Monday, April 27, 2009

In Treatment: Season 2, The Rest of Week 3

Oliver shows up with his mom. She thanks Paul for miracles he's worked. She talks about how she and her husband got together. Bess talks about all her insecurities about entering the world of work. Bess gets angry at Paul-- she's anxious about leaving Oliver to go off with a friend, she can't find a balance between smothering him and letting him go. Bess leaves Oliver with Paul and goes on vacation.

Oliver tells us he's fine but he doesn't look so hot. He talks about his friend who brings him chocolate every day. I'm jealous. Then Oliver tells us he's stopped eating because he's tired of being fat. Paul tells him he can't do it alone. I can see Paul encouraging Oliver to eat healthy, but telling him he can't lose weight on his own? How does he know? Oliver wishes he was adopted. Paul says he also felt this way as a kid-- is this good self-disclosure, kind of like announcing he had an unhappy childhood? Oliver is waiting for his Dad and offers to leave, but Paul tells him he had a cancellation and he can hang out-- they can talk (haven't they been doing that?) or play blackjack, and then Paul brings Oliver into the kitchen (isn't this the poor-boundaries room?) and makes him a sandwich. It's like Paul is borrowing a son and Oliver is borrowing a dad.
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Walter has lost his job, his blackberries, and now there's no point to talking. Then he talks. "I'm in a bunker with a remote control and pills." Paul assesses Walter for suicidal thoughts. Walter talks about how he can't stand people who live fake lives. He talks about a friend who lost his job and started taking photographs, "He's outlived his usefulness." Walter talks about his relationship with his employer, the old man, and how the old man's son died. "We would build something special and we did." Paul responds, "After 35 years all he said was 'Good luck?'" Funny, that when the episode started, Paul was on the phone with his brother talking about his father's problems-- Paul didn't know his dad was in the hospital, he promised to pay more attention to him. More father-son themes and questions of guilt and perception-- Walter's daughter blames him for his role in his corporate fiasco. His product killed babies, and he's struggling with trying to figure out what his role was, in all his relationships. "It was my fault," Walter announces. And now we find out that Walter knew his brother was going swimming and didn't stop him the night he drowned. Destroyed families, a theme both men know all too well.
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Paul's life is a mess: he's being diposed in a lawsuit, he's already arguing with his new/old lover, Tammy Kent, he misses his daughter, "I hate my life." He's intensely lonely. "Do you have any water, you're so convinced I don't have water, you don't see it, it's sitting right there." He looks so vulnerable, and he picks at Gina. He misses his family life. He goes to bars at night and watches soccer and watches the women with bracelets that jingle. Paul tells Gina that Mia could be right for him if she worked through her issues, he's drawn to her, but no more falling in love with patients "for a while." Oy. Gina asks if Mia is in love with him. Funny between two therapists...to refer to a patient's feelings so casually as 'is she in love?' Gina and Paul spend the session at odds. She gets in his face, "All you can do now is hope to heal this wound so you can move on."

He's handsome, he's compelling, he's charismatic, he's so insightful with other peoples' problems. Why is he so lonely? He has so little, he's chased away everyone important in his oh-so-empty life. Pathetic and fixated.

Paul goes to visit his long lost dying father in hospital. The conversation he has with his non-responsive father feels desperate, and way too late.

Zen and The Art of The Psychoanalyst's Couch


This weekend's Sunday New York Times Magazine featured a piece by Chip Brown titled Enlightenment Therapy where Brown discusses the coming together of psychoanalysis and Zen Buddism. It's a long piece, and I looked at it several times. I read for a while, but it was long and I can't say it held my attention well. I went back several times. I'm missing something here: Why is this a featured article? What's said that's worth taking pages to say? What am I missing here? Someone want to enlighten me?

Sunday, April 26, 2009

In Treatment: Season 2, Mia's Sex Life & April's Cancer Treatment


Mia bursts in with breakfast and charges into Paul's kitchen despite his objections. She talks quickly and tells of her sexual escapades over the weekend. No sleep, she's drinking a lot, has acrobatic sex with a young band member and then David the cop, a guy she met at a bar. Paul wants to return to the office and Mia says, suggestively, "So you want me on the couch?" I'm wondering how safe Paul is alone with her.

Mia talks about her relationships with men, it moves back to her relationship with her father. "I'm 43 and I'm entirely alone. Who do I have in my life-- You?" She talks about her loneliness.

I guess I'm wondering if Mia has untreated bipolar disorder? --She's gone days without sleeping, she's intrusive, talks rapidly, promiscuous, maybe hypersexual, and her mood is labile. Paul looks at her behavior from a psychodynamic perspective only, and I'll wonder if there isn't something biologically driven to it all.
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April is back, she hasn't told her mom she has cancer and she hasn't gotten any treatment. She's sick, she's tired. Her autistic brother, Daniel, tried to commit suicide, again. She talks about Daniel. April thinks she's depressed. They talk about this and Paul tells April when she feels badly, she should call him, any time of day or night.

April sounds like the neglected child, her mom "gets overwhelmed, she needs to vent." April sounds hopeless about Daniel's prognosis. Paul points out that April will eventually be responsible for caring for Daniel, a burden she clearly doesn't want, but oops, she may be dead long before such a day arrives.

Paul wants to talk about chemo but Daniel calls and April needs to go get him. She faints in Paul's office. Paul gets angry, he screams at her. She tells Paul, "It's okay that you can't handle this, you panicked." They scream and shout at each other. The phone rings, it's April's mother, April stands up to her and says she can't go get Daniel, and mom hangs up on her.

They run over on time, April keeps pointing this out and Paul keeps saying there is more time. "What if I come with you to the hospital?"
"Would you? Now?"
"Yes, now."
He leaves with her and shuts out the lights.

The episode is advertised in it's TiVo'd blurb as Paul crosses a boundary. I thought the boundary was screaming at the patient. But he leaves with her, takes her to negotiate cancer care.
Paul is portrayed as human, he's frustrated and feels helpless. His patient is a ticking bomb. She's destined to die if she doesn't get care now (oh, and maybe even if she does). So off to the hospital they go. Yes, I think it's the 'right' thing to do, or at least I don't think it's 'wrong.' What do you think? Yes, Clink, I know it's a TV show.

Saturday, April 25, 2009

Dr V: The Doctor-Follower Relationship


Dr V over at 33 Charts (medicine.health.socialmedia) wrote a post last week about the "doctor-follower relationship," an interesting play on words that -- in one phrase -- brings ups issues about physician bloggers and tweeters, their readers, commenters, RTers, and the new complexity about where practicing medicine stops and talking about medicine begins. Go to his post to read the whole thing, expecially the commentary. Interesting times...

Recently I received a friend request from a woman in the community where I practice... we had never met but she had read my book. Her baby it seemed was miserable and the wait for an appointment in my clinic was too long for her to bear...

As a doc I offer friendly advice to friends and neighbors when they need help with medical stuff... And why not? I have a connection with these people... So should it be different with my social network? Probably not... Strangers and transients are nothing other than that despite our sometimes-flirtatious Twitter repartee...

Okay, so regarding my screaming baby from Facebook.

Self Disclosure and Being Genuine


In the comment section to the post below on Sally Satel and Stigma, mysadalterego writes:

I am rotating through psychiatry now (family practice traning) and really enjoying it, yet I feel terribly inauthentic treating bipolar patients ("I know what you mean, it is hard to give up the highs...") while being so secretive myself.

My first thought was, well, if in a given situation it seems like it would feel more genuine to the doctor and might be helpful to the patient, then why not? It got me thinking about the reasons a physician might self-disclose a personal diagnosis to a patient, or not.

Pros:
-- It really is destigmatizing when successful people 'come out' and let people know they've been treated for an illness. On a person-by-person basis, this is not any individual's obligation, but I believe it does help when public figures discuss their mental disorders and treatment with the press.
--In illnesses where the prognosis is in question, it offers hope. So yes, I think it's helpful to a patient if a doctor says, "I had the exact same type of cancer and I got treated and I'm doing great." and I think it may well be helpful if a doctor says, "I have bipolar disorder and I've been able to manage it and I'm able to function well."
--The patient may feel better able to be helped by someone who has had similar struggles.
Do note that having the same illness does not always make for the best mix: the clinician may think "I didn't think/feel/behave that way when I was sick, so you shouldn't" and the clinician's views of treatment may be narrowed if some treatments were helpful or harmful to him.
--In substance abuse treatment, clinicians are often people who've had problems and often they are quite open about their own struggles.

Cons:
--There is no right to confidentiality on the part of the physician, so the doctor must be willing to forgo his privacy if he reveals personal things to a patient.
--There is the risk that the doctor's issues/stories will become a prominent focus of the treatment if the patient uses this as a door to ask questions and compare and contrast symptoms/treatment responses. This can detract from the patient's treatment, and the physician may have trouble setting boundaries with regard to his own privacy (but may be not?)
--The patient's response is not predictable. The patient may feel comforted by the like diagnosis, or the patient may feel angry: "How come your illness is under control and you get to be a doctor while I keep going in and out of the hospital!"
--Revealing personal information to patients can be considered a boundary violation. In and of itself, a single revelation like this is simply a single revelation. But if the doctor is ever in legal/disciplinary proceedings over a boundary violation (for example, if a patient alleges sexual improprieties), the fact that he revealed highly personal information may well be used as further evidence of poor boundaries.
--It's important to keep in mind that the goal is to help the patient as much as possible. Being completely 'genuine' isn't necessary and isn't always desirable.

Any thoughts? Are there mental health professionals out there who've told patients their own psychiatric diagnoses? And what's it like from the patient's point of view?

[Edit 7/18/2011: See also Self-Disclosure: To Patients Versus to the World]

HR1558: Bill to End Health Insurance Discrimination Against Preexisting Conditions

Here are some tweets and links about this proposed legislation.  Dinah's recent post about Sally Satel on Stigma generated some great comments discussion, especially this one by AA.


  1. Roy fromShrinkRap
    ShrinkRapRoy PsyN: [hopefully] HR1558 & S623-US bills to end health insur exclusions for preexisting conditions. http://bit.ly/12pkQ4
  2. Brenda Norris
    brendanor Preexisting Condition Patient Protection Act of 2009 require insurance coverage of 133 million suffers with illness. http://tiny.cc/xJnlS
  3. Greg Diamond
    diamondgreg Political theater: 'how is that (the fork in a guys head) a preexisting condition?'
  4. Laurie Reece
    lauriereece Also pls support fed legis: Preexisting Condition Patient Protection Act/2009. Rep. Joe Courtney, Sen. Rockefeller. http://thomas.loc.gov
  5. Traivor
    Traivor Breathing is a preexisting condition. No health insurance for you!
-- this quote was brought to you by quoteurl

Thursday, April 23, 2009

Sally Satel on Stigma


Sally Satel is a psychiatrist who has strong, and sometimes controversial, opinions. She has a terrific article in Monday's New York Times: To Fight Stigmas, Start With Treatment.

She talks about a reality TV show I've never seen (one of the many) called How Mad Are You? The premise: ten people, 5 with psychiatric disorders and 5 without are put together for a week and pushed to the brink. Psychiatrists reviewed the tapes and couldn't tell who had psychiatric disorders and who didn't. This is a surprise? Some people are obviously psychiatrically ill-- they behave in disruptive ways, don't attend to their hygiene, respond to stimuli that aren't there (meaning they're obviously hallucinating and responding to those hallucination), but, as Dr. Satel points out, often they are untreated. Or sometimes their treatment has side effects that are visible, such as tremors, or with the older medications, Parkinsonism. This isn't the majority of people with psychiatric illnesses. Go into any gathering of normal-looking people and take a poll: I assure you that some (if not many) of them will have had some type of treatment with either a psychotropic medication or psychotherapy at some point in their lives. People with psychiatric disorders just don't look different from others. And people with a past history of psychiatric disorders are not necessarily fragile human beings--- this is something I tell my patients: when you're better, you're better, you don't need to live a sheltered life and people don't have to protect you from every little stress. Yes, there are some people who are fragile, and some people who need sheltering-- but not everyone.

So Dr. Satel tells us that public service campaigns to destigmatize mental illness don't work. What does work? She writes:

If “How Mad Are You?” improved viewer attitudes, the credit should go to treatment, the most effective destigmatizing force there is.

Imagine poor psychotic souls cowering in doorways, shuffling along in stinking rags or arguing loudly with themselves in the park. No public service announcement will make the public less fearful of them or reassure prospective neighbors when a group home for the mentally ill wants to settle on their block.

Altering public attitudes toward the mentally ill depends largely on whether they receive treatment that works. This, in turn, sets in motion a self-reinforcing momentum: the more that treatment is observed to work, the more it is encouraged.

Thanks to Kelley who sent the link to this article

Tuesday, April 21, 2009

Three Years and 1000 Shrink Rap Posts!


It's our blogiversary, if that's a word, and we've timed 3 years to coincide with 1000 posts. Well, sort of, Roy pointed out that we have a few unposted things in "drafts," but blogger says this is 1000, so I'm happy with that. I'm pretty happy that our little project has lasted so long, has grown to include 50 podcast episodes with more to come, and our book contract is signed, and that we're all still friends.

To three more years of things to think about....

Thanks for reading Shrink Rap!


From Roy: Thank you to my blogmates for keeping things fun and interesting. And to all our readers and commenters (and listeners) for your interest and participation. Y'all rock!

From Clink: My blogmates are wonderful, our readers are wonderful, life is good. I'm trying to post more often, I really am.

Links:
First post (2006).

Shrink Rap: Grand Rounds is up at Diabetes Mine


This week's Medical Grand Rounds is over at Amy Tenderich's Diabetes Mine.  She is calling this the Birthday Edition, I think because today is her own birthday (Happy Birthday, Amy!).  But still, this is quite a coincidence since today is also Shrink Rap's birthday -- 3 years old today (see Dinah's post coming out at noon).

Amy notes some other birthdays today or this week -- Alison Finney from Shoot Up or Put Up; Chris Nickson from Life in the Fast Lane; Health Business Blog (Happy 4th!); and the Queen of England (and others).

Monday, April 20, 2009

In Treatment, Season 2, Episodes 3, 4 & 5


Paul is videochatting with his son. The boy is animated, but Paul stops him for an inquisition about that C in writing. The doorbell rings and Paul has to go-- yup, it's Oliver's mom, here to collect the forgotten Turtle (and ClinkShrink does indeed like turtles).

Family therapy session with the dissolving family: Oliver had a great time staying with his dad, Luke, and we discover that Luke is dating Nina. Oh, and Nina is Oliver's former teacher, and she's 23. This doesn't sit well with Bess, and Paul takes Oliver out into the waiting room where the two of them talk while Bess and Luke fight it out in the main office. We hear how Oliver feels alone, doesn't feel at home anywhere, and how he thinks Paul has a son. He assumes Paul is divorced, that his son lives with his mom, and Oliver wants to meet Paul's son. Paul must be a good dad because he listens, and I'm struck by the poignance of the moment. Paul listens so much better to Oliver than he does to his own child. When Oliver talks about missing his mom, you can almost feel Paul missing his son and at the same time missing his own long-dead mother. Family parallels are everywhere. We also hear about the adoption of a sibling for Oliver-- a process started but never finished.

Back in the office, Bess and Paul are still alive. I'm not sure I would have left them alone given the hostility between them at this time.
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Cashmere Walter is beside himself about a recall at work. He's 2 hours late, he tries to give money to Paul, and he's all worked up. Paul tries to interrupt Walter, but he can't be redirected. He's wired, the phones/blackberries/iPhones are ringing out Walter's pockets; he's too busy to drink water. Paul suggests they reschedule after the crisis. Walter calms down, turns the gadgets off, and drinks some water.

So Walter has just returned from a trip to Rwanda to get his daughter. She cut her hair (Paul can relate-- "that's what daughters do.") Walter fights with his daughter, he tells her she's coming home with him, and she curses him out. "She broke my heart." "It turns out that I'm domineering, obsessive, the cause of all her problems...I'm ruining her only chance to free herself from me....Now you know why I went over there."

Paul points out to Walter how uncomfortable he is when he's not in control. Paul points out how hard it is for Walter to let his daughter go. Walter jumps up and takes a Xanax. He talks about a panic attack he had in Rwanda where he woke up thinking he was in his brother's room--the one who died as a teenager. Paul draws a comparison between Walter's loss of his brother and his feared loss of his daughter. Walter doesn't want to hear it. The man has a overwhelming need to be indispensible.
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Paul wakes up with a woman-- ah, he's been sleeping with Tammy Kent and he'd promised Gina he wouldn't. Paul's daughter Rosie calls, she's worried about her grandfather, Paul's dad, and he dismisses her concerns. Rosie hangs up on him. Later same day, now in Maryland instead of Brooklyn, and Tammy and Paul bump into each other in Gina's waiting room.

Paul announces that his dad is very sick and Gina says, "I'm so sorry to hear, Paul." Paul responds, "That's so easy to say." I cringe a little, because when anyone tells me about something troubling that's happened, I tend to say, "I'm sorry." Not as an apology, but as a statement of regret. What should Gina say? Paul goes on to talk about his sick father in a nursing home. "He was never present in my life."

Paul tells Gina he met with Tammy to discuss his memories of the Christmas Eve when his mother tried to commit suicide. Tammy had different memories...she says that his dad was there, and Gina begins to question Paul's memories and his description of the past. "We're constantly altering our memories so that the past is consistant with the present." Paul has a script of what happens where he ascribes intent to his father's actions-- Gina suggests that the father's intentions might have been different. Gina draws parallels between Paul's father and Paul's current situation, and this angers him. "No wonder my patients complain about this. Will you stop repeating everything I say!" They talk about the events of the past, of how Paul's mother had bipolar disorder. Paul talks about wanting to save his little patient, Oliver, and how he relates to Oliver's difficulty being with his father. Paul talks about how he should go see his father, and how he should talk to his own kids.

Generations of parallels, his patients', his own, and all that isn't being said about how Paul betrayed Gina's trust by sleeping with another patient when he promised he wouldn't. Gina has her own doorknob moment. "And next week, we'll talk about Tammy."

What Everybody Ought To Know About "Why Am I A Criminal?"

It's the question I get asked multiple times a week: "Why do I keep doing the same thing over and over again? There must be something wrong with me. Why do I keep coming back to prison?"

Maybe you have a genetic brain disease, maybe you had a bad childhood, maybe you chose to pass by opportunities or advantages that other people took, maybe it's pure coincidence and by random chance something happened that swung you to the wrong side of the law. Medicine doesn't have the answer, sociologists don't have the answer, philosophers and religious leaders don't have the answer.

Why do you keep doing the same thing over and over again, even if it's not good for you?

Don't ask me, I eat lots of chocolate and hang from tall rocks.

You do it because you're human, because the nature of humanity through the generations involves taking risks and random deviant chances in spite of one's better judgement. Maybe it was a stupid and risky thing to do to load up a big boat with people and cross thousands of miles of bare ocean without modern navigation equipment, but that's how our country got started. Risky or potentially dangerous behaviors can land you in prison or make you a founding father. It just depends.

The other aspect of human behavior is that we only question our repetitive habits when they result in bad outcomes. I've yet to hear anyone ask me why they keep succeeding over and over again. We take it for granted that success is the natural result of hard work and wise choices. Success is never viewed as a disease, even when it may be the result of hypomania.

The best answer I can give to the question "Why am I back in prison?" is: "I don't know, but it would help if you reported to your parole officer."

Sunday, April 19, 2009

In Treatment: Season 2, Week 3: Mia then April


Paul is late and apologizes. Mia grills Paul, was he with his girlfriend? Is this how your Maryland office looked? What happened to all those patients, did Paul abandon them too? Paul deflects her questions and she bristles. "Aren't you glad I'm back?" Mia asks questions about his lawsuit. Who is Laura? "She said you became friends after the therapy, you broke the rules for her....I think you had an affair with her."

This session is every therapist's nightmare. Paul gets angry: "You opened a legal document that was not meant for you...and you brought it into session."

Mia taunts Paul. She's goading him, and I have the sense she's jealous, she wishes Paul would sleep with her. "If you were going to get involved with a patient...you picked her." Mia imagines Paul with Laura and he looks wistful as he listens to her fantasize about Paul's relationship with his old patient.

Mia knows she's difficult: "I'm like a knife in your neck, it feels good when it's gone." Actually, I kind of agree, I'm ready for her to leave. Paul plays the tape she gave him as a parting gift 20 years ago: see, he still has it, he saved it, he does indeed care!

So I've been trying to write about personality disorders for our book-to-be. It's hard. Mia is difficult, a precise diagnosis is unclear, but perhaps something in the borderline, histrionic, dependent realm, "I push everyone away, I'm demanding and I'm needy...." Paul does a good job of addressing her fears and desires.

At the door, Mia asks Paul if he slept with Laura. He hesitates. And then he tells her he didn't sleep with Laura. Should he have answered this extremely personal question about his sexual life with another patient? Yes (especially since the answer is "no, I did not"). Laura is asking two things: Did you choose her over me? And, Am I safe With You? Any way you dice it, it's better for the honest answer to be No, to put these issues to rest, and to move on with the psychotherapy.
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April's been up all night and she's a wreck. She's tired and fragile and she wants to go to sleep for just a minute. She looks like she could sleep for hours and Paul wakes her by shaking her gently. She smashes her class project and the violence of it is such a stark contrast to the peacefulness of her sleep.

April has thoughts that get stuck in her head. She gets offended when Paul calls her thoughts obsessive, and he realizes how hard she tries to feel her autistic brother's feelings. April talks about her parents dancing and how they didn't notice that she'd fallen out the window. We hear a little about the family dynamics, about how April can't tell her mother she has cancer, and Paul asks her to call her mother now, but April doesn't tell her. Should he have offered to call April's mother for her?

Psychiatry on Broadway


The world is so weird. This morning, I looked out my back window and wondered if the neighbor behind me was pregnant. You can't really ask someone this-- it could just be 15 unwanted pounds, kind of concentrated in one place. I went to her Facebook page, and there was a comment on her wall, "Congratulations on the Pregnancy!" Okay, so it's official.

So today's New York Times mental health Shrink-Rappable article comes from the Arts & Leisure section. Patricia Cohen writes in "Mental Health, the Musical, Aims for Truth" about Broadway plays where mental illness is the focus of attention. She talks about a new Broadway play, Next to Normal, as well as about Proof and Equus. Cohen writes:


Mental illness on the stage and screen is often portrayed in extreme ways, and not just for dramatic effect. In Western culture psychic pain has tended to be seen as the territory of the artist, visionary, rebel and genius, from Emily Dickinson to Sylvia Plath and Friedrich Nietzsche to John Forbes Nash Jr. So it should be no surprise that madness is often used to signify creativity, sensitivity or spiritual and intellectual depth.

She goes on to write:

The musical now presents a much more subtle and complex view of psychotherapy. In “My Psychopharmacologist and I,” Diana catalogs the side effects of her drugs — nausea, drowsiness, sexual dysfunction, headaches, seizures — until she finally says, “I don’t feel anything.”

The doctor pronounces, “Patient stable.”

Will I see it? No...sounds too much like going to the office.

Thursday, April 16, 2009

Shrink Rap: Grand Rounds is up at Pharmamotion


Some great Grand Rounds reading is over at Pharmamotion this week.  Be sure to check out the music video of the leukocyte chasing the bacterium (very cute).

Wednesday, April 15, 2009

In Treatment: The Rest of Week 2 of Season 2


The turtle is in a pie dish on the microwave and daughter, Rosie, is visiting for the night.

Cashmere Walter returns, and this time therapist Paul has dressed up for him. No jeans, and he wears a vest and jacket (Walter still doesn't warrant a tie). Walter talks about his company and his symptoms, which Paul has now labeled panic attacks. We hear how they started when Walter was a kid, and how his GoldenBoy brother drowned, right before he was to begin college at Yale. There isn't much to say here: it's a therapy session. Walter pays at the end, it's cleaner that way, he says, then waiting until the end of the month. We're left to wonder why Paul looks so stressed when Walter leaves. Next time, perhaps.
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Paul goes to see Gina and it's busy in her waiting room. His ex-wife is lurking with the kid's financial aid forms and his childhood sweetheart walks out of the session before. Paul asks Gina about Tammy Kent, only to be told she can't talk about another patient (hey, didn't we just have this session with the kid Oliver? And who's watching the turtle?). Paul announces he's decided he doesn't want therapy, and in a theatre-of-the-absurd moment, Gina grabs her purse and announces she's going to the market, does Paul need anything? He begs her to stay, but if he doesn't want therapy, she wants to get her grocery shopping done. He offers to pay her for 'conversation' and in the same moment, mutters about how he hates that Walter pays him by the insight and he doesn't like people who think they can buy anything they want. This is the most interesting part of the session!

Ground rules: if Gina's going to treat Paul while she's treating his ex-high school sweetheart whom he might call, they have to promise not to have a relationship while they are both her patients. Wow! How does one control such things--- if they hadn't bumped into each other in the waiting room, Gina might never know they knew each other. I think I wrote a novel about this scenario once, where the psychiatrist didn't know he was hearing the same story from two patients falling in love: anyone want to publish it? Okay, so she won't let these two people date (who haven't seen each other in decades and just said Hi), but Gina doesn't find it a conflict to have been Paul's friend, colleague, supervisor, and have treated his ex-wife. Oh, and she's testifying in his malpractice case but she won't mention in her deposition what he's said in therapy today. Oy. And Oy.

Paul goes on to talk about his relationship with Tammy Kent, his father's abandonment of the family (for one of his patients) and his mother's suicide attempts. Gina is clear: he has to find those memories and sort out what happened to gain some clarity and deal with his monsters.

What do I think of the "you have to talk about it" mandate? I'm not much for insisting that people talk about things they don't want to talk about, but if someone's old demons keep intruding, I've found it useful to ask that they retell painful, powerful stories. I hadn't quite thought of it as gaining clarity--- but that's not a bad way to put it--- I think of it more as getting it out in the open, of taking away some of the power of the awful. Gina has done to Paul what Paul did to Walter: asked him to pull up painful old memories, moment by moment, and give them a little breathing room.

So Clink hates In Treatment-- --- these people aren't real. So far, two weeks into it, and it's been a really good season. I keep figuring ClinkShrink might come around for the turtle.

In Treatment: Season2, Episode 3: The Turtle in Therapy


Oliver is back for therapy because of his parents' separation. All three family members are in the waiting room plugged into their iPods (Oliver has a shuffle). A smiling couple walks out of the office, "That wasn't so bad." Beacons of hope: Paul cured them, perhaps he can cure the Oliver family.

Oliver's having a rough time. He's reading Lord of the Flies, people think he's fat, and oh, he has the class turtle with him, one he's sure he can't keep alive. To every question, Oliver says, "Because my mom would call my dad and they would fight." Paul does a good job in addressing Oliver's questions about the happy couple who left-- "I don't talk to my other patients about you and I can't talk to you about them."

Bess (Oliver's mom) distorts Paul's words: "You don't think we should get divorced....parents should stay together no matter how unhappy they are and ultimately it would be better for the children?" Ah, this has to be pushing newly-divorced Paul's buttons. And it's suddenly clear that one of the issues here is that Mom is still hung up on Dad. It's a kind of ugly session when dad announces he has a new girlfriend... kind of amazing it isn't bloodier. Little Oliver gives Paul's next patient a rather hopeless look and the forgotten turtle remains in the office with Paul. He (?) retracts his turtly little head into his shell.
--------------------

Book Pics!


Wow! Thank you all for the great novel suggestions.
First, I'm going to tell you some of my favorites, then I'm going to print your comments below.
In no particular order:

The Kite Runner ---maybe my All Time Favorite book?
Lying on the Couch -- by a shrink about a shrink, quick read
I Know This Much Is True-- starts with a man in a library cutting off his own arm, lots of psychiatric issues.
Middlesex
-- a novel about gender identity in a young woman who begins masculinizing at puberty...great read
Of Human Bondage
-- a classic about obsessive love
The Poisonwood Bible
Blink

Outliers-- Both by Malcomn Gladwell. Neither are novels, both are great reads.
The Orchid Thief also not a novel, but I was 25 pages into it before I realized I wasn't reading fiction.
The Namesake.... and then you have to read The Overcoat
Snowflower and The Secret Fan
Waiting

Atonement
A Gesture Life--
I loved this
Native Speaker
Life of Pi
The White Tiger
Out Stealing Horses
God of Small Things


Three Cups of Tea--somehow I never got into it. And as a kid, I loved Kurt Vonnegut so it was fun to see him on the list in our comments below. And my pic for the moment was Shadow in the Wind.

Reader Recommendations:


Have you read I Love You, Beth Cooper by Larry Doyle? Doyle used to write for the Simpsons tv show and Beth Cooper is a funny book along those lines--intelligent but lighthearted. Perfect for anyone who needs some un-brooding. Grab the paperback edition for extra laughs. The back pages are filled with true high school horror stories. I wish you good reading.

Just start Alexander McCall Smith's hilarious "The No. 1 Ladies' Detective Agency" series, whose protagonist Precious is an amateur detective in Botswana who snoops and fixes her neighbors' business. You will laugh out loud, but her comments on character and motivation are pretty universal in application. Wonderful characters. One in the series describes a woman searching for her supposedly straying husband who, it turns out, has been eaten by a crocodile while being baptized in the river by an evangelical sect. Smith grew up in Africa. It's light reading but good.

Other possibilities:

Cold Comfort Farm by Stella Gibbons ("I saw something nasty in the wood shed..." is the most famous line)
I Capture the Castle by Dodie Smith
(cool eccentric and tragic British family in the 1930s)

For a real brooding downer (but good) there's always Malcolm Lowry's "Under the Volcano" ("the world was always within the binoculars of the police")
Current favorites: Shusako Endo and Nobel Laureate Jose Saramago.

I agree with Anon 2's recommendation of "Snow Flower & the Secret Fan", Catherine's "Time Traveler's Wife" and Dragonfly's "The Book Thief".

I just started "A Thousand Splended Suns" by the author of "The Kite Runner".

Outlander series by Diana Gabaldon. Right now there are 6 volumes. You will be sucked in. =)

I'm also in the middle of Middlesex (mentioned above) and it is a good read, too. :)

Pure escapism?
Try anything by Neil Gaiman. I loved Neverwhere and American Gods, and couldn't read them fast enough. His other books are great, too. :)

Pure fluff? I'd try any of the Speedy Motors series (the first of which is The No. 1 Ladies Detective Agency) by Alexander McCall Smith.

Anything by David Sederis (his books must be fiction)

Anything by Sue Hubble - essays about science - but Waiting for Aphroditie is my favorite

Curious Incident (although I firmly believe that A Spot of Bother, his newer one, is far better)

Never Let Me Go - I absolutely loved this

Oryx and Crake - fantastic too, but preferred The Handmaid's Tale

Pharmakon - maybe a little close to home (psych-wise), but fantastic novel about family with elements of thriller and the history of psychopharmacology.

Rough Music / Notes On An Exhibition / Friendly Fire (all by Patrick Gale) - simply my favourite author, and his books are both devastatingly sensitive, and infinitely powerful (at least when it comes to describing the trials of family life).

Free Food For Millionaires by Min Jin Lee - my friends and I have all loved this.

Call Me By Your Name by Andre Aciman - romantic, heart-wrenching, escapist. Puts into words the often bizarre feelings that we've all experienced about another person, romantically, at some point. Full of longing and Mediterranean Summer heat.

Case Histories by Kate Atkinson - the first of the Jackson Brodie novels. A series of truly intriguing mysteries, all involving Jackson Brodie, the only literary detective I have ever really warmed to, or see as anything more than one-dimensional.

What Was Lost by Catherine O'Flynn - this is one of the books I buy people as a gift. This story is so tragic, so involving and so funny, it's almost impossible that the author managed to combine all this into one book, but it is absolutely fantastic.

Others I recommend:

Wicked by Gregory Maguire. You must have heard of the musical that was based on this book? This book, is much darker and deeper than the show, but just as wonderful.

The Poisonwood Bible by Barbara Kingsolver(sp?). I read this over a very hot summer in my younger years and I felt the heat of the Congo resonate with the heat of my summer. Haven't gone back to it in ages, but I loved it then.

Middlesex by Jeffrey Eugenides. Greek hermaphrodite. Saga. Does it get better?

Shadow of the Wind, Carlos Ruiz Zafon a GREAT READ.

The Book Thief - Marcus Zusak. Or We Need to Talk About Kevin by Lionel Shriver. Both stayed with me after reading them.

Never Let Me Go - Kazuo Ishiguro

Remains of the Day - Kazuo Ishiguro

Tam Lin - Pamela Dean

The Wild Swans - Peg Kerr

Three Cups of Tea - Greg Mortenson

Persepolis (graphic novel) - Marjane Satrapi

Time Traveler's Wife - Audrey Niffenegger

In the Land of Invisible Women: A Female Doctor's Journey in the Saudi Kingdom - Qanta Ahmed

A Long and Fatal Love Chase - Louisa May Alcott

Welcome to the Monkeyhouse - Kurt Vonnegut

I also agree with the suggestions for Oryx & Crake, Snowflower, and The Curious Incident.

Try anything by Anita Shreve

If you're looking for something girly, anything by Jennifer Weiner is good. I really liked "Little Earthquakes" and right now I'm reading "Certain Girls" and I'm totally caught up in it.

If you want something to take you out of this world I would try reading Tamora Pierce, she writes children's/young adult fantasy and even as an adult I love it. It's my comfort reading. I'd recommend starting with "Alanna the First Adventure" or "First Test". It's all nights and magic and fun. There's also "The Mists of Avalon" by Marion Zimmer Bradley if you like Camelot type books. And of course, Madeline L'Engle is always good.

If you're looking for something with suspense, I recommend reading Arthur Hailey. They're older books so the context is a little out of date, but I can never put them down. Same thing with Michael Crichton, for him, I recommend "The Andromeda Strain".

I loved these:
"The Kite Runner" by Khaled Hosseini gives a wonderful look into the mind of an immigrant from a strife-tron country. Lots of action, lots of introspection, guilt, atonement.

"The Curious Incident of the Dog in the Night-Time" by Mark Haddon
If you read this you can combine psychiatry with reading a novel. The narrator is autistic and goes about solving a murder mystery. Light. Fun reading.

"Snow Flower and the Secret Fan" by Lisa See Engrossing tale from a female perspective of life in 19th century China. Wonderfully rich descriptions.

"The Joy Luck Club" by Amy Tan
Maybe everyone has already read this, but if you haven't this is a "can't put it down" novel intertwining modern Chinese-American life with historic Chinese life, culture.

" The Hidden Life of Dogs" by Elizabeth Marshal Thomas: For dog lovers only: This is not a novel, but reads like one, if you love dogs.

"Marley and Me" by John Grogan
For dog lovers only: This is autobiographical not a novel, but funny and light except for the ending. Heart-warming.

1. Oryx and Crake by Margaret Atwood
2. Old Man's War by John Scalzi
3. World War Z: An Oral History of the Zombie War

I just finished Time and Again by Jack Finney- it mixes history and time-travel, and I loved it.

For something lighter and brighter, I go to Terry Pratchett. A mixture of fantasy-humor-social commentary.

Spirits need lifting? Try The Shack by William Young- haven't read it, but have read great things about it.
Dune I found quite compelling.


I am just about to finish what very well may be the best book I have ever read. It is called "The Shadow of the Wind" by Carlos Zafon... I promise you won't be sorry!

Great blog, by the way!

Have you read Life of Pi by Yann Martel? Boy and Tiger get stuck in a life raft in the middle of an ocean... It's fabulous reading - I think I've read it 9 or 10 times now... and I may just need to read it again soon.

Tuesday, April 14, 2009

Shrinks, Shrinks, Everywhere!



I wanted a shrink-free day. I still haven't bought a new novel, but I'm getting there!

So I went to Washington this weekend-- it was rainy and muddy on the Mall, and there were people everywhere---long lines to get into the Archives and some of the more popular museums. We ended up at the Sackler Gallery checking out the Asian art. There's a photo of Arthur Sackler and I stop to read about him. You guessed it: he was a psychiatrist. There're everywhere.

Sunday, April 12, 2009

In Treatment: Week 2 Season 2. The Return of April and Mia


Mia the malpractice attorney is back, this time as a patient. She needles Paul: he had an affair, didn't he? He left his wife for a younger woman, didn't he? He wishes he was close with his daughter, doesn't he? She's uncanny.

Mia remembers every detail of Paul's old office, and she holds him responsible for making the decision that she should have an abortion. Still childless and entering an early menopause, she feels he owes her a child. She implies that maybe they could have a romance-- ah, she asked him out for a drink before asking him to come for a therapy session. And Paul's boundaries are so much better than last season. Mia talks at length about her special relationship with her father, only to stop and announce she doesn't want therapy. Paul notes that this is all he has to offer, and that perhaps he will once again disappoint her.

Patients sometimes remember details in a way that therapists might not. Mia remembers the black and blue colors of Paul's couch 20 years ago, the way the light fell in his office. How Paul goaded her into an abortion. We're left to wonder what exactly Paul said, and I hope Mia's memory has distorted the events that transpired. But who knows, Paul's done some pretty outrageous things. Ah, but at least he has his old notes from his 20 year old sessions with Mia.
--------------------
April is back, she's angry and wants to use the phone. Her iPhone battery just died (wow, an iPhone at that). She kicks Paul out of his own office to use the phone. She talks about ex-boyfriend Kyle, autistic brother, Danny. She talks about her fears of relationships and how she slept with Kyle's best friend. Now she's hung up on her ex and "I hate girls like this." She thought of letting Kyle help her schedule chemotherapy. Mostly, the session is about April connecting with Paul. She's starting to trust him, to open up to him. They can talk about her cancer in a more genuine way, she doesn't run out and scream. Ah, but she gets heated when Paul mentions he talked to an oncologist about her condition, without mentioning her name. She yells, "You had no right to do this." Oh, but he did (if he gave no identifying information). They make a deal: He won't talk about her to anyone, she won't leave therapy without calling. The session was about rapport. It went well. And Paul takes note now, in a spiral notebook. The guy's never heard of patient charts?

Friday, April 10, 2009

Recommend A Novel to A Blogger


Enough psychiatry! I need an escape...from the psychiatry day job, the psychiatry blog, the psychiatry book, the psychiatry TV series. I'm not particularly fond of heights, and unlike ClinkShrink, I can't imagine lowering myself down a 170 drop pretending to be SpiderShrink.

So, someone, please recommend a novel! I'd like a great novel, one so compelling I can't put it down. I read Out Stealing Horses a couple of weeks ago and that was good, but heavy and brooding, it left me feeling cold and dark all day (it takes plays in Scandinavia). Any suggestions?

Thursday, April 09, 2009

Does the Failing Economy Lead to Psychiatric Disorder?

In yesterday's New York Times, Pam Belluck writes "Recession Anxiety Seeps into Everyday Life." She talks about people who've needed psychiatric care, including medications, because of the poor economy. Some are people who are not actually having financial problems, but are very symptomatic, nonetheless.

So what have I seen? I work in two different outpatient settings, but I can summarize what I've seen pretty easily.

---In the private practice setting, every patient has at least mentioned the troubled economy and concerns about money, if not in passing, then as a cause of significant worry and personal concern. Some people have decided to come less often. Referrals are down. No one new has presented with their only complaint being anxiety because of money worries, but in the realm of things causing stress, it's pretty much on everyone's list. Many people are worried about losing their health insurance.

--In clinic settings, many of the patients I see receive disability or some other source of fixed income. Money is always a stress, there's simply not enough of it. Or, they live in a setting where their needs are met, their money is managed with no room for luxuries or savings, and it's not something they mention to me. There are no jobs to be lost, no cars to be repossessed, no luxury vacations to be longed for. Here, few mention the economy or money worries in a way that relates to economic changes: they have no credit, mortgages, or portfolios, and paying the bills is the same struggle it's always been.

Anyone else notice anything interesting?

Wednesday, April 08, 2009

The Secret of Climbing Perception


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It turns out that Tom Stafford, co-author of Mind Hacks, is a rock climber. He wrote a nice blog post about the psychology of perception and climbing entitled Rock Climbing Hacks. In this post he gives some of the neuroscience background to what climbers call 'route-finding', in other words the ability to pick out handholds and footholds as you go up a wall.

I really appreciated this post after this past weekend when I climbed to the summit of some of the best rocks in the Mid-Atlantic. Somewhere midway up the several hundred foot rock I learned that my idea of a 'good' foothold had changed dramatically. Suddenly a good hold was any little nubbins of a protrusion that I could use to balance on my big toe. And a 'good' handhold was one that I could hold onto just enough to stay balanced on my toes. Miraculously, it worked and I didn't fall. Pretty cool.

Who Else Wants To Climb Like An Orangutan?



(See more rock climbing designs from CafePress.com. While you're at it, pick up a My Three Shrinks t-shirt.)

While googling around the Internet I found an article by Steven Kotler on the Psychology Today blog entitled "How We Learned To Walk: The Uneasy Origins of Rock Climbing". Talk about a surefire, catch-Clink's-attention title!

The article reviews anthropology finds over the years and talks about a new theory of human evolution, specifically how humans began to walk upright. Anthropologists once thought humans started walking upright after they came down from trees. Now primatologists are suggesting that walking is a natural offshoot of climbing. They site orangutans who have been observed "tree walking", or walking across branches while holding an upper branch with both limbs (a bit like a toddler 'cruising' while holding on to furniture). This climbing method is energy efficient and stable because it allows for four points of contact at all times---it also happens to be the way a beginning rock climber climbs.

OK, so it's a bit of a stretch (literally) but at least it gave me a chance to link some of my favorite subjects together in one post.

Tuesday, April 07, 2009

10 Sure-Fire Headlines: Now You Can Have a Thousand Posts in Only Three Years


Brian Clark wrote on Copyblogger back in 2006 about "10 Sure-Fire Headlines That Work." This is a classic article on how to write headlines that make people want to read the article or click on the link.  I came across it just as Dinah was reminding us that Shrink Rap's 3-year anniversary is coming up on April 22, and this post here is our 984th post.


"Wouldn't it be cool if our 1000th post was on our 3rd anniversary?"

So, I came up with the idea that our final posts should have "Sure-Fire Headlines That Work."  So, stay tuned for our final posts in our triennial millenium.

Why I Hate In Treatment


Dinah, I still love you even though you ignore my opinion and write about In Treatment.

A while ago Dinah wrote about why she hates the television show House. I didn't have strong opinions about the show, I had only watched a few episodes and I thought they were OK. If Dinah hated it and wanted to blog about it that was cool with me. So now, I'm taking my turn.

In the interests of full disclosure, I'll tell you first that I've never had cable TV. Not only that, but since about last July I haven't had a television. I really haven't missed it. I've been to places that had cable TV and what I saw just reinforced the idea that there was a lot of content that just wasn't worth watching. I spent more time channel surfing than viewing. So that's my disclaimer. (I watched the first week of In Treatment on the Internet.)

In general I think it's a bit unsettling to be immersed in TV culture. I notice it more now that I'm not part of the American "viewership", but it feels odd to go somewhere and listen to people absorbed by characters who aren't real and life stories that don't actually exist. I mean really, there are earthquakes and wars and important international events going on and we're wondering who is going to get voted off American Idol? Don't we have real issues to talk about?

As far as the show specifically, I don't like it because it's neither treatment nor is it therapy. Face it, the guy's a goofball whether he's a psychiatrist, a psychologist or a licensed angel adjuster. If you're going to be that far off base from reality you might as well write a show around the complicated dysfunctional relationships between an auto mechanic and his customers. (Oh wait, there was that Taxi series---that's pretty close.) It's too laughable to be drama and too self-important to be comedy. Like I said when it first came on, I'd rather have a more realistic series about seriously mentally ill folks making their way in the world than a gossipy pseudo-introspective contrivance like In Treatment. Dinah didn't like House because the doctor was obnoxious and the show wasn't realistic. Oddly enough, the same reasons I don't like In Treatment.

I'd even prefer blog posts about ducks.

In Treatment: Reflections on the First Week of Season Two


I liked it. I really liked it. My attention stayed focused, my blood pressure didn't soar. I didn't rant once (I don't think, can that be? Maybe I'm just starting to age gracefully).

Now that I've had time to reflect, here's what I liked:

In Treatment captured some of the sub-text, the underlying angst, that we, as therapists, might fail to talk about in a unifying way.

So Mia meets her therapist 20 years later: now she's a head litigator in a prestigious law firm and she sports a Prada suit--he's the vulnerable one being sued and she can save him! She was very attached to him, and he left her (to move) in a way she found painful. And he never contacted her. From the shrink side of the couch, that doesn't seem odd--- psychiatrists don't typically continue to initiate contact with former patients. She feels jilted, and she's never really gotten over that or something else. It's easy to see both sides-- she's too demanding, he's too aloof, why is this still lingering for her? It's pulled to the open when Paul says she must like showing him both her success and her pain. This was good.

And there's his frustration with the limitations of the therapist's role--- he wants to DRAG his patient who is refusing cancer treatments to therapy:if she were her daughter. If only Paul's daughter would return his phone calls. What would the CEO in the cashmere coat do? The one who wants to drag his daughter home from Rwanda? Oh, if only Paul's daughter wrote him such lovely, heartfelt emails. The father-daughter issues are upon us. And if that's not strong enough, there's the whole Mother-son issue with Gina that bonks us over the head.

I've criticized the blurred boundaries in the Gina's relationship (friend, supervisor, therapist, have a shot of vodka?) with Paul. But the reality is that when one psychotherapist consults another, the issues can get a little blurry and the lines of when and where the lines lie might well be a bit fluid.

So, I liked it.

Monday, April 06, 2009

In Treatment Season 2, Episodes 3, 4, and 5


Oliver and his parents present for family therapy. Only the family has split and Oliver prefers the company of his over-solicitous mom. There's not much to say about the session-- looks like a family session to me. Paul does nothing too unusual, and family therapy is hard. There are many agendas and many subtexts, often an overwhelming amount of material to deal with.

So far, what we know is that the personalities are all strong and the issues are complex. Mom makes the point that dad is irresponsible. He plays Wii with his friends and parties all night and he doesn't stock the fridge for his son. Dad makes the point that he makes the bucks and Mom is a perennial student--we've already been set up for the idea that the face one puts on may betray the reality of the behavior. Mom hovers, she moves too closely to the boy and doesn't even suggest he carry his own backpack, and Oliver sucks it up and plays the two of them off each other. It will be interesting to see what comes of the family.
-----------------------
Walter is a big-shot CEO in a cashmere coat, or so he tells us. He can't sleep and he wants his problems solved quickly, even if he has to pay more for more intensive sessions. In fact, he seems to magically want Paul to know what the cure is without being very forthcoming about what the problem is. Walter seems to want to spar with his new therapist, and he's quick to be condescending. At some point, he becomes downright angry when Paul doesn't agree that Walter should rush to Rwanda and 'rescue' his daughter who is working in a clinic. Walter begins to leave in a huff-- he came for relaxation exercises and an insomnia cure, not to talk--when he falls to the floor clutching his chest. Paul tells him to breathe (finally!) and gives him some water. No one calls 911, and Walter tells him, in a gasping, pathetic sort of way, that these episodes always resolve.

Walter's persona is too overtly grandiose-- I can't help but wonder if his blowhard narcissism isn't a defense for an underlying insecurity (--there, I'm finally sounding like a real shrink!). What isn't he telling us and what secrets are still to be had. So Walter-- insomnia, panic attacks, is he really as important as he tells us? An edge of paranoia? And, okay, I admit, the 'bipolar' word crossed my mind when he talked about taking a one hour nap and then being good to go for 24. There's energy and there's Energy. Too soon to tell.
------------------

Paul returns to Maryland to see Gina. She's being deposed in his lawsuit. Paul had decided he's going to lose his license and go bankrupt. And, oh, "I've decided I'm sick of sitting in a chair day after day listening to peoples' problems." We find out that Paul's office is in his apartment and he sleeps on his couch and never sees his kids. He's a disaster, and he confesses that by the end of his patient's therapy, he hated Alex. He's come to Gina for clarity. They have a drink and a lot of ground is covered.

Paul and Gina: so like what is this? Sometimes they call it friendship, sometimes they call it therapy, sometimes supervision. They flit in and out of different modes and the conversations are the same, no matter what they call it. He doesn't want therapy, and then he does want therapy. They're sitting next to each other on a couch, sipping vodka, when they decide to resume therapy.

Signed, Sealed, Delivered: Status Update From The Shrink Rappers


Later this month, Shrink Rap will celebrate 3 years and we're coming close to the 1000 post mark. I'm not sure if we can get them to coincide. We have news:

Signed, sealed, and delivered, the Shrink Rappers have a book contract. So far, the tentative name is Off the Couch: How Psychiatry Works and What Psychiatrists Think. It won't stick, no one likes it, but for now, it's a "provisional" title. The book will be published by Johns Hopkins University Press, sometime in 2011. Since it's not written, it's hard to have an exact release date.

When I asked our readers for thoughts about a sample chapter, I got a lot of conflicting feedback, but one theme was voiced by several-- the book is more serious, more dry, not light and witty. The editorial feedback we've gotten when we tried to mimic the blog was clear: we have "weird doctor humor" and there was concern that we trivialize mental illness. Other than that, they loved it and it was approved unanimously, what can I say? So the book will be different than the blog, it will be a look at how psychiatry works, but it will be a serious endeavor, not banter. If you like you Shrink Rap, you may or may not like Off the Couch. If you like Shrink Rap, I have good news: we're staying here in the blogosphere, we're staying free, and we're staying weird-- ducks, chocolate, and all.

And what about our My Three Shrinks podcast? That's a good question, one I've wondered about myself. We have some podcasts "in the can" waiting for production. I don't know when they'll go up, I don't know when we'll resume on a regular schedule. One thing I do know is that we will be resuming My Three Shrinks with renewed enthusiasm, but it may not be until after we finish the draft of the book. That's due in June of 2010, and we're aiming to have it done a few months earlier.

So ClinkShrink is off climbing every mountain. Roy is looking for the next gadget to count gigabytes on. I'm signing on to a year as president of our state psychiatric society and thinking that between that and writing the book, I'll be tired of psychiatrists pretty soon.

We're all excited about the book. Thank you for reading Shrink Rap and for all your comments and insights; our readers really are what fueled our interest in writing about our work.

Sunday, April 05, 2009

In Treatment: Season 2, Episode 2


April enters and we're struggling to figure out what she's doing here. She asks a lot of questions, and she offers information, but what's she doing here? Paul reassures April she can't offend him. "I can't?" "Well, of course you can, but I can take it." Oh, can I try? It was a funny thing to say.

April tells us about her last imperfect therapist who told her the same insignificant story twice. April left the treatment without calling and "the woman was borderline stalking me...second of all she was an idiot." April tells us right off that she can't take being pushed. She tells us she wants to be listened to, and Paul's wasting her time asking about her last shrink. Finally, they come to a calmer place and she has to write down her chief complaint, it's just too hard to say. April has cancer, she doesn't want to talk about it, she just wanted to tell someone. Lymphoma.

April is angry at the medical care she's gotten, she feels like a specimen. She hasn't told her parents. Or anyone else. April is angry with the treatment world. She's not sure she wants treatment and she wants to think about alternative therapies. And then Paul says something nice, he puts April's difficult demeanor in to a nice perspective: "You seem to be a very independent person."

He gives her a list of what she should do: talk to her oncologist, tell her parents. She leaves in a huff without scheduling another appointment. "I'll call you." And we think she might not.

There's not that much to say about the session. Paul has a history of pushing patients a little too hard (if you ask me). This is a difficult patient and we don't know if her anger is part of her, or an acute response to a horrible stress. We do know that, at least for now, she's quick to judge and feeling terribly vulnerable. She pushed Paul by asking about his decorating, why he's moved...and this time he crosses no boundaries.

In Treatment Without Boundaries: Paul Gets Sued


Okay, I'm going to try to follow the series. ClinkShrink, please love me anyway.

The season opens-- Paul, now with too-short hair, unshaven and in jammies, opens his door to Alex's dad. Dad is angry that he's lost his son, the pilot, and says Paul should have told the Navy he was unfit to fly. He wants Paul to suffer: here, have a subpoena, you're being sued and Dad is hand-delivering it.

Lawyer's office, Mia in a Prada suit. Paul is surprised, it's not the male lawyer he thought it would be, and we're led to believe this is one of Paul's old girlfriends, he's clearly uneasy. We learn he's 53, now divorced, moved to NY, and he has an MS and a Ph.D-- somehow I thought he was a psychiatrist, but now we know he's a psychologist. Also, I thought his diplomas last season were from the University of Pennsylvania, but those aren't among the schools listed. Oh, and Mia keeps getting disrupted during this very important meeting-- a call from her father is put through where she tells dad he looks great in green, and a colleague bursts in to the session. Nothing feels sacred here.

Paul acts surprised when he hears the term "malpractice" and it's news to him that Alex's death is being construed as a suicide. And now the episode gets interesting. Paul hasn't sent his clinical notes, ah, he doesn't take notes. That could be a problem. Is it better to be a bad therapist who takes notes then a good therapist who doesn't, he challenges Mia. No one's told Paul that it's best to be a good therapist who takes notes. I'm not sure of the rationale for never taking notes (and that is what he says, he Never takes notes). And it gets even more interesting when we learn that 20 years ago he did take notes, back when he was Mia-the-litigator's therapist. Ah, he left her precipitiously when his family moved and she felt abandoned. He's sorry she felt abandoned, and she jumps right on his words...you felt abandoned, and he seems to have forgotten the details of her distress, of the gift she gave him, of how hurt she was that he never contacted her. Therapists do sometimes if the patient is special. We feel her pain, we watch Paul squirm, and the tables keep turning all episode as to who is grilling who. Mia asks Paul some questions that leave him feeling defensive, angry, and like some of thse strings might go pop at any moment. Mia then gives him an earful on the loneliness and pain of her life. It could have been prevented (we're left to wonder why) and while they both agree this is a bad idea (No? ). Mia gets the final satisfaction of telling her long ago abandoning shrink that his time is up and she has another client. Touchée

It's like everyone here is naked. The therapist is thrust in a room with his former patient and it's not what he wants. She reassures him it's okay, but we know it's not okay. She asks how a patient leaves treatment (Alex) too soon, and we hear the pain of a therapist leaving when a patient still needs them. You're left to wonder: can a therapist force someone to remain in treatment (generally, no) . And is there ever a way for a therapist to depart without causing angst. People move, but somehow I have the sense that Paul could have done so with more sensitivity.

Back with the next episode shortly.


Saturday, April 04, 2009

Should People With Mental Illnesses Hold Public Office?


After my post Depressed and Running for Governor post, one commenter (MWAK) asked if people with depression should run for governor. Novalis responded with his own post, Uneasy Lies the Head where he says No and gives his reasons for his thoughts.

It got me thinking. As a psychiatrist, we generally feel mental illness should be destigmatized, and life should be more 'fair' for those who suffer from mental illnesses. I have to say, sometimes I struggle with this--- it's nice to be accommodating, but if the symptoms of one's mental illness make one's companionship intolerable, or one's job performance erratic and inefficient, or one's behavior disruptive or dangerous, how much should others be expected to bend?

So Governor or President....in Doug Duncan's case, it seems he personally decided that the campaign itself was too stressful while he was actively symptomatic. Let's suppose that we can agree that we don't want someone with a symptomatic mental illness running our country. Actually, I don't want them driving my bus, train or airplane either, not while they're thinking about how to suicide or dealing with slowed reaction times or poor judgment.

For the sake of argument, let's say our would-be President or Governor, or pilot or bus driver or armed soldier or police officer has a history of mental illness. Let's suppose it was treated with full remission of symptoms and he hasn't been ill for a while.

Novalis says No: psychiatric illnesses are chronic and recurring (and for some reason he thinks hypertension and diabetes are more likely to stay control or be predictable, but I'm not going there), symptoms can be insidious, gradual, and hidden.

I agree, they can be all of these things and I don't want someone in the midst of an episode running a ship if there really are those buttons one can push to blow up the world. Or decisions that need to be made quickly. Here's my sort-of/maybe beef with this logic: people without mental illnesses can : 1) suddenly get them, 2) have bad judgment or make bad decisions in the absence of a psychiatric illness, 3) keel over and die or become disabled with no warning. We need to have provisions for such things, and the fact that it's higher probability with a history of mental illness doesn't change that we need to have perimeters to check on people involved.

One thing seems clear: If you take away someone's job simply because they seek treatment, then you limit the ability of someone to get treatment. I'd rather have a pilot on Prozac who is being closely monitored, then a pilot who's been afraid to tell anyone his dark thoughts about the plane I'm on.

Novalis says, "If or when our understanding of mental disorders progresses to the point where we can more reliably predict and modify their course, then a major mood or anxiety disorder might survive the vetting process."

We can't predict the behavior of anyone (remember that W guy?). If we know someone has a history and an increased likelihood of recurrence, at least it can be openly discussed and some checks can be put into place.

So no answers here. I do wonder why it is that people have been required to have psychiatric evaluations before all sorts of procedures (in vitro, bariatric surgery) and we don't require our presidential candidates to spend a couple of hours being evaluated by a psychiatrist before we let them run.

I will point out that many of our presidents have had serious mental illnesses, including some of the most popular of presidents.

I'm rambling. Hope I didn't say anything too objectionable.


[Edit 4/5/09 11:30: This is Roy. I just wanted to clarify something here. When I first read Dinah's post, I thought "OMG, she's saying people with, say, a history of bipolar disorder shouldn't fly planes or be President." After reading some comments, esp Nonstandard's comments, and then Dinah's reply, I realized that what she wrote does not clearly state what she seems to intend. So, as a way of either clarifying or distancing from what she said, here is what I think : A 'diagnosis' of anything should not -- in and of itself -- prevent someone from taking on a high-responsibility position (IMHO). The question should be about how they are currently functioning. And if a position carries enough high risk (say, the nuclear button-pusher job, prez, airline pilot), then there should be built-in safeguards that require some sort of ongoing assessment of functional capacity, regardless of one's presence or absence of diagnostic labels. Come on, even dealing with, say, a divorce or your daughter's breast cancer could have a negative impact on one's performance in certain positions. I'll put more in the comments, esp asking why the legal system has put us in the situation that Nonstandard Mind points out in the first place. Back to your regularly scheduled program.]
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Dinah's Addendum
Arg From Dinah! See my clarifying remarks in the comment sections.
Regarding pilots: I'm not the one who said they can't fly with a history of bipolar disorder, it's the FAA's idea. And the FAA is pretty picky about what meds pilots can take and still fly, psychotropics in general are not allowed, so this pretty much eliminates anyone with a chronic or recurring mental illness. Benedryl is a no-go as well, so no acutely allergic pilots. What surprised me is that they can be on blood thinners or anti-arrhythmics and people who need those medicines generally have underlying illnesses that make them susceptible to strokes or sudden death.