Mental Health Blogs

Archive for June, 2010

Another story came out of the APA conference that Dinah wanted me to blog about.

I was in a cab going to pick up Dinah for dinner. The cab driver found out I was a psychiatrist so he told me about his life-changing experience with therapy. At one time he was having an incredible problem with his life. He was using cocaine, couldn’t keep a job and his relationships were going down the tubes. Therapy helped him quit cocaine and change all that. (Which was good, since he was the driver of my cab. I really wanted him not to be high or in distress.) This kind of turn-around story isn’t unusual for me; parolees will often come back and tell me about things they’ve done in free society that they’re proud of.

The unusual part of this story is the fact that he made all of these changes after a single one hour session.

OK, that got my attention. What was it about this therapist?? What happened in the session?? I had to ask all the questions.

The cab driver told me that it wasn’t so much what the therapist said, but rather who she was. She was a kindly, older woman who was sincere and compassionate. She told him he needed to start taking care of himself, eat better, get enough sleep, etc etc.

And that worked. Geez, I was impressed. It changed his life. The last remaining habit he wanted to fix was his smoking. He wanted to go back and see his therapist again, but she had retired. He was sorry he couldn’t go back, and so was I.

That’s my cab driver story.

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Wait, says Dinah (who added the pic and subtitle): you told it in a more dramatic fashion at the time. He was running 8 miles a day now. There was a religious/spiritual component, something profound about the experience and about the therapist. Oy…we’ll never make a novelist of you, Clink.

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One of our blog and podcast followers wrote to us with a few questions. I’m not going to mention the person’s name without permission, but they’re a pre-med student with an interest in psychiatry. I thought I’d take a stab at some of the answers. Dinah and Roy can chime in with their own thoughts on the subjects. Here we go:

Dinah: I’ll chime in in green. Roy? Roy? Where are you Roy?

1. Firstly why did each of you choose to go into psychiatry?
There were many reasons. I loved neuroanatomy and did well in it. I was a big fan of the “popular science” brain books as a med student–Andreasen’s “The Broken Brain” and anything by Michael Gazzaniga. I enjoyed mysteries and “black box” kind of puzzles, and the human mind is the biggest “black box” puzzle in medicine.

Dinah: I was intrinsically interested in why people do what they do and feel how they feel. I’d planned to get a Ph.D. in psychology and do research, and then realized that if I became a psychiatrist, I’d have the option to do both research and clinical work. So why didn’t ClinkShrink become a neurologist???

Clink redux: I didn’t become a neurologist because gross neurological impairment wasn’t interesting but mind-brain issues were. Neurologists don’t deal with hallucinations and delusions, usually. There’s a big difference between psychiatry and neurology.

2. How do you cope with some of the stupid and strange stuff people say to you? How long does it take to learn to keep a straight face?
The “strange stuff” is what psychiatrists enjoy hearing about. Complicated delusional systems can be bizarre and fascinating and I enjoy listening to that. It’s not hard to keep a straight face when you know the person actually believes what’s happening to them and it’s frightening or bothering them. If you put yourself in their mind set and think about what it would be like if your food really WERE being poisoned, or you really did have something implanted in your teeth that controlled your mind, well, that wouldn’t be very fun.

There were a few times as a medical student when I did want to laugh. I haven’t found that anyone says anything I feel is stupid. Sometimes I have have trouble empathizing with peoples’ ideas, especially if they are paranoid or are offensive to me. This is unusual, though, and mostly I enjoy listening to stories about people’s lives, and nothing about their pain feels stupid or strange. Some of it feels desperately sad.

3. Do SSRI’s make non-depressed people relatively happy? Do TCAs have any mood altering affect on non-depressed people as well?
Antidepressants are mood-correcting rather than mood elevating. There is some research to suggest that SSRI’s may make non-depressed introverts more outgoing, and I have direct experience with non-depressed antisocial patients who like SSRI’s because it makes them more apathetic and less reactive to minor slights. Dinah and Roy may have other experiences.

Many people take SSRI’s for anxiety and find them very helpful, even if they aren’t depressed. I guess what Clink said. Also, they can induce mania, so theoretically, if someone with no mood disorder takes an SSRI, they could unmask bipolar disorder.

3. What is the neurological basis behind the symptomatology in disorders such as depression, bipolar and schizophrenia? Does it explain all the various subcategories assigned to depression and bipolar?
This one is easy. We just don’t know. In spite of all the research being done in neuroimaging with PET scans and fMRI, we still don’t know for sure what goes awry in these disorders, and we can’t use these technologies to diagnose or subtype psychiatric diseases.

As per Clink: We don’t know.

4. Why and how do some people with depression suffer from psychotic symptoms?
See answer #3. There’s still a lot we don’t know. Some people are genetically predisposed, some people have vascular or traumatic brain injuries that predispose them, some people have overwhelming life events that trigger an event. For me a better question is what makes people so resilient—able to survive horrible childhoods or natural disasters and “bounce back”, while others can’t handle routine life events without checking in to a hospital.

Regarding the question: Great question. We don’t know.

Regarding Clink’s answer: I agree that their are some amazingly resilient peeps out there. I don’t, however, know of people who end up in the hospital because of inability to handle “routine life events.” Seems to me that people have episodes of illness….sometimes they identify a precipitant, often they don’t, and sometimes I think the search for a triggering event is just a human nature way of trying to explain what may, at this point, be the unexplainable.

Clink redux: Some of my patients with severe ASPD seek admission to hospitals for, by their own report, being “unable to handle life”. In other words, having no place to live, no friends or family to help them, and not being able to keep a job. They lack the resilience and ability to maintain the basic necessities of life. Or a girlfriend breaks up with them and they end up in the hospital.

5. What are your views on prevention for psych related problems? How do you think they should fit in a model of public health?
This is the next phase of psychiatry—primary prevention. We already have national depression screening day in October, and primary care providers are starting to use simple screening instruments for various psych disorders. All of this is well and good, but it means nothing if everyone can’t afford a doctor. Finding the problem is one thing, doing something to solve it is even better.

Prevention? We’re a long way from knowing how to prevent mental illness. World peace and drug prevention would go a long way towards helping some people to not develop problems.

So those are my answers to lots of questions.

And mine, too!

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Posted for ClinkShrink:

OK, so here’s the rat story:

Dinah, Roy and I were walking down Bourbon Street at midnight during the APA conference. (Three psychiatrists REALLY didn’t fit in down there, even though we were wearing duck necklaces.) All of the sudden this huge rat ran out of an alley about two feet in front of us. Dinah screamed and did one of those cartoon-like “peddling in the air” jumps, then turned and ran. Roy and I were in hysterics. We all got back safely. Not sure what happened to the rat.

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Years ago, I had a student who repeatedly asked me how psychotherapy works. “How is it different than a conversation?”

When I think of psychotherapy, I think in terms of the talking itself as being the aspect that helps– and yes, of course it can be used in conjunction with medications. I think of it as being structured–in terms of time and place and frequency– and being all about the patient. And whether or not it’s actually discussed, some of what works is about the relationship–most people don’t get better talking to someone they despise, and the warmth, empathy, feeling listened to and cared for, well, they’re all important. And I also think of it as being a process over time. These are all parts of my definition, however, and they may not be parts of yours.

So what about about a one-time event? If someone meets with a therapist once, has wonderful insights and feels better, is that psychotherapy? (–Clink, this is your cue to put up a post about the taxi driver in New Orleans). If someone meets with their priest/hairdresser/auto mechanic once or twice or 57 times and feels better, is that psychotherapy? If someone talks to a friend over coffee every morning while the dogs play, is that psychotherapy (…clearly, it is “therapy” because most things involving either chocolate or coffee have some therapeutic value)? If a patient meets with a therapist every week for an hour-long session for years on end, but never utters a single word, is that psychotherapy?

Some psychiatrists include education about illness and medication as part of their definition of psychotherapy. Others measure it by time—if it’s 20 minutes it’s a med check, if it’s 45 minutes, it’s psychotherapy….

Okay, so what makes it ‘psychotherapy?’ FYI: there’s no “right” answer.

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Dear Victor,

I’m sorry I forgot to wish you happy birthday on the actual date. I hear you were rock climbing with ClinkShrink and hurt your knee, so I hope you are okay.

I would email you, but I’m at the hospital, and the computer here does not let me access my email addressbook. I’ve never understood why that is. I would put up a picture for you of pretty rocks or of a birthday cake, but the computer here doesn’t let me transfer images.

I would call you, but you don’t have a phone. This is a psychiatry blog, not a birthday blog, so perhaps here is where we can find a psychiatric theme in your cell-phone-free state. What does it mean when someone doesn’t own a cell phone? It has to mean something, right? WWFS? (What would Freud say?). Would Freud have a cell phone? I called your landline and sang, in my own tone deaf sort of way, but you didn’t answer that either.

Happy Birthday, Victor. Let’s eat!

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Patient complains that I’m not educating anymore, that all the good stuff is in the archives, 2006. He doesn’t say it in a critical way, he says it in a just saying way. He says it so nice, I hear it..

So back to work.  Do I have to remind you that I make up people? The patient below doesn’t exist, so if you think it’s you, it’s not.

The Story:

A woman who has been passive all her life determines to make a change. No more Mrs. Nice Guy. She wants to level the playing field when her husband’s family criticizes her.  She wants to err on the side of aggression, and wants me to teach her how to criticize, to insult back.

I’m thinking: No.  Let’s not.  It would work, would make her one of them.  But it’s not who she is; she’s better than that.  Why regress?

The joke is that her spouse has married her because she is really, really nice. She never hurts anyone’s feelings. Before she opens her mouth she thinks, “Is this going to hurt someone’s feelings? Am I going to be disrespecting this person?”

I know, unbelievable. But there really people like this. If you find some of these, don’t let them go. Hang on for dear life.

Anyway, he marries her because she’s so nice, and he’s very happy. But she discovers that his family is very difficult, very different from hers, very quick to criticize. She has married the white sheep, a nonjudgmental, easy-going person, but they judge people, especially her and how she looks, expect her to be perfect, at least to look perfect, to be like them.  And they carp on her when she’s not.

Perfect, in this family, means every hair in place, dressed to the nines, make-up. Some people dress up to go to the grocery store, others wear sweats. Our friend falls somewhere in the middle. She asks me,

Should I have to put on heels to visit a sister-in-law in the middle of the day?  Is this normal?

I’m thinking: No.

But maybe, yes. Maybe she should.   Maybe if she does this, dresses up like them, looks like they want her to look, they’ll feel more of a connection to her. The subtext, the unconscious text, is that when we conform, when we follow the herd, the other sheep assume we admire them, that we’re not judging them, irony of ironies, so their unconscious anxiety is mollified. That’s why like attracts like. So fake it ’til you make it, baby.  Join the club.

Those of you with self-esteem are thinking: No.  Let’s not and say we did.  (This is a sarcastic remark, passed down to me by my older brother, very useful, although in general I frown when it comes to sarcasm).

And you are correct. No matter how hard we try, we’ll come up short with a person who wants us to come up short. Sometimes I think the world is binary. There are only two kinds of people* — those who communicate in a sensitive fashion, and those who don’t.

Many would say we learn more from those who are not esteeming, who are insensitive. We hear a negative message and think, “Wow, I really am a zjihlub!  (Yiddish, two syllables, je, as in the French je, and lub, rhymes with tub  Means slob). I should change!”

Except most of us are just hurt when someone insults us, so we don’t change. We get angry and resistant and depressed, immature. We’re regressed when it comes to criticism. We feel like we did when we were little and our parents shamed us for things like playing with our food.  It is an art delivering a message that fosters emotional growth, personality change, and still doesn’t hurt feelings in the process. It is why parenting is so hard.

But back to our story; better would be to assert:   When the sister-in-law frowns, turn on the baffle, that confused look.  Act as if you seriously don’t get it but want to understand.  If you use the following script, first emphasize that you don’t want to be interrupted.

The long version, for the short, skip the first paragraph:

I notice you always make a point of making nasty remarks when I’m not wearing nice clothes. In your family, seems to me, people can take it, the nasty remarks, it just bounces off of you, and you seem to enjoy jumping on one another, or on anyone who isn’t dressed up.  You’ll even laugh about total strangers if they don’t meet your approval.

But you need to know that  when you say something negative about how I look, it hurts my feelings. I wasn’t raised to be judgmental. So I take it as this huge put-down, a comment about how I look. Could you try not to do this? Just don’t comment about how I look and I won’t go home feeling badly.

And why do you do it, anyway? Why is it so important for everyone in this family to have to look fabulous all the time?  I don’t know how you all pull it off, always gorgeous.   I don’t understand why it’s so important.  Seriously, what’s the deal?  Where’s this come from? How do I get to be like you?  How did you all get so fashion conscious?

This should stimulate dialogue that you can steer to the topic of criticism in the family.  It can be a really decent, intimate dialogue. Often about child abuse.  Don’t back down if they shrug and say, “Don’t know.”  Someone knows.  Someone’s got some psychological saichel.  (Rhymes with Rachel, but a soft-gutteral ch, means smarts).  After the dialogue you predict the future.

“Okay, so when I come over here in pajamas, you are not going to say anything, right? But I’ll try not to come over in pajamas if it’s a disrespect to you.  I’ll wear sweats.”

Then you label the process. When it happens again, the criticism, you say,

“See? You’re doing it again. I thought the new deal we have it that it’s okay that I be the zjilub, and you be the gorgeous one.

Works every time.

therapydoc

*Binary thinking is shallow, black-white thinking, and virtually nothing is black and white. That’s what the bell curve is all about, normality, the normal curve. To be exceptional, extraordinary, abnormal, one’s score on a certain trait must be in the tails, must be rare. But you can be anywhere, totally normal, and still not know what’s flying when it comes to relationships.

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Okay, so my gang wanted the Celtics to win. But then Lakers player Ron Artest thanked the people in his hood, his family, and his psychiatrist! You can watch the video above.

From Puggle:

The famous player of Lakers, Ron Artest thanked his psychiatrist. Ron Artest delivered a surreal interview after winning the seventh game of the ‘National Basketball Association’ finals. He showed his gratitude to his supporters in the interview. After thanking his neighborhood buddies, his family, his wife and his children, he surprised everyone by thanking his doctor and his psychiatrist (a daring confession). Even Dennis Rodman did not dare do such kind of act.

At the final and the most important moments of the game, Kobe Bryant passed the ball to Ron Artest and Artest displayed his career building shot.
After thanking his family, his family friends, his dear ones and his wife and children, Ron Artest stunned everyone by thanking his psychiatrist. In fact, he expressed his thanks twice. He stated that his psychiatrist had a lot to do with his success. He added that his psychiatric consultant helped him a lot in staying calm, relaxed and focused. Furthermore Ron Artest added that his psychiatric analyst cleared his mind and offered him a perspective of lucid ‘Visualization’. The scenario resembled the famous Hollywood flick “The Love Guru” in which the ice hockey player thanked his Guru for his words of wisdom.

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Alone on the sofa, remote’s all mine, I hit Power and what do I see? Well, it’s Sarah Jessica Parker.

Do I really want to watch Sex in the City? No, but this looks like it’s the movie, the first one, 2008.   And I missed it. So yes.

Except it’s a No, a serious waste of time. The film is overly soppy, boring, and as much as I love a good chick flick, this doesn’t work for me. The only thing I like about Sex in the City I  is Jennifer Hudson. Carrie Bradshaw, a writer, has hired Louise from St. Louis, Ms. Hudson, as her personal assistant. 

Jennifer owns the screen, she’s the only thing to watch in this movie.  When Louise leaves the job, when she leaves the script,  I’m thinking, I don’t need to watch any more of this. But I do watch just a little more to see how Carrie resolves her conflict with her girlfriend Miranda, and how in the world will Miranda ever get back together with Steve?

Marital therapy, of course.

Anyway, why bring up a movie with very little, in terms of redeeming social content, unless you’re into not-so-soft porn?

Because Jennifer Hudson is a woman of color, and you say to yourself, watching this eminently watchable, lovely, young woman,  How could anyone judge anyone else based upon the color of their skin?

A Story:
I’m training my intern about sexual discrimination and sexual harassment.  She asks me a question about the law.

What law?

The Civil Rights Act of 1964, specifically, Title VII. The Civil Rights Act, Title VII, defines protected classes of people.  Individuals in these classes are protected from unfair discrimination in the workplace, and in schools. The ironic history of this law is that in the early sixties, when the law was not a law but a hotly debated bill in Congress, the United States workforce consisted of primarily males. Indeed, most working people wore blue collars in the early sixties. This was a time when a person in tool and dye, or the auto industry, could find steady work.

It was pretty obvious to the men (men– I think they were all men) in Congress, certainly the men of the South, that if it became illegal to discriminate based upon race, skin color, national origin, things like that, then the security of their constituents, their job security, was at risk.

And yet, that’s what was on the table. A bill to do just that, eliminate discrimination. So someone thought up something absolutely brilliant. Throw in sex! Make gender a protected class, and the bill won’t pass!  Nobody wants women competing for jobs!   But when this came out, that this was all hype, political strategy, the good people in the Congress passed the law anyway.

All well and good, says my intern.  But why are people so prejudiced? How do they become judgmental? Is it because they learn this in their families of origin?

Sharp kid.

And maybe it’s true, for sure some people carry on a fine tradition of racial/ethnic hatred. But for others it is the personal experience that cinches racial stereotyping. Joanne Trapani is a diversity presenter for Cook County and I had the pleasure of hearing her associate being Irish with being a drunk. (Three dates with three Irishmen who drank her under the table).

Here’s my experience with generalizing based upon too little data.

My mail doesn’t come. Not altogether true, but it isn’t delivered, on occasion, not to my office address.  Worse yet, it isn’t picked up from the box on the street, either, not at the times posted on the mailbox.  My mail carrier is Afro-American. The last mail carrier was Afro-American, as was the one before her. I work in a postal district primarily staffed with Afro-Americans. I should, of course, know better than to blame race or skin color, and I don’t.  But the data speaks for itself.

So even though I won’t stereotype, I’m not stupid, not usually, so when I want my mail delivered, not resting in a blue metal box on the corner,  I take it to another neighborhood. Over there the postal workers are Asian, primarily Korean. Once I mailed a letter at 10:00 a.m. and the letter arrived same day. So you know who’s getting my business.

What do I do with this? Fortunately, the same thing that Joanne Trapani had to do with it, see that my experience has nothing to do with race, that there are dozens of other variables at work.  Never, ever assume that skin color has anything to do with productivity.  The bell curve indicates otherwise.  My experience is random.

When social scientists say, It’s all random, we’re saying, when it comes to mail carriers, my luck is bad.  That’s all it is.  Nothing to do with color.

It is scary, however, how our assumptions about people are formed based upon a few random acts, how our attitudes about millions of people are shaped by our experiences with a few.  It is so scary that Congress made it illegal to do this in the workplace, act upon our fears.

And lucky for us, Hollywood is doing everything possible to to publicize the absurdity by sprinkling our positive experience of diversity with something millions of people love.  Soft porn.

therapydoc

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Hmm… I recently learned that Maryland’s Department of Motor Vehicles has a long list of illnesses that must be reported to the DMV —by the driver, fortunately, not by the shrink. If a driver reports one of these illnesses, his doc needs to fill out paper work about his ability to drive.

Here is the link, and here is the list:

Customer Self-Report of a Medical Condition

Maryland law requires drivers to notify the MVA if they are diagnosed with any of the following conditions:

1. Cerebral palsy;
2. Diabetes requiring insulin;
3. Epilepsy;
4. Multiple sclerosis;
5. Muscular dystrophy;
6. Irregular heart rhythm or heart condition;
7. Stroke, ministroke, or transient ischemic attack (TIA);
8. Alcohol dependence or abuse;
9. Drug or substance dependence or abuse;
10. Loss of limb or limbs;
11. Traumatic brain injury;
12. Bipolar disorder;
13. Schizophrenic disorders;
14. Panic attack disorder;
15. Impaired or loss of consciousness, fainting, blackout, or seizure;
16. Disorder which prevents a corrected minimum visual acuity of 20/70 in each eye and a field of vision of at least 110 degrees;
17. Parkinson’s disease;
18. Dementia, for example, Alzheimer’s disease or multi-infarct dementia;
19. Sleep disorders, for example, narcolepsy or sleep apnea; or
20. Autism.

A driver must report the problem when it is diagnosed, or when he or she is applying for a driver’s license or renewing an existing driver’s license.

I can’t imagine that everyone with these disorders reports these illnesses, because I’m never asked to fill out form for DMV. And how would I know if someone can drive? I suppose if I’m being told about 6 crashes and getting lost….but I have patients who don’t have any of the above disorders, who drive, who get into lots of accidents. If everyone abided by this law (and I wasn’t able to find the actual law(s), but I didn’t look that hard), I think we’d see 1) a lot less traffic and 2) many more clerical positions available at DMV.

Psychiatrists aren’t trained to assess driving abilities. We do know the meds we give can cause sedation, and we do warn people of this. Apparently the form that is brought to the doctor asks about conditions which “may affect” ability to drive. So there’s the issue of guessing about driving ability, and the issue of predicting the future, without a working crystal ball.

Your thoughts? And this post is about driving cars, not airplanes.

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The draft of the book, along with it’s Table of Contents and The Suggested Reading (which you helped with!) is now officially done and off to the copy editor. Miraculously, we didn’t kill each other, but there were moments….

How long did it take? Who knows any more, at least two years. Roy wrote (finally). Lots of forensic psychiatry. Lots of psychiatry psychiatry. It’s done. And we’re actually still friends.

Look for

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