Family is Family

Family is Family

She must be in her mid-thirties, I thought. Kids – it looks like she has kids. She was well dressed, with a pleasant, kind face. Everyday Mom – a person who is easy to like, a person next door who everyone wants to be friends with.

Just right now though, she was spouting angrily, full of righteous indignation.

“And just to think that they could have easily killed him, I just could not believe it.” Her eyes were flashing. “I told them right then and there, I will never take him back to this doctor. He almost died and ended up in the intensive care for DAYS!”

The reason for the outpouring, my new patient, was sitting quietly, fondly looking on as she continued. He looked to be around eighty, which I knew was about 10 years more than his actual age. Recently diagnosed heart failure, stroke last year – this would make anyone look older.

The daughter was at the end of her rant. “So, we just decided to come straight here and find another cardiologist.” She pulled out a large binder. “Here are all his records – we want you to take over now.”

Usually I try to be understanding of my own profession and not be quick to join in the blame game. After reviewing these records, however, it was difficult not to be blunt in my judgment. Her father’s case had indeed been poorly handled – he was prescribed two medications at the same time with predictable life-threatening interactive side effects. His daughter’s diligence likely saved his life – when his mind started slipping, she had checked his blood pressure, found it extremely low, and immediately called for help.

After some painful experiences in my career, I had learned that instead of pronouncing judgment, it was best to find things to praise.

“You are quite lucky to have such a devoted daughter, sir,” I remarked. “If you are not aware, I can tell you – research shows that men with daughters live longer, so you have an edge there.”

The patient smiled. His daughter looked pleased.

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

As I was going through his medical records, I was relieved that this new patient had been scheduled into an hour-long slot – there was a lot to cover. Making notations in the chart, I asked follow-up questions – what other medical problems he had, what were his habits, when was he first diagnosed with heart disease. The daughter answered most of the questions – not unusual when the patient is elderly; younger people tend to have better memories.

Working through the records, I noticed a condition the daughter had not mentioned.

“So, the prostate cancer – when did you have that?” The daughter looked confused for a moment and then turned to the older man. “When was that, Dad? This must have been a long time before I met you.” They started discussing the possible dates – the patient did not have the best memory.

This snippet in the conversation caught me off guard. First I thought I had misheard the word ‘met’. Surely one would not use that word for one’s own father? Should I ask? Social history is an important part of the medical exam. Also – let’s face it – I was curious.

“That was an unusual word choice,” I started carefully. “So, I assume you are adopted then?”

“Oh no,” the woman answered cheerfully. “As biological as can be.”

The utter confusion must have shown on my face. She decided to have pity on me.

“Well, of course, I didn’t know who he was.”

…. That did not make things any clearer.

“My Mom refused to tell me who my real father was – so after she died, I started looking for him. Went through as many genetic tests as I could – and I finally found him!”

There was an unmistakable triumphant note in her voice.

The patient just smiled and continued looking at her fondly.

She went on. “So, then I asked him to come visit us last year. That’s when he had the stroke. Of course he would be better off here, so I just asked him to stay and he lives with us now.”

I tried not to react. To be perfectly honest, I wasn’t sure how one would react. The commitment she described was flabbergasting… and to a father who had never been in a picture. This woman had taken a virtual stranger into her home and into her life and acted not only as a forgiving daughter but as a caregiver to an elderly man with multiple medical problems.

“Family is family,” she announced. “I am so happy I could finally be with my Dad.”

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

I must confess that there was a small suspicious part of me wondering if she will stick to it. The old man was not healthy and with the recent stroke needed a lot of help. After the initial euphoria of having a father wore off, would she think it too much?

On the next scheduled visit, the daughter was there, with the same updated binder. The father was looking better – the combination of optimized medications and stable home care had done wonders for his health.

On the visit after, the granddaughter had joined them. She was a bright-eyed little thing, curious about everything and intently looking at her new grandfather’s heart pumping on the ultrasound screen I was showing them. The daughter was making notes about medication changes. While I talked to the her about the home care, the granddaughter was trying to talk the grandfather into playing a game once they got home. The whole visit had an atmosphere of care and contentment.

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

I never asked more questions about their history. Why had the mother refused to talk about the father? What skeletons were in that family’s closet?

She probably would have told me. But it was not my place to ask. As a physician, I was happy enough that my patient had good social support.

Family is family. In this case, family that almost wasn’t.

 

 

False Thoughts about Getting Healthy

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Think of walking in a rainstorm. Your clothes and hair hang heavily. They provide no protection. They offer no remedy. You take a hand towel out of your bag and try to mop up your icy wet face. Wring it out and continue to wipe. 

This is like choosing to do all the psychosocial efforts in your life, but missing the biological. Until you treat the underlying illness, much of our efforts to heal are like using a hand towel to dry off in the rain storm. We think that we can get better without medication. Or, we may reject other treatment options, like ECT or TMS. We think false thoughts. 

It’s not healthy to take pills. 

I’m better than that. 

All I need is God. 

My parents would be upset, so I shouldn’t. 

If my work found out, I’d lose my job. So I shouldn’t. 

THC is better. 

Exercise is better. 

Some of these are entirely false. But some are just partly false, encased in a disconnected truth. This “rain and the hand towel” idea is not an analogy meant to minimize or bring shame to those who choose not to engage in treatment. It is not meant to talk down. Please forgive me for the crudeness and limitations. It is just meant to crack open this idea.

Yesterday, Louise commented that her physician told her taking sertraline, or Zoloft, was like taking “a vitamin for my brain”. That clicked for her! Vitamins were ok.

Question: How has your physician helped you get past not wanting to take treatment? How could your provider do better with this?

Self-care Tip: Allow healing with medical treatment for medical disease.

Get You Some of That – Medical Treatment for Medical Illness

…Continued from yesterday.

Cole_liveCole Swindell – Get Me Some Of That

Why do I feel so horrible when I start a treatment that is supposed to help?

Medication treatments for depression and anxiety, and some other brain illnesses, often worsen how you feel before you feel better. I can’t tell you how many patients have told me that if they had known this before, they never would have stopped their mediation(s).


Yesterday, our post discussed a Dr. Jones and Presley.

Presley fired Dr. Jones when after following her directive, he subsequently experienced an extreme panic attack. Dr. Jones may not have done anything wrong in her treatment recommendations. Presley was just an individual, as compared to a “number on the curve” of treatment responders. Escitalopram, the medication discussed as an example yesterday, (one medication option out of many), may have been dosed at an initial amount that Presley’s body couldn’t handle “straight out of the gait”, so to speak. But likely, if he had started at a lower dose, maybe ½ or even ¼ of the tablet, and then waited for his body to accommodate to the medication. Then Presley would have tolerated it. Presley would have tolerated slowly increasing the medication if approached, rather, piece-by-piece of a pill. I’ll even joke with patients,

I don’t care if you lick the pill. Just get on it.

When slowly titrating a medication, it allows the individual’s neurotransmitter receptors to down-regulate whilst the agent floods the receptors. If there is a neuron targeting another neuron, there’s a baseline balance in time. There is a baseline understanding between these neurons. An agreement, of sorts. “I’ll sit here and receive your messages,” (neurotransmitters, or chemical messengers such as serotonin, norepinephrine, and/or dopamine). “I’ll then carry those messages on your behalf to their intended recipients,” (such as the amygdala or hippocampus). But then this person artificially takes a higher quantity of these messengers, for example, by way of medications, and floods the system. The receivers, (or neuroreceptors), have to adjust to this to establish a new healthy baseline. 

In this initial time of treatment, when 1st introduced to the increased neurotransmitter-load, (ex: as released by a tablet of Escitalopram), there can be a negative response, such as panic and/or depression emotions. We call this, “initiation side effect’s.” Once the neuroreceptors get used to the new load, then the response improves. 

After accommodating to the new pharmacology, the brain is allowed to experience the blessing that comes from treatments, and heal.

Some individuals are outside of the curve and cannot tolerate the standard initial treatment dosage, like Presley was. Some are inside, and can without much difficulty. The point in treatment, though, is that the person just needs to get on it.

Get on treatment. However you do it. You have to make the treatment work for you, an individual, in your own way. The prescriptions are there to serve you. You aren’t there to serve the medications. I like to analogize Jesus’ statement,

The Sabbath is there for man, not man for the Sabbath.

Make it yours as an individual and reap the benefits; the blessings inherent there. (See Mark 2:27). 

If you don’t get on the treatment, you won’t get better. Anything less than this will be inadequate. It’s like drying water off your face with a hand towel while still walking in a rainstorm.

What is your agenda in treatment? List it. Write it out. Then, go get you some!

Outside a medical approach is like flicking water off in the context of a rainstorm. If your agenda is getting to your healthy self. Get out of the storm and get dry. Then go get it. 

You have a medical condition. Treat it with the assistance of a medical professional. 

I don’t go to a plumber to help with my electrical home repair. I don’t go to an accountant or a church counselor to treat a medical one. 

The plumber, the accountant, the church counselor are what they are. This is not minimizing their efficiency in their own fields of excellence. But why do we seek care in psychiatry from those who haven’t studied this? From those who are not experts in this? Maybe stigma keeps us away from psychiatric care. Maybe misinformation directs our search for mental health treatment elsewhere. 

Self-Care Tip: Get you some medical therapy for medical illness.

Question: What are further concerns you may have about taking medications? How would you prefer your medical providers to work with you? Please tell us your story. 

But I’m Not Someone Who Likes Taking Meds

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Presley couldn’t breath. A truck just drove through his thorax. A monster-hand was closing around his heart. He couldn’t swallow well. Was something stuck in there? Dizziness nearly dropped him, but instead of moving to sit down, like any other normal person would do, he bolted. A fire chased him. He had to escape or he would die. In the bathroom where he found himself, the mirror reflected a sweaty face and crazy eyes. Was he dying? Presley’s phone looked blurry as he dialed, 911.

Please help! I’m having a heart attack!

That was the first time this had happened. After the third visit to the emergency room over the past month, Presley was able to avoid calling 911, although still convinced he was going to die when the next episode hit. He agreed to seek counseling, where he was taught different skills to connect his mind and body, to slow his breathing down, to process, even when he was convinced he was dying.  For a time, Presley improved. It was like it never happened. He was almost able to convince himself that it wouldn’t happen again.

This turned over and over, feeling like he was going to die while losing his mind, re-engaging in counseling, thinking he was better, stopping counseling, and then another violent emotional event, thinking for sure, he would die.

It was after his second trip to the ER when he received the recommendation to schedule an evaluation with a psychiatrist. But he preferred to work through this in therapy. Presley didn’t like pills. He wasn’t someone who medicated. An olive-skinned athlete, he lived clean and didn’t believe there was much that healthy living couldn’t cure. And Presley did live clean. He ran fifty miles a week. He ate raw foods. He read his Bible.

After several months of this, his therapist, Dr. Wu, recommended he get a psychiatric evaluation. However, Dr. Wu agreed that he would continue to work with him, whatever Presley chose. (Was this the right thing for Dr Wu to do?) Presley chose, no. No psychiatrist. What would a psychiatrist do to him anyway?! He wasn’t crazy. (Except when he thought he was.)

Presley visited his primary medical physician, Dr. Belinda Jones. It had to be better than seeing a shrink!

Dr. Jones, I don’t want to take meds.

Dr. Jones, cleared him for any medical condition that might be contributing to his events. Only then was she able to convince him to try a “safe antidepressant”, escitalopram. After one pill, Presley had the worst event of his life. He’d never had any experience that was more terrifying. Presley didn’t go back to Dr. Jones, “of course.”

When these emotional tornadoes hit more frequently, he became paralyzed with fear that he would have them in public and be humiliated by them. Presley stopped going to work.  If it wasn’t for his rent, he’d never go back. But he had to. So finally Presley agreed to see a psychiatrist. …

To be continued

  • Sincerely, Dr. Q

Questions: What would you tell Presley? 

How would you like your physician and/or therapist to handle this, if it were you?

Why is Presley so opposed to taking medical therapies?

Please speak! We need to hear you.

Self care tip: Keep on! 🙂

Looking at your better future

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Dr. Kowalski walked into the hospital cafeteria and found me at our usual table, saying, “I hate it when I go to hug someone really sexy and my face smashes right into the mirror.” It wasn’t his joke but he always had something like this to toss at us other onlookers at the caf on our lunches.

He made me laugh and I felt like there weren’t enough of his type of friendship in my town. He was a peer in my community. He was a professional, a parent, a spouse. I enjoyed working with him and I respected so much about him.

Most of the time, with Dr. Kowalski, we talked about random stuff; hospital politics, his parents in England, God in his life, his kids’ latest antics, and the conversation rolled with content and interest. This day, after his short stent with humor, he skipped the food line, and just sat down to talk, starting in with a doozie.

My son is smoking a lot of marijuana.

Dr. Kowalski described the skeletal points of Frank’s, his son’s, journey with anxiety and then with marijuana. Now nineteen, Frank had anxiety his entire life. Paralyzing anxiety at times, and completely preoccupying at others with worries and inner tension.

Once when Frank was seven, “such a beautiful boy,” Dr. Kowalski told me, how Frank reacted when he was twenty minutes late picking Frank up from school. Most of the kids were gone already and Frank had to wait for Dr. Kowalski in the administration lobby next to the “mean secretary,” quietly in a big chair by himself, until Dr. Kowalski arrived. For three months after this, with his fluffy cheeks and round blue-blue eyes tilted up, Frank asked his dad over and over again, if he was going to pick him up from school that day. Would he pick him up and,

“Would he be on time?”

It was super hard for Dr. Kowalski to witness. Sometimes he would get impatient and snapped at Frank in response. Maybe raised his voice, or just ignored Frank’s questions. Dr. Kowalski felt a lot of guilt about this. He blamed himself in part for the persistence in Frank’s anxiety. If he had been more patient with him, if he hadn’t scared him with his voice, if he had gotten him into treatment… If he had been a better father, would Frank still have anxiety? Would Frank now be using three bowls of marijuana three days a week? Dr. Kowalski states that he would do anything to help Frank get better, and often does. Just about anything he can.

Whether Dr. Kowalski did or did not, Frank believed that anxiety led him to using marijuana.

Dr. Kowalski was the director of the adolescent psychiatry unit at our hospital. He knew that, although marijuana use often decreases the perception of anxiety at the moment, over all, in the way it affected gene expression, it exacerbated their anxiety. The disease exacerbated. So the user felt better at the moment, perhaps, but then the underlying anxiety process became worse and worse. Frank told me,

Using marijuana for anxiety is like a diabetic who takes insulin so he can eat a big cake.

But what could a father do for his son in this scenario? Being right, being correct about something, having knowledge apparently isn’t always how things, like convincing one’s son to stop using, are won. Dr. Kowalski did not know what to do.

Perhaps the guilt, perhaps the love, or for other reasons, Dr. Kowalski had spent the last several years of Frank’s marijuana-using and anxiety ridden life, trying to help Frank get into treatment. Treatment for anxiety.

When treating any biological psychiatric condition, something medical, we have to first look at anything we are doing to harm ourselves. Is there anything that is pushing us in the opposite direction of our efforts? Maybe we are drinking caffeine. That triggers anxiety. Or maybe we are using another substance that triggers, and/or worsens an underlying mental illness. With this in mind, Dr. Kowalski spent much of their discussions trying to engage Frank into preventative measures as part of his treatment recommendations. But what could a father do? Dr. Kowalski was not Frank’s treating psychiatrist. He was Frank’s dad.

Dr. Kowalski told me, with lines seemingly appearing out of no where on his usually bright and happy face, about his frustrations.

The amount of energy I am putting into helping him without results bothers me. And a lot of money to help him get better. I feel it is wasted until he puts in the effort to help himself.

I want to invest in my child! I do! But to help him get better. Not to just spin our wheels. He isn’t working to stop doing the things that actively work against this goal.

Feeling violated to a degree, used, Dr. Kowalski didn’t get it. He was giving his energy, his finances, his time, his emotion. He was giving every time Frank came to him or called in an anxiety crisis. Dr. Kowalski no longer wanted to do the “energy wastage.”

“It’ll be sad if Frank doesn’t get this idea,” Dr. Kowalski said. Frank may never choose to further work on his wellbeing, but the difference is that Dr. Kowalski decided he wouldn’t continue, with Frank, through talking therapies, and talking emotional rescue efforts, pretending they were working on something.

Dr. Kowalski wanted to tell his son,

I’m being taken advantage whether you realize you are taking advantage of me or not.

However, Dr. Kowalski was scared of stopping. He was scared of not staying on the phone for the long long conversations with Frank in crisis. He was scared of not continuing to pay for the talk therapy. He was scared of not continuing to give Frank his monthly living allowance while Frank was in college.

I asked Dr. Kowalski what the difference was between where Dr. Kowalski was now and wherever he thought it would be for him when he wasn’t being “taken advantage of?” If Frank wasn’t going to put in whatever effort Dr. Kowalski thought Frank should be doing to get better, where would that put them? Dr. Kowalski feared that this bond, yes maybe a bond somewhat founded on illness but still a bond between him and his son, would fail.

Their relationship, true, has strengthened, like an Indian trail that is treaded down daily on the forest floor from their repeatedly hashing out the anxiety. If that changed, Dr. Kowalski feared that maybe Frank would not see much reason to call Dr. Kowalski. Maybe what Frank valued in his dad was just that.

Dr. Kowalski told me that he believed there was, in reality, a sustainable bond between them. But Frank? He didn’t know what Frank would believe.

Dr. Kowalski and I rolled this story around in the air between us. After a stretch of disclosing his sincere grief, real fears, and underbelly of sorts, Dr. Kowalski decided, rather than starting with what he would stop giving and doing for Frank, he’d like to ask Frank,

What do you think your life would look like if you didn’t have this anxiety? Who would you be? Who would we be?

Dr. Kowalski said, “I’d love to find out.”

Self-care tip: Start with open-ended questions with yourself and look ahead.

Question: What is keeping you where you are and where would you be if it weren’t?

The Path of More Resistance, and Brain Health

 

The bar hummed with the energy of human emotion.  It was one of the few places Alfred could still smoke in public. He remembered the first time he was directed to a smoking area in the airport that looked like an enclosure for zoo animals, with glass walls, and positioned in the line of traffic. What in the world?! So Alfred felt unjudged at the bar, and also pumped up.

Alfred got energy from being with people – gravitated to them like a little brother follows his big sister around. If it was the bar, or the smoke break, Alfred got energy if he wasn’t alone. He absorbed every moment, marinated in it no matter how brief. The “moment” was his forever, for however long that moment would last. He was inside the color, flavor, aroma, texture, and song. He noticed. And, Alfred grazed. Amongst ideas, people, choices, and of most anything that came into his field of vision, he chewed it up in that space of time, and then moved on without guilt. Generally people didn’t hold grudges when he moved on. Alfred was just so nice!

When Alfred was in sync with his energy, senses, feelings, and perceptions, and his wife was in sync with her own, she looked at him like he was someone she was interested in. He could make her laugh and play, whereas she was never normally someone who was playful. This was nectar to Alfred’s pollinator.

Out of sync, however, Alfred’s wife called him names when they argued. He was “flakey,” or “narrow-minded.”  And Alfred, awkward with conflict, developed the habit of escaping during those times. He did not like conflict.

Alfred began to drink a lot more alcohol. After work instead of going straight home, he’d “catch a few beers with the guys”. When entertaining clients he started joining them when he offered alcoholic beverages to his clients, imbibing during work hours. His work performance started to smell sour like his alcohol.

You can see where this is going for Alfred. When he came into my office, he reported his inability to enjoy anything, increasing hopelessness, and now when he left the bar in the evening, his mood regularly plummets, a false weight in the scale of life.

Alfred looked at me with a degree of distrust, expecting judgment. But of course, he was also coming to me for judgment – an evaluation and diagnosis, and then to present a plan for treatment.

The treatment plan was short this day. Go to alcohol rehabilitation. Telling Alfred that there was nothing else we could do for him until he engaged in a rehab, was nerve-racking for me. (I never know how a patient will respond after similar directives like this. Sometimes they are not kind. Especially when talking about their substances or addictions, of any sort.)

Alfred stood up, a bit like a mechanical man, thanked me for his contact referrals, and left. I thought that was the last time I’d get to see him. It’s impossible not to hope for the best.

The deal with brain illness is that the treatments I am able to offer in an outpatient setting are ineffective in this context. Other stuff going into the body hits those brain receptors, turning genes on and off, like Wile E. Coyote in the back country. It would be enabling the mal-behavior if I diverted our focus onto anything else. Even so, like so many in the company of users, it is wilting not being able to offer more.

About two months later, I was completely surprised when Alfred came back sober! He told me he did just what we talked about, and rehabilitated. More surprising though, was his statement,

Thank you for refusing to treat me. You saved my life.

Alfred was still married, and yes, the marriage was still volatile. But he wasn’t plugging his ears and disconnecting from his wife with alcohol. It was a start. And Alfred still had restarts available to him.

We did end up starting psychotropic medication and psychotherapy, with which Alfred continued to heal.

I am humbled by Alfred’s courage to pursue rehab, the path of more resistance, and recognize that I should never underestimate the same courage in others when they present similarly.

Self-care tip:  Taking the path of more resistance may bring just what we are hoping for.

Question: What have you done courageously? Where has it taken you? Please tell your story!

The Sins of the Fathers, and Mental Health

 

“We know the Bible speaks of sins of the fathers passing to the 3rd and 4th generations while God imbues his kindness and mercy far beyond that to those who love him and keep his commandments.”

Rosa had no experience in the world of mental health, or so she thought. She had spent her formative years studying the world through the perspective of her church and interpretations of the Bible. As you know, there is a lot in both with a lot to say about emotions and behaviors. However Rosa was taught and modelled that these were moral issues and not biological. An either or, verses, part of the same thing. Could we call it sequent variants, maybe something like genetic alleles? Or maybe something better to describe this is out there, rather than an either or.

Rosa Leticia Montoya, at this point in her development, with her own overwhelming emotions and her husband’s plummet into dark moods, felt forced into considering mental health. She did not want to go there, but here in the space of losing control, not trusting herself or Carl any more, and before she was willing to say she didn’t trust God, she was doing what was a last resort. Considering that she was going crazy was the only thing this chaos could mean.

Before she completely surrendered to the idea that biology was behind this sinister change, she had to ask, “Is this because of our parents?” She had spent her life trying to untwist the bad choices her parents had made and the consequences those choices had on her life. Drugs, alcohol, and cheating were what she had grown up with. Quietly. Hiding it in the church. Rosa there, praying a lot to live well and be forgiven. Praying that bad thoughts would go away. Praying to depend on God and not on herself, as seen through her perseverating worries ever since she was a child. Worried and worried. Not speaking of the wrong Bible-breaking life her parents wore like underwear beneath nice tailored clothes. Would she ever be forgiven? Would she ever stop sinning?

So she asked me, “What do you think?”

That’s a lot to work with as a psychiatrist. So I did what most of us do. Ran to the shelter of medicine. Whew! But there is the added benefit that God created medicine, psychiatry, and all that there is in my tool bag worth working with.

Even so, there was only so long that I could avoid the topic of God and His punishments, per her perspective. It came up every visit.

If you believe in God, at some point within your discovery of mental health, this question will come up. Rosa is not alone. Are the emotions and behaviors gone amok, such as seen in anxiety disorders and depression, secondary to moral weakness? Living with “too little” dependence on God’s power? Is it this? Or is it an “either or”, with our biology? …a matter of cellular grey matter composed of DNA-expressing pathology? And is this something evil woven into my DNA because of what parents did? Well, I’ve spent 30-some years in school and now 15+ years in practice in this space and am still trying to understand.

I’m wondering if you would help me articulate this. It’s fundamental for us in self-care. It’s not possible to be very friendly to ourselves with the dissonance.

So in our self-care question today, please answer us. What is the relationship between “the sins of the fathers” and biology? Please speak!

Self-care Tip: Pursue kindness in your belief systems toward yourself.

Thank you for speaking with us! Keep on!