What is your daytime energy like? Alertness, attention, and memory? Do you sleep well in relation to this?
Please tell your story. Keep on.
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?”
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.
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.
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.
Self-care Tip: Answer the question and start over.
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!)
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
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?
I: Clinician/Caregiver barriers
II: Patient barriers
III: Understand Personal Biases – Likes and dislikes
IV: Define Stigma
1. Prejudice – Attitudes, feelings/emotions (Amygdala)
2. Discrimination – attitudes lead to actions
What are our fears? Fears are an emotion and/or attitude…
Caregiver stigma – “self-stigma” comes when we internalize public attitudes and turn it onto ourselves
2. Discrimination – How we act on those prejudices.
Who has Stigma?
Everyone. It is in our community, including we who serve and are involved in mental healthcare services.
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.)
V: What are the barriers to talking with psychiatric patients?
VI: Why bother about Stigma?
Because It Affects:
Because It Engenders:
1. Traditional agendas in the medical model:
a. Serve altruistically.
c. Serve patient (Service)
2. Traditional agendas of business
3. Quality of work experience
1. Start with Me. Own that we have stigma: prejudice and discrimination.
2. “Contact based” solutions.
3. Education (Still important and demonstrates degree of efficacy)
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.