Friday, July 30, 2010

Must have been something he said

That was quite a week wasn't it?  Just buzzed passed so fast you'd  think it was one of those old Camaros, you know, the ones before the first gas crisis, the ones with the big engines, the little body and rear-wheel drive, that would spin out a lot and were fatal on snow.  Yep. that's the kind of week it was. varrrom.

 And everyone showed up, almost, except for Danny, who really has not made much progress in 18 months.  But why should he, his parents still pay for everything.  He gets angry when they won't give him his allowance, even if he did spend last week's money on cocaine.

But everyone else.  Angela brought in her husband. They have been separated for two months. He was angry, dominating, and mean. He was outspoken and direct and it was clear what he expected things to happen his way.  That's why Angela kind of snuck around behind his back.  She felt she could never negotiate with him, he just rode right over anything she said.  But running up $45, 000 in secret credit cards did kind of come as a shock.  Especially since it was the third time she promised never to do that again. I think that is a very American form of pathology; I have seen it much more often than I expected.

I had one open hour, but Stan called and needed to come in ASAP.  I have not seen Stan for four years.  Stan has not worked for four years.  He's had some problems.  He's been jumpy, irritable, depressed and isolated.  He doesn't finish things, he drinks a bit too much, and he has temper outbursts -- all of which made keeping a job difficult.  He couldn't come to treatment earlier because he didn't have insurance.  Now that he has completely run out of money he can get insurance from the State.

Stan showed me his arm.  He had a scar with seven stitches.  He turned his arm over and showed me another scar with four stitches.  The second one is where the knife came out.  It must have been something he said.

Marla lost two pounds, now she is six pounds under four-hundred -- but it's a start -- I think.

Alicia and Martin: still no sex.

Phoebe, out of the hospital and into a one-month residential treatment program.  Out of that in three days after when she told them she was very upset and did not feel safe alone, the one staff member handed her a coloring book and went back to talking on her phone.  Phoebe is going into a day program for two weeks.

Those and twenty-eight others: loss, loneliness, addictions, stress, conflict, illness, doubt, broke, bored or burdened.

My last appointment was Sheila and Mark.  They came in snarling and tense.  They left tearful and arm in arm.  A good end to the week.

Today I spent time in the kayak, bobbing up and down on the slow rolling not very high waves.  The cormorants were back in their usual positions, on a rock, with their wings spread out to dry. As I drifted I could hear the noise of running screaming and laughing on the beach. The sun was moving lower, turning the few clouds pink.

I am very aware that I am a week older. I am very aware that I can't stop time.

It was a good week.  I love summer, even if the Red Sox suck.

The dance continues, doesn't it Mr. Fellini?

Sunday, July 25, 2010

Glorious! .... yet

Another glorious weekend down by the water.  This time down at the beach house watching the tide go out.  We sat with friends, eating and drinking, discussing not much of anything. Again, in my life, the world seems to be doing what it should, pretty much.

It's at these times that I realize how fortunate I am that my wife and kids, and their spouses, and soon their kids, and I are all healthy, and even somewhat prosperous.  I look in the paper and often see that people my age are dead.  I walk down a winding path through scrub pines, go up a sandy hill, and  from there, on a bluff, I can overlook the entire expanse of my favorite beach, with it's large curve, and it's small, but rolling and lapping waves. Except now, I realize that it was not only me who felt that this spot was so special.  For now there is a new bench to sit on, and linger and watch the sunset from this spot.  The bench has a plaque that says it was dedicated to a great guy, someone I never knew.  He was eight months older than me, and now he's a bench.

I read something else in the paper today also.  There was a line that mentioned that the top twenty hedge-fund and money managers in the US made in ten minutes last year, the amount of money that the average American worker made ALL year.  Something is wrong there.  It is psychologically de-stabilizing for that to be going on.

What's worse is that these people --- and they did nothing wrong or illegal (probably, well maybe), didn't really produce anything that did our society any good.  They just moved money around, mostly following the directions of computer algorithms. 

Something is not good.  that should not be valued more than nurses, scientists, business people who actually make something, or deliver a service someone wants to pay for, or even street cleaners and garbage collectors, who work hard to keep us healthy.

Not good.  What do you think Justice Roberts?

Wednesday, July 21, 2010

While that was happening...

I am still often amazed by two very obvious occurrences, which kind of shows how little I have matured over all these years.  First is the huge dichotomy between my work world and my home world.  I come from  a fairly stable background and, considering all the radical and unstable ideas that rattle around in my mind, I have lived a fairly measured and reasonable life.  In many ways I have made fairly conservative decisions, and they have helped me and my family life pretty well, avoiding major crashes, crises, turmoil and upheaval.  It certainly hasn't been perfect, and I can list a dozen or so bad decisions right off the top of my head, but really, compared to what I see and deal with on an hourly basis at work, my own life chugs along.  And still now, whenever I see a chance to take a big risk, make a major change, throw caution to the wind, fly in the face of reason, defy all odds --- I don't do it.  Sometimes I admire those who do and who can, but that admiration has faded over the years, especially the more I have had the professional responsibility to pick through the wreckage.

The second constant occurrence, which is related to the first, is that while I am away from work, wandering around through my reasonable, fun but not overly exciting existence, my patients continue to live their lives of chaos, destruction, pain, aggravation and foolishness. At the very same moment!

That means that while I was sitting on that deck, sipping a high-priced gin and tonic, watching the sun go down on a glorious day over Boston Harbor, many of my patients were doing their best to make my work more complicated. (I know that was why they did these things.)

Some of the troubles happen to some of the same people I wrote about on May 5th. One is Alice, who while I was feeling so good, was lying in great pain, unable to move, as she had a seizure in her bedroom and feel off her bed, smashing her good knee, and couldn't get up.

Also, Saturday night a couple who I had been working with, who had been trying to overcome serious disagreements, lost control, and began throwing things and belting each other.  She came to the appointment on Monday; he left the state.

At the same time, a woman I have been seeing for a long time, who had been doing so well over the last few months that she was only seeing me once or twice a month, became so frustrated by the pain from her various physical ailments, in her back, feet and knees, that she locked herself in her room and began to drink, after being sober of almost two years.  When she woke up the house was a mess, with many things in unfathomable places.

Yet another woman, a complete recounting of her history would include four Shakespearean tragedies, was home with her sons and two of her son's girlfriends when she realized her home was surrounded by the police SWAT team.  Seven officers came in and she expected at least two of her three n'are- do-well son's to be carted off, but no, they arrested the beautiful but ditsy girlfriend for breaking into a liquor store.  (she was back in the house five hours later).

Phoebe, who did not hurt herself when I was away, but still said she wanted to, spent Saturday night in a hospital, where she felt safe and is doing better.

Archie, who did not have the nerve to call the woman he had been chatting with on-line, spent Saturday night in his basement, watching porn.

Martin and Alicia, who I have been trying to get to spend time together instead of fighting about the kids all the time, left the kids with her mother, went out and had a good time.  Maybe next time they will figure out a time and place to have sex and be even happier.

Lia, who I had seen last year with her husband, came back to treatment by herself to tell me that she has left her husband, and that last Saturday night, while I sat on the deck, she was in NYC to reunite with her first love, from twenty-five years ago, when they were both seventeen in Toronto.

Lots goes on, all at once.

Sunday, July 18, 2010

Olives and Chicken Wings

I sit having a gin and tonic on a wooden deck overlooking Boston Harbor on a hot summer evening. The sun now finds it's way through the buildings and hits the white sails of the two and three masted ships on the same side as the wind that pushes them toward the outer islands.  The ferries come and go, crisscrossing from shore to shore. The harbor cruises chug in lazy circles, with more boisterous crowds, drinking and laughing, full of vacationers from Detroit who are amazed to find Boston so warm, sunny and welcoming.

Life is not always  mean. Certainly not mine. Away from work the world can seem beautiful, friendly and hopeful. I watch families walk beside the harbor with children jumping from rock to rock, laughing and teasing.  Couples wrap themselves around each other despite the heat, which is alleviated by a sweet, salty  breeze that blows off the harbor.  Walk further to the fancy hotel that hovers over the water and a bride is standing, smiling, being photographed with her hair and dress blowing in that breeze.  Passers-by blow her kisses and she smiles. Someone believes in love, or at least in marriage, which, from my work bias, is even more of a risk, but rest of my life tells me otherwise.

Nibble on olives and chicken wings, as the gin adds a rosy glow to the already strawberry blonde light that bounces off the big, steel bridge, built high over the water.  Boston looks prosperous and happy, and for the most part it is.  People are relaxed and smiling and enjoying themselves.  They have come from all over the world to be here, on this kind of a day, in this kind of a place and they have been rewarded.
We have evolved as creatures in a way that allows us to be mellow, content, sociable, and relaxed, even if only for a day.  That's what summer is for.  Many people seem very able to appreciate that.

Smile and nod at strangers, laugh and talk with your friends, hug the ones you love. Spread it around.  Help the world have a good time. It's the best thing we can all do for each other.

Friday, July 16, 2010

What's so funny about...

What happened to this week?  Whooosshhh, just like the sound of my iPhone sending an text.  Gone, zipped off with hardly a trace.  I went back to work, each day was full of people coming and going at the wrong times, wanting more time, missing appointments since I was out a week. Everything seemed off schedule. Two new people who had to wait for me to return, didn't even show-up.   Too long to wair?

It shouldn't be that hard.  I was there, in the office, every day, on time.  But when your life is a mess nothing is easy.

"I understand that your aunt hung herself in the next apartment and died leaving two children, aged ten and six, but your appointment was at 1, and somehow you forgot?  But that's OK because the person who was scheduled for tomorrow at 1 showed-up for your appointment, so I can see you tomorrow.  I guess everything happens for a reason -- but I'm not sure I can say that about your aunt.

A week off has a lot to be said for it, especially when it's hot and humid and you're down by the water.  But it really isn't as interesting as sitting here being amazed by stories of how people screwed up their lives during the time I was away.  Loneliness, illness, stress, conflict, addictions, death and general stupidity are the basic diagnostic categories I work with, but they don't come with billing codes.  And the last one applies to both the insurance companies and the current chaos of health-insurance reform.

 Life is complex.  It can be difficult and unforgiving.  Our society does not make it easy or offer much relief.  Jobs are scarce, money is tight, and important things, like an education, are getting wildly expensive.  The feeling out there is like riding on the sleigh in the winter in old Russia.  If you fall behind the wolves will get you and tear you apart.  The rich and well-protected have no trouble going on without you.  They have learned how not to look back.

This has always been true. We all can justify what we do to take care of ourselves.  For some reason, when I was a naive child of the '60s I had the strong belief that everyone wanted that to change.  There was no reason why it shouldn't.  We were smart, educated, rich and aware.  Make Love Not War! 

"What's so funny about Peace, Love and Understanding?"

I still don't know the answer, but I fear that everyone else does.

Friday, July 09, 2010

still summer

The high point of the day was kayaking past the cormorants.  (no laptop in the boat)

The tide was coming in, the wind was blowing out.

That was after Phoebe's mother called to say that Phoebe  ( who I have not seen in two years) broke up with her boyfriend and came home.  She is thinking suicidal thoughts.

I called her and told her not to.  I will see her Monday morning, during the time I had saved to open a week's worth of mail.

It can all wait until Monday.

The cormorants told me that, as they were drying their wings in the sun.

Thursday, July 08, 2010

therapists on the beach

It's summer again.  You can tell because it is really hot.  Is it that Global Warming thing, or is it just hot?  You can also tell by the number of bugs that are flying around my computer screen and crawling across my keyboard.  I can't squish them into the keys because the screen will turn colors and flip pages.  I can only blow them away.  But then they think I'm a wimp and take advantage of my lack of power.

When it is summer I go down to the beach, especially when it's hot, like it was today.  Usually when I go to the local beach it is just full of vacationing families playing family games and splashing each other until the youngest kid begins to cry.  If I go to the bigger beach a half hour away there is a much greater chance of being surrounded by vacationing NY psychiatrists.

But today there were a couple of NY therapists on my beach.  I kind of knew one of them and he knew the others so we talked about our practices a bit and complained about insurance companies, and did some of the things that therapists do when they suddenly find themselves bunched together.

These guys are from NYC.  They charge a lot more than I do, and I think they get more.  They make their patients bill the insurance, and that way, since they don't sign contacts with insurance companies, they can charge what they want.  I am not too thrilled with that, but I understand that they play in a different market and they serve a population that can pay.  Rich people have problems too.

What does bother me is that they seem to see their clients two or three times a week, and they do so for months, and often for years.  Even for years and years.

Now it is rare when you read here that I am in favor of anything that insurance companies do, but if I kept getting bills for three sessions a week, and it continued for year after year, I would be upset too.

The basis for my being upset comes from the word "therapy."  If someone comes to me for "therapy: I take it to mean that I will treat them for something that is wrong, with the goal that it will get better, with the understanding that whatever is wrong, it can and will get better, or else there is no reason for treatment.

To me, endless treatment is not "therapy." It is hand-holding at a high price.  It also encourages dependency, while therapy encourages independence.

I guess the competition in NYC is great enough that therapists have time to see people three times a week.  I rarely see people twice a week, and when I do, it is to keep them out of the hospital, and I feel they are on the edge. If I saw someone three times a week, for more than two weeks, they would be in the hospital the next week.

I don't mind them having a different business model, but I do mind how it makes the whole profession look inefficient, and perhaps incompetent, AND at a very high price.  I mean, if you're sixty-two years old, how many years can spend talking about your mother. You only lived with her for eighteen, and you've talked about her for forty.  Let's get to the part where you grow-up and change your life!

Monday, July 05, 2010

Recollections (revised) Part 1A

I don't talk about dreams much in therapy.  I don't ask about them, nor do I think that they are the window into the unconscious. But sometimes they do trigger interesting discussions.  In many ways they are kind of the neurological cleaning out of the flotsam left in the brain at the end of the day. For me, I know that I have to be more careful about what I read after I get into bed.  I often fall asleep and then suffer with blurred visions of the Taliban or Sarah Palin running through my mind, disturbing my rest.

But I had a dream the other day which was clearer than most and the feelings that came with it stayed with me for a while, making me wonder what is going on in my own head.  In the first part of the dream I was an MC of a big party, like a wedding or something.  I was making all kinds of clever cracks, entertaining everyone.  But that quickly morphed into a scene where someone, a good friend, was telling me how I had insulted his mother, and that she was very hurt by things that I said.  The dream then quickly shifted to an image of me and this same kid, whose mother I had insulted, riding on a bus.  He was saying to me something like, "isn't this great, we are finally growing up and going off to college."  I sat there, on the bus, on one of those plastic seats of city buses.  I was nodding in agreement, but I said, yes this really is great, but I feel as if I have done all this before."

When I awoke from the dream I was in a good mood.  I remembered those parts of the dream very clearly and I loved the irony of the last line.  I enjoyed how good I was at recognizing, as I rode of to college, that I had already done that, even though, in the dream, I was confused by what I was feeling.

All of this made be reflect upon what I was really like when I shuffled off to college. What I remember clearly, was that unlike in the dream,  when I went to college the real time, I had little insight and even less  perspective.  I was really pretty clueless about how the world worked, and what I could do to make it work better.  I was having a tough time figuring out where I fit into the whole scheme of things.

I already had developed a very quick and sarcastic wit, mostly because I needed something to protect me, as I was very skinny and did not project an image of physical power.  But my wit was very unconventional and disarming.  One of my high school teachers told me that I was really funny, even if most of what I said went right over the head of most of my classmates.  He added that he hoped that the things I said would not get me killed some day, if per chance, someone did get the joke.

But even in high school my attitude about the world was becoming established. Because I was slighter than most of the boys, and this was because I was younger than most of the boys due to my mother sending me off to school early,  Look, she said, he's smart enough and he's just wasting his time being a pain in the ass at home.  So they started me at school two days after I turned five.  I didn't have to wait for the next year.  I was about ten months younger than most of the kids in my class, which, in fourth grade, is a lot.

I think I had to protect myself by paying closer attention to what other kids were doing and thinking.  I got to be a pretty good at predicting what people were going to do.  I could tell what songs were going to be "hits" the first time I heard them.  I could tell which I my friends were going to be dumped by their girlfriends.  This sense of observation developed to the degree that I began to be a ble to tell which of my teachers really didn't know what they were talking about. I had some really good teachers, and some who were real phonies. Some of them knew that I knew, and that wasn't helpful for me in school, but I knew that this kind of knowledge was what I really should be leaning.

The more I paid attention, and by my Junior year, it was a lot, I developed an awareness that most people were being played for suckers.  They were being lured to put their efforts, beliefs and money into things that were either, illusionary, worthless, harmful or nuts.  At the time it was things like big houses, constant new cars, and bomb shelters.  I also was confused by all the fuss made about religion and patriotism.  I didn't get it.  For me it just didn't make sense to get all worked up because I happened to be born in a certain place.  I mean, I am that different from the people who happened to be born over there?

I didn't get it .  And no one did a very good job explaining it to me.

So I made a lot of sly, kind of sideways remarks. I knew enough not to say anything directly, especially about religion and patriotism.  I could tell that could get me in real trouble.  So I remained, just kind of confused. I had no solution.  I had nothing else to offer in their place, so I kept a lot of it quiet. I didn't really know what to say.

I also realized, that few other kids that I knew even gave these things a thought. They did what was being done around them.  They just kind of accepted that this was the way it was, and went on.  Most of my friends were much more concerned with hitting a baseball and getting their hands up under a girl's sweater.
With that, we shared a common interest, so I was accepted and did Ok.

Because of my confusion I was voted the "most individualistic" kid out of about 700 in my class.  That meant that people thought I was weird, but I guess I was clever enough to make it seem interesting.

And that's why I became a psychologist. 

I thought, geez, if what I'm thinking about is so weird, what the hell is everyone else really thinking about?

For the past forty years, people have been coming in and telling me.  So that part has worked out.

Thursday, July 01, 2010

Not ready yet

I listened to the series that has been running on NPR the last few days about the use of fMRIs  and PET scans for brain imaging.  Many neuro-scientists have been studying the brains of various kinds of people and watching how their brains react in different situations.  They would like to see if they can determine if different kinds of behaviors cam be predicted by different brain patterns. I have read about, and read some of the stuff of the two neurologists who were discussed on the show, Kent Kehl and Jim Fallon.

In the last report they discussed the case of a man in Tennessee who sliced up a neighbor into little pieces, and then went after his wife with a machete.  In court, testifying for the defense, the neurologists showed that the man had a brain pattern and genetic pattern that is often associated with serial killers.  He was physiologically pre-disposed to be more violent and explosive.  This tendency was made manifest by the abuse he endured as a child.

Therefore, they argued, and the jury seemed to agree, this man was up against too many factors, and that he was much more destined than most people to lose control. 

This is fascinating stuff, which is why I have read about it.  Sometimes I feel that I would like to have a brain imaging machine in my office so I could tell the areas of the brain that were activated whn my clients were expressing certain emotions, or recalling specific events, such as today when a woman I have been seeing became enraged because the man who had abused her as a kid has appeared on a friend's page on Facebook.

But I think the use of brain images at this time can be very misleading, possibly very inaccurate and can be a very dangerous direction to go in.  I don't think we are close to having demonstrated that we can think that pictures of our brains can mean more than self-reports or actual behaviors. 

Yes, perhaps this man had more of a predisposition to lose control and he was "out of his mind" at the time he was slicing his neighbor into chunks.  But, a case could be easily made that anyone who slices his neighbor into chunks is "out of his mind." Is this man more a victim of his genes and the other person just "bad?"

The slippery slope factor here is that, because of the current fascination and belief in new technologies, there is a tendency to believe the machine more than the person.  So, if the brain scan shows a pattern that says you are depressed, then you are depressed, even if you don't feel that way.  Or the opposite could be true, that you feel very anxious and panicked, but your brain pattern does not fit that of a panicked person so your insurance will deny payment for treatment. (I realize that that is not about to happen because the price of the scan is about the same as a year or so of treatment.) but the point is that I hope we don't get sucked into the use of great a technology long before it is ready, and it may never be ready for that exacting a purpose.

However, we already have doctors who can look at a brain scan, and then begin hawking their pills, brain exercises, or electronic brain-wave massaging machines that will cure your depression, ADD, or help with your math SAT scores.

Sometimes they get good, measurable results. But in my skeptical mind I would file those results in the placebo file.

I hope you all enjoy feeling free this weekend, if you are in the USA or not.  Real freedom, the freedom to think and do what you wish, not just the freedom to let corporations make a lot of money.