of his brain done.

So, the first question is: why go to all this trouble and expense in assessing this relatively ordinary case? The initial cost of all these evaluations was to be $3,000. Let’s do some math. Typically someone like Owen would be swept into a once weekly treatment, possible emphasizing CBT. The psychological testing without the neuropsychological component and minus the neurological workup might cost $1,500. But, think about what you would have with the bare bones approach.

It would be easy enough to conclude that Owen suffered from ADD. A stimulant might help, and there certainly would not be any harm in trying one. But is that the whole picture? In Owen’s case it certainly was not. There was his father’s heart attack when Owen was nine and his brother’s perfection. There was Owen’s incredible intelligence and capacity for creativity. There was Owen’s stubbornness and objection to being scrutinized.

The jump start we got allowed me to begin medication in spite of Owen’s parents’ abject fear of it. It allowed Owen to participate in treatment planning and to set the frequency of sessions to one and a half hours every other week. He preferred the infrequency and said the length of the sessions allowed him “to get into and not resist them.” The extended length of these sessions also helped us to jointly witness and work with his impatience. In accordance with Center protocol Owen’s agreement to have repeated “minor versions” of the original testing every six months assured that we would not slip into any illusions about whether treatment was working.

The neurological examination was entirely normal as was the MRI of Owen’s brain. Even his cervical spine was within normal limits, a finding leaving the source of his headaches obscure. The neuropsychological testing, which in this case was not done by Diane, underscored the seriousness of what the assessor called Owen’s combined ADD and irritable temperament. While irritability is frequently associated with both childhood and adult ADD, personality testing was needed to fill in the  blanks about Owen’s diagnosis.

Philip Erdberg, Ph.D. did the personality testing. His unique take on the situation, in contrast to the neuropsychologist’s, emphasized Owen’s intelligence and, even more, his creativity. Owen simply got bored easily, excluding him from the class of people who, like his brother, could sit still for four years  of college. Also, it became apparent in sessions with me that Owen was remarkably unrealistic.  Cheese sandwiches were fine for breakfast, lunch, and dinner, just so long as no one was forcing their agenda down his throat. Put in another way, he craved and needed constant stimulation and excitement. Owen’s propensity set up a vicious cycle. He’d get bored, move locations to create stimulation, get bored again, and leave one more time. To make matters worse, in each of these  situations Owen would progressively isolate himself socially. Even if I could get Owen interested in understanding and finding alternatives to these habitual patterns, there was every reason to expect that he would soon become impatient and quit our work.

So, here’s where I had to be especially creative. In spite of Owen’s age, and with his consent, I worked with his parents, providing guidance on how to manage Owen. That he trusted me was a godsend, since I didn’t have to report back to him at each point.

The alternative
Of course, we could have done this assessment without the bells and whistles, no neurological and no neuropsychological assessment. But, consider this. Everyone was exasperated with Owen. He needed a diagnosis and a fix. Maladjustment based on brilliance and understandable contempt for people he felt were his inferiors were certainly an important part of the picture. The diagnosis of ADD alone didn’t fit, but having that label made everyone feel purposeful. Owen could see the logic in the ADD label, but it wasn’t the whole picture and made Owen feel at odds with everyone else. Yes, of course, ADD was right, and Adderall worked to a point. But, the rest?

There was an interpersonal part to be addressed in the form of focused, interactive psychotherapy. A cognitive-behavioral component helped him learn to sit still and deal with his impatience. Owen agreed to ten to fifteen sessions of behavior training with a neuropsychologist who worked particularly with ADD. And there was the encouragement. The “encouragement” piece consisted of clarification that indeed he was a fish out of water and would have to stretch to comprehend and reach others who were not as smart and rigorous as him. Since Owen said he wanted to make a normal adjustment and have friends, he acceded that the stretch should be worth it. He is now taking classes in computer aided design, working in that area, and planning to return to college in the spring.

And the extra cost of the neurological and psychological workups? My claim is that they were more than justified by the fact that with them we knew exactly what we were treating and could tailor the treatment, its interpersonal and behavioral component precisely to Owen’s needs. No wasted effort or money.