Sunday, November 29, 2009

Enjoy the Season!

I hope you all had a warm and wonderful Thanksgiving. Mine went pretty well, we had friends, family and fun, and I did a lot of cooking.

Families can be the source of great pride, warmth and comfort. They can be nurturing, encouraging and/or just plain fun.

Of course there can be the other moments: if you younger sister is sleeping with your older sister's husband, or when Uncle Ben enters in his usual inebriated state and throws up on the turkey, or Mom gets offended when you spill the cranberry sauce on the table cloth so she runs crying to her room and stays there for three days. Did you miss cousin Rick because he's back in the slammer, and now you have to take care of his three totally undisciplined kids for three to ix years? Did your thin cousin mock your fat cousin mercilessly, until pudgy dumped four pounds of macaroni and cheese on slim's head. Or, when everyone raised a toast to say what they are thankful for, did Uncle Ray use the occasion to announce that he finally has the balls to leave Aunty Beth, after 27 years of a miserable marriage.

Feel free to join in on the chorus....

Happy Thanksgiving!!

Thursday, November 19, 2009

ending treatment

I have been seeing Pauline for over three years. For almost two years she came every week, than it was every other week. Today we decided that we would meet once a month for the next three months, and that would be it.

She was a fascinating patient. She thought about things we said. She was a nurse, so she knew a lot about her own health and what to look for, and she wanted her life to get better.

Her problems were a combination of all the factors that affect how someone lives. She was a wound-up child who was crawling out of her crib at one-year old. Even then she hardly slept, and by the time she was three she was defiant.

Her father was over-bearing and tried to get her to behave by being loud and threatening. Her mother cried a lot. She married young and divorced early and was left raising two kids on her own. Along the way she developed an eating disorder and a drinking problem. By the time she reached me she had just bounced off the bottom of being frantic, drunk and suicidal. She had terrible panic attacks and had been isolated from the world. She had tried about eleven different medications, and an intensive group program. She is now on two medications that she agrees that she needs. They don't do wonders but without them she is awful.

During her time with me she got better, then got worse, and then slowly pulled herself together. And now we have reached a point when it seems to be enough for a while.

Her drinking has stopped. She is back working part-time. She had a terrible relationship with an older man, and now she is still sees him a lot, but they have learned how to deal with each other. Her being sober helps a lot and she is grateful that he stuck by her. He can still be selfish and irrational, but she has learned how to deal with him.

Her eating disorder lingers on. She won't go to a more intensive treatment program for it. She hardly even wants to talk about it. She finds ways to push it away sometimes, but it haunts her. I worry about how much it limits her, and so does she.

But over the last couple of months the tone of the sessions have changed and it is clear that we have reached a stable plateau, even if it isn't perfect. She is working, she has a relationship, she is out of debt, she is sober, and even enjoys herself once in a while.

She is a good example of how so many factors interact to make a life: genetics, family, environment, stress, health, other physiological factors, brain chemistry, as well as luck and random events.

We only have limited control of so many of these factors. We have to make the most of the leverage we have.

Monday, November 16, 2009

inherent difficulties

I treat, or try to treat, a lot of people who are depressed. Most are depressed because their lives are rotten: they are broke, they are in bad relationships, and even those end badly, their parents are/were, mean, abusive, negligent or crazy. Stuff like that. Loss, loneliness, illness, injury, all those bad things tend to add up.

When anyone gets depressed then their outlook turns negative, often hopeless. They feel that othing matters, nothing is enjoyable, nothing will help. That's what depression is.

So, when people feel that nothing will help, they don't show up for their appointments. Then I can't help them.

If they do come, I can help them. And things go well because they want to be helped, and they believe that there is hope. So, am I helping, or just being their while they get better?

If they don't come, they they have no hope and then they won't get better. Can I help that?


I can think good thoughts and send them their way, but it is difficult to know how far I can project these thoughts.

I can make a phone call, but who answers a phone these days.

So I leave a message.

Sometimes they call back.

Monday, November 09, 2009

more difficult social trends

Here is another thing I am seeing going on in our ever-crumbling society. It is interesting to note, however, as I continue to complain, that things have always been getting worse, no matter whom you ask, and whenever you ask it. Yet, in truth, things remain about the same. The sad thing really, is that despite all the "progress", things remain about the same. (But, consider the source here. Me; old, cynical, on the verge of being bitter, and enjoying every moment of it.)

Anyway, what I have been noticing that for many people who have graduated from college over the last five years, things suck. If they go on for more education, to become a lawyer, scientist, doctor, or in finance, then they seem to have a chance. But getting out of school with a B.A. in any of the humanities soon leads to a $25 to $35K job that has little chance of going anywhere fast.

What this seems to have led to is that there are a lot of people who live in apartments, drive old cars, and slip into fun, but tenuous relationships. This seems to be because they feel that the money it takes to settle down and raise a family is not going to be coming in the foreseeable future.

I have had several patients who are within three years of thirty in both directions, who are in relationships that last a year or two, and then they kind of move on, sometimes just by moving to another city, or by getting bored and finding someone new. They often stay friends with the old partner because nothing bad happens. But if there is not going to be a family, and there isn't much money, then the entertainment factor is easier to find in a new relationship, with a new body to rub up against and a new mind to tell the old jokes to. These kids(?) seem to dabble in music and art, and to have a decent time, but they also have the sense that their lives are stuck and that figuring out how to get out of extended adolescence is going to be difficult.

Really, it isn't their fault. They are caught in a bad time in America, when they can't even be corporate clones, and they realize that they don't want to be. Hopefully, they will create their own communities, in which they can buy and sell to each other, support their own lifestyles in new, close to the neighborhood ways, and turn the consumer oriented values upside down.

It's much more difficult for them than it was for me. I just got yelled at by old folks because my hair was long.

Friday, November 06, 2009

The sound and the fury

Another week blows by. All kinds of stuff. Stuff with the family: one kid bought a new house; another had an operation. We are hoping for more changes to come.

The parade of clients. Three didn't come because they said they had the flu. How many hysterical? Just as well.

Began with the woman who had left the bad relationship, gained confidence and is now leaving the bad job for a much better one. Bu† she has to leave me to take the job. Moving on. The woman on crutches with seizures. We talk of horror movies. The guy waiting for his disability hearing, still has to see three more MDs. The woman who began computer dating at 48, is IMing six guys at once. MT is sober for a year. JR for six months. TL for two weeks, but he's lying. One couple is still fighting over whose job it is to parent the other (no one wins that). Another couple has decided not to revisit the same argument they had three years ago. It's good I didn't leave town.

The week ends with SS. He holds the current spot in what somehow has come to be a long line of those who take the last, late in the evening appointment. Somehow I put them there. They are usually male, but not always. They have always been smart, accomplished, a bit overly intellectual, well read, and depressed. They usually have been raised by accomplished, emotionally distant, disapproving, often alcoholic parents. They have been married or divorced themselves, but often did not have children. Two had recently been treated with cancer.

The theme that they all have in common is that life, as they have experienced it and have come to understand it, is meaningless. What they have accomplished has not gotten them what they want. Despite houses, cars, big incomes, beautiful wives, they often have felt like phonies and failures. People have let them down, or worse. They feel distant and lost.

The other feature they have in common is that they have all love coming to therapy. Those who are a bit too vain, love to come and complain and have me take their complaints seriously for an hour. But for most of them, it is the first time they got to feel what it is like to be in a supportive relationship. That part is nice. It takes about six months for them to begin to feel it, and another three months for them to understand what it is.

Then comes the long process of getting to to believe that they can not only find someone else whom they can trust, who can be supportive to them, but that there are even more rewards in being the one who is kind, understanding and supportive. That, if you do things right, and choose right, and then become invested in a relationship, all of the craziness of the world, all of those things that they so accurately see as greed, violence, betrayal, and wickedness, seem like they are "out there" and are just part of the parade. They are no longer the feelings that live inside.

This is very gratifying.

But, then, after my last appointment, I want to go home, sit alone in the dark, and have a drink. I don't want nobody bothering me no more.

Sunday, November 01, 2009

We have a problem -- 1

We in the psychotherapy profession have a problem, and it is going to be getting worse in the near future. I am going to probably take a few of the next several entries here to spell it out for you. I know that the world has been waiting impatiently for me to do this so I will try to work on it here a few times so that I have a chance of making sense.

Part of the problem is that we are low-tech. The world has become very impressed with technology. I know I have. As soon as my eye heals and I can read the small font I am getting an iPhone. 85,000 apps! My God, there is nothing I will have to do any more -- except psychotherapy.

Look at the equipment we need -- chairs. And we don't even need them, although it is better than standing for almost an hour. Sometimes though, I have gone for a walk with a patient.

But that is only a small part of the problem, The big part is that, after a hundred years of trying somewhat scientifically to deal with psychological, emotional and behavioral problems, there is still not direct way into the mind. In fact, we really are still trying to find out what the "mind" is. Yes, we agree, it has a lot to do with the brain, but it is not the brain; it is different.

Yes, but then, what and where is the "mind?"

See, we have a problem, and already it is getting complex and confusing.

But, given all of the marvelous new technologies, people expect that there must be some way to get in there and make people better.

As I said a month or so ago, when they fixed my eye they went in, cut out the bad parts, threw them away and replaced them with good parts. My eye is healing and I expect that soon I will be able to see pretty well.

Now, even though we have marvelous fMRI machines to watch the brain, lots and lots of drugs to pour into people, and we are even learning about the genes that contribute to our talents and temperaments, we still can't get right at it. There are thousands, if not hundred of thousands of attempts, but none of them have really been that successful. We don't even really agree on what we are trying to get right at.

Now, the new US health plan (whatever it will be) is on the way. And the plan will expect that there will we empirically validated and specific treatments for whatever we do, if we are to get paid.

See, we have a problem.