Sunday, September 09, 2007

Are You My Patient?

I'm actually blogging (or starting to blog) from our hotel room at the beach, waiting for the kid to wake up so we can check out and catch some final rays and junk food.
It's our traditional weekend-after-Labor-Day away with the Camel Family, a final sweet kiss goodbye to summer. With many thanks to ClinkShrink for moving in with Max and the teenager who couldn't miss practice.

So Fa
t Doctor has up a great (aren't they all?) post about patients who check in to the hospital with abdominal pain and then refuse either the work up or the necessary intervention. There's the guy with acute appendicitis who won't allow surgery ....and if that hot appendix ruptures, the mortality rates are quite high, even I remember that. I read it and wondered, just like Fat Doctor, if you don't want treatment, why go to a hospital? Okay, okay, I'm being harsh, maybe AppyGuy is only refusing surgery and had hoped there was another option for treatment-- maybe he's taking antibiotics and this will help and maybe he won't rupture and will get better. But to refuse a non-invasive work-up? Or to die rather than have a routine procedure?

So here's another good thing about being a psychiatrist: patients rarely die (and even more rarely from their psychiatric disorders) and we Never send patients out thinking there's is the Probability they will die from their psychiatric symptoms. I'm not saying we always get it right...sometimes patients hide their symptoms, sometimes they talk about being suicidal so often that we lose the ability to distinguish when it becomes imminent, but if we think the patient is in danger from their symptoms, we hospitalize them, either voluntarily or involuntarily.

I work in a private practice and in two clinics; I haven't set foot in an Emergency Room for years. It's been a really long time since I've hospitalized anyone involuntarily and I'm happy about this. While in psychiatry, there are moments when it's absolutely necessary, for the most part, I don't like making decisions for other people.

In outpatient practice, people often have very strong opinions about what kind of treatment they want when they walk through the door. It's not uncommon for me to tell people on the phone before I see them that I don't provide the treatment they're looking for and they'd be better served by someone else (--there are lots of psychiatrists in Baltimore, if someone is looking for a doc to prescribe high-dose Xanax, I'm just not it). Other people are pretty set on what kind of treatment they don't want.

Mostly, I try to work with people, I try to give them what they want or help them understand why what they want isn't the right thing to want. So Prozac helped your friend and you'd like to try that? I might think Lexapro is a better choice, and I'll tell them why, and if they still want Prozac, well, perhaps I let that choice be theirs. So Prozac helped your friend and you'd like to try that? Oh, but you have Bipolar Disorder, something totally different than your friend has, and Prozac may well destabilize you, throw you into a dangerous manic episode, shorten your cycle length, and worsen your overall prognosis: I think we should try a mood stabilizer first and only after that's on board should we even think about adding Prozac or any other antidepressant. You get the idea. And yes, I'll tell you why I asked what your favorite SSRI is soon, but in the meantime, if you haven't voted on our sidebar poll, please do.

Sometimes a patient tells me they won't take Drug X. Ever. And if I think Drug X offers the best chance of relief or recovery, I persist in telling them this. My kids can assure you that I'm very good at repeating myself to the point of nagging. Mostly, I convince people to at least try what I think might work best, but I have never, ever, said to a patient, "If you won't take Drug X, I won't treat you." That's just not what this is about.

Thinking about the Fat Doctor dilemma, there is a psychiatric correlate. Mostly I'm either able to talk patients into trying it my way, or I'm able to achieve some level of comfort while they do it their way. Every now and then I have a patient who is really suffering (or is behaving in a way that causes others to suffer) and who repeatedly foils any shot at recovery. They're miserable, and yet they refuse any treatment suggestions--either they argue with every suggestion I make, or they simply don't do it. The don't get blood levels, they won't try another medication, they won't raise the dose of the old medication or even take the old medication that worked for them the last 14 times, they won't try any behavioral changes (regular sleep hours, exercise, stop the substances, give up the boyfriend who beats you), they won't allow me to communicate with crucial significant others in their lives, they call all the shots, leave me standing there feeling helpless. And before you click on the comment button to tell us about the one or two times you didn't do what your doc suggested, that's not what I'm talking about-- I'm talking about the person who comes, pays, says they want help, but doesn't follow ANY recommendations. I'm sometimes left to point out this dynamic and say "Are you my patient?"


ClinkShrink said...

I might quibble with one point where you say: "So here's another good thing about being a psychiatrist: patients rarely die (and even more rarely from their psychiatric disorders) and we Never send patients out thinking there's is the Probability they will die from their psychiatric symptoms."

In my post The CIC ICU I blogged about sending psychiatric patients out to the emergency room from the jail because of concern they could die from their symptoms.

Other than that, welcome back from the beach. Max and Boy were both well-behaved. Max needs more love and attention; being slathered with it for one weekend is obviously not enough for him.

Sarebear said...

Well, shoot.

In a way, you're the patient, there. Pun-wise, you've gotta have a lotta patient(ce) to continue to see such patients.

Say that ten times fast. That, that, thatThatthatThat . . .hee hee.

Anyway. I think continuing to try to work with the patient in these situations is commendable, especially as I might guess that others would not. There just may come a day, life situation, concatenance (I hope I've used that right!) of events, that might trigger something inside, like the chain on a lightbulb in a bare room being pulled, and all of a sudden they can see the, or some of (depending on the wattage of the bulb/degree of "aha" moment) the problematic stuff, in this analogy, like gouged walls, graffiti sprayed willy nilly, rusty junk here and there that could cause great harm if a sharp edge comes up against 'em.

Dont'cha just love my analogies? Lo.

I can say this, from my own experience; you NEVER know when something you say, when even not the words, or not just the words, but HOW you said them, the care you take with your patients, the way and nature of how you continue to (as well as content of), work with them, recommending what you think are efficacious options for them, . . . . you never know when something will resonte years or decades down the line.

Hopefully, for such confabulated but certainly representative of some presentations of human nature, patients, it won't be decades, but . . .

In early teenagerhood, when I became more . . . well, not grown up, but I began to think of myself in the world, and how (usually painfully) I interacted, fit in (or not, usually) with, the world and the ways and process of the world, society, culture, etc . . . . . I had nary a CLUE that the problems I became aware of in myself, were anything other than a flaw of self, a flaw of my soul, a flaw of my me-ness. This, plus raging hormones that caused all sorts of the "usual" 13 yo female adolescent internal torment, and externally shown types too, all mixed up together . . . . I CRINGE at how I was . . . . .

The thing is, though, there was an adult or two, mostly just one, that exercised MUCH patience with me, in a world in which I was completely isolated and alone, in a world in which I pushed far, far against and away from my parents/family (not that there was a relationship of quality there to begin with, anyway).

There have been things these people said, that I didn't "get", or take in, until years or decades later, when all of a sudden I'd "get it". Of course, I was definitely not equipped then to understand many of the basic ways and behaviors of human socialization(s), but they patiently accepted me no matter how cringe-worthy my behavior and selfness and interactions and feelings were/was.

Adults are a different story than a 13 yo girl who is in mental, hormonal, emotional, and social anguish, but add mental illnesses and disorders on top of that (with the painfully tragic yet how could I, or my parents really, have known (especially since I did NOT open myself up to them about anything) issue of thinking that I, myself, was the flaw); yet that supreme, basic, human RIGHT of being accepted as a fellow person, who may be difficult, and yet is still worth and (this next is hard for me to say) deserving of patient, repeated and ongoing effort to work with, or interact with . . . .

I cringe at how I was then (hell, I cringe at how I am NOW), and yet I thank God for the miracle that that person was in my life. I would have died, I think, without that, because I would never have had any idea that I was tolerable, or even likable or acceptable.

Which, is far from the point at hand, in many ways, and far in some ways from recalcitrant adult patients.

I started out trying to say hey, I think it's commendable that you do this, that you keep going with such patients, that you do not give up on them, and that, from a somewhat different context, but still relatable, that you just never know when such seemingly fruitless, as well as being repetitive efforts might, one day, bear fruit.

Corny though it sounds, how sweet that fruit is, when it is borne.

I think you, in your work, are potentially sowing quite a few future fields of "aha" moments, not to idealize you or anything.

Sorry to ramble, and maybe get too much in to my own thing. Obviously I identify on a deep level with issues of people having heart enough to stick with someone, or some situation, or whatnot.

Since I don't know where you can get an "aha" fruit plant for your office, maybe you can stash away a couple boxes of Kudos granola bars, and on difficult days, or ANY day, pull one or more out because you never know when you've had a sort of "XR" time-release effect (akin to all those XR versions of meds) in someone's life.

Sarebear said...

I think I was looking for "concatenation".


Dang it, now I want a granola bar.

Anonymous said...

In a sense it goes like this, at least for me: I want help but I don't know how to let you (meaning anyone) help me. I don't like myself very well and I am not sure I trust you (meaning anyone) terribly much. Give me a good reason to trust you. I still won't be able to, not for a very long time. Even then I will not know if it was a good or bad idea (to trust) and so I will waver.
I know the drugs helped before but I want not to need them. I want not to be weak. Please don't tell me that if I had diabetes it would not be a sign of weakness to take drugs and we would not be having this conversation.
I must never need anything or appear weak. I cannot bear to give in, and allowing someone or some drug to help feels too much like giving in in some fight for my life. I want help but I cannot cede control and anything you (meaning anyone)tell, advise me to do makes me feel as though I am losing that control. Sometimes I will listen to you but that depends upon many factors. Examples include your (meaning anyone's) tone of voice, the way you look at me, if you make it seem more like it is my decision even though I know that if things get out of hand you will take away my power to make decisions and you will put me away.I will listen to you when it is clear that it has come down to that. When it goes that far I will hardly care anymore. I will listen to you if you do not make it seem that you need me to listen to you, which is different from you not caring at all.I will listen to you when it feels like you are making a suggestion. I will listen to you when you acknowledge that what you are suggesting is not such an easy thing and that I can stop when I feel that I have to. And I will stop because I cannot bear the side effects in the long term. Even though I know that I will feel better, I cannot listen to someone who tells me I must take something forever. I will listen to you when you understand that. You may not agree with my decision because it may seem more black and white to you: take drugs and stay sane, don't and all hell breaks loose.It is not so black and white to me. I will take them when I know I am about to die. I will stop taking them when it feels as though they are killing me.
I do not refuse to listen to you or to change the things you see as wrong with my life because I am playing a game with you. When you understand the reasons for the things that I do or do not do ,and when you help me to understand those reasons better I may start listening to you more. You cannot understand me without my input and I really cannot understand me without yours. Hopefully, we are both trying to understand me. My self needs a lot of work. A lot of work takes time. It takes patience, yours and mine. It is frightening. It doesn't feel very good. You may get frustrated. Believe me, I will.
I am not convinced that it can be done, that I can get out of this mess. You put me in an impossible situation. Okay, not you. I have put myself in an impossible situation, coming to see you. All my life people told me what to do, told me who I was, what I was allowed to think or feel or do. I was allowed to feel not very much at all. I was allowed to say only what was in the handbook of allowable things to say. I was not allowed to ask questions. I was not allowed to say no. My body and mind were not off limits, someone else owned them. (No I was not in a cult.)I am not sure that I have a soul. Maybe I did once but not now.Please excuse me while I sort all this out. I will be back in a few decades.
I know that your job is difficult. I am glad that I do not have your job. While I am sure that you have faced difficulties and tragedy in your life, (who hasn't?) I doubt that you would want to trade places with me.I could be wrong.
I know you really do not understand why I just do not listen . If only I would listen to you everything would sort itself out.(?) There are times that I would like to just listen to you but it isn't about to happen.
It is the ultimate Catch -22.

I would like to point out that patients do die from psychiatric disorders and take what Clink said a step further. Suicide is a big risk in certain disorders. I have known several who have succeeded.

Alison Cummins said...

I admit, I am also curious about the statement that patients rarely die from psychiatric disorders.

Strictly speaking, untreated mania can kill all by itself - physiologically. But I suppose that you wouldn't consider anyone with untreated mania to be a patient? By definition, being untreated, they are not going to upset a treating physician?

In a more general way, bipolar disorder, depression, schizophrenia and substance abuse commonly lead to death through suicide, even when treated.

"At present, suicide is the number one cause of premature death among schizophrenics, with 10 to 13 percent killing themselves."

"Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD.5 The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder."

In a more indirect way, schizophrenia shortens lives by damaging individuals' abilities to care for themselves.

While I suppose it is rare that you are face-to-face with someone who will die within the next ten minutes without IM Zoloft Stat! that doesn't mean your patients' illnesses are not lethal.

RE people refusing treatment: some people may want help but not know how to accept it, as sarebear and anonymous describe so eloquently. But from personal experience, I absolutely believe that some people are completely unreasonable and want someone to do something about a problem which is entirely within their own control.

A dog trainer I know of describes being called to help paper-train an apartment-dwelling dog who was being stubbornly difficult. It turns out that the dog's paper was in the kitchen, but the kitchen door was kept closed at all times to keep food odour out of the apartment. The poor dog would scratch at the kitchen door to be let in, then pee in front of the door, clearly demonstrating that she knew where to go. The dog trainer tried to work through alternative solutions, but all were rejected. Installing a pet door in the kitchen door was out because it was a rented apartment. Paper in the bathroom was not a possibility because that's where the boa constrictor lived. Etc, etc. The owner had decided that the solution was to have a professional train the dog, and she would hear of no other.

I'd hate to be this woman's dog, but I'd also hate to be her psychiatrist.

Jayme said...
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Dinah said...

Oh gosh, people die of psychiatric disorders all the time, suicide is one of the more common causes of death, and as has been pointed out, people don't take reasonable care of themselves during episodes of illness, and in the throws of a psychiatric episode people do dangerous things all the time and sometimes they die.

Still, in the course of your usual day as a psychiatrist, no one dies. And while suicide is a common cause of death, many psychiatrists never have a patient die of suicide or even those who do, can count the number in a career on one hand. Not so uncommon for my friends in geriatric medicine to have a couple of deaths in a week, you never hear a psychiatrist act like suicide or death is a routine thing.

I've had a few patients die-- one many years ago in an MVA when he was someplace he probably wouldn't have been if he hadn't been drinking (he wasn't driving). It still sticks with me. One patient who died unexpectedly of unclear causes. A few elderly patients who've died of cancer.

I never meant to demean the power of psychiatric symptoms to kill, but death is not something that psychiatrists expect or take in stride--in other specialties, it's part of the deal and the doc hardens.

Anon: Please add a handle to your signature so we can know who we're talking to. To listen to you, it's more more complicated than it feels to me.

Alison: Thanks for your input. And I love the dog/boa constrictor story.

jcat said...

I'm a half-good patient.

I take whatever meds you want me to take, in whatever way you tell me to. I go for blood levels just before you want them. I show up for appts, and I listen to what you say to me.

What I don't do is the lifestyle things. I don't go to gym, because most days going to the places I absolutely have to go to is more than enough. I don't go out with friends unless cornered into it because most days I feel like I've talked too much already before I even wake up. I don't stop drinking completely even though I know it's self-destructive because on the days I do drink it's a less final choice than what I'd rather do instead. And leaves less physical scars than the other alternatives.

I try though. I do hard labour in the garden, I try to eat healthily, I drink less often and less in quantity, I try to sleep enough most nights (and conversely not to sleep most days), I do enough to not alienate friends, and to keep both my jobs somehow. I keep my head down, I use whatever reason I can find for today to hang on.

I do listen though. And I keep hoping that one day I'll wake up with enough energy and motivation to do all the things you'd like me to be doing. I'd enjoy that a whole lot more than you can ever know...

toni said...

I'm not your patient. It would never occur to me to tell you how to treat me. You're the professional! Like JCAT, I do my best to follow the advice of my doctors. I take the meds prescribed for me. I show up for appointments and I pay close attention. I spend time thinking about my sessions, and writing about them and how I am doing. There are some things I just can't do like make eye contact with strangers. But at least I consider it enough to sort out why I am afraid. Then I get the wonderful "Ding, Ding, Ding!" from my therapist that makes me feel like a dog in training.

I wish she gave out chocolate instead.

Anonymous said...

A different "anonymous" than the one before...

I think it's probably more common than one might think for a person to have a significantly "BAD" experience with mental health care providers. (As evidenced by the lengthy discussion on that topic a few weeks ago.)

I know for myself that I walk into a session with a lot of trust issues. I currently have the best "team" I've ever encountered... I'm confident in their ability to help me... but there's a part of me that is remaining stubbornly insulated and immune to their suggestions. I'm working really hard to be more open and more compliant, but it really is WORK.

On another note, I'm glad to see you finally mention that you don't prescribe "high-dose xanax" (vs. xanax in any form). I take less than 2mg a week for panic... (none whatsoever for weeks at a time sometimes). I've been doing this without any ill effects for about 10 years now. Truly, xanax is the only medication that has ever worked for me and I've willingly tried everything that has been suggested over the past decade. Most of the others I've tried made me feel as if I was being dragged, terrified, into a pit of slightly less sensation without any relief from the panic at all... maybe even an exacerbation because of the out of control feeling.
I've always been a little offended to think that none of you would prescribe to me the only thing that helps with that.

I love the podcast... I know, I know, I need to write a review...

Roy said...

Not sure if it was Dinah or Clink who put the pic from "Are You My Mother?" up, but that is EXACTLY the book I was thinking of when I read the post title in my email (but I was thinking of the cover picture). One of my favorite illustrated childhood books (#2 perhaps, with "Where The Wild Things Are" #1).

Dinah, I see what you are saying. Death is considered an unusual event in our field, whereas is many other areas of medicine, it is par for the course (sorta). And, though we may count on one hand how many have died while in our care, if you actually tracked everyone down you have ever seen, the stats would likely be sobering.

Anon (I agree with Dinah, it is confusing... maybe call yourself Anon#378?), I understand exactly what you are saying. Yes, it is complicated, but... well, people are complicated. Like my son's iPod headphone wire, which always seems to be in a knotted mess, through no apparent actions on his part. It just happens. But, at times, they become unusable and I am the knot-getter-outter in the family. That's part of what psychiatrists do... help to unravel life's knots. But folks like Anon#378 cannot just hand over the headphone and say "fix it, please." They let out one loop of a knot, not letting go of the rest of the mess, just to see how you do with that loop. If you can undo that, while not making the patient feel bad about their need to hold on to the rest, then you get a bit more. That process sometimes takes years. Others can hand it all right over. Guess it depends on how many times you've handed your headphones over, only to receive back an even bigger mess. You get gunshy.

Hmm... iPsych?

Alison Cummins said...

I'm trying to figure this out.

We all die, so in one sense 100% of any doctor's patients die. But we aren't at the same risk of dying at all times in our lives and we are more likely to be under the care of one specialty than another at the time of death.

If you treat people with schizophrenia and bipolar, you can expect, say, 2% of your patients to die of suicide. (Assuming that treatment works well enough to significantly reduce the rate of suicide even though this population tends to be noncompliant.)

But that 2% is over a lifetime - say 40 years of carrying a diagnosis.

If you have a caseload of 500 patients, then you would only expect 10 to die of suicide (while they were your patient) in the course of 40 years of practice.

This is wholly counterintuitive to me, but it jives with your experience.

I'll have to think about it some more. Any more thoughts? (Anyone sneaking offstage to die unnoticed in the wings?)

(And yeah, I love that dog-and-boa-constrictor story too. I think it's the first time I've told it though.)

Roy said...

Oh, blib, (that's a good one... blib... that's a word just screaming for a definition), my post on Xanax was not aimed at folks like you, who take it non-daily. It is something I prescribe sometimes, just not a lot, and then in limited amounts.

And I see patients *coming close* to dying all the time. Almost daily. (The ones who do die, I don't get consulted on.)

toni said...
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Anonymous said...

To Roy from Anon #378: Yes, you get it. That's all.


Sarebear said...


First Anon, there is much in what you say that is me, to differing degrees, and some to same degrees, and some stuff that isn't me.

Wow. I am so sorry that life has shaped you painfully (understatement) in this way, to this point.

Trust . . . . that is such a big thing, even for little things.

And so many levels . . . . SO SO many.

I was wishing, Anon 1, that I could use your comment as a sort of "guest post" on my blog, anonymously of course . . . .

And then so much in the rest of the comments, WOW. lots of me in lots of those, too.

Anon 378 or whatever that number is . . . . wow.

Roy, your analogy is excellent, although I picture it as a situation where you've got three hands working on it, like when my yarn gets tangled really bad near the end of a skein partway through a scarf or something, and as I'm working things around and through, it gets complicated and I have my hubby hold something in some way, or untwist something while I take the knit-in-progress, needles and all, and move it around and through when that's the only way, and it can be a tricky and delicate process.

Anyway, same thing as the ipod headphones, basically. That's a GREAT analogy. In my analogy, sometimes stitches get dropped in the process and some mayhem/crisis results, sometimes with drastic preventive/repair measures taken.

Gee, knitting and yarn management as analogy to therapy . . . I like it! For me, knitting has been a huge personal development & learning process and analogy, the way many people use golf as an anology for life, hardships, learning patience, practice, other things . . .

GREAT discussion here, Dinah . . . and I've been enjoying everyone's posts, guests included. Even if I'm wary of possible angles and possile opinions that I think might be the view of the religious impulse guest poster, twas a great discussion.

I have a post about my new psychiatrist, but blogger isn't letting me post it.

Anonymous said...

sorry ,sarabear, i'd rather you didn't. can't insist that you don't. it's not as though there is a copyright; it just makes me uncomfortable.

Anon 378

(which is a lucky sort of number)

NeoNurseChic said...

Anon 378, I also see a lot of my own thoughts and life in what you wrote. I even came back on this blog tonight, just after getting home from a very long day at work, to reread your comment.

Roy - your analogy demonstrates that you get it. I liked that. I'm one of those people who hands over a small piece of the knot - but you've gotta do quite a number on that piece before I give you the next one. The way I talk and how open I am sometimes here, you might think that I would willingly hand it all over, but no way. The most difficult things I face are things that nobody knows, that I talk about with nobody, and don't even think about myself most of the time because it is far too painful. I talk a lot, but often my talk is filler - yes, the things I say are important to me, but they ultimately pale in comparison to the real issues which I cannot look at because they scare me too much. We'll unknot it all someday. :)

Sara - Knitting! I have been working on this baby blanket for over a year - because I knit it in bits and pieces, whenever I feel moved to work on it. This is actually the first knitting project I've ever really worked on. I'm doing 8x8 squares - one square knit, the next purled (sp?). I enjoy it. One thing further I wanted to add to your analogy - the mistakes made, uncorrected, are what make us who we are. What hand-knit object is flawless? Even when you mend a dropped stitch, the fact that there was a mistake you tried to fix still holds in the yarn - you can still see where it has been smoothed over - it's never the same as it was, had the mistake not been made in the first place. This is so much like our souls - we can eventually smooth over and work through the rough spots, but they always leave detectable (to some level) imprints on us. And the flaws in the yarn are equivalent to the flaws in ourselves that make us unique. Not bad. Just unique. If there weren't flaws, then it would be machine made, which is nowhere near as good!!

Dinah - I enjoyed this post quite a lot. Everyone's comments are so insightful. There's another comment I wanted to make, but don't feel comfortable making in public (no worries - nothing bad!!), so I will email it. :)

Take care!
Carrie :)

Gerbil said...

May I also point out Prochaska's stages of change model? It's a common misconception that people go directly from one stage to the next, from precontemplation through maintenance. More often, it's not linear at all--they flit back and forth among the stages.

So it's entirely possible that someone would decide "hey, it's time to get help," but by they time they actually make it to the office, they're back in denial that they even need the help in the first place.

And besides, isn't resistance the best therapy fodder there is?

Sarebear said...

Anon 378, I wouldn't without your express permission; thanks for letting me know.

Anon378 said...

Thanks for understanding ,sarabear

Sarebear said...

"Resistance is futile" - The Borg

Hrm, I wonder if they've been to psych school (hee hee hee), they certainly know how to get into people's heads . . . ;^D

Carrie, I've learned to knit this year, taught self/learned from books. You should see my fibery/knitting/every craft but beading blog. My beading blog is good too, though neglected of late.

I didn't really think Dinah's post wasd alot about patients with alot of fear and trust issues, I did see that she was mostly exasperated maybe but patient, with the type in the dog story, but it was and is a good prompt for discussion of other reasons surrounding this issue.

DrivingMissMolly said...

Anonymous...I am so touched by your post. I could not have said it better. Thank you.


Anon378 said...

Like you, I also much prefer the original Willy Wonka and I have fond memories of a certain ,now departed ,Bichon.

Catherine said...

Anon378: What you wrote about is the exact same relationship I have with my psychiatrist. Thank you for putting my own thoughts into words.