Sunday, March 18, 2007

Max & Me

I've been off the blog for a bit of housesitting at Dinah's B & B, caring for Max the Magnificent. I must say it's been rather nice being away at a place with no Seroquel discussions, no one accusing me of abusing my "god-like powers" (I think I missed that class in medical school) or going on about how abusive and useless my profession is in general to my patients.

I haven't missed that. Besides being complete and utter poppycock (insert your own international colloquialisms here) it is just rather poor manners to come to a blog purely to insult the bloggers. I enjoy a good conversation but not when it turns to accusatory harangues.

If you don't like psychiatry or psychiatrists you are free to choose another healing paradigm if you wish. If you disagree with the parens patriae role of psychiatry you may go the legislature and change the civil commitment or involuntary treatment laws. Heavens, there are a couple states here in the US that have even authorized physician-assisted suicide.

I'm caring for Max now because he's afflicted with the condition of being a dog. Now maybe being a dog isn't a disease, but he still needs someone to look out for him and I've enjoyed doing it. I scratch Max's butt because that's what he wants. He comes to me regularly for it and I do it even though there is no scientific evidence whatsever that it will be helpful or therapeutic and I can't guarantee there won't be side effects or unforeseen harm from it. I've never forced a butt-scratching on him. I do things to prevent him from coming from harm even if that sometimes frustrates his wishes. These are just the basics of what you do when you're responsible for caring for another living creature.

Being willing to care requires no apology.


Anonymous said...

Extremism rarely adds to a good debate. Insinuations like people would rather hurt their families and be thin than take an antipsychotic are just harmful as comments like psych meds are poison. There are no easy answers here, just a lot of difficult decisions. The few zingers not withstanding, I thought there were some well thought out arguments.

NeoNurseChic said...

Well - I'm sorry :( I thought some of the comments were a little on the harsh side - especially regarding forensic psychiatrists. I don't think a blanket statement can be made (as stated in the above comment by anonymous) that people who were commenting on not wanting to take antipsychotics because of weight gain that these people would rather hurt their families to stay thin. What I took from the other commenter was that she had struggled with weight her entire life, and it was a large part of the source of her depression - so taking a med that makes her gain even more weight would not be helping things. I don't think we can assume that means she would rather hurt her family - or that she even is hurting them. Rarely can we glean from one statement the entire story. And it pains me to see that someone couldn't understand that a person wouldn't want to take an antipsychotic for the weight gain side effect if weight is largely why they are depressed - and that it is not just "vanity." But what do I know...

Dogs are great, aren't they? I played with my dog today - a big black lab named Jake. He's 13 years old and definitely aging...which breaks my heart, but I can still see the youth in him - he gets very excited, and he's very happy. :)

When I was in high school, I had an extremely rough time - everywhere I turned, things were a mess. But my dog - he was my best friend. I used to stay up really late to do my homework, and I didn't have a computer of my own - our family comptuer was in my parents' room, and I didn't want to keep them up - so I would use my dad's computer in the basement. When things got to be too much, I'd go up to the kitchen where Jake was sleeping, and I'd lay down on the floor next to him and put my head on his side. Sometimes he'd breathe a "heavy sigh" - which let out exactly how I was feeling. He was my best friend......

The reason I often post so many disclaimers on things I write is because on the internet, people forget that others are also human. They can't see them - so they often just blindly lash out - in ways that they wouldn't speak to someone otherwise. I sometimes wonder if it's that they feel the internet is a place where they can lash out and blow off their aggression on other people - while throwing it at another human, but with the disconnect that the person on the receiving end has feelings and might feel hurt by it. I get upset by personal attacks on the internet - as if they were slung at me in person. Even though I try to have thick skin and think about it rationally most of the time - the problem is with the other person, and not with me.

Carrie :)

Anonymous said...

Hmmm maybe a trial of butt scratching therapy for treatment resistant psych patients would worth a shot...

Dinah said...

Thank you again for taking care of Max and he's thrilled to be on the blog!

And thank you for the Post ranting back at the anti-psychiatry crew, I was just sort of steaming and avoiding thinking about it.

I will write a post soon on Side Effects.

The issue of insulting psychiatry on the blog of 3 mainstream psychiatrists isn't one of people talking about their individual experiences with meds or even their fears of possible side effects, it's the comments about how psychiatry forces treatment upon its patients and the implications that the meds we prescribe do more harm than good (and the further, but more subtle implication, that we are well aware of this but for some unclear agenda--money? power? sleeping with the drug reps?-- continue to prescribe medications that we know will disfigure and kill people.) Not to belittle anyone who has had a bad reaction to a medication, nor to say I don't believe they happen, but the harangue against psychiatry, rather than a more reasoned request for awareness that every med doesn't effect ever person in the same way and a call to monitor more closely and simply be aware of unpredictable bad reactions, belittles those who have been helped by the treatments, and funny but I hear an awful lot of people asking for, then saying they were helped by, those suicide-inducing (forgive the sarcasm here) SSRI's.

Just my post-flight thoughts. It's cold here.

Anonymous said...

Sorry if the three shrinks see my attempt to raise questions of ethics and responsibility (that are on topic to the post) as 'harangues' and 'abusive'.

Particular apologies to clinkshrink for raising my personal experiences with unethical Australian forensic psychiatrists in a manner that caused her to think I was talking about her. I am sure you would never use risk assessment tools like HCR-20 (with its false positive rate of 5:1) to endanger the parole of those in your charge.

Just for the record - I do not hate psychiatrists and am trained in psychology myself. In fact some of the people I respect the most are the Australian psychiatrists I know who are prepared to buck the propaganda and stick their professional necks out to try to bring the sort of evidence considered by the FDA and the the MHRA when they black boxed or restricted SSRI prescriptions to a wider consumer audience.

And if I was looking for alternatives to corporate psychiatry, I would go to Trieste, not fairyland. I'm into evidence based medicine remember.

But I must admit that I have no respect at all for other psychiatrists who try to panic consumers back onto potentially dangerous drugs with bogus statements attempting to link well considered warnings to tragic outcomes for young people.
That's abusing both the evidence and the dead.

But I guess I know when my criticism has gone beyond any hope of being constructive. So I'm outta here ...

Sarebear said...

I've been wishing a virtual hug to you Clinkshrink. I felt for you as I read some (couldn't keep going through to the end of all that.)

Nothing like a good butt-scratching to soothe you. Er, soothe the dog.

(Insert giggle here).

Anonymous said...

Dr. A, thanks!

Alison: I never said sex with strangers was bad for YOU! I had used it as an example of driven behaviors that people persist in despite bad consequences-- this from my experience of hearing folks talk about their continued engagement in such behaviors despite a history of negative consequences (I have patients who have been subjected to violence, gotten STDs, wake up feeling horrible about themselves, or people who abuse drugs despite bad psychotic trips and the downfall of their lives). It was meant as a quicky example, not a value judgement, sorry if it came off that way.

Sara--thank you for the support on the guilty-mom thing. We've agreed on some added video limits here, people would fry me if they knew how much I'm still letting him play (weekends only). Great kid who has been forced by parents into many interesting experiences. Truthfully, I think he'd rather play video games than hike the Grand Canyon, snorkle on the Coral Reef in Belize or stare at the Mona Lisa (he's done all those things).

Anonymous said...

Your patients are not your pets. It is disturbing to read a psychiatrist comparing caring for psychiatric patients to caring for a dog, even if the comparison is being made in jest.

You do wield considerable in power in your role as a psychiatrist. Your fidiciary responsibility should be exercised with the utmost concern and respect for your patients. Equating them with dogs is demeaning and dehumanizing.

Anonymous said...

To Anon--
My read on Clink's subtext was that she was frustrated by the blog, found the simplicity of Max a relief. I saw nothing that compared caring for Max (who is a very sweet dog) to caring for patients. She did make a comment about being relieved to be away from Seroquel discussions-- this was in reference to my blog post, I'm sure, as I believe that Seroquel is not formulary in the jails (too expensive) and ClinkShrink is therefore not having philosophical discussions about this medication with her patients.

Since I know both Clink and Roy in Real Life (is there such a thing anymore)...I can assure you that they are both rather tempered shrinks who would never treat any one, be it a patient, a friend, my dog, a waiter, a co-worker, in a disrespectful or demeaning way.

It's a blog, we are allowed to rant a little.

Anonymous said...

"I saw nothing that compared caring for Max (who is a very sweet dog) to caring for patients."

Scratching the dog's behind is a very thinly veiled allusion to drugging patients, complete with comments about scientific evidence, side effects, therapeutic benefits, use of force.

Of course it is your blog and you can rant all you like. But you are blogging about psychiatry, as psychiatrists, in a forum available to and read by the public. Your attitudes towards and descriptions of your patients has an effect on the public's perceptions of them.

Even in the blogging world, and despite your anonymity, as doctors you have a responsibility towards your patients to not depict them or allude to them in ways that lessen their humanity.

I think this post very clearly compares caring for a dog as similar to caring for psychiatric patients.

NeoNurseChic said...

I see absolutely nothing about this post comparing psychiatric patients to a dog. What I see is talking about caring - from someone who cares very very much for her patients, but has been attacked and at times rather rudely, on a previous post(s) - and so is talking about how at least when she's caring for a dog (and each of those comparison points that were just raised were simply sort of sarcastically building on all of the ways she was attacked in previous posts of late), the dog still loves and respects her - she's still a caring person. Sometimes caring for animals is the only way we avoid being constantly attacked by the PC police and others who have nothing but negative things to say. At least this was my take on it.

This is a blog - blogs are not supposed to be professional - they are, by nature, informal personal writings. Some people make them more formal than others, but for the most part, they are places to share stories, rant, share the other side of what it is like to work in health care for those of us who blog about health care. You think this post about how she cared for Dinah's dog is should go read around the other med blogs out there and see some of the things doctors say about patients and truly mean it!

It's a personal website - they're allowed to rant/vent/whatever if they want to. If you don't like it, you have no obligation to read it!

This is turning in some ways into what neonatal doc's blog became once a certain group of parents started analyzing every word he typed and basically attacking every post - even when he tried to drop one subject and move onto something else. There was always some dissenter - and if it wasn't someone who flat out disagreed based on priciple, it was someone who took each word literally and then told him how immoral they thought he was. Not all of his posters were doing this - but his blog never used to have any of that, and of late, he's had quite a bit more of this.

But I guess when a blog gets popular, people feel more like it's "their" site - and they can say or do as they please.

Dinah, Clink, Roy - sorry to rant on your blog here - but I'm sick of the negativity. Half the problem on the other thread was that each and every word being typed was being scrutinized and taken literally - so of course if you take someone's writing and make it 100% literal, you can find ways to disagree with them and paint them to be something they are not. I think all 3 of you are very kind, caring professionals who would never belittle anybody.....

This too, shall pass... ;)

Take care!
Carrie :)

Anonymous said...

"I see absolutely nothing about this post comparing psychiatric patients to a dog... (and each of those comparison points that were just raised were simply sort of sarcastically building on all of the ways she was attacked in previous posts of late)"

Huh? You completely contradict yourself, stating that there is absolutely no comparison being made but then acknowledge that the "comparison points" are simply sarcasm. It is sarcasm that draws parallels between caring for a DOG and treating people who are mentally ill.

"you should go read around the other med blogs out there and see some of the things doctors say about patients and truly mean it!"

While it is terribly troubling when any doctors make disparaging remarks about their patients, I find it particularly concerning when psychiatrists do it because there is such stigma attached to being mentally ill. I would hope the doctors entrusted to care for psychiatric patients would not do anything to perpetuate that prejudice.

While blogs are not professional endeavours, these doctors identify themselves as physicians and therefore should continue to hold themselves to a high standard of courtesy and concern for the people they have taken an oath to care for. That many do not is a shame, to the entire profession.

ClinkShrink said...


Anonymous, the problem with analogies for the caretaking relationship is that it is very difficult to find ones that couldn't be interpreted as patronizing. I purposely didn't use the parent-child analogy (even though that is the historical origin of parens patriae) because I knew that example might offend some readers. I chose a non-human example because that most clearly illustrates where I think the responsibility lies in a caretaking relationship---with the caretaker. It was not meant to be offensive or demeaning. I used the technique of exaggeration to make a point about the ethical responsibilities of caretakers. Nevertheless, your point is well-taken and from now on I will stick to using my Car Momma analogy.

To SareBear, Alison and Carrie: Thank you for your kind words; that was sweet.

Dinah: I see why abf loves you. Sorry about the burned popcorn. The dishes in the dishwasher are clean.

Anonymous said...

"I used the technique of exaggeration to make a point about the ethical responsibilities of caretakers. Nevertheless, your point is well-taken and from now on I will stick to using my Car Momma analogy."

Thank you.

I have truly enjoyed reading your blog but was very troubled by this one post. I was not commenting to flame you but to try to point out what I feel is a valid concern about the way the mentally ill are discussed.

I appreciate the difficulties in finding neutral analogies. As a psychiatric patient myself, I found being compared to a dog distressing. I am a person who is struggling and do not want to be viewed as an animal.

Roy said...

Anon- I see your point, but I think you misinterpreted Clink's intent. Please try to cut people some slack and assume good intent.

Speaking of good intent, I have a bad pun...

"Car Momma": what Buddhists with palilalia try to improve.

Roy said...
This comment has been removed by the author.
jcat said...

Shit. I wrote a huge long reply and Blogger ate it. So now I have to get angry all over again.

It's worth it.

1. Clink...I'm glad you are back from looking after Max. When he and you have finished discussing the analogies between dogs and you think you could come scratch that spot just above my tail? You know, the one us dogs can never quite reach...

2.Dinah, I know of course that you deliberately posted something really controversial and then went away. Please do it again - there were a few of us across the world that (up till tonight) were enjoying the debate.

3. Michael, chill bro. As Roy said, even when you are posting completely opposing opinions, you are doing it in a well thought out way with good references.

4. Anon, #1, #2 and #3. Get fucked. I apologise to the 3Shrinks for the tone, but you really don't justify much more of a response than that. I'm gonna give you one though, seeing as the first 'anon' comment here is pretty much as direct an attack on what I said under the seroquel post as an 'anon' can ever be.

It wasn't an insinuation that people would rather hurt their families and be thin than take an atypical A/P. It was a direct and straightforward statement.

You don't know my DuckBuddy.

Obviously. If you did you wouldn't post such feeble and inane comments.

You don't know my DuckBuddy.

You don't know that she is the sweetest, funniest, most superbly intelligent, well-read, sexiest, smartest woman I have ever known. You've never heard her laugh. You've never heard her argue rings around anyone who has ever posted here, including all three shrinks, and the best and brightest world wide. You have never seen her talking kak about every subject under the sun, including what utter whack-jobs we both are.
You've never seen her holding down a seriously intellectual job in a major listed company.

You have never seen her, short and skinny as she is, leaning against her 6'2" husband and holding him close. Or picking up her gorgeous little blonde 2 year old fairy daughter.

You probably won't get to see most of those things I mention even if you know her very well.

Because my DuckBuddy is psychotic.

And because some asshole out there has convinced her that even though she is almost anorexic already, atypical anti-psychotics will make her fat.

So instead, she is gradually losing her husband, and her daughter. She is losing a mother who loves her, and friends who love her too. She has lost the ability to hold that job, and the degree she had almost completed. She is losing the psychiatrist that she adores, because she won't take the drugs he recommends, and because he cares too much about her to watch her just descend into madness without being able to help her.

She is not just 'hurting' her family and being thin. She is losing everything she cares about.

She just doesn't realise it, because some dildobrain told her that atypical a/p's will make her fat.

And so...she won't take them.

Sometimes the nice thing about being psychotic is that you don't know that you are. Which is cool, if it means that you don't know what you are stuffing up, and you don't see the correlation between your illness and what you are throwing away.


My DB is not THAT psychotic. She is close enough to normal that she knows what she is losing. Just not close enough to stop it from happening.

Because, God forbid, if she took an atypical anti-psychotic, she might get fat....

Like I said - not an insinuation. A straight out statement. Some halfbrain out there has jumped up and down so much about atypical A/Ps making you fat that they kind of forgot about the purpose of an A/P in the first place.


I'm sure that when my DB's daughter eventually grows up without ever knowing what a sweet and wonderful mother she had, she will appreciate that at least her mom was always skinny in the asylum pictures. Because thanks to the hype, that is where my Duckling is heading.

And I am not going to forgive those lamebrains easily. They deserve a hell of a lot more than non-forgiving from someone like me, who is, after all, just another loser psych patient.

Wanna respond, Anonymous? Pick a nick, establish a history of thoughtful comments. And go ahead. I look forward to hearing from you.


P.S Michael, I popped into the centre for literally two minutes, today. No Meerie contact, but the closest relative to a one - a mongoose. All of about a week old, and just as cute.And the little bugger rolled over from being half asleep and cuddly - and bit the girl who was holding him! He's on his way to Oz via a long-range drop kick....

Midwife with a Knife said...

Maybe Max finds it insulting for his dogginess to be considered an "affliction". I think my cats feel that their kittiness is not an affliction but rather a gift. ;)

(I'm totally kidding, and this is all purely tounge in cheek)

alwaysthegoodgirl said...

ClinkShrink, your post was very nicely put.

Dinah said...

Alison-- Sorry I stumbled onto a sensitive topic. The blog is my place to rant, and this was a quicky example I thought of, I tend to write the posts quickly and not necessarily think out the full repercussions. I re-read the post, it was in my discomfort with Uncertainty post-- and I questioned if it was wrong that I continue to treat patients with self-destructive behaviors on their own terms. I do. Probably a more clear issue with drug abuse. Probably when people have sex with strangers and it ISN'T a problem, they don't bring it to the table in therapy, so I hear about the select cases where it IS a problem. No one has ever gotten upset with my response or has seemed to feel judged or chastised. Either my example or the way I worded it wasn't the best. I hope that helps.

Anonymous said...

Dinah says the blog is her place to rant. I guess everyone needs to rant now and then. When you rant and publish it all in a blog for everyone to see, you can hardly be surprised at comments that rant back. If you are, then diaries are a better option. I wonder, and it's just idle curiosity, how your patients feel reading so many of your personal thoughts/opinions. If this was my doc's blog, I would read it and then be very guarded about what I said to her, wondering if she was ranting silently to herself while I was speaking. You are not anonymous, as has already been pointed out. It's like I might be curious, but I really don't want to know all that much about my shrink. So, is this your place to rant or is it a place to inform the public or is this a foray into the entertainment business? It is your blog, so rant back, by all means.

Dinah said...

I'm not aware that any of my patients read Shrink Rap, but I write with them over my shoulder always. And having on my name on it takes away any temptation to forget that. Not a diary-- if I had one, it would be a passworded Word document, not on line, not even with a pseudonym. More a place to exchange ideas about psychiatry, and I believe my patients are all aware that I'm a mainstream psychiatrist, trained in a pretty conventional program.
Oh, I think you've inspired my next blog post....!

Anonymous said...

The thing is that if I was one of your patients, I would not tell you that I was reading your blog. You can say that I must not have a very open relationship with my shrink if I can say that. That's not the way it is really.But, I have had a number of experiences with other shrinks who shared way too much personal info and crossed over the boundaries so that now I really, really like to keep this one at comfortable (to me ) distance. If I saw her in the supermarket I think I would leave my cart and duck out of the store.
I wouldn't want to see her writing things that make her sound kind of sarcastic becasue I would assume that she was really dying to say something sarcastic to me but was holding it in, trying to stay all professional. I am not saying you aren't justified in feeling exasperated or what not, reading some of the comments you get to your posts, but when it comes through (at least to me) it makes me very uncomfortable about even looking my shrink in the face.
As though I don't really want her to yell at me. I know she must yell. At her kids, sometimes, whatever. I don't figure she is immune to anything that the rest of the world goes through. I just wouldn't want to know about it in great detail. I don't want to know when she is all angsty etc.

jcat said...

Gee ssitoc, have you explored the original Freudian analysis yet, the kind where you lie on a couch and don't even make eye contact with your t-doc? And you both pretend that absolutely nothing in his/her life or yours is related to how you feel? Sounds as if you might be comfortable with that.

I WANT to engage my doc in discussion. I want him to tell me if he thinks my choices suck, if he has ideas about what I think.

I want him to treat me like a real person, not to just regard me as the walking host for my illness.

And if we don't talk, even if it might be crossing boundaries, how do I ever show him that I could be more than the loser I currently am?

If he had a blog, I'd love it. Although I dunno if I'd tell him the nic I would use to comment!!

Anonymous said...

Didn't say anything like what you are implying ,jcat. Shrink can talk all she wants about her ideas/opinions re: whatever it is we discuss. I merely said I don't want to know her PERSONAL stuff. Don't see how knowing how she votes or if she is worried about her own kid or whether she has had an abortion or not is relevant or would be helpful to me.
Of course I want to be treated like a real person, within the confines of the professional nature of the relationship. The opposite of the original Freudian blank screen is not the doc letting it all hang out.
I was commenting on how I feel, not trying to insult anyone. You don't have to agree but it would be nice if you didn't insult me in the process. Of course, you don't have to agree with that either.

Anonymous said...

Something about Jcat's post made me think... How often does it happen that a patient becomes infatuated with his/her shrink?

Not drawing direct parallels, btw, Jcat!

jcat said...

AP - no problem. Answer? Very often. In my case, totally.

Helps in one way - if nothing else, I don't want to disappoint him. Makes me extra compliant with my meds, makes me hang on just that bit harder.

Doesn't affect how much I believe in learning for myself about what I'm taking, or what I'm willing to endure as a side-effect.

I'd do that anyway.

Anonymous said...

Jcat: So aside from yourself, you have come across others who "fall" for their shrinks?

I know you pointed out some of the good points it has for you, but I can't help thinking that it must have many drawbacks in terms of one's treatment. I mean, for one, how do you keep a clear head while you are talking to him? (I presume you are a her and your shrink is a guy...!)

And while its all very well to be willing to endure a side effect in the name of recovery (which I agree with), would you still feel 100% comfortable discussing the side effects with him? Even constipation? And sudden onset breastmilk? Haha!

Do you know what I am getting at?

jcat said...

AP - yes, a few. I don't know how they handle it within the relationship, so anything I say is based purely on me.

With him, it's not only the whole therapeutic bond thing, it's just that he is virtually my ideal man. Except for being 5 inches too short! But it's mostly that he is super smart, cynical, explores information at a tangent etc. And it took about 5 mins - so I don't think transference has much to do with it.

How I've handled it was to tell him - by email, of course :-)) - and leave it at that. For me, as I mentioned, the result is that it has, at times, made me try just a bit harder to not go out and kill myself. Or to stick with a med a bit longer. Keeping a clear head is pretty easy - no colder bucket of water to dump on yourself than reminding yourself that the only reason you see him at all is because you are a psycho loser.

As far as some of the more unpleasant side effects go, I am a real wuss anyway. Unless it was really really bad, I wouldn't tell any doctor that the meds were making me constipated, or the reverse. The breast milk one has come up with him though - he was quite cool asking about it. I just told him that if it ever happened he would be the first to know about it because I'd be rampaging through his reception yelling about being a human cow!

I know it's off the topic (and crude), but want to share this one with you.
The wildlife rehab centre I work for is mostly staffed by women, but we get the occasional male volunteer - and at the time, Dave had only been there for a few days. We were in the kitchen preparing food and the subject of milk came up, as in what kind of formula would be ideal for some small mammal. So my boss gets onto this rant about mother's milk is always better, and that humans are the only species who go to a lot of effort to wean our young off our own milk, and onto that of another species, cows. There's a moment of quiet, and Dave says from the corner 'I don't think that's so bad. I'd rather not have my mother's tit in my morning coffee!'