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Archive for the ‘Shrink Rap’ Category

ClinkShrink climbs things all the time. She crawls up these huge vertical ledgy rocks and then rappels down them like Spiderman. It’s very athletic, but not very dignified looking. I think it’s how she directs her adrenaline risk-taking protoplasm, because in real life, she lives this life of law-abiding citizen, nun look-a-like, low profile, tuna-for-lunch with white milk, kind of soul who just happens to like working with mentally ill violent felons. It’s a disconnect and the Spiderman thing connects-the-dots.

So yesterday, I went hiking. I hiked to the top (well, almost, I got to the bald part of the mountain, minus the skin on the front of my leg, and decided the view from almost-the-top was just fine). It was described as a “very popular 4.7 mile hike with well-marked paths, the easiest of the Adirondacks high peaks.” What it didn’t say was that it was 2.4 miles straight up, a giant stair-case of boulders, with none of those wimpy switchback things to make for some level hiking. And 2.4 ish miles of scrambling straight back down.

Perhaps 30 people passed me. I was climbing with my youngster–a high school athlete in the midst of training for pre-season, and my husband who has recently lost 30 pounds with a regimen that includes 4-5 miles/day of running. I gained 12 pounds last year, and this summer I let my gym membership lapse for the first time since 1996. Let’s just say I was holding up the rear.

ClinkShrink does these things all the time. She’s older than I am and she looks like a nun. A skinny, athletic nun, but still.

I was offered water, by a stranger. I was offered a first aid kit, by a stranger. And I was offered Motrin, by a stranger. I came back and crawled into the hot tub with a glass of wine. It was some comfort that husband and kid were also sore and complaining.

Oh, this is a psychiatry blog, you say. Where’s the psychiatry? It’s August, the shrinks go on vacation, and so for the moment this is a vacation blog.

But I have now climbed the 36th highest peak of the Adirondacks.

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“What good are you?”

It sounds harsh, but sometimes that’s what I hear from my patients. When a prisoner first comes into my office, he may announce a list of things he wants me to do for him: get in touch with the public defender or case manager, look up a court date, make a phone call, give him the lower bunk, order extra portions of food, etc. When I explain who I am and add that I am seeing him only for psychiatric treatment, I hear “the phrase”: “Then what good are you?” Apparently, I’m not good as a concierge service.

Defining the physician-patient relationship is the first step in correctional treatment. Life is simpler when it’s clear what you will or will not do for a prison patient. Inexperienced correctional physicians feel uncomfortable doing this because they want to be “nice” to the patient or because they’re afraid that denying a request might harm the physician-patient relationship.

The problem with complying with all these requests is that the patient will continue to take it for granted that the doctor will always do these things, which draws the focus of the appointment away from treatment. Other prisoners will learn that the physician will do errands or give privileges, and the clinician will find his clinic swamped with requests for appointments that involve issues other than mental health care.

The clinician may be tempted to pretend to help, going through the motions of a request that he knows will not be granted. Worse yet, he might promise to help but then be too swamped or overwhelmed to actually carry through on that promise. Either way, the promise is not kept and prison patient learns that the clinician can’t be trusted.

All of this can be prevented by clearly establishing the boundaries of the treatment relationship and the limits of the appointment. This does not harm the physician-patient relationship. In fact, prison patients appreciate a straight answer, even if that answer is ‘no’. I find it helpful to give a straightforward response: “If I can help you with something I will. If I can’t help you, I’ll tell you upfront I can’t. This is what I CAN help you with…” and so actual treatment begins.

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I took my car in to the shop last week to visit his Car Momma. I’ve been going to this garage for years and I know most of the mechanics. I’ve run into Car Momma at the hair salon with her head wrapped in a towel. I’ve heard about her son, his school activities and her home renovation projects. She’s heard about my vacations and seen my climbing pictures. I’ve always been on a first name basis with the people I know there.

This time, I had to leave the car and get a rental. I left a voice message with the rental desk and when the rental guy called me back at work I answered the phone with my usual, “Dr. ClinkShrink”. Now, my garage knows what I do for a living and it’s just never been an issue or really even a topic of conversation once the novelty wore off.

The difference this time was that the guy worked on my car was new to the shop. When I arrived at my scheduled time the next morning, he was standing in front of the shop, clipboard in hand, waiting for me. “Dr. ClinkShrink?” he asked and he shook my hand. He had all the paperwork waiting to go, my rental was lined up and waiting, and every reference to me was preceded by “Dr.”. I gotta tell ya, it felt weird. Eventually he asked me if I was a medical doctor, explaining that he asked because “there are a lot of people who go by ‘doctor’ who aren’t actually MD’s.”

My first thought was: “blog material”.

I never go by my title or my initials when I’m off duty. When I first graduated from medical school a got several letters (hand-written, pre-email) from my mother addressed to “Dr. ClinkShrink” or “ClinkShrink, MD”, but that was about it. I think (and still do) that people who flash their initials around are a bit obnoxious. This was just the first occasion that I really was struck by what initials can do. (And no, I don’t plan to make a habit of flashing the ‘MD’. It just felt too weird.)

And for the record, I did make a point of telling the rental guy that PhD’s earned their degrees too.

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I got an email from one of our readers asking for the Shrink Rappers’ opinion of an article in the New York Times by Daphne Merkin entitled “My Life in Therapy“. My first thought was: “I am sooo not the person to be blogging about this.” My clinical practice consists entirely of medication management, occasionally with additional crisis intervention and brief supportive therapy. I know that Dinah will have more to say about this story when she gets back and will probably say it better than I can. Nevertheless, I’ll give it a shot.

In keeping with the Dinah tradition, I’ll summarize the story and post a couple excerpts, then give my thoughts on it and ask for comments.

Merkin writes about her forty-plus years of experience as a psychoanalytic patient in New York City. Her first therapeutic contact took place when she was ten years old; she writes about her initial ambivalence and resentment of her therapists, what therapy has taught her over the years and also what therapy has cost her in both financial and personal terms. In spite of her professional and successful outward appearance, she suffered from repeated episodes of depression. Therapy helped keep her alive, but also occasionally provoked the symptoms she was struggling to contain:

“In therapy that was more psychoanalytically oriented…I tended to get trapped in long-ago traumas, identifying with myself as a terrified little girl at the mercy of cruel adult forces. This imaginative position would eventually destabilize me, kicking off feelings of rage and despair that would in turn spiral down into a debilitating depression, in which I couldn’t seem to retrieve the pieces of my contemporary life.”

Although she knew that therapy would not provide her with a “cure” per se, she travelled from one analyst to the next in the hope of converting her “hysterical misery” into “common unhappiness”. Finally, while looking for her last doctor, she came to a conclusion:

“Now, however, in my 50s, I only felt persuaded that the last thing I wanted was to put myself into Dr. F.’s hands. I realized that I had been carrying a “Wizard of Oz”-like fantasy with me all these years, hoping to find someone who would not turn out to be just another little man behind a velvet curtain. It was not that I found all my shrinks to be impostors, exactly, but it dawned on me that I no longer had the requi site belief in the process — perhaps had never had it in sufficient quantity.”

For the first time, she decides to try living a life without therapy: “All those years, I thought, all that money, all that unrequited love. Where had the experience taken me and was it worth the long, expensive ride? I couldn’t help wondering whether it kept me too cocooned in the past to the detriment of the present, too fixated on an unhappy childhood to make use of the opportunities of adulthood.”

There are obviously limitations to what Merkin can write about: the only type of therapy she experienced was psychoanalysis, and it was unclear to me whether or not her clinical depression was ever adequately addressed pharmacologically in spite of the fact that all of her analysts were psychiatrists. Setting aside these issues, I was disappointed in the story. Her chronological list of therapist descriptions eventually took on a vacuous, droning tone of endless disappointments. She admitted that in spite of years of experience with treatment she lacked the ability to recognize a good therapist; she judged each new potential doctor based upon their wardrobe, or the office decor. The article appeared to be mainly a depiction of the New York analysand zeitgeist rather than a progressive story of one individual patient.

Frankly, I’ve heard better descriptions of the therapy experience, descriptions that were deeply personal and more heartfelt, from our readers. Merkin’s article lacked poignancy, intensity and warmth and for me it had the feel of an intellectual exercise rather than a personal revelation.

She made one point successfully: that although the unexamined life may not be worth living, sometimes the examination of life takes the place of living.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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Dinah is away so Roy and I are left in charge of the blog, heaven help us all. Real life has taken over my blogging time so I’ve really gotten out of the habit. Also, I’ve got a 383 page proof copy of the book to review and edit by the time Dinah gets back. I may have to choose between the two tasks. Here goes.

I was listening to my Nightline podcast this morning and I heard an interview with Naomi Campbell, the celebrity model called to testify in Liberian dictator Charles Taylor’s war crimes trial. There were a number of curious aspects to the story: Campbell’s admission that prior to traveling to the country she had ‘never heard of Liberia’, and the fact that she receives gifts so often that she thought nothing about having a bag of raw diamonds delivered to her in the middle of the night, or the fact that she’s so rich she immediately gave the diamonds away to an acquaintance. I was also struck by her statement that she was annoyed by the inconvenience of being involved in the prosecution of someone accused of hundreds of murders. I’d say ‘inconvenience’ was a small price to pay for justice.

Separate from the celebrity spectacle aspect of the story, there is a back story here which I find more concerning. Campbell mentioned that she was reluctant to testify out of concern for the safety of herself and her family.

This was the issue that brought this story directly home for me and the patients I work with in Baltimore. Witness intimidation is probably the single biggest factor in the failure to gain convictions for serious crime in this city. It happens so often that prosecutors routinely take witnesses before a grand jury to testify prior to trial, to preserve their testimony before they can be threatened into changing it or they ‘disappear’ before the court date. This is not to suggest that Baltimore citizens care less about justice, or are less conscientious citizens. They have reason to be afraid. One infamous drug gang in Baltimore created the notorious Stop Snitchin’ DVD to warn people against cooperating with police; witness intimidation entered the mainstream media.

Witnesses have had their houses firebombed. They’ve been threatened and family members have been killed. Criminal defendants have even orchestrated witness killings from behind bars, causing Maryland to be a leading proponent of cell phone jamming technology in correctional facilities. Maryland has also taken legal steps to hold the perpetrators responsible, making witness intimidation a felony offense punishable by up to 20 years in prison.

I can’t say that I have an answer to this problem. I do know that hearing Campbell express her fear instantly changed my mental image of her. Instead of the fabulously wealthy, inconvenienced supermodel she became someone I felt I knew. She could have been anyone in Baltimore.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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A psychiatrist I know is going through a phase-of-life change. It’s one you only get to once. He’s made the comment that in looking back, he made some mistakes and said some things he shouldn’t have to patients who were going through this same phase-of-life change, long before he did. The event of it has made him more empathic to what his patients were feeling, something he didn’t comprehend until he was in the same shoes.

I know the feeling. People look to their psychiatrists for wisdom, and you know, we don’t always have it. Patients will ask for suggestions about marriage or child-rearing from psychiatrists who may be single, childless, or on their eighth divorce. It doesn’t mean we don’t have the answers– sometimes these things are better dealt with from a safe distance– but sometimes it might. I look back at some of the things I said to the parents of teenagers, back when mine were oh-so-cute-and-loving toddlers…and I wince…oh, my, I was so clueless back in the day. Can I recall my patients? I’m sorry, I said some stupid things back then. I shrug a lot more than I used to. I don’t know if it’s helpful, but I do know it’s more honest.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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Katina writes to us from onlinecolleges to let us know about a post on which jobs are the top ten most depressing:

Check it out here: 10 Professions with the highest levels of depression.

What I found to be interesting is that the assumption is that the jobs cause the depression.
For example:

1. Social Workers: If you had to deal with abused children, unkind foster parents and less than stellar family dynamics all day, you might be depressed too. Those working in this field are three times more likely to be depressed than the general population, and many are so focused on helping others they don’t get the help that they need themselves.

There’s nothing in the post that addresses the chicken-or-egg? question. Maybe people with depression are drawn to certain fields. Artists are listed, with the statement that those who chose to work in the field “found it depressing.” And everyone kind of gets it: doctors, nurses, social workers, lawyers, artists, janitors, food service people, finance, nursing home and childcare workers. What’s left? What’s the depression rate among bloggers?

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In case you missed Morning Edition today, it was about how grief fits into the diagnostic criteria for major depression, and the debate that went into this for DSM-V.

Want to listen? Click HERE.

Want to read? Click HERE.

Excerpts:

- Holly Prigerson, a researcher at Harvard University who studies bereavement.

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I’d rather make the mistake of calling someone depressed who may not be depressed than missing the diagnosis of depression, not treating it, and having that person kill themselves.

- Dr. Sid Zisook

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- Dr. Allen Frances

And finally: a shout out to Peter who told me about this program this morning.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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From the front page of today’s Baltimore Sun: Researchers Explore Link Between Schizophrenia, Cat Parasite.

Frank D. Roylance writes:
Johns Hopkins University scientists trying to determine why people develop serious mental illness are focusing on an unlikely factor: a common parasite spread by cats. The researchers say the microbes, called Toxoplasma gondii, invade the human brain and appear to upset its chemistry — creating, in some people, the psychotic behaviors recognized as schizophrenia. If tackling the parasite can help solve the mystery of schizophrenia, “it’s a pretty good opportunity … to relieve a pretty large burden of disease,” said Dr. Robert H. Yolken, director of developmental neurobiology at the Johns Hopkins Children’s Center.

Roylance continues:
A University of Maryland study last year found that people with mood disorders who attempt suicide had higher levels of T. gondii antibodies than those who don’t try to take their own lives. Still, the links between schizophrenia and toxoplasmosis are not simple. For example, most people infected with T. gondii never become schizophrenic. And not all schizophrenics have been exposed to toxoplasma. Yolken believes additional factors, such as an unlucky combination of genes, are probably needed to produce schizophrenia among Toxoplasma-infected people. The parasite’s DNA may also be important, since some strains are known to cause more disease.

Meow?

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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