Seaonal Affects

Boo!

Gottcha with that one.

Big surprise. Scared ya. Right, didn't I.
The sun goes down early, the dark falls fast. The shadows of the swaying branches seem to reach out for you. The wind picks up, the dry leaves blow up and and around your face. Is that a leaf or a bat? Does it bite?

Yes, but it's darker in here, isn't it?

Darker in the depths of my mind.

Oh yes, I good caring therapist. Works hard to do good and be helpful.

Ha, sure.

What about all the resentments stored up after all these years?
The slights, the times I've been over-looked or not even heard.

The fantasies of going into those trashy bars that the downest of my clients go to when they are angry and depressed and looking for trouble. How I can be clever enough to set this guy up against that guy, watch the fight break out and then walk off with their trashy women.

And what about all my counter-transference problems, now that I've become an invisible old man?

But that's nothing; that's trite. It's really about the feelings and thoughts that well up like the slime and sludge that sinks to the bottom at the sewage treatment plant. It's the vileness, corruption, and decay that builds up after decades of being battered and beaten by the demons that come howling out of the night, a world that just won't give a guy a break. The demons of stupid wars, of needless excess, of vain-glory, of unrequited vengeance over the smallest, unintended indiscretion.

The soul get nicked, then chipped then cracked. It gets covered in scar tissue that hardens as it holds the remnants together.

It comes to the worst of all conclusions:

Trick or Treat?

Who the fuck cares?

Scary things

Driving home today I heard on the news that a psychiatrists was stabbed at a major Boston hospital. Also, and almost as upsetting, was the the guy who stabbed her was almost immediately shot to death by an off duty security guard.

It seems from early news reports that it was a man who stabbed a woman psychiatrist. The security guard did not work for the hospital.

Stabbing or shooting a therapist has happened s couple of times that i know of. Last year in NYC and a few years ago in a town up near whey I work.

I have really never felt frightened. There have been a few irate husbands who have blamed me for their wives leaving them. One wife told me that he was going to wait for me in the parking lot. That was about ten years ago. I still glance over my shoulder when I am the last car in the parking lot, and it is him that I have in mind.

I have been threaten in my office about three times. Two males patients got angry when I told them that their grandiose opinions of themselves were not warranted. I tried to word it more tactfully than that but apparently the message got through too clearly. Both threats were neutralized when I raised my index finger as a quiet reminder that they should sit down and reflect on what I said.

The third threat was from a woman who threatened to take her shirt off in the office. I guess I am not like the therapist on "In Treatment," who I hear has boundary issues. I think I convinced this woman that even thought I did care for her, it was not in that way, and that while the idea was tempting, it really would not be good for either of us, or what we were hoping to accomplish in therapy.

Being in private practice can be dangerous. I usually have other people who are working on the other side of a thin wall in our suite that has three offices in it. As a therapist it is important to be able to control the mood of what is going on in the session. I think that is comforting to the patient.

But if someone comes in angry and determined, and if unintended, unreal, or totally imagined slights or insults have festered in a mind that has not been working too well, bad things can happen suddenly.

I don't know if the reaction had to be immediate and fatal. That seems a bit too extreme and too American. Maybe he had to do it to save the doctor's life. I don't know, I wasn't there. Scary, all around.

In my pocket

There is a patient of mine who I still see once or twice a year who often would say to me, "Can't you just put me into your pocket and take me home?" He assured me that he wouldn't be any trouble, and that he just needed a safe place to be. He wanted some protection from the life he was leading, which was really, as bad as you can imagine.

Sometimes, as a therapist, I feel like doing that. At least I do while I am sitting and talking to some of my patients. Actually, when I get out of here I am very skilled at not thinking about anyone. But I do see some really interesting and fascinating people who are insightful and articulate, but who never got a break, and who have just retreated from blows of the world.

This guy today, Frankie. He began life as a minority immigrant. His parents sent him to his uncle, who was in this country. His uncle sent him to the grandparents, who already had custody of a few of his cousins. All kinds of chaos and craziness when on in that house, which left permanent psychic scars on Frankie.

But Frankie persisted. He went out in the world full of hesitation and doubts, but he got jobs and he started relationships. Not surprisingly, they ended, sometimes softly, sometimes in disaster.

Today he told me that he just lost the job he had for the last three years. Frankie has been in human services for the last ten years. He does very well taking care of the people no one will take care of. He is caring, empathetic and he treats everyone with dignity. Because of that he got into disagreements with the people who ran the program because he took too much time, he bent some regulations, he responded to the people he was taking care of more than to the rule book. When this was pointed out to him he wold explain how what he was doing took more effort, but it really was within the rules.

So, they fired him.

Now Frankie is not naive, and he is not really trying to be a martyr, but he has standards and sensitivity, and he won't go against that. But because of this, and because of his life experience, he is depressed, and he withdraws when he gets slapped down like this. It will take a while to help him re-group, stand-up, and get out in the world again. (Of course, he will only have insurance coverage for another two weeks, but we will have to deal with that too).

It is difficult to do the "empirically supported" cognitive/behavioral therapy when the patient's belief that the world is mean, unfair, and generally sucks has been well documented by his life's experience. Sometimes you know it would be much more beneficial to take him home, wrap him in a blanket and give him some chicken soup. Which is something he never had anyone do for him, ever.

bipolar?

I've spent a bit of time clicking around the blogosphere and I have easily found many blogs by people who have been diagnosed with a bipolar disorder. Some of them feel they have been successfully treated, some don't, and many are kind of in the middle.

There has been a dramatic increase in the use of that diagnosis over last ten years. This has been a part of the increased view of the biological basis of mind disorders. Some of it has to do with new medications that slow down the racing thoughts and temper the manic phase, and some if it has to do with more brain research.

Many more people who come to see me bring in this label with them, and what it means seems to be very varied. It covers people who have mood changes, who get irritable, who get very depressed. It gets put on people who spend $8000 shopping when they have $400 in their bank accounts. It covers CEOs who work 20 hours a day, buying and selling other companies.

My view of all this is that there certainly are differences in how people's brains function. I think that what is called bipolar disorder today will be called five or six different things if five to ten years. People brains vary over a range, but I think what we call bipolar covers different kinds of ranges. When the thinking is adaptive, such as when people are creative and have the energy to follow through on something that wouldn't seem like a realistic undertaking to someone who was more moderate, it can work in someone's favor. But often the thinking becomes rapid, tangential, skipping logical steps and ending up in a mess or personal disaster. Then things are bad, and it takes a long time to recover and sort it all out.

A real bipolar depression seems worse than just a depression. It seems more totally devoid of energy and hope. It is more dangerous because the thinking becomes not just bleak but unreasonable. Many people, who are just depressed are often more realistic.They can see how much the world sucks, and they have more difficulty than most overlooking it. A bipolar depression just seems to be like falling into an abyss.

So, to all of you who struggle with this, I can offer the encouragement that the more you can reflect on your own thought patterns, the better chance you will have to see when you are rolling a bit off track. It is often very difficult to know when the energetic feeling you get are going to be fun and helpful, or dangerous and destructive.

I think that is where a good therapist, who you can really trust, one who wants you to be happy, and not just under control, can be helpful.

I hope so.

in his truck

I am back at work now, searching for minds -- where they are, what makes them, and watching how they get stuck.

My list is all backed up. I put it on the phone machine that I am not taking any new people. That just means I get calls with people giving reasons justifying why I should see them.

One such call came from a woman who I had seen about twelve years ago. She was calling for her husband, a guy who we could not get to come to see me then. She was very worried about him. She said he would come. So, when my 3 Pm appointment canceled I told him to come in.

He came in in his work clothes. He works for the city, maintaining the trucks. He has done that for at least twenty years, probably more.

This is where his mind is:

For an hour or two every day he drives his pick-up truck to a spot that over-looks the river. There he sits and smokes and listens to talk radio. Sometimes it's Rush Limbaugh, sometimes Michael Savage. He sits and listens, and gets angry.

From what i remember he has always been angry. He has always felt that the world has not been fair, and that he, for some reason he can't figure out, has gotten the short end. He resents that. For years he had been a heavy drinker. He lost his license for a year because of a DUI. He got into one fight too many in a bar, and being older, got knocked cold by some kid. That was about eight years ago. He has not had a drink since. He resents that. He works for the city and will not get a raise this year. He is angry at that. He blames it on foreigners and socialists. I'm not sure how he works that out in his head, but he resents them too.

But he came to see me because he is scared. He remembers that his father was a guy who was also always angry. He remember his father as sullen, distant and mean. But what he remembers most about his father is that when his father was about the age that he is now he stuck a double-barreled shotgun in his mouth and pulled both triggers. He doesn't want to do that, but he finds himself thinking about it, often.

We talked about depression and genetics. We talked about how he hasn't spoken to his son in three years because they are both stubborn. We talked about how he never really figured out what his wife wanted from him. She seems more relaxed since has stopped drinking.

I told him that he really didn't want to blow his head off. That depression may have some genetic link, but genetics are not fate. I told him that here is a difference between thoughts and actions. Perhaps he could try some medication (no). Maybe he could call his son. Maybe he could take his wife to a movie. Maybe he should listen to something on the radio that makes him happy instead of angry. Maybe country music, maybe Mozart.

When he left he told me that I had helped him. He liked that part about genetics the best. I told him he could come back whenever he felt like it. I doubt that he will.

To paraphrase Darrell Martini (anyone remember him) "It is a wise man who rules his genes, it is a fool who is ruled by them."

the time it takes

I'm going back to work tomorrow. My eye, which gets tired when I read a lot, will be fine when I just sit and talk to people, even if parts of them look a little blurry.

First I go get the eye checked, and then I'm off to work. I am pleased at how well and quickly I am healing. It makes me wonder how awful it is for my patients. They come to see me and in the first hour we discuss a course of treatment, and what we hope will happen. But for most people, it will take months, if not years to make changes in their minds and lives.

I waited five months to have this surgery, and now I have to wait another three to six months before the swelling in my eye will go away, and I don't want to wait. I feel like they, those who do modern medicine, should be able to just pug in a new eye, and I should go on my way, seeing better than I ever have before. But nooooo, I have to wait until the swelling goes away.

At least my doctors operated directly on my eye. In my business we don't have direct access to the mind. We don't even know where to find it for Chissakes. Yes, it has something to do with the brain, but what? And we don't even have direct access to the brain; at least not for psychological stuff.

So how can any anyone really expect efficient treatment, given how indirect it all is?

I think we are lucky to be doing as well as we are doing.

When you find you mind, let me know where it is.

newsweek trashing

The whole profession got trashed in Newsweek this week. Some columnist named Sharon Begley read about, or spoke to a couple of guys who do research and they told her that clinicians don't pay attention to their research, so she decided that means that clinicians don't pay attention to science. She seemed to say we, especially those of us with experience, are a bunch of charlatans who make it up as we go along, based on our own whims and fantasies. Just another shot in the arm for those of us who are already over-regulated and under-paid.

She read an article that says that cognitive/behavioral therapy has been proven in the laboratory, but not all psychologists do cognitive/behavioral therapy all the time with all of our patients.

A few posts ago I wrote about how I reacted when I received the Guilford catalog. It's the same thing. There are books on their list full of research that has shown how to be helpful to someone who shows certain behavioral, emotional or physical symptoms. Now, none of those symptoms are exact, nor are they all indicative of the same underlying causes. The causes can be stress in the environment, in the family, in the sub-culture, or just in the person's mind. They can also be the result of an illness, perhaps a brain condition, or even some genetic factor. The truth is, and this is THE TRUTH, it is almost always an interaction of two, three or four of these factors.

And good clinician knows this. A good clinician takes what he has read in all these books, all the research, and research from more than just psychology, and puts together the best treatment he or she can, using all of his or her own experience of what works and how to do it.

And then, do you know what? Here is the reason we get trashed in Newsweek, because despite all of this science, experience, knowledge and the art of therapy -- there are cases when it all doesn't make much difference. We can't get right into someone's mind and make it change. We are not all Dr. Phil.

Sometimes we can do a great job: be helpful, healing, transformative,
Sometimes it bounces right off, rolls down the block and falls in the sewer.

But, none of these guys in the lab, these guys with the pills, the ones with the new machines have really demonstrated that they can do any better. You can look at the data.

survived

Hey, look at this. I can do it with two eyes now, which is kind of fun. Of course one eye is pretty blurry and I really can't make out any letters, but I can sort of see black smudges across the white screen, and that is about 40 times better than what I could see out of that eye a week ago. Now, sometime between three months and a year, the swelling in my eye and cornea will go down and I can get my vision corrected, and see even better. How much better? No one is making any promises, but this is a good start.

I was a bit nervous going into this. People had begun to quietly relate how they had a friend who went in to surgery to get his finger fixed and then died of a blood clot, or was asphyxiated by anesthesia, or were stabbed in their aorta, and such stuff. But, when I got to the hospital all I saw were people going into the door looking nervous, and people coming out with eye patches. Then, after almost four hours of just waiting, an hour of prep, a hour and a half of operating time, and a half-hour cool down, that was me, walking out with an eye path.

The coolest part (Warning -- this may gross you out) was that I was awake the whole time. I was mostly sedated with some relaxing drug. The effect of this drug was measured by the anesthesiologist who asked "Does it feel as if you had one drink or two?" Then he pumped a local into and around my eye, and I was off the surgery.

I watched as they covered m other eye, lowered a microscope and light over the bad eye, and then I could see more light when they cut the dead cornea off, and then removed the cataract, and then began stitching up the cornea. I had a team of two women surgeons working on me. They have worked together for twenty years. They gave and took directions about stitches and angles and placement. And they talked about their kids, and how they don't like electronic medical records, and how the paperwork is much worse.

The next day I went to the doctors office. She took off the patch and wiped away all the goop, and I can see. Not too clearly, but it certainly is a good start.

Psychologically, I was asked one question by the admitting nurse: How do you feel about this operation? I think it will help me see," I answered. "Optimistic" she put down. There was no follow-up question about my thoughts on waking up and being unable to move.

Doesn't matter, I'm moving now. Slowly, but that's fine.

stop by the O. R.

I don't think things were always this way, so fast, so busy, so far. We traveled a few hundred miles this weekend to be with a friend, and his friends for his birthday. One of my kids flew a few thousand miles to be with her friend for a wedding. My other kid started a new job, my son-in-law is about jump to a brand new company and take a risk. I have every hour booked for when I get back and a waiting list of about a dozen people who I have no time to see. All thin insurance companies are, again, slightly altering their rules, so I have to revise how I handle the paperwork. I am sure that the results of all this health care reform, no matter how it comes out, will be that they will pay us less. It makes me want to flee the system, except that 95% of the people I see are through the system.

And tomorrow I stop by the hospital and have two parts of my eye replaced. One will be replaced with plastic and for the other I will have somebody else's cornea stitched onto my eye.

I was getting kind of freaked out by the surgery until I read that I probably won't need too much sedation. I should be hone in a couple of hours.

I will see what I can see ....literally.

It's never one thing at a time

The Guilford Press catalogue came to my office again. I get them quarterly. It is full of books for therapists about how to deal with what faces us. Psychotherapy has moved far away from the time when grand theories of psychology, psychotherapy or psychopathology ruled the field.

Now everything is specialized. Each book is 450 pages about a sub-specialty. ADHD in the work-place. ADHD in Jr. High. Anxiety disorders in soc ail situations. Anxiety disorders in young women with abusive histories. Depression in older males. Depression in young mothers. Depression in Jr. High boys. Alcohol dependence in women, in families, in teens, in teens with alcoholic parents.

On and on two, three, four hundred titles. All of them are well thought out approaches. Some are well researched by very capable groups at major universities. All of them seem like useful and necessary additions to our knowledge and skill base.

Except they're not. Yes, it can be useful to learn what other people are thinking and doing, but really. My nine o'clock appointment was the depressed son of an alcoholic with a depressed mother, who was having anxiety attacks at work because his company is going out of business and his anxious, formerly addicted, wife, who is grieving for her recently departed mother is pregnant.

My ten o'clock appointment is a cancer survivor who has seizures, who lost her son in a motorcycle accident, and has a father who was alcoholic and a mother who is bipolar.

So, to be able to keep up with the latest theory and research I need to read at least a dozen books before my eleven o'clock shows up.

We, those of us here working the front lines, have to deal with the whole package. That's what makes psychiatric diagnoses a joke. Bipolar disorder isn't one thing in he brain, it is probably hundred of variations. Every body's brain is different and they have all been shaped by every one's life, all of which have been very different.

This kind of stuff doesn't come out of a manual -- despite what the insurance companies want.

So, it's surgery on Monday. And my figurative model of the Sydney Harbor Bridge has been partially knocked over by the tide. I will have to begin building most of it over again after my eyes recover. Perhaps then I will look at things differently.