How To Find A Psychiatrist

Seems like a simple enough questions: How do you find a shrink?

It's not that easy to answer. There are all sorts of shrinks who do all sorts of things (therapy, not therapy, specific forms of therapy like psychoanalysis or CBT), and then there's the overriding insurance question. Not to mention location, location, location.

We've talked before about insurance, and if you haven't read Why Shrinks Don't Take Your Insurance, please do. It's a good place to start. In areas where shrinks are in short supply, often, they do take insurances and they only see patients for medication management. In areas where there are more docs and people have treatment options, they may split between those who do and don't take insurance. You should be aware that if a shrink doesn't take your insurance, you will likely still get reimbursed, but there may be a higher deductible, you'll need to mail in the form yourself, and there will be a long wait (and assorted hassles) for the money to come back. Some people are reimbursed very well, others or not. If your insurance is an HMO or has no out-of-network benefits, then a non-insurance doc will costs you the entire fee.

So start here:
--Does it matter if the shrink is in your insurance network?
If it does, and you live in an area where many shrinks don't participate with insurance, then call the insurance company and get names and numbers and do hope they aren't all dead or not-accepting patients.

--What kind of shrink? If the patient is under age 16-18, your best best is a child & adolescent psychiatrist. Be aware that many psychiatrists at academic centers run research projects and teach, and don't see many outpatients. That's not to say never---and most have a few patients, but they are often a bit harder to reach, especially when they are presenting at conferences or have grants dues, and may have difficult parking. So child, general adult, or is there some specialty need which may be very restrictive---for example treatment of sexual or eating disorders or psychoanalysis? For ClinkShrink, I will throw in that if you are looking for evaluation for a matter pertaining to the legal system, you may want to look specifically for a forensic psychiatrist.

--Finally: does it matter to you if the shrink does psychotherapy or are you fine seeing one person for therapy (if necessary) and another for meds? If it matters, you need to clarify this upfront.

Now you've got the big three questions. There are other obvious ones: parking is always a biggy, the setting may be a concern (is your ex-lover working in the same practice?), how difficult is it to get an appointment? How long do appointments last? If the first evaluation is routinely scheduled for under 50 minutes and you have a choice as to where you go: then go somewhere else. In an institution---jails, a substance abuse clinic, the medical unit of a hospital, an emergency room--- evaluations may be very brief, but in these settings your records may be available for review and the evaluation may have a very specific and limited purpose. But for a thoughtful, comprehensive evaluation before beginning on-going treatment, the usual is a minimum of 50 minutes and often 90-120 minutes. Some psychiatrists do their evaluation over several sessions.

Okay, so to start:
If you have no insurance and no money, your options are limited. The traditional place for treatment in this case is a local Community Mental Health Center or CMHC and the standard has been to have one per geographic catchment area. These clinics usually offer split care, there may be a wait, and you don't get to choose your shrink. They take Medicare and Medicaid, and they sometimes don't take private insurance. How do you find your CMHC (or OMHC)...I'm not really sure. Try Google, and then call any clinic in your area and have a heart-to-heart with the receptionist. He may be able to give you the number of the clinic that serves you.

There are other agencies that over care for the indigent. In Baltimore, HealthCare for the Homeless offers psychiatric treatment, and The Pro Bono Counseling Project will give referrals for free or discounted care from professionals in the community who have agreed to volunteer their time. Again, there's no choice in which shrink you get.

If you have insurance and want to stay in network: Call your insurance company for a list of names.

Aside from money concerns, here are the best ways to find a good shrink:

• If you know someone who likes their doc, see that doc!

• If you know someone who like their doc, but you can't see their doc, ask your friend to get some names from their doc, or call yourself.

• Call your state psychiatric society and ask for a referral. If the office is located near where you live, the staff may well know some of the psychiatrists and you can ask for a nice one.

• Ask your primary care doctor, they are used to making referrals.

• Ask a Shrink. Ask any shrink---shrinks tend to know each other....so if you can get one on the phone, they may give you names even if they can't see you. In our state, we have a shrink listserv, and people frequently post, "Does anyone know a psychiatrist in Timbuktu?" for a patient who is moving, a child of a patient, friend of a friend of a friend. As a rule, shrinks don't know what insurance networks other docs participate in.

• Ask a doc, any doc. A random doc may not be able to help you, but they may. My favorite was the friend who asked me for a referral for a breast surgeon in another part of the state. Not something I'd know, but my neighbor the breast radiologist was able to give some names and so I was email-helpful. Between listservs, Facebook, email, etc...people can sometimes find names.

• If you're a student, try the school's counseling/health center. They may also be able to suggest off-campus referrals.

What to ask on the phone (besides the obvious money issues):
It's fine to tell someone the one-sentence version of what you want help for and to ask if they are taking new patients. It's probably a burden to try to tell them your whole history.
It's fine to ask how long the evaluation is, how long a typical appointment is, and if the shrink sees people for therapy or just meds.

One Of Us: Physicians Who Kill

"I have already said that if you kill a doctor, all the doctors are instantly on your neck. But what if the man who does the killing is a physician himself? That complicates the situation most damnably..."

---Foursquare: The Story of a Fourfold Life by John Oliver

I've been reading, along with everybody else, the story of the Army major and psychiatrist Dr. Nidal Hasan who killed thirteen people in a spree shooting at Fort Hood yesterday. Let me say first that I've never met Dr. Hasan and know nothing about him; I have no particular information or insights about this offense beyond what I've read in the media.

The CNN article today interviewed two of Dr. Hasan's patients, who both said nothing but glowing things about him and his care. I've blogged about spree killers before ("Shooter Psychology") but this case is different. It got my thinking about the general issue of physicians who kill.

Physician killers are certainly a relative rarity, but they are not unknown. Dr. Jack Kevorkian is probably the most famous here in the United States, but in the United Kingdom there was the case of Dr. Harold Shipman. Dr. Shipman forged the will of, and then killed, several elderly female patients. Then there was Michael Swango, a serial poisoner who killed his patients specifically so that he could take credit for his heroic "resuscitation" efforts. As far back as 1920 Dr. John Oliver wrote about an anonymous psychiatrist colleague who killed another physician and was found legally insane. The quote at the start of this post is from Dr. Oliver's autobiography were he discussed the case. For anyone really fascinated by the topic, I refer you to the book Demon Doctors: Physician Serial Killers. I haven't read it myself so I can't vouch for it; feel free to write in reviews.

But I digress. Getting back to what happened at Fort Hood, the news reports don't indicate anything to suggest that Dr. Hasan was psychotic, motivated by greed or financial gain or out of a need to be a hero. He wasn't an infantryman who had been exposed to combat and who might have been terrified of going back to a traumatic environment. He was educated and presumably in a better financial and social situation than most of the patients he treated, unlike many of my murderer patients who have burned multiple social bridges prior to the killing.

Regardless, a killing by a physician---particularly by a psychiatrist---creates a bizarre aftermath. The military is sending mental health professionals to counsel the victims and witnesses; I'd be willing to bet those military mental health professionals will be required to check their weapons at the door.