Tuesday, August 31, 2010

The Texting Shrink


I like texting. It's a fast and efficient way to exchange information, and I'm a bit prone to yakking, so this allows for a no-nonsense exchange without all the gabbing about how the kids are doing or the latest on someone's ingrown toenails, or the usual assortment of small talk items. Running late, order my salad. Yes, Bobby can get a ride home with us. Or, if you're Roy: "do you have triple sec for the mango margaritas?" Roy makes surprisingly good mango margaritas without using any triple sec. Just so you know-- and I don't mean to brag-- I'm fast with the thumbs.

I text with patients as well. Do other psychiatrists do this? It works well for "Need to cancel my session this week, see you next week." Or "Running 10 minutes late, traffic." Once in a while I'll even text a reminder to someone who misses appointments frequently. I was happy to hear that there is a dentist in town who also sends text message reminders.

Here's the problem with texting patients:
People have taken to texting me with problems. "I feel horrible and like I might want to end it all right now." (This did not really happen). I've done a few back and forths and realized that I'm not good at psychotherapy via text. Usually problem texts get met with "Come in at....." and if .... is not Very Soon, or if the patient says that's not good, I call, or text "call me." I've been texted insurance information, drug reactions, appointment changes, negative biopsy results, "will you call refills in to my pharmacy?" and most notably, "Your office door is locked" after I haven't responded to the knocking, only to find my patient sitting on the hallway floor.

What's good about it? Somehow it feels less intrusive than a phone call, and the time taken up is more predictable. I'm prone to ramble and so are many of my patients-- texts messages take seconds and phone calls can take minutes and involve many phone-tag back-and-forth exchanges. When someone texts their pharmacy number, I can click on it and get through--if it's on voicemail, I often have to re-listen when I have a pen available, and often the number is at the end of a long message. It seems to me that texting is no less documentable than a phone conversation, so I can't come up with any legal reasons it's not kosher.

What's bad? I have taken to telling patients that while I'm happy to try to negotiate appointment times via text, or "running late" messages, that it's not a good way to negotiate problems-- for drug reactions and symptom changes, we should start with the phone. My biggest concern is that if I'm on vacation, there's no way to set a coverage text message, and my voicemail has the names and numbers of covering doctors. I've been pretty clear with people that I'm not blowing them off, and that if they don't get quick reply to a text message, they need to CALL the office.

What do you think? It's a different take on the shrink when there's nearly instant access a good deal of the time.

Sunday, August 29, 2010

First Medical Marijuana, now Healthy Hallucinogens?

~from Lanny-Yap

Last week's article in Science looked at the effects of the anesthetic/dissociative drug ketamine ("vitamin K" or "Special K" on the street) in brain cell function in rats, concluding "that ketamine might be useful in treating depression because it increases brain activity instantly - so there is no need to wait weeks or months for the drug to take effect."

Another article from Nature Reviews Neuroscience reviewed the state of the art in psychedelic science and found that "countless studies show that hallucinogens promote healthy neural activity in the brain. The researchers also created a chart to show what test subjects' states of mind are, according to studies, when under the influence of various substances."

Go to Lanny-Yap (great site!) for links to the articles.

Saturday, August 28, 2010

What's Next?


Cut and Paste. I don't know what to say. Oh my.
In tomorrow's New York Times, Lisa Miller will write "Remembrances of Lives Past"

IN one of his past lives, Dr. Paul DeBell believes, he was a caveman. The gray-haired Cornell-trained psychiatrist has a gentle, serious manner, and his appearance, together with the generic shrink d├ęcor of his office — leather couch, granite-topped coffee table — makes this pronouncement seem particularly jarring.

In that earlier incarnation, “I was going along, going along, going along, and I got eaten,” said Dr. DeBell, who has a private practice on the Upper East Side where he specializes in hypnotizing those hoping to retrieve memories of past lives. Dr. DeBell likes to reflect on how previous lives can alter one’s sense of self. He, for example, is more than a psychiatrist in 21st-century Manhattan; he believes he is an eternal soul who also inhabited the body of a Tibetan monk and a conscientious German who refused to betray his Jewish neighbors in the Holocaust.

Belief in reincarnation, he said, “allows you to experience history as yours. It gives you a different sense of what it means to be human.”

----------------------

I'd comment, but I don't know what to say.

The Bickering Friend

Our regular podcast listeners know that the Shrink Rappers love to bicker. The topic doesn't matter: Xanax, allocation of health care resources or punctuation, if there's a potential for argument we will have one. Some of our reviewers commented that the bickering makes them uncomfortable or is embarrassing to listen to. All I can say to those listeners is: we've always been this way, we're never going to change and we wouldn't do it if it weren't fun for us.

Everybody probably knows someone who likes to debate. If you say one thing, they'll say something different just for the sake of having a discussion and engaging someone. It's a relationship thing, like talking about the weather. Nobody really cares if it's sunny or too hot or if there's a storm approaching, it's just a way of maintaining a connection. For some people, bickering serves the same function.

I appreciate a good debate occasionally because this keeps me sharp mentally. When someone tells me I'm wrong I question my assumptions, do some homework and learn something. My bickering friend learns something too (I hope). If the debate goes on too long or gets uncomfortable, I disengage or admit that I'm too tired to continue. It's not a big deal. People who maintain relationships with bickerers can't be too sensitive. There's nothing personal about it, it's just a way of life.

And by the way, Dinah was right: the period goes inside the quotation marks. Dinah effectively affected a change in my writing affectation. Can you guess what her writing quirk is??

Affectionately yours,
Clink

Friday, August 27, 2010

I Speak Your Language


In spite of crime-solving TV shows like the CSI series, as a forensic psychiatrist I know that real life is much more mundane. Although I get to interview lots of interesting folks, most of the work involves writing extensive reports (or editing the reports of others). And just when I think I've got my writing skills down pat, a copy editor comes along to prove otherwise.

Dinah, Roy and I spent several hours together this week going over the proof of our book. We reviewed our editor's corrections and quibbled about our own. I discovered that Dinah had learned rules of grammar that I had never heard of, and that some of the truisms I learned no longer applied. Language is like that.

Fortunately, as children we pick up grammar and syntax without any conscious awareness. Certain sentences or phrases just naturely "sound right" because they get built into our brains somehow. We speak the language and vocabulary we hear, and we write the way we speak.

This is a problem when you live in Baltimore. Every day I get exposed to Baltimore urban vernacular. In this city people don't get beaten up, they get "banked." They aren't relaxed and happy, they're "chillin'.'" They aren't merely annoyed, they're angry "for real." And they don't lose their tempers, they "zap out."

In my clinical practice it helps to speak my patients' language. If my patient tells me he "caught a hopper", I know he doesn't like his young and restless cellmate. If he asks me for help with an "8-505", I can explain the legal process for doing this. I am unexpectedly multilingual through the coincidence of where I live and work.

I just have to remember not to write like that or my editor will "zap out for real."

***************
Dinah adds:
OMG! I can't believe we wrote an entire book together and you're still putting the periods outside the quotation marks! Shoot me now. From Grammarbook.com:

Rule 1. Periods and commas always go inside quotation marks, even inside single quotes.
Examples: The sign changed from "Walk," to "Don't Walk," to "Walk" again within 30 seconds.
She said, "Hurry up."
She said, "He said, 'Hurry up.'"




********************************

Clink responds:

Life is never that easy. See discussion here and here. Nevertheless, I changed them.

Thursday, August 26, 2010

Very Little Very Sad People


I thought I'd give you a heads up that The New York Times Magazine will be featuring an article on Preschooler Depression this weekend. I am working on my ability to see into the future, and it's going well.

Pamela Paul will write:

Diagnosis of any mental disorder at this young age is subject to debate. No one wants to pathologize a typical preschooler’s tantrums, mood swings and torrent of developmental stages. Grandparents are highly suspicious; parents often don’t want to know. “How many times have you heard, ‘They’ll grow out of it’ or ‘That’s just how he is’?” says Melissa Nishawala, a child psychiatrist at the New York University Child Study Center.

And some in the field have reservations, too. Classifying preschool depression as a medical disorder carries a risk of disease-mongering. “Given the influence of Big Pharma, we have to be sure that every time a child’s ice cream falls off the cone and he cries, we don’t label him depressed,” cautions Rahil Briggs, an infant-toddler psychologist at Children’s Hospital at Montefiore in New York. Though research does not support the use of antidepressants in children this young, medication of preschoolers, often off label, is on the rise. One child psychologist told me about a conference he attended where he met frustrated drug-industry representatives. “They want to give these kids medicines, but we can’t figure out the diagnoses.” As Daniel Klein warns, “Right now the problem may be underdiagnosis, but these things can flip completely.”

It's long. Just say, "I saw it at Shrink Rap first."

Wednesday, August 25, 2010

Emotion versus Mental Illness


My favorite commenter, "Anonymous," wrote in to my Duckiness post to say that it was good I could post something totally silly without being told I need more meds. Oh, if life were that simple. And it is true that once someone has a diagnosis of bipolar disorder, not only does the world question their emotions in a black & white "are you sick again?" kind of way, but patients don't trust themselves to feel for it's own sake.

If you're not sick, then being asked if you took your meds is insulting and degrading. And so I thought I'd put together some guidelines for Emotion versus Mental Illness. I'm inventing this as I go, with no evidence-based anything, so take my suggestions at your own risk.

  • If you are ultra-successful, rich, brilliant, gorgeous, famous, and comfortable with your diagnosis, you may want to consider telling people you have a mental illness because it decreases stigma and people like being with the ultra-successful rich, famous, brilliant and gorgeous and won't care that you have a mental disorder. It helps even more if you're charming.
  • If you're not ultra-successful, you may want to pick and choose who you tell that you've been ill and are on medications. This isn't always possible, especially if your illness is evident to others or if the presentation of your symptoms resulted in a hospitalization. It's good to tell close family members.
  • If multiple people are looking at you strangely, or commenting on your behavior, or saying you need medications, you might want to at least entertain the option that you could be sick. Unfortunately, poor insight and judgment are symptoms of mania.
  • Tell the people close to you not to make medication jokes. It confuses the issue if you seriously do need medication changes, and it's rude, degrading, dismissive, and disrespectful. There, I said it.
  • If you want to be silly, go for it. Be silly when you're well so that being silly is part of your baseline personality and no one equates this with being out-of-character. You'll note the duck invaders did not come after me, rather they said, "There's Dinah posting yet another stupid duck post." If I'd posted about why chocolate should be outlawed and made into a controlled substance, those same duck invaders would be asking "What's wrong with Dinah?"
  • Mental illnesses come as constellations of symptoms. There is no "Sending out silly duck stuff" as a symptom. People think about mania when the ducks are combined with more energy, racing thoughts, a decreased need for sleep, increased mood OR irritability, and other symptoms of mania. Know the list and if someone bothers you, say, "I posted about ducks, I do not have any other associated symptoms." Recite them if necessary. If you do have the other symptoms, refrain from posting about ducks. I don't want Posts Duck Blog Posts to show up anywhere in DSM-V and these days you just never know.

  • No one controls how any other person thinks of them or judges them and it's not reasonable to live life ruled by a desire to be perceived in a certain way . It's another form of poultry, but Don't Let the Turkeys Get You Down. There are a lot of turkeys out there.

Moods happen on a spectrum. Some people have large variations in their mood---large enough or severe enough such that it causes suffering, and we call it an illness. Some people don't have much variety to their moods and live in a calm, even-keel place, and it's great that we have such people. But, I absolutely promise you that if we lived in a world where everyone had a very narrow range of mood, this would be one terribly boring planet. We should celebrate our diversity, not condemn those who like ducky stuff.



Tuesday, August 24, 2010

My Favorite Lawsuit

Clink note: There are certain cases that are just fun to read. This is one of them.

*********************************************


JOGEZAI KAKAR KHAN, Plaintiff, v. WILLIAM SESSIONS, Defendant.

No. C93-04394 CW

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA

1994 U.S. Dist. LEXIS 1385


February 7, 1994, Decided
February 8, 1994, Filed

CORE TERMS: forma pauperis, intelligence, prostitution, kidnapping, software

JUDGES: [*1] WILKEN

OPINION BY: CLAUDIA WILKEN

OPINION


ORDER DENYING PLAINTIFF'S APPLICATION FOR IN FORMA PAUPERIS AND DISMISSING COMPLAINT

BACKGROUND
Plaintiff's complaint alleges a vast conspiracy involving, among others, named Defendant William Sessions (former director of the FBI), former President George Bush, the Queen of England, the Consulate of France, French President Mitterand, the San Francisco Chronicle, several university professors, gangs in Hong Kong, the drug cartel, CIA agents, U.S. Army Intelligence agents, British government agents, former British Prime Minister Margaret Thatcher, H. Ross Perot, Israeli corporate intelligence "consultants," Paul Newman, Kirk Douglas, Frank Sinatra, John Carradine, Dennis Hopper, Robert Mitchum, Orson Wells, Phil Donahue, the founders of Israel, the "Jewish Mafia" in Russia, U.S. Postal employees, a "humanoid alien extra-terrestrial leader speaking Greek," Oliver North, and several local people known and unknown to Plaintiff, including hypnotherapists who advertise in local papers.

Plaintiff brings the action for concealment, false information, fraud, threats to commit a violent act, racketeering and treason. Specifically, he alleges that the people [*2] named above acted separately and together to accomplish the following: false processing of computer chips, or software, containing dangerous elements to endanger the life of users; the shooting death of Pablo Escobar in Columbia; placement of a former political prisoner high up in the Pakistani government to conceal secret sales of computer software parts; the poisoning death of Plaintiff's father (whose death was attributed to heart attack), allegedly a witness to illicit shipments of oil and petroleum products; covert prostitution at local utility companies; the theft of Plaintiff's father's luggage in New York city in 1953; operation of various prostitution rings, and related blackmail, murder, kidnapping and torture of American and foreign women and girls, including forced transsexual operations; withholding of Plaintiff's letters to George Bush, and issuing false receipts for mail; trafficking in various drugs, human blood and body parts for witchcraft and human sacrifices; electronically bugging Plaintiff's residence; bribing university personnel; the sale of a major American airline to a British company; participation in a "Traitor Spartan Greek club co-opting Persian habits [*3] and Golds since 478 B.C."; planning and participation in the Polly Klaas kidnapping through using remote channellers in alleged kidnapper Davis's home; use of UFO-like aerial objects to wire remote-control or radio-in false signals to the human ear and brain using planted electronic devices; and entrapment and framing of California State Assemblymen and U.S. senators (for unspecified crimes).

Plaintiff seeks leave to proceed in forma pauperis.

DISCUSSION
Title 28 U.S.C. Section 1915(d) authorizes federal courts to dismiss a claim filed in forma pauperis prior to service "if the allegation is untrue, or if satisfied that the action is frivolous or malicious." Under this standard, a district court may review the complaint and dismiss sua sponte those claims premised on meritless legal theories or that clearly lack any factual basis. Denton v. Hernandez, 118 L. Ed. 2d 340, 112 S. Ct. 1728, 1733 (1992); Neitzke v. Williams, 490 U.S. 319, 324, 104 L. Ed. 2d 338, 109 S. Ct. 1827 (1989). A finding of factual frivolousness is appropriate when "the facts alleged are 'clearly baseless' . . . a category encompassing allegations that [*4] are 'fanciful,' 'fantastic,' and 'delusional,'" Denton, 112 S. Ct. at 1733 (citations omitted), or "rise to the level of the irrational or the wholly incredible. . ." Id.

Plaintiff's allegations clearly come within this doctrine.

CONCLUSION
Accordingly, Plaintiff's request to proceed in forma pauperis is DENIED and the complaint is hereby DISMISSED without prejudice.
The clerk shall close the file.
IT IS SO ORDERED.
Dated: February 7, 1994
CLAUDIA WILKEN
UNITED STATES DISTRICT JUDGE

Monday, August 23, 2010

Too Much Duckiness to Ignore.




Let the facts of the case present themselves:

1

In the early pre-dawn morning (approximately 4:00 a. m.) of June 18, 1972, the windshield of the automobile which appellant was driving along North Columbia Boulevard in Town X, suddenly shattered causing a splinter of glass to enter Smith's right eye, which resulted in permanent impairment of sight in that eye. Investigation proved that the cause of this unfortunate mishap was that Smith's car had struck an airborne mallard duck or conversely that the mallard had struck Smith's car. The rationale for this conclusion was the finding of the body of a deceased mallard at the scene of the accident and duck feathers and other parts inside car. The question of negligence, or the degree thereof, attributable to the only participants involved in the accident, namely, the mallard and Smith, is not before us.

2

The scene of the accident was that portion of North Columbia somewhat adjacent to the plant of defendant-appellee, Malarkey Company (Malarkey). Since Smith is a citizen of Washington, Malarkey is an Oregon corporation and the amount in controversy exceeds $10,000, the federal courts have been chosen as the forum in which Smith seeks recoupment for his injury.

3

His complaint, a model of brevity, contains two counts: (1) negligent maintenance of a duck pond on the Malarkey property, near North Columbia, a public thoroughfare; and (2) creating thereby an unreasonably dangerous condition to the public using that thoroughfare.

4

After several unsuccessful attempts by Malarkey to dispose of the matter by motions to dismiss for failure to state a claim, for partial summary judgment and for summary judgment, the case came on for trial before the Court without a jury. Subsequent to the trial, the Court delivered its opinion1 finding for the defendant.

5

The Court refused to conclude that the maintenance of the pond by Malarkey was an "ultra-hazardous activity" and referred to parks and places, public and private, in the vicinity where waterfowl might congregate. As to negligence, the Court held that there was "no showing that the defendant knew, or reasonably ought to have known", that such a pond "was likely to lead to harm of the general character involved in this case" or that the fact that dead ducks had been found on the highway was notice to Malarkey that ducks were a hazard to motorists. In short, the Court could not find "the vital element of foreseeability" in relating the Malarkey pond to the accident. Accordingly, judgment was issued dismissing the complaint.

6

Plaintiff called as witnesses persons who, while driving along North Columbia, near the Malarkey property, had seen dead ducks at the side of the road, ducks walking across the road, ducks sitting in the middle of the road and ducks flying at low levels across the road. In one instance, the front of a motorist's car had struck a duck, with unfortunate consequences for the duck. If ducks chose to walk across a well-traveled public highway used by motorists instead of using less dangerous aerial routes better suited to flying ducks, they might well have subjected themselves to such an eventuality. The roadside dead ducks certainly indicated that motorists were a hazard to road crossing ducks, but by no means that such ducks would be likely to be the cause of the type of injury incurred here. Furthermore, even if it had been, one would have expected the record to have been replete with incidents of ducks crashing into motorists with notice thereof to Malarkey.

7

Appellant also adverts to the Malarkey habit of putting food and grit around the pond about 4 o'clock in the afternoon and argues that even if the pond itself was not the well-spring of the dead duck's conduct, Malarkey was still culpable because of these other lures with which it seduced the birds to come to the pond. However, once again, even assuming appellant's premise that mallards find food and grit irresistible, there is no way of knowing whether the Malarkey provender was the aim of this duck's low trajectory. And there is no evidence which would indicate that the duck was in the area for a midnight snack twelve hours ahead of schedule or that the pond was the duck's intended destination. Further speculation along these lines would be pointless. But even if this feeding practice caused an undue assemblage to partake of Malarkey largesse, it would not account for the unexpected flight of a single duck in pre-dawn darkness. Furthermore, the pond was 100 yards from the highway, surrounded by a seven foot fence with railroad tracks between highway and pond.

8

The area is a game reserve and should be naturally attractive and conducive to migratory birds. In addition to the parks and open areas previously mentioned, there is somewhat nearby the Columbia River, the Columbia River Slough and green fields where ducks have been observed to congregate and feed.

9

The waters of the Malarkey pond might well be said to be alluring to ducks but by no stretch of the imagination is the maintenance of an artificial pond an ultrahazardous activity or a foreseeable cause of an injury of the unusual nature suffered here. The activity is neither abnormal, unusual, or especially dangerous see, Reter v. Talent Irrigation District, 258 Or. 140, 482 P.2d 170 (1971) at least not in an area which is already rife with waterfowl and water.

10

Appellant says "Nothing short of removal of the pond could eliminate the risk" (Appellant's Brief, p. 6). But query, would elimination of Malarkey's rather minute pond remove the risk? Complete protection of motorists might well require the elimination of the game refuge, the surrounding green fields, the Columbia River Slough and possibly the diversion of the Columbia and Willamette Rivers as well, if flying ducks were to be recognized as a constant peril to motorists.

11

The parties here both have proceeded in a well-accepted format of argumentation, namely, an almost biological analysis of cases and the Torts Restatement. They have dissected and then put under the microscope each and every element stated therein. Tort cases, however, so much dependent on their own particular facts, are not suited to such treatment. The Trial Court here heard and reviewed the evidence presented and then, in finding for the defendant, held that the maintenance of the Malarkey duck pond was not an "ultra-hazardous" activity and that the type of accident here suffered was not foreseeable. The law and the facts support this conclusion.2

12

Judgment affirmed.

*

Honorable Leonard P. Moore, Senior United States Circuit Judge, Second Circuit Court of Appeals, sitting by designation

1

The oral opinion dated March 14, 1974 has been transcribed as an opinion, filed as findings of fact, and conclusions of law and order pursuant to Rule 52, and is to be found at pages 149-155 of the record on appeal

2

There is an indication in the record that the Judge and counsel planned to visit the Malarkey property on the afternoon the trial ended, thus giving the Court and counsel the advantage of visual inspection

The Psychology of Survival

I read this BBC story recently about the Chilean miners trapped for 17 days, who now face months of waiting underground while a rescue tunnel is dug. Although they are all physically well and expected to survive, they face the psychological challenge of waiting for rescue from the cave.

This story resonated with me because lately I've been hearing a lot about a new book, No Way Down, which was featured on NPR along with some other mountain disaster books. No Way Down covered the story of several teams of mountain climbers who were stranded on K2 when an icefall cut their ropes. Most of the climbers died although a few managed to pick their way back to base camp.



Survival stories have always been popular. Entire television series now feature teams of people pitted against one another to overcome some test or challenge. Disaster movies were popular back in the '70s, when the Towering Inferno, Airport and the Poseidon Adventure let us watch people get picked off one by one.

Why do we love this stuff?

I think it's because these stories reflect humanity's greatest strength, the power of adaptation. Whether we're talking about natural disasters, accidents, the exploration of Colonial American wilderness or longterm science expeditions to Antarctica, the psychology of survival is fascinating because we like the idea that one's mental attitude can make the difference between life or death.

A search of Amazon reveals a surprising number of books about survivor psychology. Most focus on outdoor adventurers, but others were based on interviews with survivors of accidents like plane crashes or fires.

The survivors in these books lived because they were trained and experienced in outdoor living. They weren't "survivalists" per se, people who stockpiled food and weapons for the future fall of civilization. These survivors were people who were able to stay calm and reason in the face of fear, people who retained their optimism and determination in spite of great odds. Survivors focussed on others rather than themselves, either thinking about their families or their fellow survivors.

Sitting in a prison cell for several years seems like nothing compared to surviving a high altitude mountain disaster, but I think there are some principles that apply in both cases. The prisoners who do well are the ones who are future-oriented and determined to "work the time" for self-improvement. They have external family they care about and plan to return to. And yes, previous prison experience helps too.

Sunday, August 22, 2010

I Thought We Were Friends


Social networking adds a whole new dimension to human interactions. I used to ask people about their relationships during my initial psychiatric evaluations, and would include questions like "Are you close?" "When did you last talk?" I've had to change this...because now "talking" means oh, talking...in person, on the phone with a voice-to-voice conversation, via text message, a note on a Facebook page, an IM chat, an email message. They all count. We've become a weird world. And oh, yes, I've "spoken" to Roy and Clink this morning-- a couple of emails, so I'm not sure if they've "heard" yet. Clink wrote on my wall in the last day or two, I tagged her in a photo of an orange mushroom, and we've had numerous text messages (and Roy and I actually Spoke-on-the-Phone) yesterday....all inspired by the request of our publisher for a photo of us for the book. The big issues have been addressed: I got a unanimous vote for Curly-not-Straight, and Clink has refused to pose until she gets a haircut. Okay, I'm rambling off topic.

So people talk in therapy about their FB relationships. They get upset about things that are written on walls, they feel spied upon by family member friends, friends and enemies alike. (Oh, but the family would be torn apart if we unfriended each other!)....

So the other day, I realized I'd been unfriended. I used to get regular newsfeed tidbits from someone I work with. I realized they were no more, and I wondered about what was happening in his life. First off, let me say that they were a little unsettling at times anyway--- lots of "I don't like my job" groans, and his boss had said to me once, "I think he forgets who his friends are." Well I decided to check in on "George" and I searched him on my FB search bar. Ah, he only lets his friends see his info, it tells me. "But I
am George's friend!" I shout. (-Not really, but it makes the plot more interesting). And then I realize that I was George's friend. Not anymore. I'm left to wonder why. Did I offend him? I thought he liked me. I like him. Did he decide he wants to rant in ways I shouldn't see....well that's okay. How do I now act with George in 'real life?' Do I ask about this? I won't: What could there possibly be to say other than to make George uncomfortable. Did he think I'd notice? Does he want me to ask?

Roy is groaning about now, he says I over-think these things.

Saturday, August 21, 2010

The List


Dinah has Monday off but this is the weekend, and the weekend is the time to Get Things Done. It's time to tackle The List.

I have lists for everything: grocery shopping, personal errands, work-from-home assignments, travel (all types---climbing vacations, hiking, biking, beach and conference), even hobby activities. I know I'm not alone---Dinah has a mental "to do" list, and even keeps them for her friends (ask me how I know!).

The advantage of listkeeping is that you are less likely to forget something, which means that you avoid embarrassment and people getting annoyed with you. A good list keeps anxiety at bay when you're swamped with responsibilities and keeps you focussed on the next task at hand instead of running around like a scattered person. You can work more efficiently when you can organize errands according to location or time of day.

There are a few bad things too: a certain amount of anxiety is necessary to actually get started on a task. With a list, you're temped to think, "I've got that covered---it's on the list," but then you never actually do it. When the list gets too short (that actually does happen sometimes! I get caught up.) then the list disappears and duties get lost.

The other problem is that task begets task. You cross off one task, but that leads to another: you make the phone call, but the conversation leads to a new task. The List becomes an unending series of responsibility, which is rather demoralizing.

Task management is a psychological issue. Some people never make a list and live 'on the fly', some people make lists occasionally, a few rare people start the day by running the list.

What's your style?

And no Dinah, you can't have access to my list. I put enough stuff on there myself.

Friday, August 20, 2010

Yes! I Have Monday OFF!!!!


I got it, again, like clockwork. The joys of city life: yet another jury duty summons.

My number is 897 and that's high, really high, but sometimes on Mondays they call up to 900. The problem with being a shrink is that there's the question of what to do? Pray my number won't get called, or take the day off? In my private practice, I could just give people a heads up that I might need to cancel if I get called, but Monday mornings, I work in a clinic where people are scheduled months in advance, and short notice is a hassle on everyone involved. Family members often take off work to bring in patients, or other agencies send people to appointments with case workers. Last minute doc-outs create problems for everyone.

I used to hate the uncertainty of it all, but I'm trying to grow more flexible as I age, oh so gracefully. I used to call and request a specific day, one that would work better with my schedule, and the courts are happy to oblige this: they'd let me pick any day I want, as long as I agreed to take the number 1. No uncertainty here: I was going to be called.

But how do you give up a number like 897 (and a high likelihood of getting a pass) on an inconvenient day for a number like 1 on another day. Face it, there's never a good day to sit with 900 people in a jury room.

So I gave 6 weeks notice at work and took the day off. And the verdict is in: number 1-650 are to report. I have a day off! See you Monday. Please feel free to write in with suggestions about how I should spend my day.

Drugs, Soap, and Rock and Roll


There's always something new, even in the world of substance abuse. Lately I've been reading a lot in the media about K2, a synthetic cannabinoid that's being sold (and outlawed) in many states. It's commonly mixed with herbal incense and smoked. Nicknamed "spice", it was originally created by scientists and called JWH-018. Apparently some states' poison control centers have been getting calls about it due to the physical symptoms it can cause, specifically palpitations and GI problems. The part of the story that I thought was interesting was the fact that originally only 250 milligrams of the stuff was created, in an "official" research lab, but that home chemists quickly took up the experiment and it's now a part of our national drug culture. There's a part of our drug problem we need to think about---should research labs be allowed to disseminate information about how to manufacture controlled or intoxicating substances? Drug control efforts almost completely focus on those who possess, prescribe or sell pharmaceuticals but you don't hear much about the regulation of research labs that invent the new stuff. Federal and state drug enforcement agencies mainly target "home chemists" by pressuring retailers to make certain chemicals less easily available----fertilizer and pseudoephedrine for example.

I'm a bit of a home chemist myself, since I occasionally whip together batches of homemade soap. In order to make soap you have to mix oils with lye. What I didn't know was that lye is also used to make methamphetamine. My hobby took a hit when when the makers of Red Devil lye decided to pull their product off the shelves, due to government pressure. Talk about a stir in the soap makers world! It eventually came back to the market, but in a form that's no longer good for soap. Or for drugs either, presumably.

Monday, August 16, 2010

Too Chipper?

For those in need of a laugh:


FDA Approves Depressant Drug For The Annoyingly Cheerful

Not Enough To Go Around

In Friday's New York Times there's an article entitled "Pharmacists Take Larger Role on Health Team". The article discusses pharmacies that are expanding their revenue by adding services to their usual role of dispensing medication. In addition to watching for drug interactions, pharmacists are recommending alternative cheaper medications to patients and offering life style advice for chronic conditions. In some pharmacies they work with nurses to monitor diseases such as diabetes and hypertension. As one pharmacist in the story put it, “We are not just going to dispense your drugs…We are going to partner with you to improve your health as well.”

Why is this happening?

Business forces, of course. Once pharmacists did a lot more than they do now. They used to manually make medications---compounding pills and tinctures and unguents---in a time-intensive process. Now, they dispense packets of pills that are mass produced in factories. That's a lot of education just to stand behind a counter and fill a prescription. The profession becomes more attractive when it is framed in terms of patient counseling and fundamental health care interactions.

Also, health care plans will pay for it. Medicare pays $1 to $2 a minute for a medication management session with a pharmacist, according to the Time story. Not bad. One person in the story claims that "pharmacists could do as well and better than a physician” for less money.

This is a claim doctors hear periodically. There aren't enough doctors to go around, so other professions try to fill the void. Rather than train more doctors, it's quicker and cheaper to grant lesser-trained professionals similar privileges. There's a standard rationale that's given:

1. We're not competing
2. We work under supervision
3. We know when to refer

All of this may be true as a whole, but not necessarily for a given allied health professional. Supervision usually isn't on site, and it doesn't necessarily mean that each case is being discussed with a physician. The "we know when to refer" part should mean that there is a written policy or procedure documenting the limits of the scope of practice or the criteria that should trigger a referral to a physician. And a means to ensure that those procedures are being followed. All of this means that an additional layer of bureaucracy---with its attendant costs---will accompany the broadened scope of practice.

Why don't we just train more physicians?

Saturday, August 14, 2010

Hut, hut...Hike!


ClinkShrink climbs things all the time. She crawls up these huge vertical ledgy rocks and then rappels down them like Spiderman. It's very athletic, but not very dignified looking. I think it's how she directs her adrenaline risk-taking protoplasm, because in real life, she lives this life of law-abiding citizen, nun look-a-like, low profile, tuna-for-lunch with white milk, kind of soul who just happens to like working with mentally ill violent felons. It's a disconnect and the Spiderman thing connects-the-dots.

So yesterday, I went hiking. I hiked to the top (well, almost, I got to the bald part of the mountain, minus the skin on the front of my leg, and decided the view from almost-the-top was just fine). It was described as a "very popular 4.7 mile hike with well-marked paths, the easiest of the Adirondacks high peaks." What it didn't say was that it was 2.4 miles straight up, a giant stair-case of boulders, with none of those wimpy switchback things to make for some level hiking. And 2.4 ish miles of scrambling straight back down.

Perhaps 30 people passed me. I was climbing with my youngster--a high school athlete in the midst of training for pre-season, and my husband who has recently lost 30 pounds with a regimen that includes 4-5 miles/day of running. I gained 12 pounds last year, and this summer I let my gym membership lapse for the first time since 1996. Let's just say I was holding up the rear.

ClinkShrink does these things all the time. She's older than I am and she looks like a nun. A skinny, athletic nun, but still.

I was offered water, by a stranger. I was offered a first aid kit, by a stranger. And I was offered Motrin, by a stranger. I came back and crawled into the hot tub with a glass of wine. It was some comfort that husband and kid were also sore and complaining.

Oh, this is a psychiatry blog, you say. Where's the psychiatry? It's August, the shrinks go on vacation, and so for the moment this is a vacation blog.

But I have now climbed the 36th highest peak of the Adirondacks.

Friday, August 13, 2010

What Good Are You?

"What good are you?"

It sounds harsh, but sometimes that's what I hear from my patients. When a prisoner first comes into my office, he may announce a list of things he wants me to do for him: get in touch with the public defender or case manager, look up a court date, make a phone call, give him the lower bunk, order extra portions of food, etc. When I explain who I am and add that I am seeing him only for psychiatric treatment, I hear "the phrase": "Then what good are you?" Apparently, I'm not good as a concierge service.

Defining the physician-patient relationship is the first step in correctional treatment. Life is simpler when it's clear what you will or will not do for a prison patient. Inexperienced correctional physicians feel uncomfortable doing this because they want to be "nice" to the patient or because they're afraid that denying a request might harm the physician-patient relationship.

The problem with complying with all these requests is that the patient will continue to take it for granted that the doctor will always do these things, which draws the focus of the appointment away from treatment. Other prisoners will learn that the physician will do errands or give privileges, and the clinician will find his clinic swamped with requests for appointments that involve issues other than mental health care.

The clinician may be tempted to pretend to help, going through the motions of a request that he knows will not be granted. Worse yet, he might promise to help but then be too swamped or overwhelmed to actually carry through on that promise. Either way, the promise is not kept and prison patient learns that the clinician can't be trusted.

All of this can be prevented by clearly establishing the boundaries of the treatment relationship and the limits of the appointment. This does not harm the physician-patient relationship. In fact, prison patients appreciate a straight answer, even if that answer is 'no'. I find it helpful to give a straightforward response: "If I can help you with something I will. If I can't help you, I'll tell you upfront I can't. This is what I CAN help you with…" and so actual treatment begins.

Wednesday, August 11, 2010

The Power of Initials


I took my car in to the shop last week to visit his Car Momma. I've been going to this garage for years and I know most of the mechanics. I've run into Car Momma at the hair salon with her head wrapped in a towel. I've heard about her son, his school activities and her home renovation projects. She's heard about my vacations and seen my climbing pictures. I've always been on a first name basis with the people I know there.

This time, I had to leave the car and get a rental. I left a voice message with the rental desk and when the rental guy called me back at work I answered the phone with my usual, "Dr. ClinkShrink". Now, my garage knows what I do for a living and it's just never been an issue or really even a topic of conversation once the novelty wore off.

The difference this time was that the guy worked on my car was new to the shop. When I arrived at my scheduled time the next morning, he was standing in front of the shop, clipboard in hand, waiting for me. "Dr. ClinkShrink?" he asked and he shook my hand. He had all the paperwork waiting to go, my rental was lined up and waiting, and every reference to me was preceded by "Dr.". I gotta tell ya, it felt weird. Eventually he asked me if I was a medical doctor, explaining that he asked because "there are a lot of people who go by 'doctor' who aren't actually MD's."

My first thought was: "blog material".

I never go by my title or my initials when I'm off duty. When I first graduated from medical school a got several letters (hand-written, pre-email) from my mother addressed to "Dr. ClinkShrink" or "ClinkShrink, MD", but that was about it. I think (and still do) that people who flash their initials around are a bit obnoxious. This was just the first occasion that I really was struck by what initials can do. (And no, I don't plan to make a habit of flashing the 'MD'. It just felt too weird.)

And for the record, I did make a point of telling the rental guy that PhD's earned their degrees too.

Tuesday, August 10, 2010

My Life in Therapy

I got an email from one of our readers asking for the Shrink Rappers' opinion of an article in the New York Times by Daphne Merkin entitled "My Life in Therapy". My first thought was: "I am sooo not the person to be blogging about this." My clinical practice consists entirely of medication management, occasionally with additional crisis intervention and brief supportive therapy. I know that Dinah will have more to say about this story when she gets back and will probably say it better than I can. Nevertheless, I'll give it a shot.

In keeping with the Dinah tradition, I'll summarize the story and post a couple excerpts, then give my thoughts on it and ask for comments.

Merkin writes about her forty-plus years of experience as a psychoanalytic patient in New York City. Her first therapeutic contact took place when she was ten years old; she writes about her initial ambivalence and resentment of her therapists, what therapy has taught her over the years and also what therapy has cost her in both financial and personal terms. In spite of her professional and successful outward appearance, she suffered from repeated episodes of depression. Therapy helped keep her alive, but also occasionally provoked the symptoms she was struggling to contain:

"In therapy that was more psychoanalytically oriented...I tended to get trapped in long-ago traumas, identifying with myself as a terrified little girl at the mercy of cruel adult forces. This imaginative position would eventually destabilize me, kicking off feelings of rage and despair that would in turn spiral down into a debilitating depression, in which I couldn’t seem to retrieve the pieces of my contemporary life."

Although she knew that therapy would not provide her with a "cure" per se, she travelled from one analyst to the next in the hope of converting her “hysterical misery” into “common unhappiness”. Finally, while looking for her last doctor, she came to a conclusion:

"Now, however, in my 50s, I only felt persuaded that the last thing I wanted was to put myself into Dr. F.’s hands. I realized that I had been carrying a “Wizard of Oz”-like fantasy with me all these years, hoping to find someone who would not turn out to be just another little man behind a velvet curtain. It was not that I found all my shrinks to be impostors, exactly, but it dawned on me that I no longer had the requi site belief in the process — perhaps had never had it in sufficient quantity."

For the first time, she decides to try living a life without therapy: "All those years, I thought, all that money, all that unrequited love. Where had the experience taken me and was it worth the long, expensive ride? I couldn’t help wondering whether it kept me too cocooned in the past to the detriment of the present, too fixated on an unhappy childhood to make use of the opportunities of adulthood."

There are obviously limitations to what Merkin can write about: the only type of therapy she experienced was psychoanalysis, and it was unclear to me whether or not her clinical depression was ever adequately addressed pharmacologically in spite of the fact that all of her analysts were psychiatrists. Setting aside these issues, I was disappointed in the story. Her chronological list of therapist descriptions eventually took on a vacuous, droning tone of endless disappointments. She admitted that in spite of years of experience with treatment she lacked the ability to recognize a good therapist; she judged each new potential doctor based upon their wardrobe, or the office decor. The article appeared to be mainly a depiction of the New York analysand zeitgeist rather than a progressive story of one individual patient.

Frankly, I've heard better descriptions of the therapy experience, descriptions that were deeply personal and more heartfelt, from our readers. Merkin's article lacked poignancy, intensity and warmth and for me it had the feel of an intellectual exercise rather than a personal revelation.

She made one point successfully: that although the unexamined life may not be worth living, sometimes the examination of life takes the place of living.

Monday, August 09, 2010

It Wasn't About The Diamonds

Dinah is away so Roy and I are left in charge of the blog, heaven help us all. Real life has taken over my blogging time so I've really gotten out of the habit. Also, I've got a 383 page proof copy of the book to review and edit by the time Dinah gets back. I may have to choose between the two tasks. Here goes.

I was listening to my Nightline podcast this morning and I heard an interview with Naomi Campbell, the celebrity model called to testify in Liberian dictator Charles Taylor's war crimes trial. There were a number of curious aspects to the story: Campbell's admission that prior to traveling to the country she had 'never heard of Liberia', and the fact that she receives gifts so often that she thought nothing about having a bag of raw diamonds delivered to her in the middle of the night, or the fact that she's so rich she immediately gave the diamonds away to an acquaintance. I was also struck by her statement that she was annoyed by the inconvenience of being involved in the prosecution of someone accused of hundreds of murders. I'd say 'inconvenience' was a small price to pay for justice.

Separate from the celebrity spectacle aspect of the story, there is a back story here which I find more concerning. Campbell mentioned that she was reluctant to testify out of concern for the safety of herself and her family.

This was the issue that brought this story directly home for me and the patients I work with in Baltimore. Witness intimidation is probably the single biggest factor in the failure to gain convictions for serious crime in this city. It happens so often that prosecutors routinely take witnesses before a grand jury to testify prior to trial, to preserve their testimony before they can be threatened into changing it or they 'disappear' before the court date. This is not to suggest that Baltimore citizens care less about justice, or are less conscientious citizens. They have reason to be afraid. One infamous drug gang in Baltimore created the notorious Stop Snitchin' DVD to warn people against cooperating with police; witness intimidation entered the mainstream media.

Witnesses have had their houses firebombed. They've been threatened and family members have been killed. Criminal defendants have even orchestrated witness killings from behind bars, causing Maryland to be a leading proponent of cell phone jamming technology in correctional facilities. Maryland has also taken legal steps to hold the perpetrators responsible, making witness intimidation a felony offense punishable by up to 20 years in prison.

I can't say that I have an answer to this problem. I do know that hearing Campbell express her fear instantly changed my mental image of her. Instead of the fabulously wealthy, inconvenienced supermodel she became someone I felt I knew. She could have been anyone in Baltimore.

Wednesday, August 04, 2010

I Haven't Gotten There (Yet)


A psychiatrist I know is going through a phase-of-life change. It's one you only get to once. He's made the comment that in looking back, he made some mistakes and said some things he shouldn't have to patients who were going through this same phase-of-life change, long before he did. The event of it has made him more empathic to what his patients were feeling, something he didn't comprehend until he was in the same shoes.

I know the feeling. People look to their psychiatrists for wisdom, and you know, we don't always have it. Patients will ask for suggestions about marriage or child-rearing from psychiatrists who may be single, childless, or on their eighth divorce. It doesn't mean we don't have the answers-- sometimes these things are better dealt with from a safe distance-- but sometimes it might. I look back at some of the things I said to the parents of teenagers, back when mine were oh-so-cute-and-loving toddlers...and I wince...oh, my, I was so clueless back in the day. Can I recall my patients? I'm sorry, I said some stupid things back then. I shrug a lot more than I used to. I don't know if it's helpful, but I do know it's more honest.

Tuesday, August 03, 2010

Is Your Job a Downer?



Katina writes to us from onlinecolleges to let us know about a post on which jobs are the top ten most depressing:

Check it out here: 10 Professions with the highest levels of depression.

What I found to be interesting is that the assumption is that the jobs
cause the depression.
For example:

  1. Social Workers: If you had to deal with abused children, unkind foster parents and less than stellar family dynamics all day, you might be depressed too. Those working in this field are three times more likely to be depressed than the general population, and many are so focused on helping others they don't get the help that they need themselves.

There's nothing in the post that addresses the chicken-or-egg? question. Maybe people with depression are drawn to certain fields. Artists are listed, with the statement that those who chose to work in the field "found it depressing." And everyone kind of gets it: doctors, nurses, social workers, lawyers, artists, janitors, food service people, finance, nursing home and childcare workers. What's left? What's the depression rate among bloggers?

Monday, August 02, 2010

Shrinky Stuff on NPR's Morning Edition


In case you missed Morning Edition today, it was about how grief fits into the diagnostic criteria for major depression, and the debate that went into this for DSM-V.

Want to listen? Click HERE.

Want to read? Click HERE.

Excerpts:

What underlies a lot of this discussion is: Is it harmful to interrupt a normal grief process by medicating?

Over the course of time, we've become looser in applying the term 'mental disorder' to the expectable aches and pains and sufferings of everyday life.

Sunday, August 01, 2010

Did Your Cat Cause Your Schizophrenia?


From the front page of today's Baltimore Sun: Researchers Explore Link Between Schizophrenia, Cat Parasite.

Frank D. Roylance writes:
Johns Hopkins University scientists trying to determine why people develop serious mental illness are focusing on an unlikely factor: a common parasite spread by cats. The researchers say the microbes, called Toxoplasma gondii, invade the human brain and appear to upset its chemistry — creating, in some people, the psychotic behaviors recognized as schizophrenia. If tackling the parasite can help solve the mystery of schizophrenia, "it's a pretty good opportunity … to relieve a pretty large burden of disease," said Dr. Robert H. Yolken, director of developmental neurobiology at the Johns Hopkins Children's Center.

Roylance continues:
A University of Maryland study last year found that people with mood disorders who attempt suicide had higher levels of T. gondii antibodies than those who don't try to take their own lives. Still, the links between schizophrenia and toxoplasmosis are not simple. For example, most people infected with T. gondii never become schizophrenic. And not all schizophrenics have been exposed to toxoplasma. Yolken believes additional factors, such as an unlucky combination of genes, are probably needed to produce schizophrenia among Toxoplasma-infected people. The parasite's DNA may also be important, since some strains are known to cause more disease.

Meow?