John M. Talmadge, M.D.

A GENERAL OVERVIEW AND COMMENT
My work includes general psychiatric problems like anxiety, depression, attention deficit disorder, substance abuse, family conflict, childhood behavior, stress, and other issues. Many people know me through my work as a specialist in the treatment of alcoholism and other addictions or chemical dependencies.

My approach to psychiatric practice reflects many years studying human nature and working to help people who are having a hard time in life. By the time most people see a psychiatrist, they are worried, or they are sad, or they are very confused about something I will just call “the problem,” or “the complaint.” Let me make some general comments about my approach, and then I will discuss my thinking on the use of medications.

People seek psychiatric help for a variety of problems, but everyone wants the same result: to feel better, to think more clearly, to rediscover satisfaction and happiness, and to regain a sense of self control and personal freedom. The problem may be related to mood, energy level, motivation, sleep, worry, relationships, anger, troubled behavior, obsessions, compulsions -- it’s a long list. People who drink too much, use drugs, or misuse prescription medication are often using these chemicals to find relief. Alcoholism and substance abuse are widespread in our culture.

Dealing with life is rarely easy.

Most persons first try to solve the problem or deal with the complaint on their own. Frustrated that things aren’t improving, they may seek advice from others. Sometimes a person hides the problem or lives in silence with the complaint. They may read a book, go to a support group, consult the internet, or try a new religious practice. We all have problems and complaints, and we all do the best we can to solve the dilemmas of life. When someone calls me about consultation, I almost always hear them say that they have a problem, they have tried to solve the problem, and they are looking for someone who knows how to help make things better.

One of the individuals consulting with me said, “I feel like I’m in a box, and the directions for getting out of the box are printed -- on the outside of the box.”

A successful airline pilot, a Vietnam combat veteran, said, “Doc, I’m out of altitude, airspeed, and ideas.”

Often the person seeking help has waited so long that demoralization has begun to set in, and they are beginning to lose hope. This doesn’t mean that the individual is suicidal or, in fact, any more unhappy than many of the people at the workplace or in the neighborhood. It means that they are resigned to always feeling this way, never feeling any better than this. Demoralization means a state of mind in which a person considers accepting fate, giving up, and abandoning the idea that things can get better.

Fear, anger, resentment, feeling constantly wounded, feeling overwhelmed, feeling unappreciated, feeling worthless -- all of these emotions are part of our lives. But when we feel negative all the time, or most of the time, most days, then we need help. There are very few emotional problems that defy intelligent therapy and reasonable efforts toward a solution.

When I meet someone for the first time in consultation, I have three major concerns. First, I want to get to know the person and hear about the problem are the complaint. My first question usually is simply, “How can I help?” or “What brings you to see me?” Second, I want to explore the individual’s point of view or understanding of the problem, including what solutions have been attempted. Third, I want to consider what we can do, working together, to improve the situation. I tend to focus more on results than on reasons. I’m not always sure about why things happen, but I am very focused on what we can do now. Sometimes I explain in detail how the brain works, and sometimes I discuss how life works. The process of recovery involves growth, change, and even personal transformation.

HOW CAN PSYCHIATRY BE HELPFUL?
Research shows that psychotherapy can help, medication can help, and intelligent problem solving helps. Psychotherapy is not for everyone, and medication is not for everyone, but the vast majority of people who want help can find it. One of my favorite expressions is, “You have to do it yourself, but you can’t do it alone.”

Over the years I have developed a style that I call “sober conversation.” The word “sober” does not apply just to alcohol and addictions. To be sober is to be serious, to focus on what is most important, and to try to get it right. I believe in the importance of what we care about, and in this regard I have seriously studied the specific problem of human will. I call it “the problem of human will” because we are often confused about what we will ourselves to do, or not to do. When I work as a psychotherapist, I am most interested in what people care about, how their beliefs and assumptions about life have been formed, and where they feel stuck or at odds with themselves. Sometimes we have conflicting feelings about the same thing. For example, someone wants to take life in a certain direction, but he or she feels conflicted about it. Or someone tries to solve a problem, not realizing that it’s part of a bigger problem, or a different kind of problem. My definition of psychotherapy is that it is a form of personal consultation, focused on the situation of the client, with the goal of solving problems and feeling better.

Not everyone is cut out for in-depth or long-term conversation. Some people like to come for a few visits, and some like to keep going for weeks, or even months on a weekly basis. Some people prefer to come two or three times a week because they want to do the work and get on with whatever is next. Some people come for an hour, and some come for an afternoon.

Psychotherapy does take time, because the process is basically two people getting to know each other in the context of a specific purpose. Psychotherapy at its best is about taking life seriously, getting it right, and feeling the satisfaction that comes from clarity of thought, commitment to integrity, and comfort with the complexity of one’s own emotions and ideas. Some say that psychotherapy is a dying art, and this may be true. Psychiatrists today (and perhaps psychologists as well) do not receive the extensive training in psychotherapy that we did thirty years ago. Many psychiatrists and psychologists are not interested in psychotherapy. And many psychotherapists are not really very good or very well trained. Today there are thousands of people who call themselves “life coaches,” and anyone can hang out a shingle and call himself a “life coach.” There are several private organizations that offer “certifications,” but there are no license requirements, there is no government regulation, and no educational standard that is generally accepted. For these reasons, I think the concept makes sense, but in practice let the buyer beware -- caveat emptor!

Medications can be very helpful in treating some specific psychiatric problems. Today we have excellent medications for anxiety, depression, mood swings, insomnia, attention deficit disorder, and other conditions. Bipolar disorder, for example, is a devastating condition that can be very effectively managed with medication, restoring individuals to a life of normalcy and stability. I have absolutely no doubt about the value of psychiatric medications. I also believe that what is most important is getting the right diagnosis and the correct strategy for intervention and treatment. I see many people who have been misdiagnosed, and even mistreated, because they have not been well assessed. Assessment can take time, and I never jump to conclusions about diagnosis. After knowing someone for a few weeks, together we may decide that we see the condition in a different way.

Psychiatric medications are powerful, effective tools when used properly, but they also have side-effects, and they are expensive. Getting the right medication for the right diagnosis is extremely important. And there is an old saying from Hippocrates, creator of The Hippocratic Oath: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.“