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Note: The Board of Directors Here at Spo-Reflections thought this entry rawther altiloquent. The told me to expunge the similes and smarty-pants words. Nerts to them. I left’em as they are.   After all this article is about control.   – Spo

In my line of work I see a lot of stress. One of the most frequent and most upsetting emotions people have is the feeling of not being in control. “I have control issues” they tell me. They quickly go into a horrible fantod when they feel not in control. They spend a lot of time and energy etc. trying to be in control.  For folks with ‘control issues” the poor dears never seem to have any control. It’s like being a perfectionist who can never get anything right.  The gods seem to find the vow for control comical; they like to surround thems with control issues lots of thing uncontrollable.

After thirty years of encountering this issue I’ve come to these conclusions:

There isn’t much you can control.

Control is overrated.

Letting go of needing control paradoxically helps you feel more in control.

Alas, these truisms are seldom comforting to these poor unfortunate souls. Rather than feeling relief to hear their ponderous yokes can be thrown off patients with control issues double down and up the ante in their agitation to become more in control. Oh the pain.

One of the reasons they fare so badly is they continuously confuse things they can control with what they can’t control.*  In ‘The Serenity Prayer’ people ask for the knowledge to know the difference. Not so my patients.

Alas, Babylon! One can’t control Life – or most of it. In the proverbial Pandora’s box of Life’s uncontrollable elements there is hope. There are few things we can control, and happily they do a lot of good. In Life’s game you don’t have many cards but you hold a few trumps.

– Things you CAN’T control –

Other people  (what they do and what they think of you)

The weather

The past

Random bad events  – which are not due to God’s will/Fate/destiny etc.

 

– Things you CAN control –

Diet

The company you keep

How you treat others

Asking for help

Your choice in beliefs and attitude

Saying ‘no”

The philosophy of Stoicism rests upon the axiom Life is not a field knee-deep in buttercups and daisies but full-up with sorrow and disappointments. One can not control things yet we take comfort knowing we will be OK enough.

Spo fans are welcome to put into the comments additions (and disagreements) what you think we can/can not control.

*This in itself is a problem viz. control-types don’t want to sort out what they can’t control; they want to control everything.

 

NOTE: this one was written without too much careful thought or editing. It is more catharsis than careful prose. I thought to store it away until I could carefully comb it for errors and such. I decided to post it as it is.   

When I was a newbie shrink I was filled with enthusiasm and psychoanalytical theories; I was ready to shrink heads and assist others in their exploration towards awareness and better being.  Thirty years later I am not so excited in that way. I now know many (most?) people don’t want to ‘get better’ or they lack the courage and/or resources to do so even when they want to.  A lot of my nowadays work it trying to do what I can; I try to alleviate some pain and keep major bouts from blossoming.  The vast majority of my patients aren’t looking for self-achievement; they are looking for a means to keep their symptoms from dominating their lives so they can function. Medications often work better than insight-oriented analysis when it comes to helping agoraphobia or manic reckless behavior.  For folks with intrusive ruminating thoughts it’s better to give them Prozac than to explore their alleged unconscious violent ideation towards others, which was the standard approach in psychoanalysis for the treatment of OCD.  What I professionally do, and the tools and paradigms I use have little resemblance to what I had in the early 90s. It’s like looking back in your photos to how your dressed in the 70s. Oh the embarrassment.

Sometimes I think this is a bad thing viz. being mostly someone who writes prescriptions to treat a conglomerate of symptoms. I no longer deal with patients more personal problems. It feels a bit soulless. After all Psyche is the Greek word for soul. I hear tell psychiatry residencies no longer teach psychotherapy other than the basics of how cognitive behavioral therapy works (the one therapy with data to back up its efficacy).  Having psychiatrists learn psychoanalysis has been compared to astronomy students being obliged to learn astrology.

One the positive what I do is more and more ‘evidence-based’ and not based on theories without good data to back it up.  I feel more like a proper physician. Funny how my field was once criticized for being mumbo-jumbo and now it is accused of pushing pills.

All the same it is a field constantly growing as we learn more about the puzzle that is the human brain. It’s exciting to be continually learning   albeit a bit discombobulating to have all my beliefs redone every decade or so.

It’s late and I am tired. I’ve been dealing with patients and their matters all day and into the night. It’s been a rather tough week with each day ending with a sense I don’t think I can or want to keep going.   Perhaps I will feel better about it all tomorrow after a rest. It will be another full day as I try to juggle objective scientific data with human empathy and compassion.  May my efforts do someone some good.

 

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The Other Doctor (TOD) and I have different approaches when it comes to seeing patients who are associated with existing patients. If TOD has “X” for a patient, he will not see X’s spouse, children, siblings, etc. Even distant relatives are declined.  I take the opposite approach:  I subscribe to the ‘Family Physician” style of shrinkdom in which the doctor sees relations to appreciate all that’s happening at home, work, and family.

My style as a drawback I have to retain patient confidentiality. This is no small task. I have to remember who said what. Mr. R sometimes asks me will I see their spouse, child, parent, coworker, or friend. This is a compliment as he must feel good about my services to ask me for such. I explain yes I am willing but on the agreement despite my attempts to keep boundaries inevitably I will bungle.  I give an example of asking Mr. R about so-and-so only to see him raising his eyebrows and asking me how do I know about so-and-so as he hasn’t ever brought it up. Inside (I explain) I am thinking “Drat, it was Mrs. R who told me that”.  If Mr. and Mrs. R don’t mind these human mistakes then make it so.  I don’t remember a time when this dissuaded them from both seeing me.

Getting different views and perceptions of what’s happening can be curious. The missus comes in with remonstrations about the mister. A few weeks later when I see the mister I ask how are things at home he replies oh everything is fine really no matters.  Is one of them ‘right’ and the other ‘wrong’? Are both ‘true’ from a subjective point of view? I have to maneuver around these Roshoman moments all the time.

The ‘family practice’ style of psychiatry has a harder issue than merely keeping tabs on who gave me what or different points of views. I wrestle with ‘secrets’ the other one doesn’t know but ought to. The Other Doctor doesn’t have to contend with these matters, which is probably why he does not do the family practice approach. Recently I had a new patient who was horribly depressed in his relationship. He felt stifled to speak up his partner about the many miseries in their marriage. A few days later I saw his partner who remonstrated his partner the new patient is depressed but he can’t figure out why when all is so well at home and they are groovy.  I remember a case I saw the mister who was having hook ups unbeknownst to his wife my other patient.  Do I tell her?  I am allowed to break patient confidentiality if there is an immediate threat to self or others. If someone says they plan on killing themselves this weekend but don’t tell anyone you bet your knickers I am going to call someone. However what if they are voicing thoughts of suicide without immediate plans or intent and the spouse doesn’t know. That’s not as clear.

As for complaints about the other, I often sense A is telling me things as A doesn’t trust B is forthcoming with me. I try to get A’s permission for me to talk to B. When they so no, I point out how the heck am I supposed to bring up something?  Often I have to find some way of discussing a topic with B without letting on I know the scoop because A said so. Once in a while B smells a rat; I remind B this happens when A and B see the same shrink.

You would think these matters would be enough for me to take TOD approach. I too should tell folks I won’t see their friends, family, and coworkers – but they don’t. The benefits of seeing the bigger picture outweigh the drawbacks.

Office  I spend a lot of my professional life trying to figure out ways to get people to do things they don’t want to do. In Medicine this is called “nonadherence to treatment’; in classic psychiatry lexicon this is ‘resistance”. Really though it is just human nature. We are wired to seek the immediate reward as ‘the future’ was tentative at best. Our monkey brains like food and sex and avoiding unpleasant situations. They aren’t designed to think of retirement planning and cardiovascular disease. I plead, coax, and (sometimes) threaten patients to improve via long time plans often to no avail. Patients – humans really – want short time immediate fixes and results.

I often channel The Cassandra Complex, on which I have written. Cassandra (for thems who don’t know her and/or too lazy to look up that entry) was a Trojan princess cursed by Apollo to always speak the truth but no one would believe her even when she was spot-on correct again and again. I was recently reminded Cassandra had impediments that made the situation worse. If she could have worked on them things might have been more communicative.

1. She spoke in cryptic metaphor. I recently reread some of her wailings and it is no wonder no one could deduce what the hell she was trying to say.

2. She spoke of things too far in the future. People couldn’t connect the dots to what was happening now in their immediate lives to faraway consequences

3. She asked too much of people.

4. She didn’t have any authority.

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I keep these Cassandra-mistakes in mind if I want my patients (and myself) to overcome the propensity to procrastinate and avoid anxious endeavors.

#1 is easy. I try not to speak ‘psychobabble”. I move between lexicons depending on the abilities of the patient before me. I need to be clear with my words and what I am trying to communicate.

#4 used to be a sure thing. When doctors spoke it was with an authoritarian-don’t-question-me voice. Those days are over (and probably for the best) but I still hope I have some clout. I am up against what’s on the internet, often pointing out to patients their Google search does not surpass my expertise.

#2 and #3 are more difficult. They are the Scylla and Charybdis of the medical odyssey. Let’s start with #2:

With few exceptions my patients are not dumb. They ‘get it’.  They know if they continue smoking and eating Oreos instead of oranges they are going to have trouble. But the human brain makes long term abstract thinking (and consequences) hard to make happen. This is especially true for folks in their 20s and 30s who all too readily believe they are invincible and they won’t be like their parents (remember thinking that way?).

Defining what is “asking too much” in #3 and how to circumvent it is an ongoing art. I think this is where Medicine as a ‘practice’ gets its namesake. Rome wasn’t built in a day and Naples wasn’t rebuilt in a year. People are more likely to start with – and succeed -with one specific task than a cosmic transformation.  “Give up sugary drinks” is more likely heard and done than ‘stop sugar for the rest of your life”.   “Start walking 15 minutes each day” is better than ‘lose 30lb or else”.  Sometimes if a person travels the sensation-based route of life I entice them via that road. Rather than telling a man with a drinking problem he will die of cirrhosis if he doesn’t stop swilling gin I tell him he will lose easy weight and look better and get better hard-ons. (Hot puppies!).

Being a Cassandra is a frustrating job but with some more careful approach and wording some things may be heard and heeded and I won’t end up with an axe between my shoulder blades.

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My work day officially starts sharp at 8AM when I see my first patient. However I usually start working around 6 to 630AM. I am always the first one into the office. When I arrive I make a pot of tea or coffee (the latter, if I know The Boss Man will be in that day), I sit down to the computer, and I get to work.

I like this twilight time. It is quiet and I am by myself. What I do in the early morning hours is helpful  later on when I want to stay on time. It has a certain peace. I am able to work uninterrupted by calls and staff matters. I turn on music or a podcast. There is a pleasant low-key industry to renew prescriptions and set up the progress notes for the pending work day.

There is a sort of virtue to this time of the day . People tend to respect and admire you.  I daresay this is a hangover from medieval times when getting up early to work was a necessity. Perhaps we made it a virtue to compensate for the misery of long work days.  Over time the sure sign of ‘success’ was NOT working but having long leisurely days initiated by sleeping in. History has come full circle and long hours are again a sign of success. Being busy is the new status signal: “I work 12-14 hours a day I am very important”.

It’s nearly 8AM here at work. The secretaries and billing staff are coming in. There is a sense the place is ‘waking up’. I will see nearly thirty patients today between now and closing time. These are long days. I don’t mind really. On the other hand, my interest starts to wane around 3PM but the work ends at 5. I pity the patients coming in after 4: they are getting the last bitter drops out my gray matter grapefruit that has been squeezed a bit too many times today.  🙂

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Some folks have jobs in which they move about; they are constantly on foot at the workplace or driving/flying to interact with clients. My job is the opposite: I sit still and my clients (A.K.A. patients) travel to see me. Some of them (the dears!) travel a long way. Some come from other states rather than find some local doctor. I listen to peoples’ comings and goings while ensconced and sessile in my chair.

This iniquitous arrangement makes me sometimes jealous. This was apparent the other day when “Peer” showed up for his appointment. He pops in every 3-4 months for a routine check-up. As usual he’s a bit late to return to clinic as he’s been vagabonding.  As I escorted Peer into the office it seemed to me he’s aged – not in a bad way but simply I’ve watched him grow older. Peer reported he was fine and he feels a fortunate fellow. He is retired; he has a cabin in northern Arizona that he adores. When he isn’t there he is traveling – a lot  – for he loves it so. After a few formalities to convey he’s steady and the meds are worth continuing I asked what’s coming up. Oh, he replied, he’s traveling to Chile ‘for the millionth time” to hop a cruise ship to NYC. Maybe afterwards he may visit Canada, he isn’t sure, or perhaps he will just relax at said cabin.

On his way out he joked he’s seen me growing old which makes sense as ‘I’ve been coming here for five years or so”. I looked this up: we first saw each other in 2005 – 14 years ago.  This made him laugh and he doubled his gratitude for my care taking. Well, see you after I get back from South America and he waved good-bye.

I went home that night feeling a bit melancholy. We have watched each other grow old and the years have flown by. The difference is he’s circled the globe countless times while I, Solveig-like, have stayed home. In a way it seems a disappointment to spend one’s life growing old in chair watching others live out their lives.

A lot of my success at being a shrink and as a physician is being constant. In a world of perpetual change my patients appreciate I’ve been there for nearly fifteen years and counting. I hang in with them while they go on their peripatetic tumultuous Journeys. I’ve received many thanks for ‘doing well for me’ based not so much on making them better but just being there.

All the same, I don’t want another 5-10 years of watching patients grow old. It is very difficult for me to take time off from work but it isn’t impossible. I don’t want to see Peer in another ten years under similar circumstances. It’s time for me to get out and be more than everyone’s rock.   I can be both Peer and Solveig.

journeys

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A while back a Spo-fan emailed me the question: “What causes depression?” I wrote a response; I decided to post it here for other’s edification.

We humans like simple ‘A causes B’ explanations. Unfortunately this approach seldom if ever properly explains anything. I won’t dwell on the cliché (albeit true) explanation depression arises from of a complex multi-factorial gunge ranging from genetics to what you are eating nowadays. Here is a simple enough (and hopefully accurate) explanation.

There are two main causes of depression:

The main one comes from the perception of loss: loss of status, resources, companionship, leverage or independence.

The other main cause of depression is from sickness. Chronic conditions, especially chronic pain, are greatly correlated with depression. Either the sickness leads to depression or an underlying factor (inflammation) creates the physical and mental conditions. Some say sickness is just another variation of loss viz. loss of health. Therefore the perception of loss is the main cause of depression.

Depression and loss are linked as the consequence of evolution. We evolved as social creatures. Being involved and connected helped us relatively naked and defenseless animals to stay alive – alive long enough to reproduce. We had to anxious battler fronts to win: beating the bugs and keeping in good standing with The Tribe. To lose connection with the latter meant you were ‘on your own’ and at risk of death.

Notice I wrote ‘perception’ of loss. Back in the bad-old days if you got infected or booted from society both usually led to death. The mind developed depression as if to say ‘You have inflammation! or You are on your own! You’re doomed! Shut down and die!” Nowadays we have treatments for infections and losing your group, job, or status doesn’t lead directly to death – but the body/brain still reacts the same.

Unless depression is purely a ‘brain disease” like a stroke, the treatment for depression involves mostly treating the body and the mind not the brain. The treatment depression addresses improving general health thorough regular exercise, good diet, and sleep to diminish stress hormones and general inflammation.  Connection to others is vital via social network and ‘talking about it’; avoid isolation which the mind sees as a death-kneel.  Improving autonomy and removing things that trap you (bad job, bad relationships etc.) help depression.  Talk therapy often looks at and challenges our negative thinking viz. the loss of a relationship, a job, etc. is not really ‘the end of the world’ as our monkey brains like to go to in a loss situation.

Office

After 13 years of working where I do, I finally have ‘M.D.’ after my name on the letterhead. I’ve never been one to flex my medical muscles but I think it is appropriate to include my credentials whenever I am writing pompous letters to insurance companies or pow-wowing with my fellow wizards. All it took was a simple request to The House Manager. Who would have thunk it?  This revelation was like the radiance of a brilliant sunrise so I asked her to send me the other templates for coiffing. All the forms are updated and nifty looking.* I’m pleased as punch.  I arranged the sentences and such to accommodate my left-handedness. I added ‘please’ to some of the imperial-sounding instructions.  Manners count!

Alas, I won’t be attending the annual office holiday party this weekend for I am away on a medical conference. Each year at this party I get a modest cash stipend which I immediately use to buy a good bottle of scotch I am too cheap to buy with my own cash. I wonder if I will get it given my absence. Let us hope so. I have the bottle already picked out.

One of the counselors is quitting work this week. I am sad to see him go for he did a good job and the patients liked him. A new one started this week but I haven’t met him yet. Glancing at him in the hallway he looks a bit overwhelmed. Let’s see if he stays.

Where am I going this weekend Spo-fans may be asking? I go to Lost Vegas for a medical conference. Last night I received an email from the Conference asking me to clarify which of the two seminars am I attending: “Updates in substance abuse disorders” or “The pelvic anatomy and gynecological surgery symposium”.  Dear me! I suspect the latter would be more intriguing – and probably with better luncheons. Shrinks tend to feel guilty being fed by pharm reps so they don’t eat lavishly, but surgeons have no such scruples – and they demand only the best, baby.  I will attend the one on ketamine, opioids, CBD oil etc. as sooner I’d eat rats at Tewkesbury than sit among surgeons. If my group becomes dull I can tiptoe across the hall and go have a look-see at the newest in prolapse uterine repair – or at least to swipe me a proper sandwich.

 

*It’s always the queer one to make things fabulous.

I want to share something recommended to people with depression; may you find it thoughtful and perhaps useful.

The awful axiom of depression is it clouds ones entire being and outlook in dark and dismal despair. Nothing has hope; all who could be helpful are believed to be useless and actually uncaring. In times of improvement people can see in hindsight the lie of their depressive delusions. Alas, when back the depths of depression it is all forgotten. 

People with depression sometimes are asked to compose a certain list. This roster consists of the names and telephone numbers of people who are meaningful and helpful to you. These are the folks you can turn to at times of despair, for they genuinely care and see you worthy. They pass the test of those you can call at any time when feeling down or even suicidal. I tell patients not only to include names and numbers but ‘why’ they are important. 

Perhaps you know someone from church who thought you funny. Maybe theres was a teacher from college who thought well of your prose. Is there an aunt who always saw you as clever? It is important to list the ‘whys’ because in moments of depression you don’t remember this stuff or if you do you doubt their truthfulness.

 “I, who have written this in a time of wellness, remind you these people and the reasons listed are genuine. They really said to call when you feel bad. Do so.” 

It is important to get the permission of these lifelines, so they (and you) know if you enter despair you can count on them even at 2AM. 
I do not have clinical depression but there have times I feel bad enough I yearn to reach out just to someone to assure me I am not as bad as I feel and someone loves me. Yes, I plan on doing this very soon. I hope I can find a few willing to be on my blessed list. I may not ever use it but I see myself in dark moments pulling it out to read to comfort me and stiffen my spine.

Circle

 

officeThroughout each day we are continually asked things to which we need to respond with yes or no. There is a careful craft to knowing which response is right. In my line of work I see a lot of people who don’t do well with this viz. they often say yes when they should say no and vice versa. They blurt their response without pause or thinking.  Some learn to ‘play it safe” by responding nearly always with “yes” as“no” as panacea for all inquiries. Both ways are bad.

Thems who say ‘yes’  often are sometimes too impulsive: “Would you like try smoking this?” The ‘yes’ people often believe succumbing to another’s wants will make the other(s) like them or say yes to avoid friction/keep the peace.

Thems who use ‘no’ a lot often do so out of fear. “Wanna try something new this weekend?” “No” often deprives us of new opportunities.

I try to train patients to pause whenever they are asked anything, from a small request like “Do you want fries with that?” to the more ubiquitous “Will you do this for me?” In the pregnant pause they should do some self-analysis. I want them to consider the pros/cons of saying either answer. I am keen on intuition and ‘gut-responses” but these are raw and usually driven by habit and neurosis. Adding a bit of thinking before speaking can help us not walk into a regret.

When we say ‘yes’ to something this means saying no to something else. We should ask ourselves what am I indirectly saying no to here and is the trade-off worth it?

Does saying yes personally excite me or am I saying so for some external reason like ‘people will like me if I say yes”.

Is this opportunity wasn’t handed to me would I spend time creating it myself?

I think the propensity towards saying no is less nuanced. When we are confronted with something new, unknown, and out of our comfort zone we become wary or fearful.  To avoid such we often just say no. Our monkey-brains are wired this way. Before saying ‘no’ to someone ask yourself am I afraid of something here? If fear isn’t a factor would I say yes?  Is there a change to the opportunity to make it a yes?

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