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After a few tedious weeks of experimenting with ‘classical radio as background noise’ the Mesa office hall sound system has gone silent. I was just in the process of preparing some politic email to ask thems in charge to turn it off or even back to the ‘classical rock’ station when it happened. The quiet hallway is now quite peaceful. On the downside I sometimes hear through the walls the more boisterous therapy patients bemoaning issues of Love  but this is a small price to pay.  I don’t know which I now hate more, Journey or Telemann. Brother #2 recently reminded me The Nephews have hours of the most horrible cacophony and I should count my blessings. I have no idea who the hell is making music these days but it all sounds dreadful.

I realized just before they pulled the plug on the classical rock station nearly every song was about Love. I don’t often think of Love but what to make for dinner and what to do about the car door. Perhaps these topics are not suitable for singing but I am in favor of songs other than about Love.  In my profession I don’t meet many made happy by Love. Rather it drives them crazy. No one has ever come into my office dancing for joy about Love but many have come in to cry about it. The smitten one often is of two opinions about Love: the loved one should either devout all his/her life to the smitten one or should drop dead. I don’t hear this in the classical rock station songs. Sometimes they admit Love is over and now it’s time to move on with dignity after conveying they have made complete fools of themselves on social media.  They don’t sing about that either.

I am on pins and needles waiting to hear if the office music remains off or goes back to the Scylla and Charybdis of rock and roll vs. classical music or it goes on to some new sort of horror-show.  I suggest if we merely want sound to drown out the lamentations of the smitten ones we try some sort of new-agey sort of songs, which are easily dismissed and they never have Love in them.

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A friend of mine was recently the victim of a horrible crime. He was assaulted. He is now dealing with the medical, legal, and psychological consequences of such an event. I recently wrote to him. I want to post a copy of what I wrote.  I’ve removed some of the personal bits. I decided to do this on the hopes its contents can do more than help heal a specific person. Perhaps it may help someone else who needs to hear this. Urspo. 

My dear Friend,

Like everyone else who knows about your matter, I too want to reach out and say something – anything – to help you. I am glad to see on Facebook you are surrounded by Love. I thought I would add something else along my area of work. I treat trauma patients; here are some thoughts I hope bring you comfort and hope. 

From what I read on Facebook you are probably having what we shrinks call an Acute Stress Disorder. This is psychobabble to say the obvious: you’ve had a nasty traumatic event which has left you are feeling raw. You seem to be having the usual emotions and behaviors: scared, anxious, despondency, and withdrawn from others, along with poor sleep and paranoia. 

Most people with ASD recover. Really. The symptoms suck and it’s painful but for the majority it all passes other than a bad memory. There are no good studies to predict who is prone to developing ASD after a trauma, or who recovers soon, late, or not at all.   

ASD is not PTSD (post traumatic stress disorder). Both can have nightmares, flashbacks, triggers, hypervigilence, numbness and startles easily. The difference between the two conditions is straw splitting of time. If ASD lasts more than six months it is renamed PTSD. In PTSD the event ‘haunts you’ still despite time and treatments.  

No one really knows why some with ASD go onto to develop PTSD.  None of the variables – trauma type, intensity,  baseline character of the patient – predict who comes out of a trauma relatively unscathed. 

So do not assume the emotions you are feeling now will be permanent. The majority of people ‘get over it’.  Keep hope. 

With that said, there are some things you can do now to better your chances of recovery and to ward off ASD/PTSD. 

1 – Keep in touch with the support network you have. Social support has the most correlation to recovery, wellness, and resilience. Accept all support offers, from someone to cry to at 3AM to the person willing to come in to walk the dog or fix the yard. 

2 – If you are having insomnia or anxiety/panic, avoid tranquilizers. They immediately help but they get in the way of the healing process. If medications are needed, there are others more likely to help in the long run. 

3 – Although it is awful to do, don’t avoid things. Avoidance is understandable but it leads to a slippery slope of isolation.  Get out and get around. Some day – I hope sooner than not – go back to the scene of the crime. Go with friends and go in the day time. Make it a ritual. Call  back your energy and proclaim the place/the bar will no longer dominate you. Perhaps a poem or a reading  may help. Maybe a primal scream is what’s called for , or something along the line “As God is my witness, I shall never go hungry again!” figure it out. 

4 – Avoid Victim energy.  Yes, you were a victim of a legitimate crime which demands Justice, but don’t let it take over. Channel instead Warrior Energy towards social advocacy and awareness.  

5- I know this sounds corny/cliche and it is easier said than done but when given a choice of action or thought choose the positive option. Choice-less, you have a choice now : get better or get bitter. I have no good advice on how you are to do this. It may take a very long time. Take comfort you are not alone on this Journey. 

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I find it exciting I work in a medical specialty that is continuously changing. The challenge of this is keeping up with all the changes, including evidence-based data that supports a change in paradigm.  This is along the line of “Yes! Everything you know is wrong!” and please discard X in favor of Y.  Some see this as a sign of fault, but it is the cornerstone of science viz. new stuff helps us discriminate what is valid and what is no longer valid.  Here are some curious things in psychiatry you may find interesting:

The use of technology to tailor treatment. Imagine!  You go to a shrink, he/she takes a DNA analysis, sticks your head in a scanning device and exclaims you have a deficiency in the frontal lobes for serotonin and prescribes a specific serontonin-based medication for you.   This would save a lot of time in the trial-and-error of trying this-or-that medication.   We have DNA tests; we have scans. Alas, they are not good enough yet to use them effectively.

More integration of non-pharmaceutical interventions. It is always nice to see common-sense notions supported by data to ‘prescribe’ them for treatment.   Research supports daily exercise, proper sleep, and real socializiation (not FB!) is vital to the treatment of anxiety/depression.  Psychiatry is getting more into mental wellness as a result.

Psychedelics in the treatment of PTSD, depression, etc.   Nasty old forbidden party drugs like peyote, LSD, MJ, and Ecstasy are being re-examined for treatment in mental illness. So far the data is sparse but there are hints of ‘something there”.  Ketamine, a powerful hypnotic (and dangerous street drug) looks to have quick and profound (but not long lasting) benefits for suicide and depression.  It is fascinating stuff. It will be even more fascinating to see how society/pharmaceutical companies react to the evidence viz. will the government allow such and will Rx industry bother to develop them into proper regulated prescriptions?

Parity of mental illness to other illness. When I started shrinking head in the 90s, most people (especially over 40yo) would rather drop dead than see a psychiatrist. That was a sign you were crazy.  Nowadays, I have 20yo coming in already having researched their self-diagnosis asking for particular treatments (as if I were a short-order cook). I also get men in their 50s who ‘heard about me through a guy at work who sees me” suggesting people (even men!) are talking openly about their struggles with depression, anxiety, PTSD etc.  I am glad to see mental illness being seen more on par with having diabetes, blood pressure, etc.

Nutrition. This one sounds like a no-brainer but there is evidence to support ‘eating right’ is good for mental health, but probably not in the way one first thinks.  There is fascinating research going on about the microbes in our GI system acting in harmony with our immune and mental capacities. If they are happy being fed proper, then they harmonize our brains; when they are stressed/cranky from bad food, they produce things which cause inflammation and brain stress to worsen depression. Who would have thunk keeping the wee-beasties in our bowels happy was an integral part of mental health?

One of the great curiosities of the human mind is something called pareidolia. This fancy word means we have the tendency to perceive a specific, often meaningful images in random or ambiguous visual patterns. In other words,  we see things that aren’t really there. It is a blessing and a curse.  We want – need? – explanation for why things are. Things ‘don’t just happen”; there must be a reason(s) for every event. When we can’t find an explanation we make them up.

Once upon a time the supernatural or the divine was the cause why weather/circumstances/events etc. went one way rather than another. Although we’ve sort of thrown out the gods pareidolia continues in the belief of karma and conspiracies. Even in my psychological training there is a word for it: synchronicity. Synchronicity is a murky word meaning significance out of seemingly random actions. Jung he wasn’t clear on the definition but thems who proscribe to his psychology tend to see ‘mere chance” as not possible. One can extract meaning out of everything.

In my practice, patients are always trying to find or make explanations for their happenings, especially along the line of some sort of ill-defined fate that caused them to be at the wrong place at the right time. They say it was “meant somehow”  to be in that car accident or witnessing a murder or when s0-and-so died etc.

Turn on the news or surf the internet and you will find endless conspiracy theories to explain what can’t be easily explained. They are as thick as fleas. Nothing just happens or happens for a simple reason. Behind an easy explanation (or worse, no explanation) there must be an intricate web of deceit. What this all boils down to is purpose: nothing happens without it.

The sad and terrible truth is banal and bleak.  Bad and good things happen and there often isn’t any reason or meaning to them. There. That’s it. There are no gods, no karma, no conspiracy. We have to accept there is  no meaning why the storm hit here and not there.* The stuff we see on the surface of Mars is merely stuff.  One is not fated from bad behavior or divine wrath to have bad things happen.

It is chance without meaning.

Better to make peace with fate without dressing it up as three dames dictating your life’s thread.

We would be better off to stop seeing things that aren’t there.

 

 

*Bad weather reported as ‘God’s wrath’ against homosexuality, abortion, or whatvever scapegoat-de jour is happening is especially irksome. 

Office

It is curious to see how my partner and I dress to go to work. Someone wears the same outfit every time: black trousers, white shirt with neckwear – always orange. Sometimes they are bow ties; sometimes they are long ties. He irons the shirt and pants to make them sharp and wrinkle free.  This outfit does not vary; it is the dress code where he works.  In contrast I basically wear what I want, which is often whatever is at eye level. Mostly it is a Spo-shirt and khakis, the latter I admit are not always pressed and some of them have dog-eared cuffs.  When I wear a white shirt/dress pants ensemble it may or may not have neck wear.  My boss has never conveyed a dress code*; I can wear what I please.  So I do.

If I were a ‘proper doctor” I would wear a white shirt, tie, dress slacks, and a white coat- but I am not in a usual doctor setting. A white coat would make me look like someone who is insecure about being seen as a doctor.   I dress not so much ‘what I want’ but what I am;  my shirts reflect me like nothing I could buy.  If a patient doesn’t like how I dress they can go elsewhere.  Rarely do I get something like the following:

“Why are you dressed like that?”

“Oh, (feigning concern), you don’t like it?”

“Doctors are supposed to dress [fill in the blank]”

I refrain from responding with

“And patients are supposed to [fill in the blank with something pithy]”

I have a three-month waiting list; I don’t need to coddle.

I am quite aware of the psychology behind ‘dress for success’. When you dress well people respect you more and you convey confidence, professionalism etc.  You even feel better and more capable.  I do sometimes worry  about first impressions with the new patients, some of them highly anxious and ambivalent about coming in to see a shrink. These nervous novices imagine I will be dressed like Freud or Hannibal Lector.  Seeing me in a bright colorful aloha-style shirt either assuages or heightens their anxiety.  But, I see new patient every day; they are going to encounter me in second-rate khakis and Spo-shirt so it’s best to shock’em right away.

There are two other significant factors in my choice of clothes:  the climate and culture of Phoenix. With temperatures usually above 40C a suit is most uncomfortable. They are hardly ever seen and they evoke not so much respect/confidence as suspicion.  Arizona may be the most dressed-down au casual place I know, where tucking in a shirt is considered dressy.

There are three basic clothes styles: Ruffian, Refined, and Rakish. I blend Rakish (colorful shirts without coat or tie) with Refined (quality shirts, trousers, and socks – no rubbish).  I have a good gig  provided I don’t show in last season’s Pradas.

suit_work

 

*My father once advised me to dress like the boss, but he often shows up to work looking like he just came in from working in the yard.

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I was recently reminded of some aspects about human psychology that make we wonder how on earth we survive as a species let alone get anything accomplished. Spock-like I raise my right eyebrow at the lack of logic tin human behavior and cognition.  A grim phenomena that pops up over and over is our quick and inevitable proclivity to quickly form into groups to create ‘us’ vs. ‘them’ situations, sometimes doing so based upon the most trivial of reasons. Worse, we don’t seem to need an ‘us’ so much as we need a ‘them’  to shun and exclude.  Another depressing finding is the hopeful belief if provide people ‘the facts’ they will see their error and shift their views. Fat chance of that. Rather, people either don’t change their minds or they merely become MORE steadfast in their beliefs, as if you were attacking their whole wellbeing.  We are more likely to sacrifice our integrity than go against what our ‘tribe’ wants and thinks, lest we are ostracized and have to go over to ‘them’.  Oh the horror.

This point is illustrated by a study in which thems on the right and thems on the left are told of a fellow with a PHD in meteorology who teaches at Harvard/MIT and has decades of research about the weather. The groups are asked if he sounds an expert; they confirm they see him as such. Then, the Right is told this fellow supports global warming and the Left group is told he doesn’t believe in Global warming.  Rather than the members changing their minds both sides conclude the man is a quack.

It makes me want to pack up and move to New Zealand but of course it is no better there* as people are people.

The trap is to conclude our monkey-brain wiring system’s proclivity to choose group and group dogma over truth and individualism is inevitable. Freud had his many faults but his chief axiom holds true: that we are unconscious of gets acted out. Watching these inevitable human tendencies allows us a slight chance to choose otherwise.  We can cooperate; we can choose not to exclude; we can talk to each other without condemning them when we realize they don’t agree with us on some matter.   Let us hope so, anyway.

 

*The white wines are better in New Zealand.

 

OfficeOnce in a while I sit across from a long time patient with still active symptoms looking at me to ‘do something’ despite years of attempting to do so. What to do? For these types of cases, I have made ‘cheat sheets’. These are timelines written by hand on foolscap paper, which I keep in a folder unofficially titled ‘the rock-and-rollers”. At a glance can see all that has gone on before me. They are time consuming to make but they frequently come to the rescue when I am in the ‘what on earth am I do here?” position – which happens often. Thanks to them I can make logical recommendations based on history and trends and patterns rather than micromanagement or (worse) random guessing.

The folder needs periodic tidy-up, so every season I go through the ‘active’ pile and sort out the patients who have dropped out. Those not seen in over twelve months I move to another file with the precise if not too imaginative name of ‘Inactive’.  Like The Flying Dutchman some of these will come back but the majority will not.  Yesterday as I put the sheets in order, I wondered (as is my wont) why they didn’t return. Patients drop out all the time.  I don’t know if this happens more or less in psychiatry compared to other specialties. I don’t have the data to how my dropout rate compares to other shrinks. There are many possible reasons why patients drop out and don’t return:

Death

They move away

There is a loss or change of insurance

There was a dissatisfaction with the clinic or with me.

They got better.*

Whatever the reason[s] the inactive pile always evokes thought. Since these patients were challenging (thus the need for a cheat sheet) most of them quickly come back to my memory. I sometimes recall their story but more often they disappeared without explanation.

The patients who died are the ones are the ones who evoke in me the most thought. I am seldom privy to how they died. The news mainly comes from a telephone message from a relation ‘Joe’ isn’t coming in anymore as he died last month.  Sometimes Joe’s death is announced via fax from the county medical examiner they have his body and please supply notes to help them with their inquest. Many of the inactive patients were old, sickly, and they didn’t take care of themselves. People with mental illness tend to not live as well or as long as people without such conditions.

The death of a patient evokes all sorts of emotions including angst about suicide. Most patients I see are at some risk for such. I can speak for most psychiatrists when a patient commits suicide the doctor becomes anxious about that what-ifs: had they missed something or should they had done things differently etc. Truth is when a patient in intent of killing themselves nearly nothing can stop them.

Regardless of the cause behind a long time patient going from the ‘active’ to the ‘inactive’ folder each one makes me wonder if I really did anything lasting for them while we were together. Mind, some were with me for years if not  nearly a decade. It was my task to be with them on their Journey as they moved through life, hopefully better for our interaction. I never know – and I seldom if ever get a thank you either. I have to take satisfaction in knowing I tried while our paths converged.

 

*The scientist and the businessman elements of me really wants to know this stuff. If people are dropping out due to dissatisfaction, I would like to know ‘why’ to try to fix problems.  Negative reviews online are of little help. Those I have read were either not going to be happy no matter what OR upset I didn’t do what they wanted me to do. “He didn’t listen or take care of me needs” is code for “I wanted valium but he caught me doctor shopping”.

I am dismayed but not at all surprised to be up to my oxters in post-vacation paperwork. It’s been nonstop. However it calms down.  Things will settle in time. 

Office

In med school we were taught to always touch the patient in some way, even if they were coming in merely for forms or a shot from the nurse.  In internal medicine this is easily done by taking the pulse or listening to the lungs.   Touch heals; touch is therapeutic – most of the time. In psychiatry, the  patients often have issue with touch.  There is controversy about psychiatrists touching patients at all.

Today a long time patient came in,  this time with her spouse. After the appointment concluded I shook his hand out of habit of male to male custom. I then shook her hand, in the presence of the mister. She remarked that in the many years of coming to see me this was the first time I had ever reached out to shake her hand.  There was a mild chastisement in her voice.

She wasn’t wrong. I don’t shake hands with the female patients. This is a conscious but not comfortable decision. Many of my female patients have PTSD and a history of trauma from men. Touch is often a trigger to upset or flashbacks. I have a handful of patients who still look like they have entered an abattoir when they come to see me, despite years of service.  Once I had a female complain I had come on to her when in fact I had merely shaken hands hello and good bye.

4.1.1

4.1.1

New male patients I don’t usually touch (lest they have OCD germ phobias or social anxiety) but I can sense ‘mistake’ and make sure at the end of the appointment I give them a shake.

This bias is not something I feel comfortable with.  I suppose I can err on shaking everyone’s hand and if this results in emotional upset it is hoped patients will politely decline my offered hand, but in truth they don’t speak up.*

There is a flip side: female patients who want to give me a hug. Then it is my turn to feel uncomfortable and have troubles figuring out a way to say no.  Male patients (straight ones anyway) never want to hug me.  Sometimes when a gay patient is leaving they want a hug; common sense tells me to put out and not hide behind the APA bylaws.

By the way, I see the female counselors at work regularly hug their female clients hello and goodbye.I don’t see them hugging the male clients.  The male counselors don’t hug anyone.

On Thursday I see my own physician.  When The Good Doctor enters the room he and I always shake hands and later again at the end of the interview.  When he examines me I sneak in a therapeutic jolt that this is healing and not just finding the edge of my liver.  After a decade of his care and service I want to give him a bear hug – but I don’t. I wonder how many of my patients long to do likewise with me.

I wish touch wasn’t so politically charged or tainted by anxiety.

images.jpg

 

*This parallels their trauma history viz. feeling helpless to say no to a man in power and she feeling powerless to resist.

Office

Once in a while I sit across the desk from a long time patient with again active symptoms who is looking to me to ‘do something’ despite years of treatments and interventions. What on earth is next to do? For these types, I have my ‘cheat sheets’ to consult. I sometimes make a handwritten timeline summary on a patient. This allows me to see at a glance all that has gone before. These papers are time-consuming to compose but they have come to the rescue on many occasion. Thanks to them I can make logical recommendations rather than resort to micromanagement or (worse) random treatment proposals.

Once in a while I go through the ‘active’ pile of cheat sheets to realize some patients have dropped out. Those not seen in over twelve months I move their cheat sheets to the ‘inactive’ folder. I never through them away. Some folks will come back, sometimes years later. The majority who go to the inactive file do not come back.  As I tidy up the folder, I often wonder what happened and why they didn’t return.  Patients drop out all the time in Medicine in general. I don’t know if this is more or less the same in psychiatry as in other specialties, nor have I the data to know if this happens more or less than me compared to my fellow wizards.

There are many possible reasons why patients drop out/don’t return:

Death

A move

Insurance (a loss or change thereof).

A dissatisfaction with me or the clinic.

They got better.

Whatever the reasons the inactive pile members makes me wonder. Since these patients were long timers and challenging too nearly all of them come quickly back to my memory. Some I remember they told me moved away; some I know have died.

The patients who have died are the ones that evoke the most thought. Many of the inactive ones were old, sickly, and didn’t take care of themselves. People with mental illness tend to not live as well or as long as people without such conditions.  I am seldom privy to the reasons how and why they died. The news of their deaths mainly come from a relative’s telephone message Joe isn’t coming in anymore as he died last month.  Sometimes I am told via an ominous fax from the county medical examiner office; they have Joe’s body and please supply the latest progress notes to help them with their inquest.

A patient’s death evokes all sorts of emotions, including anxiety of  a possible suicide. Most patients I see are at some risk for such. I think I can speak for most psychiatrists when a patient commits suicide the doctor wonders had they missed something or should they had done things differently. Truth is when a patient in intent of killing themselves nearly nothing can stop them.

Regardless of the cause of the transfer from ‘active’ to the ‘inactive’ status each one makes me wonder I my endeavors made a difference. Mind, some of these patients were with me for years, if not a decade. It was my task to be with them on their Journey, if only for a little while, hopefully better for my contributions. I never know – and I seldom if ever get a thank you either. I have to take some satisfaction in knowing I tried my best.

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Every January I see the same sordid situation at work in Medicine which I call ‘The Change” . This is a collection of disrupting alterations patient insurances and co-pays. Most people’s deductibles again kick in now and Rx regiments are suddenly altered usually without warning.  To top it off, the clinic where I work insists all patients fill out up-to-date insurance forms even when they insist nothing about their insurance information has changed.  More than a few patients come to clinic for their appointment only to learn their insurance is no longer taken here. (either the insurance pulled out or the clinic pulled out from the insurance).  Oh the pain. It is all quite predictable and repetitive every January.

“The Change is coming” says The Wonder Receptionist every mid-December. Alas, there is no way really to prepare for it.

It’s Wednesday night and I am pooped from it all – and I am only two days into it!  As I see most patients every 3 months ‘The Change’ usually lasts that long then is drops off to relative quiet until next January.

On the positive, lots of patients now bereft of coverage get quite upset they are losing me. For once I hear I am valued; it is rather sweet. I will be getting soon a bunch of new patients in need of a new shrink; the majority seem surprised and pleased I do a better job than the quack they just came from hohoho.

Less jolly are the patients who feel they can’t afford their medications anymore despite the fact the meds were working and sometimes they were the only Rx that worked. We spent a year getting them right only to learn they can’t continue.  It is curious to see what a patient is willing to continue or let go.  I believe if all tranquilizers became ‘not covered’ every one would sell their grandmother to pay for pills rather than give them up for $ sake.

I wonder in more civilized nations if they have all similar January chaos. Perhaps universal or governmental coverage has no yearly square-dance of changing doctors, medications, and coverage.  I dare say if Americans were to vote on health care issues  in January when deductibles are active more people would go for a new system.

Oh well. We all bitch about the system but never enough to demand real change. People seem to accept “The Change” as an unalterable truism rather than a sign of a system that needs overall.

Well that’s enough ranting. I need to get my beauty sleep to face another round tomorrow.  In my day schedule patient types are color coded.  As of yesterday my schedule is awash in lavender, the color of  thems who need insurance updates. This is rather pretty compared than the dull beige of patients without bills or issues.

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