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Back when I was smaller and people were taller the ability to change your mind was considered a sign of maturity and wisdom. If you connected the dots you were wrong about something you were adamant was ‘true’ you were either sheepishly or  matter of fact admitted you were wrong.  Either way you moved on with your new and improved state of being.  If your hypothesis was incorrect you discarded it for something better – and you were looked upon as good for doing so.  I’ve been trained in the scientific way to test hypothesis and if they fall flat to reject them even if “I really wanted them to be true.”

Or so I remember.

Perhaps this openness and plasticity of the past wasn’t so stellar as I remember. My recollection is probably colored by the human propensity to make the past a more ‘golden age’. All the same the 180-opposite direction approach people have these days is refusing to admit they were wrong and let alone change. Presented with data that challenges paradigms makes people dig further into their convictions. Changing your mind is looked upon as a sign of weakness.* What was once considered a sign you were being pig-headed is now admired as a sign of strength. Oh the horror.

In my profession (medicine) new stuff comes up all the time. There is a continuous parade of “Everything you know is wrong” findings that oblige me to discard cherished beliefs to what work with what the data actually supports.  My specialty has so many turnovers it makes my eyes cross. Public Opinion may say this is a bad sign but I see it as quite good – and proper.  I want to throw out the rubbish. Otherwise I’d still be prescribing psychoanalysis for the treatment of OCD (which is caused by suppressed anger towards your parents) and sending ‘perverts’ to conversion therapy.  Oh the embarrassment.

You will be shocked shocked shocked to hear doctors are no better than anyone else that when confronted with data telling them to think and do differently they often than not just keep doing what they have always done.  “Time-honored treatments’ don’t bow readily to ‘evidence-based medicine” I am sorry to say.

And of course, thems who want things to stay status quo don’t take kindly to thems who challenge things  Just think of Galileo, Corpunicus, Darwin to name a few.

I will continue to be open and welcome changing my mind as needs arise and see this as a virtue not a sign of spinelessness. Thems who are recalcitrant in their beliefs in are not ‘strong’.

“You see, the point is that the strongest man in the world is he who stands most alone.”
Henrik Ibsen, An Enemy of the People

 

 

*I have a vague memory of a candidate running for public office being ridiculed on TV for changing his mind on something. The ad conveyed he was therefore not to be trusted and he was ‘weak’ for being so. I recall thinking he ought to be elected as a sensible fellow open to new ideas and self-correction.  I believe he lost.

I recently read genetics is only ~ 25% of what makes a long-liver from a short-timer. Thems who live to be 100 don’t do so just because they have ‘good genes’. This is good news for folks who want to make such a goal. It turns out the key(s) to achieving 100 gets down to five factors. Happily four of them aren’t too difficult to do if you are determined to do so.*

First of all let’s get rid of the rubbish, the things 100 year old folks did NOT use towards seeing your one hundredth birthday cake:

Complicated/zany diets

Mega doses of vitamins

Supplements

Antioxidants

Goop advice

Going to the gym

Money

Abstinence from alcohol

‘Success’ in life

The world’s communities with lots of 100-year-olds members were interviewed and they consistently don’t do anything of these things.  What a blessing to know!

Here be the five: 

1] Be active.  None of these folks went to the gym or ran marathons.  Rather they had active lives. Their work kept them moving. They walked to places; they took the stairs. 

Advice #1 – take the stairs, park further away and walk a bit to the store. Get up and move lots. Get in a daily dose of thirty minutes of action. 

 

2] Take time to chill. On the other hand they did not work themselves to death, double tasks or freaked out over a wasted minute. They all had some sort of ‘down time’ each day to take a siesta, have a tea break, gab whatever. They also got enough sleep, valuing  sleeping time over getting one more thing done.  Their vacations were the type for sitting and reading and talking – not running amok trying to do a lot and see all the sights.

Advice #2 – Take some time off each day to unwind in meditation, prayer, whatever. And turn off the techie things to get some sleep.  Forgoing sleep from ‘fear of missing out’ is bad bad bad. 

 

3] Eat right and eat less.  These sages never did silly diets; they had a dietary lifestyle. They did not stuff themselves; they would eat just enough to start feeling full and then they would stop. They ate little meat (not none!) and what they ate is mostly plants.  Nobody abjured butter or booze or bread; they just ate little amounts. They also spent time to eat – and with others. No drive-through dining here.  

Advice #3.  Common sense eating (type and amount) consumed slowly with friends and family is the best diet there is. 
4] Belong to something.  The 100 years folks did not live alone or in a vacuum. They lived in communities that helped each other out and tended to each other’s welfare.  They had privacy and personal times but they also ‘us’ times and places. 

Advice #4.  This is the one of the five that is most difficult to remedy. Somehow you need to be part of a family, a community, a church, or a club. Don’t do Life alone. 

 

5] Meaning. “What am I waking up for?” sort of questions. None of them lived cosmic or fabulous or infamous lives, but their lives had meaning. This was in their work or their art, or what they do for their family, friends. 

Advice #5. Make meaning in your life. I can not tell you how I can only tell you it is vital. 

There. Long life isn’t complicated or bedazzling. The list isn’t in line with todays’ society belief it is fame, power, and money that will get us long and happy life. 

Even it you don’t live to 100 you are likely to live well. 

100-Year-Old-Birthday-Cake.jpg

*It is a fair question whether or not making it to 100 years old is a good goal. This is not the point of today’s entry. 

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While you all are no doubt goofing off or sleeping in or raiding hamlets* Urs Truly at a two day weekend long conference, powwowing with his fellow wizards, learning the latest on this, that, or the other.

Today’s topic is pain. We will hear the latest on what is it, how to properly diagnosis and address it, and the updates on the controversies around opioid analgesics A.K.A. as pain pills. Unless you’ve been hiding under a rock you know the latter topic is a hot topic A.K. A. ‘The opiate crisis.’  Society and medicine are trying to come to grips with ‘how on earth did we get here” situation we are in and what to do about it. As is often the case, people/politics/physicians all want simple scapegoats and solutions.  Fat chance of that. It’s a morass of awful gunge consisting of many, many factors. Frankly it’s a tangle and will take time to sort through the matters.

I don’t specifically treat pain but I see a lot of psych patients who are dealing with chronic pain. Most folks with pain also have depression/anxiety; it’s like a coin with two side: pain and mood. Overall they are not doing well.  Most come in to see me quite remonstrative and disconsolate** about their pain management physician.  There are four common themes to suggest they are not just whining or seeing things wrong:

1. The management of pain is inadequate

2. They are treated/seen as manipulator drug seeking scoundrels rather than patients.

3. The doctors are more concerned about them not taking pain meds than how they are doing.

4. The system went woefully wrong and they are the ones being ‘punished’ for it viz. can’t get proper treatment viz. can’t get pain meds. 

I find it hard to polish my side of the coin when the other side is not being well addressed.

One of my greatest challenges for pain-full patients are thems taking long time opioid-based pain medications and tranquilizers now being told by their pain docs ‘it is one or the other”  viz. get off the valium or they will no longer prescribe the Percocet, that sort of thing.  Ironically, it often would be a very good thing for chronic pain/anxiety sufferers to lay off these types of medications in favor of alternative treatments that show better help – but you try telling them that.  They resemble an orchestra of scorched cats as they lament these four matters listed. Poor sods. They too have to redo their paradigm and approaches as do the physicians. 

The three hour lecture on these matters is about to commence. After it concludes I will add a post-script for thems interested in updates and news and such. 

Spo-fans who are dealing with chronic pain: I am curious to hear from you if you find it difficult to get help with such. 

 

*Guess who’s doing that today. 

** Many are positively irate. 

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.

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