It’s not my fault

It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

Don’t Run Away. You Might Fall In Love With Your Flaws.

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Empower yourself by going towards what scares you.  Take it to the table and be with it.  Get to know it and openly share company with it.

Opal was throwing up.  She threw up more when she gained weight or felt fat.  Throwing up didn’t help her lose weight.  It was just a tool she had to deal with it all.  Opal was told often not to worry about her weight.  Told, she looked fine and not to weigh herself.  No one said openly, “Opal, you’ve gained weight and you’re going to get other illnesses because of it if it keeps going.”  They were afraid saying anything like that would make her throw up.  Hm.

What do you say?

We remember the three things that help maintain long-term weight loss.  Well one of the main reasons they work is because they help keep us present with “the problem” or “fear” or “shame” or however we name it.  Our natural instinct is to go away from fear but this is another example of when we don’t get help following our instincts.

What empowers Opal is to get tools to contend with her struggle with obesity.  It is probably a life-er for her and oh-well!  We can love our flaws better if we stop running from them and grow our skills in living with them in a friendly way.

Get empowered with whatever you are afraid of in yourself.  If you can’t do what you need to do to be in the place of that fear, it may be that you have a medical illness keeping you from coping better.  It doesn’t mean you’ve failed.  Staying with your journey, even to taking medication, even to naming brain illness in your life is so courageous.  You become one of the great ones.  Heroic.  It is so much easier to disconnect and lose our opportunity to love our flaws.

Have you ever heard someone call their life-er, “my old friend?”  Maybe it is arthritis?  Or recurring cancer?  Maybe it is brain disease.  Some day, we will also name our own, “my old friend.”  And we, with Opal, will mean it.

Self-Care Tip – Empower yourself by your presence.

Questions:  How do you do what is friendly to yourself when your instincts tell you not to?  What has that done for you?  Please tell us your story.

Grief Can Be Treasured At The Same Time That We Celebrate Life

Self-Care Tip #283 – Find the treasure in your grief while celebrating life.

Today is my daughter’s sixth birthday.  If ever there was a person who doubled the love she received, it is this chid.  She is all passion.  Yes, both ways, but that isn’t to judge.  Just, there is so little I can offer in words to describe her power of self.

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Tonight, we pushed two twin beds together so she and I could sleep beside each other.  Her sister slept nearby on another twin bed.  Her brother set his bed up in the closet.  (I know.)

If I wasn’t so tired, old and broke, I might be made vulnerable by times like this to having more kids.  Since that’s not going to change, these chubs are what we will stick with.  Happily.

My mind is turned toward God by this girl.  I somehow arrive in the moment praying when with her, perhaps for strength and patience or for humility and gratitude.  I learn from her.

Mommy, when I’m scared I talk to Jesus.

Often in times like this, I think of my niece, dead now six years, and how her parents and we wanted what was, what was stripped.  Still grieving and still living the life with us and in us, our braided thoughts and emotions easily lose their flow.

But today I have this clarity.  My niece is gone now six years and ten days.  Today my daughter is six years old.  Today I am sleeping with my three children.  Today I know that this is precious but this is not all we want.  We want what comes after our living years.  We want to let loose to Love the grief and the life; to untangle.  Not more.  Not less.  But we want.  We want what we have, now, although still in the unknown dimension of our forever.

In psychiatry, we are alert to grief that warps the ability to engage in life.  Grief that mars the connections of survivors.  Grief that becomes pathology, brain disease and a medical condition.  This grief disables and, for example, in the case of my daughter’s birthday today, would dissolve my ability to feel pleasure.

It is difficult to gain access to treatment as many of these survivors have ill opinions about medical care.  Such as; fearing medications will mute their connection with the deceased; mute their grief, or in other words, tribute/offering to the deceased; take away the personal punishment for surviving…

Questions:

  • What do you say to these weeping lives?  How can we de-stigmatize medical care for them?
  • How have you been able to treasure your grief and the life with you and in you?

Patient on Patient Crime – Our Response to Our Own Illness

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Self-Care Tip #238 – Think about your response to your own behaviors and emotions.

Bianca agreed with her husband.  She was too depressed.  She never wanted to go out and cried a lot. Perhaps she even deserved to be cheated on and abandoned because she was so unbearably dull.

Pause button.

We have discussed where behaviors and emotions come from – the brain.  We have identified the brain as human material, matter, biological and as susceptible as anywhere else on the body to illness.  In short, We could say at this point that Bianca is in a Major Depressive Disorder – a medical disease.   There are many medical diseases secondary to design, behaviors or lack of behaviors.  Or for other reasons.  However, I don’t know many medically ill that when the spouse walks out on her, we say,

Well of course!  She had cancer!

Or,

He lost his leg in a car accident, get someone else!

But throw in some aberrant emotions and behaviors for unacceptable time, and the escaping spouse is given running shoes as a gift from their concerned community.

How could he stand her!  Of course he left.  She wasn’t taking care of his needs.

You see the disparity and when written this way, it looks really ugly and I apologize.  I’m not trying to thumb people for biases and prejudice.  Both parties are hurt.  I’m also not trying to say that this happens only in marriage.  It happens in almost any setting.  Emotions and behaviors are just not considered to be symptoms of disease.

Have you ever heard the term, “Women on women crime?”  Well this is something like that.  I’m thinking much of this will improve when we treat ourselves with more insight and understanding consistent with our biopsychosocial model.  If we don’t do this first, who will.  We aren’t responsible for how others treat us, but we are responsible at least for ourselves.

This is one more wonderful way of claiming our right to say, self-care starts and ends with Me!

Questions:  How can we wrap our beliefs around this seemingly enigmous concept that when someone is crotchety, negative, irritable, inattentive or boring – it might not have been because they chose to be that way?  How do you own if in yourself?  Please tell me your story.

Self-Care Woven and Unravelled Simultaneously for Best Results

Change is good--Kente Cloth Loom

Self-Care Tip #222 – See the different parts of your self-care as independent yet dependent on each other.

One of my truest pleasures would be to teach well.  My temperament is, per Myers-Briggs, designed to be a teacher and I agree that I feel inner congruence when I’m doing just that.

…If you’re feeling your hands closing into a bracing grip, it is probably because you, like many, really don’t want to be schooled – which has happened in my less refined moments, so caution is understood.  This is not what I hope to do here.

After yesterday’s blog-post and comments received, it shows that I have not taught as well as I implied to myself.  Implied intimacy is a danger of any familiar relationship, including with ourselves.  The beauty of you guys, is you help me say things “out loud” decreasing misunderstandings.  You guys are teaching me and I thank you.  So whatever this is we are doing, learning, schooling, teaching or whatever it is that Mr. Rick C. does – what we are doing here together is mucho-much fun.

As we unravel the rug together, we see these threads,

  • emotions and behaviors appropriate to context – yesterday we spoke about guilt
  • emotions and behaviors inappropriate to context – yesterday we spoke about guilt as a symptom of medical illness
  • the magical miraculous beyond our current understanding – before we “see face-to-face– yesterday Carol Ann mentioned the changing power of God
  • freedom to do self-care and related choices
  • what choice yet remains when other choices are lost either by action or disease
  • (this last one I’m just putting in here to finish the pretty rainbow) – helps me get in the barn where I’m comfortable

The reason I think it’s important to see these together yet apart, as well as we can (through a glass dimly), is that too much of one or another of these, diminishes the results of our self-care intentions.  Don’t mistake this for preaching that one can get too much of God in their lives.  It just isn’t true and not in our best interest to get waylaid.

Questions:  How do you see yourself more effective in your self-care efforts and what has influenced those improvements?  In what way have certain bits of your self-care gotten “too much” attention?  Please tell me your story.

Never Let Go of Hope, Even When Depressed and Anxious

Linda, Lake of the Woods Run, 15 K

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Self-Care Tip #214 – Never let go of hope, even when depressed and anxious.

Some blog-posts ago, Be Aware of Your Feelings was written and “M” asked,

What is the difference between depression and anxiety?

Anxiety and depression are like brother and sister.  They often go together.  When we think of “paradigms,” we think of an arch that might intersect with another arch.  However, when I think of the affective (or mood) spectrum intersecting with the anxiety spectrum, I see them weaving, interlaced or chasing each other.  Not a line and nothing tidy.  So understanding the difference also includes understanding their relationship.

In training, I remember presenting a patient with anxiety and depression to my psychiatry attending physician.  I hadn’t clarified the timeline of onset of symptoms.

When presenting, every resident physician knows the moment when they are found out.  The other residents on the rounding team instinctively lean back, try to take a step away even, so the lightening doesn’t singe them when it strikes.  I’m sure I smelled like fear too.

The reason the time of onset of symptoms is important, is that it tells us the primary disease process.  Knowing that, influences the speculations on patient recovery, duration of illness and our choices for treatment.  Some medications for depression can really activate anxiety and the patient might not enjoy the free-fall into hell after starting the antidepressants.  Also, there are some treatments that work better for different disease processes and such.

It’s common for someone who has suffered from depression on and off for years, but never from anxiety, to have their first panic-attack out of the blue, without trigger.  Bummer!  Then they start to roll.  Bam!  Bamm!  BAm! BAAM! BBBAm!  The panic attacks may come in spurts and then go away for a time.  The opposite is also true, starting off with anxiety, and followed by depression.

I don’t think anyone, including “M,” is asking me to talk about the differences between anxiety and depression in that depression is a state of sadness, and anxiety is a state of autonomic nervous system activation.  Rather there is the wonder of why they follow each other in course, why the are so often in each other’s company, why so many medications that treat one will treat the other, why they run in family histories and/or why they are both “so common.”  We have some ideas we use to answer but we don’t have enough objective information to explain.

Some of the good news is that these diseases are treatable.  The sooner they are treated and when treated to full recovery, the better the hope for long-term brain health is.  I have seen people feel defined by these diseases and trapped.  My job isn’t to minimize that, but rather to highlight what might bring hope.  Selling hope turns out to be one of my biggest jobs.  The same attending physician I mentioned above told me that.  He never stopped talking about hope.  Even for me.

Questions:  How do you answer “M’s” question?  How have you seen depression and anxiety move together and how have you responded to it?  What has given you hope when they did?  Or, when you saw this in someone else.  Please tell me your story.

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There is Less Space Between Emotions And Science Than We Think

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Self-Care Tip #147 – Bridge the gap between emotions and science.  Be a friend to yourself.

She had been through a lot – Aimee.  Lost her baby brother to medical disease.  Was in a stressful marriage and didn’t like her work.  There was more but you get the drift.  She found herself thinking that things would be different if things had been different.

Would they?

Readers, I am referring specifically to her medical condition.  Not to the fact that the universe is different because her brother died.

Madeleine L’Engle talked about death affecting the whole universe.  She compared it to the death of a star.  In death, the star creates a hole in space dark and large, enough so that the absence of it has its own gravitational force, a “black hole.”  L’Engle says that when any part of creation dies, we are all touched.  Life knows and the absence of that bit of creation leaves the surviving universe changed forever.

Aimee wasn’t talking about that.  Aimee thought her emotional illness was largely secondary to her life stressors.  Because this influenced Aimee’s choices regarding her medical treatment, I had to tell her no.  Gently.  It was hard for her to hear.  “Aimee, your sadness you feel now, four years after your brother’s death, your isolation and amotivation, your low sex drive, your difficulty feeling pleasure in other things, your sleepiness during the day – these things are not because you have suffered your brother’s death, nor because your marriage is hard.”

There are times when directly saying things is the more gentle approach.  No one going through what Aimee is going through wants to hear about how I feel about it.  Yuck.  There’s not much that is slimier than going to someone for objective feedback and getting their emotions and personal opinions all over you.

Aimee left saying she understood and with a new medical treatment for the medical illness propagating emotional and behavioral symptoms in her.  We’ll see if she did some days from now.  But what about you?  Do you believe that her emotions and behaviors were secondary to medical illness?

Readers, life stress will continue to happen.  What may change is how we respond to it.  If our response does change and it isn’t serving us or others well we need to think that we might not be interpreting how we feel objectively.  We might be having changes to our biology that “taste like chicken.”  It helps to get a physician’s opinion – someone who sees behavior as more than the spirit, the abstract, the puppet of our volition.

Question:  How do you bridge the seemingly abysmal distance between emotions and science?  Please tell me your story.

Full Treatment Response Means a Better Future

wethree by Nancy Denomme

Self-Care Tip #140 – Push for full treatment response.  Be a friend to yourself.

Frankie was 45 now, feeling it, and feeling grumpy.  “I’m on Lexapro!” she said as if that should exempt her from her present condition.  She had teenagers.  “Enjoy these times when your kids are young.  It just gets worse!”  Frankie thought that if her kids weren’t stressing her out, she’d be fine.

Maybe parenting and other life-stressors do get worse as we progress through years.  Even if it’s true, it isn’t the point.

Frankie told me that she had felt “normal” until the last approximate four weeks when she wasn’t able to let stress go.  She was taking things personal, even when her mind knew they weren’t about her.  She didn’t like herself as much and was angry when she thought that her kids were thinking the same thing about her.  She was just a little angry.  Not like she was before she was taking medication.  “I’m not so bad.  I’m ok.  I’ll be fine.”  About 70% of Frankie believed that she was still good.  About 30% of her knew at some level that she wasn’t.

“Frankie, stress is always going to happen.  It won’t get better necessarily when your kids move out.  Life will keep the spin on.  Frankie, the difference can be in you, not life.  How you cope can be different.  Things don’t have to feel that hard to get through.”

We talked about partial treatment response and what that meant in regards to disease progression.  Depression progresses as does anxiety as disease processes.  Also, people lose response inconsistently to various treatments.  However, it is not the time to throw our hands up and say, “Bummer!  Life really is harder on me than necessary!”  It is the time to say, “This is medical.”  And explore if there are any other things we can do to improve treatment response and decrease disease progression.

Leaving ourselves partially treated is leaving a leaky pipe in the wall of our health structure.  We will worsen faster, more dramatically, and be harder to treat in the long run.  We will lose treatment options over time simply by not doing as much as we could earlier than later.

This is not to say, that if this blog-post finds you at a “later” position in life, that it is of no use.  Unless that’s how you see your future.  Which if true, I’d respond that this is distorted thinking.  Possibly secondary to the disease process and all the more reason to get treatment, again, sooner than “more” later.

I was so happy to have had this brief discussion with Frankie because it resonated with her.  Her approach to her self-care tweaked and she saw her negative emotions and behaviors were coming from her condition more than from the chaos around her.  She made friendly choices to heal.  Medically heal.

Later in our treatment together, I asked her about how her kids were.  Frankie brightened up with stories of their successes.  I asked further if they were stressing her out, and she looked at me like, “Why in the world are you asking me that!?  That’s out of left field!”  She had already forgotten that she had held them responsible for her feelings not too long ago.

Question:  What barriers have you been up against to get full treatment response?  Please tell me your story.

The Biopsychosocial-How-to Be a Friend to Yourself

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There is interplay between biological, psychological, and social issues that make us who we are.  You can work as a team not only  with your family, physicians, therapists, and whomever else is involved in your team approach to getting friendly with yourself – but you can also team up with yourself so to speak.

Think:

1.  Biology

Anything going on materially with my physical body?

Medical illnesses, temperament, sleep issues, diet, exercise, air, rash….

2.  Psychological

i.e., thoughts, emotions, and behaviors.

Things like lack of self-control, coping skills, catastrophizing, and negative thinking.

3.  Social

Such as socioeconomic status, culture, poverty, technology, and religion can influence health.

Think God, friends, marriage, parenting, work, unemployment….

We can do this not only with others who are here to help us, but also in our own thoughts.  We can start seeing ourselves as more than one part or another.  Separate and disconnected.  This might take some practice or it might be natural for you.  Just start wherever you are and run this through yourself.  When you’re stressed, break it down.  Take it apart to bring it back together.

Read more about this at “Forget About Divisions In Knowledge.”

Question:  How do you see the connections within yourself?  How has this played into your healing processes?  Please tell me your story.

Self-Care Tip #125 – See yourself as parts that make up your whole.  Be a friend to yourself.

The Great Lie.

One of the great lies of mental illness is that, “If things weren’t so stressful, I wouldn’t feel so bad.”  Look inside ourselves now and see them.  All the numbered and ranked stressors we tick off to explain how we feel and/or behave.  How about someone we love.  Do we tell them, “Of course you feel that way!  Look at all you’re going through!”

Because major depressive disorder (MDD) is mainstream enough, I’ll use it as an example.  Who, when they are down, doesn’t look for reasons why?  Say there is an additive effect of stressors such as home conflicts, financial duress, and poor sleep.  Since these events, you haven’t felt pleasure, you’ve felt sad and depressed.  You aren’t motivated or interested in your usual.  And where you normally would seek people out when you felt down, to get more energy, now you just want to be alone.  And so on.  You are able to say that you started feeling this way progressively since triggered with those stressors about 3 months-ago.  Before that you were “fine.”

Many people in your life, have told you that you are just going through a bad spell.  You have believed them but say, “Even if this is a bad spell, if it goes on much longer I think I’d rather die.”  Your best friend responds, “Anyone would be depressed if their boss was that evil!”

My answer, “No.”  Feeling down is appropriate to stress when it doesn’t disrupt your life for more than two weeks at this level.  And it is never normal to want to die.  Everyone has stress but not everyone responds to stress in the same way.  Not everyone if put under your same triggers would develop MDD.

Would you have developed this disease if you weren’t put under these stressors?  I can’t say.  We develop illnesses for many reasons.  One of the many reasons is external stress.  A hypothesis supporting this is that stressors trigger our genes for MDD much like we know cancer genes can be turned on by stress.  However, we do not have a direct correlation to the stressors as being entirely causal events.

Even if it were, none-the-less, we are left with the disease process in progress.  It is not an adjustment reaction to stress.  It is medical illness.

Feeling this way is not normal for what you are going through.  Telling yourself that it is, that is the great lie.

Self-Care Tip #118 – Don’t believe the lie if what you’re going through is affecting your function in life.  Be a friend to yourself.

Question:  What whispering lies are you struggling against?  Please tell me your story.

Who Cares What Your Diagnosis Is?

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Self-Care Tip #115 – If it’s not serving you well, don’t waste your time on it.  Be a friend to yourself.

Trixie Hidalgo, advocate to end violence in America, tells me that many of the people engaging in gang crimes tell her that they are put in their life positions (poor, stereotyped, impoverished) by the people who have the power, to keep those people in power and to keep them down.  They have some credible arguments we’ve shared before in history relating to oppression such as race, color, gender, money, or status.  Are these people victims?  Sure, why not.  But is that the point here?

The victims reminded me of a clinic I was in the other day.  I was working with Marcus and his father.  The father was torn about where to go to get his disabled son, Marcus, treatment.  Marcus was disabled with both brain illnesses and severe psychosocial stressors.  Currently we found Marcus, 2 years into treatment with me, and as of yet, father and mother (divorced without amicable terms) had yet to engage in treatment with me.  They wanted to know why Marcus was the way he was.  Father pointed at Mother and Mother pointed at Father.  They blamed other things as well, the schools not providing the right services, the medications for not working, his genes, and more.  Meanwhile, Marcus is tearing up his classroom and his own life.  He is barely functional socially.  Moody and volatile.  Anxious with physical symptoms.  He was having multiple medical work-ups going successively for various physical complaints.

Before I let them go, I told his parents, “Who cares what his diagnoses are?  It’s not about the diagnosis.”  The purpose of a diagnosis is to serve the patient.  The patient doesn’t serve the diagnosis.  Right now, Marcus was serving the quest for his diagnoses.  If all they can see is that, and they miss the fact that their son isn’t functioning, he’s depressed and anxious and violent and no one can stand to be around him, Marcus is worsening continually while they go on debating – they’ve missed “IT.”

They’ve missed it.  And so have we when we waste time counting up the offenses we’ve directly or indirectly suffered.  We miss it when we increase our injury by holding ourselves responsible to our history.  I asked Marcus’ parents what the point of what they were doing for Marcus was.  I ask the victims of America, what the point is when they point to history to answer for their present condition.  If it’s not serving you well, if it’s not doing something good for you, than what are you doing with it?  Do good things for yourself.

For the victims, for Marcus, and for Marcus’ parents, 1st make sure we weren’t missing something medical that was keeping them from having life quality.  You can’t give what you don’t have.  Then move on to the psychosocial issues and spiritual and so on.  What ever we ran into that missed our point, we’d walk past it together and on to something that served us well.

If you’d like to read more on this topic, read more in “It’s Time to Grow Up” and “The Whole World Becomes Blind.”

Question:  How have you managed to move past things that weren’t serving you well?  Please tell me your story.

Your Life. Your Choice. Why Are You Still Negotiating?

 

 

Self-Care Tip #102 – Take what is yours and live.  Be a friend to yourself.

Cheri came, still dressed in work scrubs, with her 2 daughters, 8 years old and 3 years old.  Having finished their dinner date, they were swinging by for her appointment before going home.  Cheri told her kids, “Get out now and go sit in the lobby!  If you don’t listen to me I’ll….”  Turning to me, she said, “It’s never enough!  I just took them to dinner and they do this to me!  No matter what I do…!”

1.  Cheri tells me she’d like to cope better with simple stressors such as redirecting her kids

2.  We talk at length about her perception of her kids abusing her.

Cheri is married.  Her husband laughs at her for “…having to take those drugs to be normal!”  “…But he just sleeps his problems away.  He doesn’t deal with them like I do.  He has no idea!”

3.  We talk more about her perception that her husband is responsible for her place in life.

Cheri believes if she doesn’t take more than 2 pills a day, she is less “dependent” on drugs.  She says, “I don’t want to go on like this!”  Her tears continue talking when her voice stops.  She is ashamed.

4.  The concepts supporting taking care of yourself as being the kick-off point to caring for anyone else comes up.

5.  We talk some more about who is “The Why” for what we do or don’t do.

Cheri feels less shame, but it’s still there.  She is willing to give a new medication a try but clearly doesn’t buy it all yet.  She’s going home with her girls to her husband with new pills.  And hope?  Yes.  It is all connected.  It all pulses together and is a living negotiation of sorts.

Disease <–> behavioral/emotional negative symptoms <–> victim role <–> self-neglect <–> greater crisis <–> seeking help <–> responsible self-care <–>  healing <–> fewer behavioral/emotional negative symptoms <–> emotional abuse from husband may continue but is no longer seen as responsible for personal choices and self-care <–> less shame <–> further healing and so on….  (Lub-dub…Lub-dub…)

 

hbofamily.com

 

Cheri is still negotiating her deal in life.  She doesn’t realize that it’s already hers for the taking.  Her life.  Her choice.

The deal is already made.  Take it or leave it.  Your life to live.

Question:  How are your negotiations?  Do you see them as still in progress or settled.  Please tell me your story.

Recipe for Treating Panic Disorder, According to Me

 

shoponline2011.com

 

Recipe for Treating Panic Disorder, According to Me:

1.  If it’s taking you to the emergency room feeling like you’re going to die, or your spouse can’t peel you off with your phone calls and new needs – you have a medical illness.  Get medication.

2.  If you are afraid of being humiliated by an episode so much that you avoid public places, or if you are more fearful than not – you have a medical illness.  Get medical treatment.

3.  If you are panicking out of the blue, without something setting you off/triggers like finding your husband in bed with your dentist – this is biological.  Get a medical physician’s opinion.

4.  If you are awakening from sleep in a panic attack, when you feel like you have to get out of bed and escape and the episode lasts for about 10+ minutes before you recover yourself – this is not because you’re not trying hard enough.  Get on a serotonerigic therapy and a sleep aid(s).

5.  If you are drinking more alcohol to relax and out of fear of going to bed – get suspicious and get smart.  Medication therapy or alcohol?  It stumps me when someone says they don’t feel comfortable with taking medication that has beed studied in double-blind studies on thousands of people and reviewed and analyzed and more… but they do feel comfortable with alcohol.  That’s not friendly with yourself.

6.  If you think you are going crazy and realize your fears and suspicions don’t make sense; if you think you are possibly going psychotic over and over – you’re having a medical illness of the brain and body called panic disorder.  Get to your nearest treating physician and trust them.

 

juno.cumc.columbia.edu

 

7.  If this is you, don’t go get insight or supportive psychotherapy at least until you have been on medication therapy for 6-8 weeks.  What you are going through is not because your mom yells at you too much.  It doesn’t have to have a reason.  It is medical.  Treat it medically.  If you go to therapy too soon, you will see that you can’t give what you don’t have.  (I may have offended some people saying this.  Sorry.)

8.  If you don’t get treatment, expect that depression may likely follow soon.  Anxiety and depression are bedfellows and can’t be apart for long.

    Self-Care Tip #92 – View Panic as a medical illness.  It is.  Be a friend to yourself.

    Question:  Have you or someone you known used a similar recipe or a different one?  Please tell me your story.

    Intent and Context Matter

     

    A Beautiful Mind by Sylvia Nasar

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    Self-care is selfless, but doing things for yourself is not always self-care.

    A reader commented, “I believe that if I’m NOT taking care of myself and feeling joy, then that IS self-centered….”  Too eloquent.  Love it.

    Some of our confusion comes from the changing scenarios of self care.  The intent sometimes gets blurry.  The intent is hard to tease apart.  Sometimes what feels like taking care of ourselves is in fact, selfish.  For example, let’s say “hypothetically,” my husband, who is a palliative care specialist, chooses to work on twitter #hpm, play chess, or play guitar.  This is potentially positive and friendly to the self.  However, it depends on intent.  Sometimes we don’t know our own intent though.

    There is also the context of what is happening.  Let’s say we were all fighting, and then my husband goes off to read Oscar Wilde.   Is this self-care or a way of abandoning and taking himself out of the present?  Self-care puts us into the present.  Whereas selfishness takes us out.

    In another context, taking yourself out of the present is necessary to ultimately put yourself back in.  Doing this requires thought processes that can abstract and empathize (connect emotional content).

    I rely a lot on intent! (Ahem!)

    There is a mind disease called schizophrenia.  This disease is famous for hallucinations, hearing voices that other people don’t hear, seeing things that other people don’t see.  However the core symptom of schizophrenia is less famous.  It is the thought form, concrete and disconnected.

    Concrete thinking is named well, unlike many other medical conditions.  (Think diabetes!  Who would know what that has anything to do with!?)  But concrete thinking is plain, hard, and flat like my sidewalk.  For example, if I asked what does the parable mean, “A bird in the hand is worth more than two in the bush?”

    1. Concrete thinkers might say, “Birds make a mess so we don’t want a lot of them.”
    2. Further, if their thoughts are also not connected, they might say, “Birds migrate in the winter and the bush is wet.”
    3. Contrast this to connected thought that abstracts, being able to answer, “If I have an opportunity to take something good, it’s better to take it than gamble for what I might not be able to keep in the end.”

    Different emotional illnesses have trouble abstracting, but fewer have disconnected thoughts like schizophrenia.

    If you are in a relationship with someone who has trouble abstracting (traumatic brain injury) and/or connecting emotional content (ADHD for example,) you might misinterpret his or her behaviors as selfish.  Being able to empathize after all is part of most Disney fairy-tail romances.  What more do any of us want?  Right?

    Wrong.  The capacity to empathize doesn’t matter much if the intent is missing.

    Wrong.  The ability to abstract doesn’t connect if the intent to connect us is not there.  The knowledge does not matter.  It is the context.

    In the film, A Beautiful Mind, Russel Crowe plays a character that suffers from schizophrenia.  The woman who loves him, struggles to understand the way he loves her back.  His disease steals his attention.  His disease takes his time.  He seems selfish.  Their love survives when she discovers his intent in context.  He stays present in the relationship, despite all his limited capacity to relate.  Further, agreeing to the treatments of his generation, limited that they are, he is doing selfless self-care.

    At the end of the day, I’m a grateful piece of dirt who means well.  Saying that up front immediately lets you get very familiar with me.  (I could have said “grateful piece of sh–,” but that would have been selfish.  The s-bomb is just playing with the word to have fun!)  Part of why I believe in God is because I know He goes for the losers.  He goes for the piece of craps out there.  That’s what the beatitudes are about.  He pours it on. (Intent and context, baby!)  At the end of the day, we are neither angel nor beast.  We are just human to Him.

    Self-Care Tip #78 – Keep self-care selfless.  Be a friend to yourself. 😉

    Question:  What do you think?  Please tell me your thoughts.  Please tell me your story.

    A Little Bit is Not Enough – Claim Full Health

    The good news is, I just ate 3 chocolate chip cookies.  You already know the bad news.  Has nothing to do with my post.  I’m just sharing it for the sake of your own

    Schadenfreude 🙂

    …Onward.  Question:

    Does emotional disease get worse even while on medication therapy?  Sometimes.  It does so more often when the disease process is treated but only partially treated.  Read a little more about this in this post if your interested.  A primary care physician recently told me, “I think the term ‘Partial Responder’ is a marketing gimmick to get physicians to prescribe more medications.  I don’t think it even exists.”

    There’s a lot to be said about interview skills in sussing out the partial responder.  If I asked someone if they felt better, many things play into their response. Everyone’s responses are biased of course.  We don’t have sterile minds.  For example there’s the patient who wants to please their physician.  “Yes I’m better!”  i.e. “Yes you’re a good doctor!”  There are the patients who don’t want to be patients and minimize whatever they’re going through.  There is the physician who leads the interview.  “So, you’re feeling better?”  “The medication is helping?”

    Partial response means that at the end of a full treatment initiation period, there is some disease remaining but a reduction of disease.  For example, in depression, I may no longer be suicidal, but I still have trouble feeling pleasure in life.  In cancer it means that there is tumor reduction of at least 30%.

    Now why would a physician presumably agree that there is a partial response in cancer, but not agree that it happens in mental health?  Anyways….  (Ahem.)  When we partly respond to mental health treatment and don’t push further for full response, about 70% will relapse.  Versus maybe 25% in those who reached their pre-disease baseline emotional health through treatment.

    Don’t get lost in this.  The point is, get treated and get fully treated.  Mental illness is progressive and causes changes at the cell level.  The brain is connected to the rest of our body.  The brain is human.  A bit better, is not enough.

    Self Care Tip #61 – Go all the way!  Claim health.  Be a friend to yourself.

    Question:  Did you find this to be true in yourself or someone you know?  Please tell me your story.

    Look Around At The Other Reasons – Depression

    Flagellants mortifying the flesh, at the time ...

    Image via Wikipedia

    “I’ve done some bad things.”  Patient tells me she can’t sleep well, is nauseated, depressed mood, worried with perseverating thoughts about acts that shame her and ramifications, doesn’t feel as much pleasure in life, isolating, tearful and more.  I was alarmed!  What could she have done that deserved this kind of self-flagellation?  When she told me, I didn’t realize it.

    I was still waiting for the rest of the story.  I got caught up in her own self-judgment and found myself sitting beside her “in court.”  Once I realized what I was doing, I was chagrined.  Here I was collaborating with her in her inappropriate guilt.  It took me too long to register that her reaction was not proportionate to the offense.  I told her I was sorry she was going through all this emotion.  She said, “It’s my own fault.”  Is it though?  We needed to start looking at additional reasons that might be influencing the way she felt.

    Start looking at other paradigms when the emotional response is out of proportion to the event(s).

    An analytical approach would look at unconscious reasons, such as other personal choices that conflict with a core beliefs.  Or perhaps, something like unresolved anger coming out in physical and emotional symptoms. Ask about our “closets,” peel away pretense and let your flawed self into the air.  Keep it real.

    Another paradigm is medical.  Inappropriate guilt is a symptom of Major Depressive Disorder, a debilitating disease process of the brain that affects the whole person/body systems.  When distorting things out of proportion, personalizing too much, we must ask if there is a depression going on.  Ask yourself.  Ask others.  But don’t let it continue if at all possible.  Major Depressive Disorder is a progressive disease that does more damage to the brain the longer it goes untreated.  In other words, the brain is affected more over time, it is harder to treat and it is more dangerous to the person.  The average length of an episode is 2 years and the more times it returns, the more chance to have the disease process continue for life.  Treating sooner and for longer, decreases the chance of relapse.

    Excellent for us are the many treatment options for this potentially devastating disease.  Even in the “lifer,” when staying on medications, the relapses are much easier to get through and shorter in duration.  The medication has a protective effect on the brain.  Prophylactic against further insult.

    In the woman I told you about, there was another emotional spectrum disorder, anxiety.  Anxiety and depression are like brother and sister.  They often go together.  But for today, we’ll leave it on the symptom of inappropriate guilt and let it rest on the reminder that the brain is human, mortal, attached to our neck and not an aura.  When the brain gets sick, it shows how it is doing the only ways it can, often through emotions.

    Self Care Tip #46 – Look at all the reasons influencing the way we feel.  Be a friend to yourself.

    Question:  What do you think?  Agree or disagree?  What is your story?

    Fear

    I dropped my kids off today.  All of them.  We had been very happy about this.  After laboring towards patient parenting for 7 years, I was also looking forward to today.  I’d never had all three out of the house at once, and the strangle squeeze on my insides grabbed me by surprise.

    We used to have this black cat when I was a kid who would hide in our plants.  In the middle of the night when I’d occasionally wake up and go to the kitchen to get a drink, she’d jump out at me with her claws.  While walking today between preschool, kindergarten, and 2nd grade, life jumped.  What left me breathless was how easy it was to get rid of my kids.  Appropriately by social standards.  School you know.  They’re doing what they need to do.  And just like that, if I wanted, they could be mostly gone.  I suddenly felt how it could happen to us, easy like that.  Like a body returning to dust.  My spirit, my soul, my essence yelled a loud “Wait!”

    My reaction can be confused by some as a hidden desire.  Sure, I acknowledge the obvious need for parents, including yours truly, to get space from their kids. But that wasn’t the slap I felt.  It was fear.

    I’ve treated many mothers, but one in particular comes to mind.  She voluntarily admitted herself to the hospital because she was afraid she would hurt her baby.  She wasn’t fantasizing about it.  She was having specific vivid imaginings that cut into her consciousness.  After enough of those, she lost confidence in herself and hid.  She confused these day-terrors with a fear that they were really some unconscious desire she didn’t understand.  Common for panic disorder.  It is the medical disease that historically gave us the phrase of “I feel like I’m going crazy!” With medication therapy she returned to a capable woman who trusted herself.

    Have you ever noticed that in the Bible, whenever God or an angel is talking, they almost always start out by saying, “Fear not for I am with you,” or some version of that?  I didn’t, until my kids came home from Vacation Bible School 2 years ago, and the refrain for the week was “Fear Not!”  They still scream it at each other with glee.  I love that about God.

    However when I hear that Bible verses or prayer or God should make us overcome fear, I am more than bored.  I’m angry.  Fear comes for many reasons.  It isn’t a spiritual thermostat.

    Today I did several things to deal with my fear.  I cried.  I prayed.  I went to work.  I felt better.  However, my patient did not feel better after doing those things.  What should God have done for her fear?  I knew that she came to my hospital.  I knew that what she felt were symptoms of a medical illness affecting her human brain.  I knew that medications could play a part in helping her.  Maybe that came from God.

    Question: What do you think? Agree? Disagree?

    Self Care Tip #31 – Fear not!  Be a friend to yourself.