psychiatry

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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!

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Dead kids and Mother’s Day 


To all the surviving mothers who celebrated this recent Mother’s Day without their children, lost to mental illness, we dedicate this post.  To the mom’s who have outlived their babies. To the mothers who have watched their boys and girls deteriorate slowly with piece meal pincing bites that brain illness has taken from them until they were gone. To the mommy’s of those who left them fast, at the end of a rope, under a car, at the point of a needle, or in the many bits of brain that a gun blows apart. 

I’m dedicating this post to the mothers who continue to live. Who remember more than the moment of their child’s death. Who celebrated on Mother’s Day the individual of her child that was more than his or her behaviors and emotions. 

This post is for the mothers who remain for us, we who need them still. We need you. Thank you for telling us your story and living with us, among us. For fighting for brain health, for freedom, we thank you. 

To the mothers who survive(d) the death of their children to mental illness, happy belated Mother’s Day. You are amazing to us. 

Today’s question is more of a request: Tell us your story please. 

Or, those of you who know these courageous women, and want to share, please do. We are listening. 

Self care tip: You tell me. How do you (they) do it?

Keep on. 

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STOP! DON’T STOP! The quandary inside of us when deciding to take medication

Everyone says “Hi” to my dog, Timothy… Way more than to me. Silence.

Is it the springy fluffy hair, I wonder? They walk up, even speed, out of an unseen shadow without inhibition and rub him down. He is pleased every time, to say the least. Do I regret all the painful laser hair removal treatments I got years ago? Hm. I am half Lebanese after all and few really know how much fur I really came with.

(Curly-cue.)

Steve came looking for help. I spied him in the hallway before clinic. That’s always a little awkward for some reason. Running into someone out of context. Like we both are caught out of costume and the curtain just pulled up. (Gotcha!)

His strings pulled in, an inner tension, apparent even then. He looked susceptible to emotional or physical attack when we caught each others eye. I could see him wondering if this was “her”, his psychiatrist. What was he expecting?

When patients come in for treatment, it’s comparable to anyone acting on a realization that they’re vulnerable, asking help from a stranger. It can take immense courage.

Part of this understanding is what contributes to the awkwardness of meeting in the hallway, out of context. We are both a little undefended there.

So what would bring a person to do this to themselves? It doesn’t sound pleasant when put this way – vulnerable, asking help from a stranger.

Steve had a wife, kids, a job, a house, and a pet. Inside this bubble, Steve didn’t think he had reasons to feel the way he felt. He looked for them and felt stupid because everyone told him how good he had it. Nor did Steve see reasons to behave the way he behaved. He described his story, a rolling out of his life, like that of a hand stitched carpet. In it, we saw together that he had anxiety then, and then, and then. He had coped well mostly, until he hadn’t. Then he would spend some time falling out of circulation and incurring losses. Then he’d recover and forget. He’d forget that worse patch and redefine the lines around the man. Then again the lines would smudge, he’d get anxious and irritable beyond “control”, grapple within the darkness of the white noise, which panic brings, grapple for reasons why the anxiety came again. His identity would be so threatened, the suffering, the feedback from everyone around him would pull on him, that the lines of his person frightened him into treatment.

There Steve was. Timothy at his feet with his puffy furry head in Steve’s lap. Steve asking for help. At the same time as asking for help, he would also refuse, stating caution.

“I don’t want to change myself.

I like being the person who gets things done so well.

I like accomplishing things.” (He thought it was his anxiety that allowed him to do this.)

It reminds me of the, “Stop! Don’t stop!” that I’d tease my brothers with when we were kids.

People think that taking medication changes who they are. Understand that in order for this to be true, that would mean medication changes DNA code.

“Doesn’t it change my brain chemistry?”

Let’s say that were true, that medication changes brain chemistry. Still that isn’t changing your DNA. The DNA is what gives a person “personality,” or, what many of us say, “Who I am.”

After getting laser hair removal, I didn’t change my DNA, but I don’t have as much hair. When my kids were born, I checked, and sure enough, DNA…. They’re gorgeous! Wink. (That’s done with one heavy cluster of eyelashes around my dark Lebanese eye.)

Question: What are your fears about taking medication?

If you have taken medication, how did you see it affected your identity?  What happened to who you call, “Me?”

Please SPEAK! We need to hear you. Keep on!

Self-care tip: Self-care means taking care of yourself even at the biological level. It starts with “Me.”

 

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The Heroic Patient

imagesSorena wore a black knit scarf around a thick neck, folds between scarf and skin. She came in with reflective smooth skin and frozen brow.  After many botox injections, she increasingly found it difficult to change her expression.  People often accused her of not caring about difficult things they were disclosing, and she realized the issue was, she couldn’t move her forehead.

She had a lot of empathy and was frustrated that people didn’t understand this.

We pulled at this idea for some time, recognizing a tension unplugged for her with each injection, a relief she experienced at visceral level. She just felt like she had to get her injections, driven toward them, like a bee toward the hive.

At some level it takes courage to get through the day.  She sees the effect.  Despite the fact that she should take a break from Botox, she can’t stop and this feels frightening.  She’s freezing her face.  It’s a terrible thing to know she has to stop something she is driven to do. It’s really hard. She’s trying to get through each day.

I told Sorena, “What you do every day to deal with this is brave. It’s harder. You have so much strength. You are doing it. You are getting through.”

I’m considering starting a podcast, “The Heroic Patient.” What do you think?

I want to interview Sorena and others with heroic life journey’s for you to discovery, connect with, increase awareness of, and appreciate.

The idea is to interview a world-community patient who will tell their “story.” It enters through the physician’s office doorway and increases transparency.

Many in our world community do not have a great understanding of what a physician nor a patient do in this exchange. You may think, “Well, everyone is a patient so at some level they do.” But:

  • How many, do you think actually go into a physician’s office?
  • How many variety of physicians does any one patient see in a lifespan?
  • How many get to tell their story?
  • How many of us hear each other’s stories?
  • How many of us understand how a physician solicits the details of a story so someone is “heard?”

If a patient were to learn the ‘behind the scenes,’ thought processes, interview techniques and analysis of the physician, would that be helpful to the patient?  Would the doctor learn from this dynamic interplay, and would the interview process evolve and grow from this? How would this effect stigma of all variety? Who knows?

What do you think? Is there a need for the “Heroic Patient” Podcast? If so, what are your recommendations and opinions?

The idea is that we are designed for connection. It’s friendly, remember? 🙂

Keep on!

Self-care Tip: Get transparent to get connected! Be a friend to yourself.

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Best Self-Care Ever! StepBet

move-it

Hello Friends!

This post is a simple plug for one of the best things I’ve ever done for myself.

You have heard me talk about neural grooves and changing habits such as those that are not friendly to Me. In a post, “Pay a Dollar,” I said,

When you feel trapped by your own self, get friendly by remembering this.  You’re mistaken.  You’re talking about a brain groove, not a vampire.  It’s not hopeless.  Not much more, not much less than what it is.  A groove can be abandoned.  New paths can be made and when the stressor hits next time, you will have a longer moment to decide on which behavior to play.  You will have a choice and you will realize more often that you are not trapped by what you thought; you are not hopeless and ugly.

So how long does it take to form a habit? Or break one? To change neural grooves in the brain. Many say, twenty-one days. Others say, you have to do it every day for a year.

This game, StepBet, is designed to get us moving as a habit. I’m loving it. I invite all my patients to join me. My team. My friends! I’m not leaving you out! Smile. Check it out.

You put $40 up that says you will walk a determined number of steps every day, except one, each week for six weeks. If you miss a day, you lose your forty bucks. Some days, I start thinking, …”It’s just forty dollars…(whine – a long high pitched complaining cry.)” The money from those who don’t make it to six weeks goes into a kitty and later dispersed amongst all those who did. Yah! So fun!

Please join me, and let me know how it goes for you.

How StepBet Works

1. Get Your Goals

2. Place Your Bet

3. Step it Up!

StepBet FAQ.

Question: What do you do to be kind to yourself, habitually? Please tell your story!

Keep on!

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Live Imperfectly, Dad is dying, and I Have no Power.

wilted flower

Living with someone like tomorrow might be their last is much harder to do when it is actually the case.

My dad told me, after my nine-year old niece died, that a parent should never outlive their child.  When I look at my own children, I know that is true. But with my parents aging process, my dad’s long and difficult past twenty years, and now near end of life condition, I just don’t know how I’d order things, if I could, between us.

When God, (Morgan Freedman,) told the complaining Bruce Nolan, (Jim Carey,) that he could have all of his powers, the audience of “Bruce Almighty” projected both a positive transference and a schadenfreude. Bringing the viewer into the character’s identity is every actor’s aspiration. And we went there. Up. “Yay! Bruce can answer everyone’s prayers with a ‘yes’!” And then down, down, down. The multidimensional disaster’s created by misplaced power, power without wisdom, love, or altruism, was just painful to watch. Power does not God make.

My Dad is dying. Not likely from cancer. Not likely from a failed liver, floppy heart, or baggy lungs. He is just dying.  He’s confused on and off. His spine is failing so he can barely walk. He has repeated blood clots. And he’s recently risen out of a deep depression. Rison right into a confused grandiosity, full awkward, awkward like pants ripping when you bend over type of awkward, and inter-galactic soaring thought content.

The first “word” Dad played in Scrabble last week was “vl.” He explained, “vl, like vowel.” …Okay? For thirty minutes Dad played without playing one actual word. I started crying when he finally stopped connecting letters. The letters floated on the board like California will look after the “big earthquake” finally hits and it falls into the ocean. (We’ve all been waiting.) Now he tells me he called and spoke to Obama and Magic Johnson. Reference point. This is bizarre and out of his character.  He’s been delirious with waxing and waning level of consciousness for a month and a half. He’s dying. Sheez.

Living well while Dad dies is not easy. Would I use power to restore him to his healthy twelve-year old self, like Elli’s seventy-year old grandfather did, in “The Fourteenth Goldfish,” by Jennifer L. Holm? Would I use power to change the order of death? Would I do anything more or less or different, while my dad is dying?

Power does not God make. I am not God. (Ta-da! It’s out of the box now.) But both of us are watching Dad die. I trust that She, with the power, wisdom, love, and altruism, is living with him well, during this time.

In Life and Other Near-Death Experiences, by Camille Pagán, Libby Miller decides to live, just live, rather than die perfectly.  And maybe that’s my answer to this unasked question. Living with someone dying will not be perfect for me.

Self-Care Tip: Live imperfectly to live well, like this is your, his, or her last day.

Question: How do you “live well?”

Keep on!

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Blood, Sweat, and Imperfections – Mommy Don’t Look!

Naked and Voyer

Naked and Voyer

Blood soaked and layered with fallen governments, the Acropolis remains, a witness and teacher to a summer fling. 

A tour of the Acropolis and its new museum taught much. #1 – Never go on such travel without a tour guide. She made all the difference. Without her, I might have lasted for an hour, or an hour and a half. I would have thought, “Check! Did the Acropolis! Next?” With her, I felt like I couldn’t get enough. Four hours later. Evi was an intelligent, independent woman, making her way in the world, with the talent of putting ideas together. Another mentor to pick up along my life journey. #gratitude.

(I’m going to try to describe Athens, as seen by a psychiatrist. Smile.)

Evi integrated the paradigms at play, seamlessly, and in flow, from the 800’s B.C. to the 400’s A.D. She spoke about the mathematics involved in The Parthenon architecture, the classical culture seen in the architecture such as the emphasis on the human senses, the development of language and democracy, and more.

None of the construction of The Parthenon is “perfect.” The columns slant, and the stairs bow in their middle. All of this is done to capture the human senses. It was constructed so that when you stand at one corner, you can see almost the entire construct, like inflation of air rounds a balloon. When you look straight on, you are almost able to see entirely around the balloon’s girth. The architect sacrificed perfection toward the ultimate and most valued goals – to experience all the human senses to their fullest, and the classical construction. 

The Greeks developed the idea that whatever is created by man, (scantily garbed statues, architecture, ship making, etc…) should demonstrate, but not surpass the excellence of the human at his or her absolute best. Perfectionism smechsonism.

The kids were a bit horrified by the genitals everywhere. “That’s inappropriate!” or “Mommy, don’t look!” with a hand posturing the Stop! sign, improved my experience 10-fold. 

The Greeks in the 400 A.D.’s recognized the irony in the loveliness of human senses; sight, emotions, spirit, intellect, etc, integrated with the flaws. We are greater, in the best of our imperfect self, than the perfect, mathematical, or any other kind of perfection, eg., 1 + 1 = 2, in a perfect world. 

For example, by tilting the columns, the architect understood that it would give an illusion of straight columns, yet still capturing more of the circumference as seen by the individual. Straight would be perfect. Tilted but looking straight is more representative of a human at her best. Never perfect. And the illusion created by the tilted columns made the construct look shorter, thus not surpassing “the human” capacity to sense it’s grandeur. 

Also, the government ruler at the time, Pericles, was the first known leader to integrate a form of democracy. He used citizens and slaves for the labor. Yet he paid them, including the slaves! Furthermore, he gave them freedom in their work to form independent decisions, stating that someone who is told what to do, doesn’t learn anything. Someone who makes their own mistakes, has the opportunity to learn from his mistakes. This was the fulcrum which our civilizations turned on toward human rights and free thought. Pretty powerful.

The Greeks gave their alphabet to the world, from which Latin developed, and thereafter the Latin languages. For example, I never knew that “Agoraphobia,” comes from the location, named at the time, “Agora,” where all the debates were held, again, inspired by this ruler during the 400’s B.C., spurring on freedom of thinking. You can imagine what happened during heated debates. Some people would suffer anxiety in that context, which would deteriorate into a disabling fear of being humiliated by another potential panic attack when in public places.

The priests of the Greek gods served also as their community’s medical practitioners. For example, they used snake venom to both treat headaches and prophylactic against strokes. It turns out that snake venom is an anticoagulant. Totally brilliant. Snake venom in Greek, is called, “physika”, which means “venom.” The caduceus, a symbol that we still use for the physician’s medical practice, shows a snake wrapped around a staff. Later Aristotle used “physika” to name his treaty on nature and the work evolved into “physician.” Way cool. 

The self-care tip: Work your damndest, while embracing and integrating your imperfections along the way, and in this Grecian effort, you will gain the greatest sensorial experience with the world around you, the individual beside you, and your own self.

Question: 1. How do your imperfections enhance your best self? Please tell us your story!

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I Can’t Make Friends – Anxiety

voyagerMr. Clark stopped talking and walked to the ringing rotary phone on the wall.

We were experts, as 7th graders, in anticipating what phone calls would be about. I’m surprised we never got around to making bets. I missed my chance to be a bookie. When the phone rang, it could mean someone was in trouble and had to go to the principle’s office.

Everyone was quiet waiting to see if their name would be called. No. That wasn’t it.

It could mean there was a school announcement. It could mean there was something wrong with our bathroom plumbing! But it had never meant that a space ship had exploded. Seventh grade was not the time to grasp what this meant. If we couldn’t grasp it, if our perceptions were unable to see it, then it could not actually exist. Right?

We kids had other things we were trying to sort out. Boys and girls. Getting your period or facial hair. Zits. What Melissa said about you when you thought she was your friend. These were space occupying in our minds. There was little room for understanding that this phone call announced the end of 8 lives, a billion-plus dollars blew up, nor especially not what it meant politically! Spouses and children, watching and cheering in the bleachers live, front row and center, witnessed as their own individual loved one exploded into tiny particles.

Mr. Clark walked, white-faced and perspiring, to the radio, asked for silence over the hum that had built up, and we heard. The challenger, the 8 people aboard (one of them a teacher), in 1986, was gone.

A spaceship exploding is about what anxiety feels like. That may sound extreme but it is the truth. And those who have experienced it, as if their were going to come apart, will do anything not to experience it again. This urge to avoid anxiety expresses itself in emotions and behaviors. But often, when anxiety doesn’t reach a full explosion, the afflicted individual doesn’t even know that they are sensing the urge to avoid, nor how they are responding to this avoidance. The afflicted person and those who know him get think that these medical symptoms are actually the afflicted’s personality. “It’s just the way I am.” 

You may be someone who feels inner congruence with decisions. By temperament, you like closure! But even so, against your own hard-wiring, you find that you have trouble making decisions. How you talk is driven by indecision. You’re couching what you say, being careful. Your self-esteem erodes.

Manuel had some similarities to this, but also, on top of his medical condition with avoidance symptoms, his personality was one that got energy from being alone. That doesn’t mean Manuel didn’t like people or interpersonal relationships. It just means that he got energy from being alone. And he did stay alone most of the time. When around others, the energy poured out of him like lemonade through an open spigot. However, he wanted others. Being lonely was not his goal. But there he was, more energy when alone combined with a thrumming buzz of nerves when he tried to make friends, when he tried to date, or when he was approached by someone spontaneously in public who asked the time.

Fudge! She only wanted to know the Blinking! Time! he screamed inside.

Manuel had some friends with whom he was deeply bonded to by shared experiences. But he had gone on to college and his friends had not. It was niggling in whispering thoughts that he might still be hanging out with them because they didn’t disrupt him. Because he came apart. Terror, like a spaceship exploding in the atmosphere after take-off, filled his perceptions, if he tried to hang out with anyone else! And Manuel didn’t like thinking about his friendships that way. They lost value when tattered by that persistent wind. Nor did Manuel like thinking about himself as someone who couldn’t get other friends if he wanted to. As someone who would use the faithful. Friendship by default? No. He felt shame just thinking it and he knew it’s falseness. In his most essential self, he knew he loved them for more than proximity. But he really didn’t know if he was weak. It was a possibility. And besides! What girl would want a weak man?

People with anxiety have barriers to any number of connections in life, like coming up to an energy force field we can’t see. There are interpersonal connections we might have had, but never initiated or explored because the anxiety held you in place. This is what anxiety does to us. Anxiety takes away our freedom to choose. And as the consequences and fruition play out, we live out the related losses.

Manuel came to me because, “Mom told me I better come and talk to someone.” Mom was fed-up with his isolation, hours of video games, and she had noticed that he was spending even less time with his childhood friends. 

Talking to Manuel, unearthing these patterns in his life, his insight grew a bit. But once he looked at anxiety, even with a sideways glance, which was anxiety provoking in itself, he came up against the need to decide,

Should I treat?

Deciding to treat is a decision to make between the patient, perhaps including their support system, and their treating clinician. When there isn’t a clear answer though, like a blood test that shows the vitamin D levels are low, we respond with vitamin D replacement therapy, but in these areas of diagnosis, it often feels nebulus to the patients on what to do.

When the decision doesn’t have clear form, like an undefined space, go toward the data. You may trust your clinician to know that data integrate it into all the information that goes toward deciding on treatment. Or you may choose to spend time researching and evaluating the data on your own and then go forward. Either way, if you stay with what you’ve been doing, you will remain ill and the illness will progress over time.

So either way, going with the data, either via your clinicians recommendations directly, or indirectly. Accept treatment. In fact, run toward it! You will have a much higher quality of life. And… those around you will too.

Self-care tip – Go toward the data!

Questions: What had influenced your choices in treatment or not to treat? Please tell us your story. We need your voice!

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NPR interviews Kitty and Michael Dukakis

In an interview with Kitty and Michael Dukakis, journalist Katia Hauser explores the benefits and risks of electroconvulsive therapy (ECT) in treating depression. Kitty shares her first hand experience with ECT and the ways it changed her life, and Michael provides the perspective of a family member.

Dukakis interview

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I’m peaking in my career

  
Supposedly, I’m peaking. And this isn’t about egg yolk and marenge pie. I’m 43 years old, have been in medical practice for fourteen years, and am looking at a canyon in 360-degrees from where I stand. That’s what the data says. I wonder if I am going to do the electric slide or how I’ll boogie through the next years of medical practice. I try to think, “This is the best moment of my life, right now,” any time self stigma and fear of mortality creeps in. (That’s not saying, “This is as good as it’s going to get!” Ha!) I want to cherish the gift of practicing medicine, for however long I am blessed with it. 

It’s a popular discussion amongst my colleagues these days, about how long a physician should practice. There’s a newer’ish respected program called, PACE, that evaluates physician competency to practice as they get old.  This is a huge shift in the culture of medicine. It’s meant to respectfully assist rather than discriminate with ageism. I try to imagine what it might feel like if I were approached and asked to take the test. 

So what does a psychiatrist rocking her best jeans have to show for herself anyway, you may ask. Well, (tapping the mike), “I’d like to first say thank you to my sponsors….” Wink.  I mean my patients! Thank you. 

…Hey! This peak is crowded! Give me some room!

Ahem. But at my “peak,” at the best of my career, I thought it would be fun to play around with, “Why?” What’s in my doctor’s bag that is so special?

  • Ask, “Why do you want to be alive?”
  • Start all work-ups with a medical work-up. 
  • Give full informed consent with the 5-Treatment Paradigms of Psychiatry: 
  1. chemical (medication), 
  2. psychotherapy, 
  3. hospitalization (inpatient and outpatient), 
  4. alternatives (such as acupuncture, massage, sleep hygiene, lifestyle change, etc.), 
  5. stimulation therapies (such as ECT or TMS).  There’s nothing else (that I know of 🙂 ) that anyone is going to offer you in psychiatry, no matter who’s clinic you go to. 
    • Push to full treatment response. 
    • Work toward quality of life, not cure, not perfect.  Ask again, “What makes like worth living for?” Design treatment toward those goals. 
    • Routinely and deliberately consider the flow of patient’s treatment agendas with physician treatment agendas. 
    • Mood journal. Nobody believes they were “that bad” after they feel better. Everyone wants to stop treatment when they feel better. (This is why there are so many repeat pregnancies, for example!). We all need our own voice (mood journal) to look back on and speak the truth. 
    • Fight for oxygen. If your patient has sleep apnea, don’t stop working toward treatment compliance. There are no medications that can take the place or make up for oxygen to the brain. 
    • Community. More community. 
    • The third eye – a therapist. None of us can be a mirror into ourselves. We all need someone outside of the “triangle” to speak.

    I’ll be thinking of more as I try to go to sleep tonight, but it’s bed time. I’m off! Sleep hygiene! Arg!

    Self-care Tip: Evaluate your position in your lifeline, and treasure where and who you are with deliberation. Keep on!

    Questions: Where are you in your lifeline? Are you struggling with ageism? What gives you value? Please speak! I, and the rest of us, really need your voice. 

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    Bilbo and Me, trying to get to the Smoky Mountain

    jake

    Imagine, a young father playing basketball with his buddies on a Sunday in the gym, joking around, slapping each others butts, (because, help us, that’s what they do!) Sweat is rolling down his face. Call him Jake. He’s heavier after three kids, but he’s trying to lose the baby weight. His wife has to wear earplugs to sleep, he sounds so loud in their bed. Jake has been playing hard for about thirty minutes. He’s feeling good. He never lost his touch. He’s with his same buddies from high school. They stay in contact. They’ve got each other’s backs. They’re running down the court. He’s guarding Tom and everyone’s diverted, running, heaving and breathing hard. Tom makes the shot and they’re all slapping each other’s butts. They are throwing the ball back into play and someone laughs at Jake. “Hey Jake! Get up!”

    Obstructive Sleep Apnea (OSA) is a leading cause of early heart attack.

    I wrote this out in what may seem almost tasteless detail only because this is how it happens. I wish it didn’t and I want it to stop. It is as horrible as you imagine. Jake dies. His wife and gorgeous kids are left to live life without his laughter and counsel and noisy snoring that his wife would do anything to have again. Jake’s community is man-down. Obstructive sleep apnea is a deadly sleep disorder.

    CPAP is 99% effective when used to treat OSA. It works. It is just not always the easiest treatment to tolerate for many reasons. But it is worth fighting for. The fight for CPAP might look something like multiple visits to your primary care practitioner to get that referral to go through to your sleep lab. A referral is made, and silence, then made again, silence, then finally by the third or fifth try, it goes through. Or multiple visits to your sleep specialist, exchanging one sleep mask after another and then another until you finally find one that keeps a good seal on your face through the night. There are truly a mountain of barriers to compliance that you will trek across, more barriers than Bilbo encountered heading toward Smaug, and you’ll need as much courage.

    Keep on!

    Questions: To start with, how is your breathing, or your loved one’s? Did you know that you might have to walk such a circuitous trail toward being your own friend? Who else will do this for you?

    Self-Care Tip: When you are deflected, when you get stuck in the moment of loss, pull back into the big picture. You are your own friend and it starts with Me.

    by

    Start Over

    fabio

    Muscled and gorgeous, he came in, like dessert, main course, and appetizer. Some people just carry themselves that way. It doesn’t work if they dress low, chest hair accentuated by opened buttons and glimmering chains. It doesn’t work if it’s their agenda, checking to see if you noticed, a finger hovering over the acoustic applause button. No. Attire must be intact, normal, not baptized in cologne. In fact, attire must be worn as if it is completely a non-issue. Attitude of a jack-rabbit, who never thought about his muscled legs. Those legs just hop because that’s what they do. That is the kind of attitude-ingredient to this kind of presence-recipe.

    How would a mother name such a son? How could she know he would turn out this way? Greg is an essential name for this elixir to work, as essential as “Fabio” is to its destruction. Everything else may have been in place, developed over years, like a bonsai tree groomed under the tender ministration of Father Time, and caboom! “Fabio.” The bonsai becomes a paint-can-frosted Christmas tree. Greg’s mother named him ‘Greg’, in fact, because it was the dullest name she could think of, not wanting him to grow up to be anything like the sort of philandering infidel his good-for-nothing pig father “Fabio” was. Greg told me this. I didn’t come up with it. He knew it because his once beautiful mother, who worked seventy hour weeks, told him whenever he messed up, “I named you Greg! This is not supposed to happen!”

    In came Greg, after three years of absentia. And it was like I had just seen him yesterday. His mother couldn’t believe that the name Greg would hold such a man, an addict. Yep. Greg hadn’t seen me for three years for a reason. There I was. Chirpy as ever.

    Greg! Where you been?

    Whenever a patient comes to see me, I believe in him or her. I believe. In part, because I believe in Me. I believe in my value. Wink. But I also believe in them because I believe in Love, and because I’m simply wired to. There are more reasons why we behave and feel the way we do, more than colors in your crayon box. It’s not just a moral issue, biology, or an adjustment to our human condition. Heck. His name may have even had something to do with it. “Greg,” is quite a name. But I did believe, more than I disbelieved, that he hadn’t been in to see me for reasons other than relapse. Maybe his primary doctor was filling his meds, and he was so stable he didn’t need psychiatry anymore! Yah! That’s it!

    (This is inside information folks. You can’t tell anyone. My patients can’t know this about me. It could ruin my career! I don’t want them to be any more afraid of disappointing me than they already are. It’s hard enough to be honest in these places, and I do my darndest not to project my Pollyanna-agenda’s on them. They don’t deserve that. They deserve the hard-earned poker-face I screw into place when my heart gets broken. I purchased it with ten-years of my life from some magic spiders I quested in a cliff off distant shores. Bargain.)

    Greg! (I said,) It’s great to see you!

    Every patient wants to please their doctor. And every doctor wants to please their patient. And we all get our hearts broken at some point.

    I was really glad to see Greg, after all. And he was looking good. But then I noticed he had more weather in his face, some clouds, lines, and gutters. And I noticed he wasn’t as glad. He had an aura of melancholy and self-loathing rolling off of him.

    His little boy was with him, too, (Fabio. …J/K! Gotcha! Good ‘ol “cycle.”)

    Greg sat there, thunder in his sorrow shaking his frame, and we reviewed his story. You may know Greg’s story. Greg may be your friend too. Or brother, husband, dad, or You. And you know the high from this addiction feels better than everything, until it doesn’t.

    The best line ever spoken in this context is, “Relapse is part of Recovery.” That is from the God of Hope. That is what makes sense in every illness, like Charles Dickens is to literature, timeless and universal content, man. When Bob reaches for that doughnut, when Harriet rolls the dice at Pechenga, when Fabio uses porn rather than intimacy in a meaningful relationship, when Myrtle has to pull over on the freeway in a panic attack, this is when we ask, “Why am I alive?” and demand to start over for that answer.

    I’ve asked that question fifty-plus times a week for fourteen-some years, and every time I ask it, I listen for an answer. I’m curious too. We all are, right?! It’s a marvelous question. Every time I ask, I wonder about the magic that keeps this beautiful creation in our community. I listen, because every answer is something that crescendos into the room, the words explosive, the best part of the atom.

    I have a daughter. She needs me.

    My dogs. Nobody loves me more than my dogs.

    I want to know what it is to live without this.

    I’m too scared to die.

    God.

    I just don’t know why.

    Oops! Wait. “I just don’t know why,” isn’t good enough. Figure it. Finger it. Cradle it, and answer. What do you want to stay alive for? Because this thing! This thing is part of your recovery. Another day will come.

    Greg left our appointment with options for treatment and a commitment to treatment. I’ll see him again and he’s one of the reasons I love life. Can’t wait.

    Questions: Why are you alive? Please give us your answer. It will explode into the universe and someone out there needs to hear it.

    Self-care Tip: Answer the question and start over. 

    by

    The Perfect Doctor – Healthy With Disease

    looking

    One of the difficulties we have in talking to psych patients is realized with the dawning truth that we are not curing anyone.  Working in those conditions of not curing, you both, patient and psychiatrist, have to come to terms with each others’ agendas.  The physician says, “(‘I’m a failure.’)  I can’t cure anything.”  Now eye contact is even tough.

    “If I don’t look them in the eye, some other emotion will surface and they’ll stop crying.”

    Rachel was crying and crying hot and hard in the emergency room.  She was unable to stop the lava flow.  It was bewildering to her.  The people around her shifted their gazes.  Those who didn’t, looked angry instead, as if to say, “Pull yourself together, Woman!”

    Psychiatrists have the advantage perhaps to these others in the lobby and receiving rooms and gurney shelves. Supposedly psychiatrists can grip and tug at the corner of the large sweater that is human behavior and say, “Emotions and behaviors come from the brain.”  They can imagine, if not entirely believing at a visceral to cognitive level, that the person they observe is responding to symptoms of what is happening biologically, at a cellular level. When they are tempted to avert their eyes, or look back impatient with the messy emotions, they can say, “This is medical.”  Impatience with emotional chaos from psychiatrist to patient, is equivalent to the ER doc saying to the trauma patient, “How dare you bleed in a public area?”

    When someone cries on the medical unit, you may hear, “Nurse! Call the psychiatrist! There’s an emotion on the ward!” Later when things are calm, I walk out and they say, “Doctor!  You’re amazing!  What did you do?”

    “Well, I bit off the head of chicken and sacrificed a goat on the patient’s chest.  Then I said, take this pill and everything will be as it should.”

    Luckily I have several chins now, and when I gesticulate, their quiver contributes to me looking very capable. As if I could cure something.  I don’t know much about art history but, The Thinker, a bronze sculpture by Auguste Rodin, is probably what that Frenchman’s psychiatrist looked like when they both came to terms with the fact that psychiatrists don’t cure anything. (Heresy.) At least he got to get nude while he did it.

    Talking to psychiatric patients can be that difficult.

    There are studies on patient satisfaction that demonstrate that patients don’t like us when they think we give them bad news.

    You see the predicament here, don’t you? So, some of the difficulty the world at large may be having with talking to psychiatric patients is that we have distorted perceptions of good and bad news. We may have difficulty with our own humanity, frailty, infirmity, and seeing it out there “without a scarf on” for decency, is a hard reminder.

    We will never be cured of so many things. All of us. And the best we can hope for…

    What is the best we can hope for?

    (We are all gluttons and all hope for many unpublishable things but please! Just humor me.)

    Say: “I hope to be healthy with disease.” There. Now we will all speak better to each other. It all starts and ends with Me.

    Questions: Have you ever had difficulty talking to a psychiatric patient? Have others had difficulty speaking with you? Why do you think that is? What could help? Please tell us your story.

    Self-Care Tip: Hope to be healthy with disease. 

    (I bet Carl D’Agostino could make an excellent cartoon with this rich irony to work with! That’s right Carl! You heard me! Maybe a blue ribbon with a hole in it?… Ah heck. I’m sticking with practicing psychiatry and leaving the toons to you!)

    by

    Making our way through the questions on ECT – Top 3 Reasons for Being an Advocate

    1. How do you address the issue of cognitive and memory impairments?
    2. What are your top 3 reasons for being an advocate for ECT?
    3. What are the differences between ‘old’ ECT and ‘modern’ ECT?

    fancy

    Ooh La La!

    So much fun to play dress up! When I was a scrub, a solid big boned unkempt of the Cleveland National Forest bordered lemon groves, when I walked barefoot, disappeared for the entire day in the rattlesnake infested chaparral, when I followed my brothers around like a desperate child, I still liked to play dress-up. I would sneak into my mother’s long closet, a dressing room really, with folding doors. I could hide behind her dresses, or climb up onto her shelves and be nothing more than luggage. But mostly I remember staring at her clothes and shoes. I remember one of her all time best outfits – a blue knit bell-bottomed jumper. A wide white belt with a hand-made gold buckle was an excellent accent. Yes, it would drag down below, but all the better to cover my brown feet.

    When I think of my top three reasons for being an advocate for ECT, I think of dress-up. There are so many great options to put on, and I can and do exchange them with aplomb, as Fancy Nancy would say. That’s a French word for poise. It’s fancy. If you catch sight of my brown feet here and there, well, you can’t take the hills out of the psychiatrist I guess.

    For today, Reason Numero Uno, (Fancy for #1, in honor of the second language I wanna-be speak):

    • It works most consistently, and most quickly of any treatment available. One must pick her fights after all, mustn’t she?

    Reason Ithnān, (Arabic for two, in honor of my fancy mother):

    • It doesn’t touch “the body,” i.e. metabolics. Clean.

    Reason Trois, pronounced I think like, twa, (Fancy Nancy’s favorite language. Need anyone explain? “French is fancy”):

    For example, just by requiring someone to help with transportation, it’s built in. That thereby inherently increases community awareness of mental illness, something we rarely speak of with each other.

    Then there is the medical staff. Our nurses are every patient’s advocate. Our masseuse increases oxytocin and other healing neurotransmitters when the patient’s get their massage waiting for treatment and then when in recovery. Our anesthesiologists are knowledgable, see the patient in their “whole person,” often picking up other issues that then will get the patient to receive treatment and improve the patient’s quality of life (QOL); such as hypertension, obstructive sleep apnea, etc…

    There’s more, but basically in ECT, none of our patient’s are alone. That stands.

    Question: What are the top three reasons you prefer the treatments you engage in? 

    Self-care Tip: It is always helpful to write out why you are doing what you are doing, when it comes to medical treatments.

    by

    Making our way through the questions of ECT – Memory Loss

    1. How do you address the issue of cognitive and memory impairments?
    2. What are your top 3 reasons for being an advocate for ECT?
    3. What are the differences between ‘old’ ECT and ‘modern’ ECT?

    memory loss

    1. Cognitive and memory impairments:

    There is no brain damage done with ECT. One way to understand the memory loss is with our own not so fond memory of carbon paper and credit card receipts. It’s not too ago that we made manual credit card receipts. We used, what was essentially, a machine that held the card in place, while we rolled over a two-part receipt, including one surfaced with ink. When rolling over the card, the ink pressed into adjacent paper the outline of the card face.

    Inevitably, whenever I had one such interaction, the carbon paper was used up. There would be little patches of ink left on it, but in all the wrong places. People would try to move the carbon paper around to maximize its usefulness. And we’d roll over it multiple times, using repetition to get a good enough copy, when the carbon-paper had gone almost white. Roll. Roll. Put your weight into it. Roll.

    The machine hasn’t changed. The machine isn’t broken or damaged. There just isn’t enough ink on that paper.

    This is a rough analogy of what happens in our cells.

    When we get new experiences, our cells try to “imprint” those memories into another area of our brain for storage and later use.  We use the intracellular “ink” to do this. However, a seizure dumps that ink, the neurotransmitters, chemical messengers, hormones, ions, and all those good ingredients needed to lay down new memories. It squirts the intracellular ink nearly completely out when we are stimulated, like squeezing a bag.

    ECT is a stimulation treatment. It uses electricity to stimulate, toward the effort of healing. There are other stimulation therapies that we have discussed already – magnetic and chemical. Not all stimulation therapies result in a seizure. We don’t know why a seizure is needed for such a dramatic benefit, but so far, in our 80+ years of experience with ECT, it is needed for this magnitude of healing. The seizure is the event that “tips the ink-well.”

    Our cells will naturally refill if left alone, after being “tipped over” and emptied. What brings about the memory loss is that in the beginning, in the ECT index trial, we don’t. The proximity of the treatments to each other is more frequent than what will allow for the cells to refill adequately for new memories. We stimulate, Monday, then just as they start to refill, we stimulated again Wednesday. And then again Friday. Then we do it again the next Monday, and so forth.

    This is only in the index trial though, the first part of ECT that we do in order to get healing. Once the first 2-4 weeks, approximately, are done, treatment response is achieved, and we progress to a maintenance program of ECT to keep those benefits. Just as with medication therapy, if we stop treatment, if we stop the pills, if we stop the stimulation therapy, often, we will relapse and become ill again.

    In maintenance ECT, we treat as infrequently as once a week to once a month or more. By allowing our cells to refill with “ink” between stimulus events, the difficulty imprinting new memories goes away. Those memories of events that happened during the index treatment, (the 2-4 weeks when we first start ECT,) may never come back. But we wouldn’t expect them to, necessarily, because there wasn’t enough ink to imprint them at the time. Like a carbon copy paper without ink on it, no matter how many times we roll over it, mechanically, we don’t have the ability, the ink, the ingredients, or whatever you want to call that stuff needed to save the memory of an experience permanently.

    I’m not going to go into the obvious juxtaposition of this with what happens cognitively with brain disease untreated, or with other treatment options toward brain health. I hope you do though. Because there’s so much there and it’s fun, liberating, and increases our personal freedom to choose.  Keep on.

    Questions: What do you think about not being able to keep the memories of your life for a brief time? What is the cost benefit ratio to you, when you think about this? Please tell us your story.

    Self-care tip: Be as careful as you can in your accounting, book-keeping, of your risk-to-benefit ratio of treatment.

    by

    Questions From Someone Important – On ECT

    Hi. I was hoping I could ask you a couple questions about ECT for a research paper I am writing.

    1. How do you address the issue of cognitive and memory impairments?
    2. What are your top 3 reasons for being an advocate for ECT?
    3. What are the differences between ‘old’ ECT and ‘modern’ ECT?
    My thesis statement is:
    Although there are many different treatments for Bipolar Disorder, Electroconvulsive Therapy (ECT) has proven to be the most effective therapy, treating both mania and depression.
    Thanks in advance,
    Priscilla

    Good morning Friends!

    What would you answer to Priscilla?  Do you have personal experience with ECT, primary, secondary, etc? Where did your beliefs and attitudes about ECT come from?

    Last week I almost lost control of my functions when my patient told me about his sister’s comments.

    Frank, my patient, had called up his sister, asking her to help drive him to ECT in the morning. Frank’s sister hadn’t even known Frank was getting ECT. She was alarmed but didn’t say anything until they were in the car together, a California dawn and sleep in their eyes for context.

    Is this for real Frank? Where are we really going?

    Frank was straight faced in his pragmatic style.

    She thought maybe we were either going to doughnuts or the devil.
    I don’t want this to sound bad or anything, but you know how people go, like to TJ, Mexico, to get some sort of cancer therapy that makes their skin fall off, that’s what she thought. Or we were going to get the psychiatry equivalent of a coat-hanger abortion in someone’s garage.
    Don’t judge me for peeing a little.

    One of my secretly favorite comedians, Amy Schumer, has a way of taking the worst negative biases in our community and denuding them w/o remorse. She did this with “rape.” The internet exploded that, demonstrating that sure enough, our community doesn’t get it. We don’t understand what rape is!

    Then Schumer did it again with women. The idea is that we lose value because of age. Sure enough, the world started talking. For example, a few someone’s noticed when Maggie Gyllenhall was told she was too old, at 37, to get the role of a 55 year-old man’s girlfriend.

    I wish Schumer would do a skit on electroconvulsive therapy, (“ECT.”) I wonder what she’d play with. Because there is awesome material there!

    …

    First introduction to ECT, some people wonder where the leather straps are. Dr. Schumer, in her white coat would say, “Oops! I forgot them at home.”

    And what do you wear in an operating room, really? Scrubs for spine surgery. Scrubs for gastrointestinal procedures. And psychiatry?

    Dr. Schumer, psychiatrist: “I’m a surgeon!”

    Funny how you celebrate things you would otherwise not…”Hey, what a great seizure!” (High fives all around.) Never Say say, “I just push a button.”

    Adding to the list of things not to say in the operating room (“OR”):

    • My Bad
    • Who is this?
    • Whoops!
    • I hope this works

    ECT patient: “I want to be the placebo guy.” Patient (an older man:) Lifted his head, slightly, after the procedure was over, and asks, “Can I still have children?”

    Patient: Being wheeled out of the OR (operating room) on the gurney, she stares up at the ceiling and mutters, “I can see why I need a driver.”two steering wheelsHow do People learn how to drive a gurney?! I just touch the thing and it’s like solid objects appear everywhere. The patients get nervous. One said, “Doctor, there can’t be two steering wheels.”

    Dr. Schumer: “I want to reduce staff work load, and since I’ve proven to be an unsafe driver of gurneys… I now control the Tylenol. I am a physician and I hate it when people say that I just ‘push a button.’ They can hardly trust me not to shock myself…. But the Tylenol, the Tylenol is mine!”

    Anesthesia: “Versed isn’t really an abused street drug—if you have a good time using it. You don’t remember anything anyway.”

    Dr. Schumer: “Yes, I’ve put vaseline on my nipples to help with chaffing.” (Patient: In his ‘twilight’ sleep…we thought, bursts out laughing.) Dr. Schumer: “Yeah, try and not picture your doctor in pasties… It’s not good for your healing.”

    Patient to Dr. Schumer: “You’re pretty good at this.” Dr. Schumer: “I’ve watched this on the Discovery Channel.” (Then, all of a sudden, she realized “I am not perfect. Such a shame.”) Dr. Schumer: “I really don’t do a whole lot in the OR… In fact, can we just get another gurney in here so that I can lie down?”

    Cheap medical service, do you really want that?

    by

    NAMI: National Alliance on Mental Illness

    Hello Friends,

    I’m enjoying this all too fast passing time at the APA annual meeting in Toronto. What I am most enjoying is the education, the community and connection with new and old friends, and the reminder of what this is all about – you and I. In honor of us, I’m “pressing” this excellent post from our national advocators and stigma-fighters at NAMI.

    NAMI: National Alliance on Mental Illness | NAMI: The National Alliance on Mental Illness.

    Check it out and let me know your thoughts. How does this resonate, or not, with you. We need to hear!

    Be well and keep on!

    Q

    by

    Handout – How to Talk to a Psychiatric Patient.

    duck

    Finished the CME talk I did last week and thought, you might find some use for it.

    I’ve received bad press many times for not being, in so many words, legit or academic enough. Check out the comments on my ECT book on Amazon.com for examples :). Maybe this one leaning into that bosom of greatness will turn public opinion. (Sneeze.)

    …Formatting has been a real bear.

    As you go through it, please talk out. Tell me what you think. I may do it again. (That’s right. I’m not afraid to threaten. You heard me.)

    Keep on, Friends.

    How to Speak to a Psychiatric Patient

    Introduction:

    • You quack like a duck, avert your gaze, and then hold a fetal position. It’s good for core.
    • Be sure to carry your portable speakers playing zen chakra music in the background.
    • Offer cigarettes.
    • Bring a healthy white chicken to sacrifice over their chest for the exorcism.
    • Introduce yourself with an alias name. Hopefully a superhero.

    This is a fail safe method of communication to pretty much hit all the difficult misperceptions we are contending with in psychiatry – demonic possession, shame, violent tendencies, weak character, and poor moral choices.

    I’d like to give you the 1,2,3’s on how to talk to psychiatric patients. But as I researched this topic, it became apparent that this wasn’t the direction for us to go in. You have better algorithms, systems, and manuals based on research for this in your own departments. I know you have people who are specialists in the administrative side of things.

    For us today, we are going to turn rather toward the innuendos that interplay in communication between caregiver and patient.

    The is the first place for us to start, let’s just talk about it here.

    What is it like for you to talk with a psychiatric patient?

    • Identifying Me in the mental health treatment paradigm.
    • Not implying that we have skills but no awareness. We are just deliberately putting the practitioner into “it.”
    • It’s a “how to,” but first we need to address our personal limitations.
    • Why do we have these limitations?

    I: Clinician/Caregiver barriers

    II: Patient barriers

    • What’s over-scored is that the problem is on the patient’s side. The patient is sick after all. We agree. Brain illness and all that.
    • Even so, what is underscored is our side. And that’s what this talk is going to be about.
    • We want to focus on our own thoughts about this. What it says about ourselves. Who am I if my identity changes with how I feel and behave? etc.
    • And then, how do we respond to that?

    III: Understand Personal Biases – Likes and dislikes

    • Figure out where we are at. What makes it difficult to talk to patients?
    • What are the common myths? Get the myths out there. 
    • Some reasons are true and not myths.
    • What are some personal biases about working with psychiatric patients?
    • (Bias means – likes and dislikes)

    IV:   Define Stigma

    1. Prejudice – Attitudes, feelings/emotions (Amygdala)

    2. Discrimination – attitudes lead to actions

    1: Prejudice

    • Weakness of character
    • Supernatural explanations. (Statistically significant association with superstitions.)
    • The word “patient” not talking about disease, perhaps, but rather about character – something of moral value.
    • Religion. (But only a few believe that spiritual leaders can play a role in treatment! People don’t relate stigma issues to biology.  i.e., It is not biology or medicine that increase the problems, but belief that the person has a personal weakness as demonstrated by their behaviors – A conflict in beliefs, or prejudice, worth exploring.) (…But where do emotions and behaviors come from? The Brain. Thinking they come from a cloud by day or a fire by night fall into the category of prejudice.)
    • Time consumption.
    • Danger
    • Treatment skepticism – no recovery, there’s less hope for them
    • Punishment from God for evildoers.
    • Demonic possession
    • I am lessened by my affiliation with the mentally ill

    What are our fears? Fears are an emotion and/or attitude…

    • Brings into play, how do we identify ourselves? …And that part of us that remains even when we are in a changing body (identity).  I call this, “Me,” with a capital “M.”
    • Think about this when we look at responses to prejudice; “discrimination.”

    Caregiver stigma – “self-stigma” comes when we internalize public attitudes and turn it onto ourselves

    • We perceive stigma from others due to those we care for.
    • Shame/Embarrassment
    • Fears of what it says about ourselves

    2. Discrimination – How we act on those prejudices.

    Example:

    • Take “Caregivers Stigma.” We can bring this into our work place as well, from what we glean in our community.
    • We avoid patients who make us feel uncomfortable.

    Who has Stigma?

    Everyone.  It is in our community, including we who serve and are involved in mental healthcare services.

    1. Patient

    2. Clinician

    Patient

    Example: Mr. Whineheart misses his medications approximately three times a week due to logistical reasons. However, we know that Mr. Whineheart has had a long history of difficulty with treatment noncompliance. As we explore further, we discover that Mr. Whineheart dislikes taking medication. It makes him feel like he is weak. Not taking his medication is Mr. Whineheart’s discriminating behaviors against himself in response to his prejudices, (emotions and attitudes of shame.)

    Clinician

    Examples:

    • Refusing care for psychiatric patients.
    • Starting with Questions:  How do we respond to challenges to our identity? When our identity’s confronted by seeing our patients with psychiatric illnesses, our patients who demonstrate changes in their emotions and behaviors since brain illness set in, we ask, what part of us remains even when we are in a changing body and mind (identity)? How do we respond?
    • If it is positive, it is not discriminatory toward ourselves. If it is negative, it is discriminatory to ourselves and inevitably to others.

    V: What are the barriers to talking with psychiatric patients?

    • The tension is when the patient and the clinician’s personal views, life stories come together.
    • Where those thoughts collide is where the tension is.
    • That’s where the barrier is.
    • Once this tension is resolved it’s easier to go into action

    VI: Why bother about Stigma?

    Because:

    • Stigma is a feature and a cause of health problems. (Both clinician and patient)
    • Belief —> action.
    • i.e., In caregivers, emotional toll can be devastating – may lead to injury or illness of caregiver

    Because It Affects:

    • How we speak to psychiatric patients. (Human Value.)
    • Choices in our clinician-patient relationship.
    • Perceived quality of work experience.
    • “Me” and QOL (Quality of Life).

    Because It Engenders:

    • Social distance. (Comes from fear. But connection is healthy for “Me.”)
    • We are robbed of opportunities (Think – Agendas, Connection, etc.)
    • Avoidance. (Comes from belief of danger.)
    • Treatment skepticism (What is “recovery” anyway?)
    • We need to ask, “What are our treatment goals?” (Agenda)
    • Frustration and anger, negative emotions.

    Responsibility:

    • There’s an unequal level of power (Us v. patients/clients) – inherently increases our responsibility toward others to overcome this.
    • What about us?
    • Identify that. Then fear can become strength. Presence. Actions of discrimination change to actions of hope.

    VII:  Agendas

    • Part of our “belief systems.”
    • Exposing agendas, leads us toward action. 
    • Just like exposing prejudice leads to actions of hope.
    • Just like starting with Me leads to actions of accountability and presence.

    1.  Traditional agendas in the medical model:

    a.  Serve altruistically.

    • Saying we don’t have an agenda is grossly dishonest.
    • Maybe we are uncomfortable speaking about agendas because it creates tension with the classic view that practicing medicine is supposed to be Altruistic.  Altruism is just another “pressure.”
    • It’s a perfectionistic model. It’s false. To ally ourselves with it is a mistake. Brings discriminatory behaviors toward ourselves, driven by prejudices of shame.

    b.   Healing

    • The paradigm that never fits for psychiatry – cure, getting rid of something bad, not joining it and integrating it. (Presence.)
    • Can’t stop disease even with appropriate treatment – Treatment agenda changes to center around QOL experience rather than cure.
    • Caregivers in long-term care are not looking for recovery in their patients.

    c.  Serve patient (Service)

    2.  Traditional agendas of business

    • $, Profit

    3.  Quality of work experience

    • Not only do we get money, we get other stuff (biopsychosocial needs).  That affects how we talk to people.

    VII:  Solutions

    1.  Start with Me. Own that we have stigma: prejudice and discrimination.

    1.  Protest
    2.  Put own selves in the way of these treatments
    3.  Rely on evidence (biomedical conceptualization or education), not ideation (prejudice, emotions, religious causation…)
    4.  Pay more attention to emotions, senses, thoughts.
    5.  Reconsider your agendas e.g., Not necessarily recovery but rather QOL
    6.  Engender a culture of expectation (ex: We expect ourselves and each other to participate…)

    2. “Contact based” solutions.

    • The impact of experience and exposure
    • Best treatment is contact with the mentally ill vs. Educational approaches, which, although are helpful, are not as effective. Nor are psychotherapeutic approaches.
    • Maybe we overemphasize education in our culture and undervalue human relationships.
    • We see this anecdotally, but also notice that nearly all interventions studied, (multiple metanalysis, etc.,) used educational interventions primarily.

    3. Education (Still important and demonstrates degree of efficacy)

    4. Collaborate

    • Involve family

    5. Collaborate

    • Involve community, Partnerships with community resources

    Conclusion

    1. Start with at Me.
    2. More contact and exposure to people with mental illness.
    3. More education.
    4. More collaboration.

    Continue reading →

    by

    Why do I Keep Living? – Chronically Suicidal.

    trainwrecklife

    Carl D’Agostino is a retired high school history teacher. His interests include woodcarving and blogging. Cartoon blog at carldagostino.wordpress.com.   Cartoons published in book, “I know I Made You Smile, Volume I.”

    Marvin lived hard for years, used up his bank, his talents used up like putting a flame to his wick.  He was wired to live in the moment. Living that way, when he had gifts galore freely given, living was different than when those gifts were used, diminished, and broken. Marvin was smart enough to rationalize his way into a chronic suicidality thereafter.

    What is the point of living, after all? Marvin asked this question, answered it, and asked it again, to the point that it separated itself from Time and place. It is a question that is infinite anyhow.

    Sometimes Marvin, with this infinite question, this question that occupies the time of God, kings, and beggars, Marvin would sit in my office with this infinite question in his nicotine-stained and inked fingers, and he would in this bring together the infinite with the finite. I remembered that the whole point, the meaning of the infinite and finite, is increased in value by the other. Marvin, living in the moment, even now years after his coin was thus reduced, was living in the infinite.

    Why do I have to keep living? I just need someone to tell me it’s going to be ok if I die.

    Marvin, If you are looking for a doctor to help you die, you need to go somewhere else. I will always choose life.

    (It seemed like that “FYI” was in order.)

    “We” made a plan …that Marvin wasn’t entirely in agreement with. I told him he could not come back to my clinic if he wasn’t engaged in that plan.

    Marvin, we are just going to do what the data tells us will work. We don’t have to feel it or even believe it. We have the data at least.

    Every time I have ever seen Marvin, I took a hard look, memorized him, knowing this may be the last time. Setting boundaries with him was freaky. It felt like trying to hold broken glass. Would Marvin be back? If not, I knew I’d be hurt.

    The patient-doctor relationship is unique to each patient. It is unique to each doctor. For me, in my patient-doctor relationships, if it wasn’t for the hard grip I keep on the seat of my chair, I’d have too many of my patients in a big, but likely awkward, (and my Academy tells me, “Inappropriate”) hug.

    This flashed through my mind in fair warning again. I compromised, saying instead,

    You matter to me, Marvin.

    I think Marvin’s lip actually curled and his canines grew. And I quote,

    How can you say that? I just don’t get it.

    This was a moment of road’s diverging, 31 Flavors, coins in your hand in front of a mother-loaded vending machine. I could see philosophers, all over the now and then of the ages, slobbering like they were at a nudie bar.

    Once, when I called 911 on behalf of a patient who needed to go into the hospital for safety, the police person looked like that, bouncey even, on her toes. I had to check her feet to see if she was actually standing on a pedestal, she sermonized my poor patient so thoroughly. I think she was even eating a candy bar as she left my office, satisfied, (without my patient, by the way. Apparently she thought her tonic words had medicinal powers.)

    Marvin was fishing me. There were so many ways to lose with that question. He was hoping I’d flop around with straining gills sucking air for hours while he tugged on the hook.

    I’ve done that often enough, and will do it many more times. We can count on mistakes. What took me by surprise was, this time I did not.

    Well, I’d guess it has something to do with me and something to do with you.

    Yup. It surprised me. The surprise brought a wave of gratitude. “Thank you God.”

    And if you aren’t as surprised or grateful by that liner, I can only explain that it was right at the time. Marvin lost his handlebar lip curl. I lost my grip on the chair. Marvin’s still alive, (I know everyone’s worried about the “for now” part of that.) And our universe cares, finitely and infinitely.

    To the Marvin’s of the world, the wasted, the used, and the squandered, work your programs.

    To the lonely and distorted, to the ones who have tried to die, to you who don’t know why you keep living, follow what the data offers by way of direction.

    To you who may not get the same freely given gifts in this life that are now gone, you have good things coming.

    We choose to live with you, than without. We choose you again. We choose, every time, what Love will bring. Keep on.

    Questions: Have you ever asked yourself and/or others, “Why do I keep living?” What has your answer been? What is your answer now? For yourself. What would you tell your own Me?

    Self-care tip: …I think I waxed on and off enough already with that – smile.

    by

    Walking in on me after my massage.

    walking in on me

    I never realized, until this experience, that during a full body massage, one’s “girls” seem to swell and grow,… and no, the “girls” were not directly handled.

    What brought it to my attention was the door opening. That misty moment hung in the air – between the massage ending, the masseuse leaving the room, and the sheet coming off my body just before getting re-dressed. The salon’s hostess stood there and squeaked,

    Oh! I sorry!

    First reaction, should this happen to you, is to laugh a little. This is what you will do. “Ha-ha.” Then you will think, “What? Did I just laugh?! Oh. Those must be ‘comedy boobs.’ …Can I have my virginity back?”

    And then, “Is this covered in the insurance?” 

    I’m simply really glad it was not more than one lady who was at the door. It could have been a crowd. And I’m not implying any of them would have liked it either. (Boys, shush. You don’t have to remind us that a male’s response to a woman opening a door on him when he is naked is entirely different.)

    But I should have known this would happen. When I was being “roomed,” the hostess wandered her facility like she was on an easter egg hunt.

    Is this the place? No? Here?

    ‘Oops! I Sorry!‘

    How bout behind this door?

    Yep. You got that. She did walk in on someone else while trolling around with me. I was forewarned. Yet, did I leave? No. Rather, I deferred with, “She’s mortified. This is the bottom of her career, poor thing. She’ll never do that again! I’ll act like I didn’t notice.” Optimism rears its perky head.

    During our room-hunt, we came upon a large one with many cots. It appeared to be a community massage room.

    I’m all for community. Community, NAMI, connection – you’ve heard my spiel. But this was a different definition of “community.” I thought,

    These massages must be cheaper.

    Because who wouldn’t wonder, “Is that relaxing?!”

    Again. Males are different, I’m sure, but really. All you do is smell feet. Or maybe it’s like the swingers version of massage therapy. You might not walk out with the same wife.

    Finally roomed, stripped and prone, my masseuse came in. She had such “rolling-pin” strength in her one arm… “She must work out.” 

    Bone…still bone. Yup. You’re still on bone.

    My face went numb pressed into a doughnut, but I kept on. (I once got an award for being “The Most Tenacious.” I think I was like ten. How did they peg me?) My back was getting worked over, and I had faith, at some point, it would feel wonderful. Just like I thought no one would walk in on me and my restored, and more than, decolletage.

    I never actually saw her. My masseuse. She came in, did her rolling pin thing and was gone. No face-to-face. The experience was difficult to identify. What shall we name this?

    But you know the next part of the story. The door opened.  

    I don’t have a self-care tip to share today. It could be to go get a massage. Or not. I, with what looks like a more full than empty glass, thought this experience was too rich not to share with my friends.  Keep on.

    Question: When has your optimism v. pessimism steered you wrong!? Please spill. Please. Spill.