Monday, March 31, 2008

My Three Shrinks Podcast 44: Guest J. Raymond Depaulo MD

[43] . . . [44] . . . [45] . . . [All]

We are pleased to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk about diagnoses, labels, and the ethics of using drugs to enhance one's cognitive skills (a fascinating discussion).

Dr. DePaulo joins us on the next podcast as well (#45) to talk about treatment-resistant depression, bipolar disorder, favorite quotes, and words we don't like. That should be up by April 6.

March 30, 2008: #44 Guest Dr. Ray DePaulo

Topics include:

  • NYT: The Ethics of Artificial Brain Enhancement, by Benedict Carey. On using cognitive enhancers, like Adderall, Vyvanse, and Provigil, to perform better. The article quotes NIDA's Nora Volkow, who wrote, "Even though stimulants and other cognitive enhancers are intended for legitimate clinical use, history predicts that greater availability will lead to an increase in diversion, misuse and abuse." Dr. DePaulo addresses the treatment of symptoms (eg, inattention in pilots) vs diagnoses, on the bases of functional impairment and subsequent consequences. Be sure to listen to the part around 24 minutes, where we discuss the ethics of a hypothetical drug that increases IQ by 30 points.

  • Diagnosis in Psychiatry. Also some comments on ADHD vs Bipolar diagnosis, which led into an interesting discussion about the nature of diagnosing psychiatric "syndromes" in the absence of a definitive diagnostic aid, like a blood test or brain scan.
    Other references and topics mentioned by Dr DePaulo: Kraepelin. // Quote from Paul McHugh: "A good clinician in Psychiatry is someone who makes prudent decisions based on insufficient information." // Judy Rapoport's 1978 study of stimulants in normal kids. // The history of "ADHD" and "minimal brain dysfunction". // Labels and diagnoses. // William Styron // Kraepelin's Manic-Depressive Insanity.

  • Prison Health Care. Clink compares correctional psychiatry capabilities with those in free society and wonders why care can be provided in jails and prisons yet we are the only country still without some sort of national health care.

  • JAMA: Loss of Serendipity in Psychopharmacology, by Donald Klein. Article in the March 5 issue of JAMA. "This Commentary on the psychopharmacological revolution focuses on 2 mysteries: fostering medication discovery and finding out how they work."

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they m
ay be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

Credit: At the end is a few seconds of "Manic Monday" by The Bangles [iTunes, Amazon].

Find show notes with links at: The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.

Sunday, March 30, 2008

HBO In Treatment....The Final 3 Episodes

Sophie's dad shows up outside Paul's office. He wants to go in with her, she's clearly not pleased. Paul says he needs an appointment, there must be time to prepare, Dad is humiliated and angry. Oh and when Paul opened the door, he had a trio of congratulatory balloons for Sophie who had moved on in her gymnastics trials. It isn't too hard to see how Dad might be feeling a bit pushed out.

He leaves. Sophie asks why Paul couldn't just let him it. She's mad. Therapy has brought her to the point where she's getting along better with Mom who's stuck it out with her, and now she's angry with the father she adored because it's been brought to her attention that he abandoned her-- an idea she'd been well-defended against, for better or for worse.

Dad reappears, he barges in and Paul lets him. He talks about how he's torn apart when he doesn't hear from Sophie-- his love is genuine. He talks about his role as a parent-- he is offended when Sophie says he didn't raise her. He got up at 5 in the morning for years and waited for her at gymnastics practice. He sat with her while she did her homework. He got tutoring himself so he could help her with math. If only he hadn't found that wife who didn't like Sophie. If only. I actually felt for him-- it's true that as a parent, your efforts are expected, your failures are tallied. The session is a meaningful one where everyone felts heard and ultimately Sophie tells her Dad, "It's my therapy" and he leaves. One senses that reparations will be made and the episode ends with Paul speaking to his own daughter while Sophie and her Dad are talking on the lawn outside.

Jake & Amy are getting a divorce. Therapy has illuminated for them how incompatible they are, how they strive on passion, be it sexual passion or simply a passion to argue about the mundane. Jake has grown over the weeks, he's come to some level of comfort, he's given up his role as the jealous stalker. Amy is sad, she calls the therapy a disaster. She doesn't want the divorce, and the tension of the session is set in seeing if they will change their minds. Paul, I believe, is not ready to give up hope. Joint custody for Lenny. A loft for Jake. The marriage is over, as it should be.

Paul finally reaches Laura. They meet at her house. She points out that she's not a lover, not a girlfriend, not a patient. What is she? We have the sense that she is getting over him better than he is getting over her. He promises not to leave her or hurt her. She goes into the bedroom, takes off her shirt, and things go dark? Did they have sex?

Soon after, still daylight, and Paul is knocking at Gina's door. He had a panic attack, he ran out on Laura. Did the right thing. He is ashamed. Gina is glad. What a fiasco. We don't know what becomes of Paul's marriage, but it's hard to imagine there's much there to fix.

The End.
Thank you for reading.

It's Sunday Morning--coffee, online shopping and the New York Times

This is published as two posts. The photo was enough to drive blogger mad. Scroll down for the rest.

Roy and I have communicated this morning. We're both on our second cup of coffee. I've been shopping on Lands End and I made a Model Me. The hair is a bit wilder than mine, the complexion much darker, no toenail polish, but aside from that, it's me. Roy tried to make himself and he couldn't. I tried to make him, and I couldn't. We won't talk about how long it took to get my Model Me onto the blog. Do you like my new outfit?

From Clink: I can't believe Dinah's got me doing this. OK, so I fixed her picture a bit and then decided to add me. Save this post for the police sketch artist in case I ever disappear.

The Rest of my Post From Above: The New York Times: Parity and Book Deals

So The Sunday New York Times:

The Murky Politics of Mind-Body
by Sarah Kershaw is a Roy article on mental health parity-- he loves this stuff, but I just couldn't add to his To Do List while he's unable to even make a Model Roy.

Ms. Kershaw writes:

This month, the House passed a bill that would require insurance companies to provide mental health insurance parity. It was the first time it has approved a proposal so substantial.

Great stuff, and I'm all in favor of parity bills. The article has some good stuff about the murkiness of mental health diagnoses. The catch to the bill:

The House bill would require insurance companies that offer mental health benefits to cover treatment for the hundreds of diagnoses included in the Diagnostic and Statistical Manual of Mental Disorders, from paranoid schizophrenia to stuttering to insomnia to chronic melancholy, or dysthymia.

"That offer mental health benefits."

Oh, they can still not offer mental health benefits.

The next piece from he style section was "Why Blog? Reason No. 92: Book Deal"

And to think, I thought it was an original idea. Can the Shrink Rappers join the bandwagon?

Coming soon, the final installment of In Treatment.

Saturday, March 29, 2008

Roy Was Here!

I came to Shrink Rap to look at the MAOI poll. Please vote on our side bar. As someone who hasn't prescribed MAO Inhibitors, I'm learning a lot from reader comments on my MAOI post (Thank you to Graham for the inspiration).

Anyway, I realized we now have search bar, Shrink Rap versus Web. Had to be Roy, just had to be. But the funny thing is that wasn't on his To Do List.

If anyone else would like to nag Roy, remind him that we recorded two podcasts with Ray DePaulo, the chairman of psychiatry at Johns Hopkins. Then remind him that we're waiting on his section of the Shrink Rap book so we can look for an agent.

Roy Was Here! He left us a search bar.

Thursday, March 27, 2008

Endorphins Fuel The Swoosh

From today's New York Times, an article entitled Yes, Running Can Make You High, which proves what many of us runners already knew: the runner's high actually exist and it's fueled by endorphins.

A pain researcher in Germany used pre- and post-run PET scans to study endorphin binding in the brains of ten long distance runners. They also did psychological tests to measure mood states before and after a two hour run. They found that endorphins bound to the prefrontal cortex and the limbic system, and that the amount of binding correlated with elevated mood. The research subjects were blind to the purpose of the study.

Just something to think about the next time you lace up the Nikes.

Tuesday, March 25, 2008

Why This Shrink Doesn't Prescribe MAOI's

Graham wrote in a question:

OK, so since it was a pretty generic post, I'm going to ask a question of you three that's pretty far off topic. Why do you think MAO inhibitors are so infrequently used in psychiatric practice today? Besides dietary/drug interactions, their safety profile is good. There are masses of studies showing efficacy. Why switch patients from one SSRI/TCA to another to another instead of trying a MAO inhibitor. Do you think MAOI's have a place as second line agents in certain circumstances?

What a great question, I've been thinking about this one for a bit and this is what I've come to. I don't use Monoamine Oxidase Inhibitors (MAOI's) to treat depression or anxiety, though from time to time, I think about it. Why not? It's a really good question, they are really good medications, sometimes helpful when other meds don't work, and lore has it that they are helpful with "rejection sensitivity" in patients with borderline personality disorder.

So Why Don't I use them?

1) They are dangerous in combination with a bunch of foods-- aged cheeses, certain red wines, fava beans, and I'd have to look up the rest of the list. It includes medications, even some over-the-counter medicines. Accidental or purposeful ingestion of these substances in combo with MAOI's can lead to hypertensive crises-- think stroke and death. This makes me a little wary.

2) Pure gut bad association-- at the hospital where I went to medical school, the young daughter of a New York Times editor died-- the combination of MAOI's and prescribed Demerol were thought to play a role in her death.

3) I don't like to give patients medicines that they can easily fatally overdose on.

4) My own naivete. By the time I started residency training in psychiatry, SSRIs were hot. Many patients were on TCA's (tricyclic antidepressants, and you can OD on these, too). I saw two patients in my residency on MAOIs. I've worked in 3 different clinics, each with an active caseload of about 1,000 patients. There was one patient in the first clinic I worked in (1992) on an MAOI. I've never seen the chart of any other patient treated at any of these clinics with an MAOI. Okay, I haven't seen any patient's chart, but the point here is that I'm just not familiar with them, so they aren't my first/second/third/fourth choices for treatment. Should they be?

5) Once you've used an SSRI, you have to wait weeks to use an MAOI, not always an easy prospect for a depressed patient.

Thanks Graham, I'm running my next sidebar poll in your honor!

Sunday, March 23, 2008

HBO In Treatment: The End Of Week 8: Why Can't We Be Friends?

Sophie is dropped off by her Mom who is trying oh-so-hard to be nice to her. She sobs while lying on Paul's floor, now angry with her dad. Paul, also on the floor, points out that Sophie holds herself responsible for relationships gone bad. She tells him that she quivers on the beam while doing gymnastics, that she has broken out in an awful rash. She lifts her shirt to show him the rash, apparently flashing him (we TV viewers just see this awful rash on her back). Paul is uncomfortable, Sophie is quick to latch onto that. He tells her how he had a panic attack and a patient had to call an ambulance for him-- the rash, the quivers, they are all from stress, she can control it. At one point he pushes her and Sophie, trying to get him to lay off, says, "I know you want me to have a breakthrough today."

Sophie remains my favorite patient-- she is likable, vulnerable, full of hope and promise, yet so so fragile. Paul will tell his own therapist later in the week that he helps her through their relationship, not the therapeutic process. I think he's right-- Sophie needs a father and finds it in Paul's intense attention. I've already said I don't think he should push her and boundaries for Paul get confused by his need to be liked by his patients. Oh, and just because his panic attack was from stress, doesn't mean Sophie's rash is. He should send her back to the dermatologist.

Just before the Jake/Amy session, Kate tells Paul she is no longer going to couples' therapy with him. It's not clear if she's leaving him.

Jake comes alone (thankfully, together he and Amy are insufferable). They are splitting, he is damaged. Jake has moved through the weeks from being an angry, controlling, jealous lover to being a sympathetic character. In this session we learn that the rough-around-the-edges Jake is the son of two college professors. He's moved from his childhood of parental disapproval to a marriage with a hotshot wife who mirrors his father's disapproval. OK.

Paul sees Gina alone. "You slap me, I punch you," Gina says. Yup. He talks about his waning faith in the therapeutic process and he throws more vile at Gina. She lives in this room, she's never lived life, it's a beautiful room, well-appointed, but what does she know about life? She comes back at him with how he knows nothing about her, how he paints her as cold and remote when really she's overly emotional and impulsive and she loved her husband who cheated on her. She cries. He puts his feet up. She tells him to try it with Laura, that maybe everyone else has it wrong with all their ethics, and she tells him to leave.

Everyone's having marital problems. Every cheats. Everyone is angry with everyone else. Why can't they all just play nice?
I know, I know, it's just a show.

What a Great Idea

I'm back from New York. We had a great trip, and now we get to return to our home, where apparently Everyone Who's Anyone is my neighbor! Roy will be moving next door shortly (I hope).

So I'm finally getting to today's New York Times magazine and I read an article by Thomas Goetz called "Practicing Patients." It's about an on-line medical community called PatientsLikeMe where people compare their treatments for a variety of neurologic and psychiatric disorders. People enter their treatments and chart their progress and therefore form a data bank of information. It was founded by the brother of a man who was ill for years with ALS.

Okay, so it's not 'controlled trials' and there's the risk that people will demand unproven treatments based on what they've read as anecdotes on-line (Goetz mentions ALS patients asking for Lithium based on information reported on the site), but what a great idea to get data on treatments, what works, what causes side effects, in a more real-life way. Research trials often eliminate Real people-- any one with a co-occuring illness, people with substance abuse problems, women who might get pregnant, children.

I surfed briefly. I didn't join. What a great idea.

Saturday, March 22, 2008

Won't you be my neighbor?

In a comment to How Dinah Thinks, I noted "I'm starting to think that everyone is Dinah's neighbor," to which Dinah queried, "Who else is my neighbor?" Here's my count just from a quick search of our blogs for "Neighbor" (34 hits).

How Dinah Thinks
I liked that he starts by discussing the work of Debra Roter who studies doctor-patient communication patterns. Why? Because Debra is my friend and neighbor and it's always fun to stumble across someone I know on the pages of a book.

My Assorted Thoughts on Tara Parker-Pope's Wellness Blog Today
Not long ago she wrote about headaches and referenced my neighbor, the Johns Hopkins migraine king-- a man with beautiful gardens, a lovely wife, who run circles around our neighborhood for exercise, but my conversation with him has been limited to mutual nods.

The Shrink Next Door
That being said, I can't say that I've ever gone to my mechanic neighbor for car advice or to my hair stylist neighbor for coloring advice (although Dinah probably thinks I should) but that's not because I don't think they'd help me if I asked for it.

Is It Worth It?
She talks about the recommendations of David Bucholz, the Hopkins migraine Guru (and my neighbor...) -- avoidance of medications that can lead to rebound headaches and a diet devoid (--I'm kidding of course, but apparently caffeine, pizza, beer, and chocolate--the foods Shrink Rappers love-- are out).

20 Random Facts (X 3 Co-Bloggers)
18. My husband is not a transvestite, which was called into question by our neighbors  [okay, not so specific with this one] when I published a novel that opened with a social worker stumbling upon her husband cross dressed.

Risky Business
I didn't know Dr. Fenton, I don't think I even knew of him, but I learned of his death at a Labor Day barbeque I hosted, from one of my neighbors who is also a schizophrenia researcher and who did know him.
Even if I don't wrestle with crocs for a living, the reality remains that people with psychosis can behave in unpredictable ways. As a child, I lived across the street from a neurologist. His office was across the hall from a psychiatrist and one day, a patient walked in and shot and killed the psychiatrist. Needless to say, my mother thought I should consider another career.

I can't believe that I must be so bored to be blogging about Dinah's neighbors. Maybe I'll do one on that new PTSD & genetics study, instead. Or maybe about the recent passing of one of Psychiatry's giants, Frank Ayd.  I know, I've also got the Ray DePaulo podcast to do, and work on "the book" (thank you for all your comments, thoughts, and ideas about our book, btw... we really appreciate the feedback). Dinah is always more than willing to help me keep my to do list filled (just think if we were married).

Friday, March 21, 2008

HBO In Treatment....Some Other Links....And How Sad Is It That I'm Blogging On Vacation?

Greetings from The Big Apple! Kids are still asleep, husband's getting ready to head to TKTS so we can see a show tonight.

Before I start talking about In Treatment, I have some links.

The New York Times has an article on So You Want to Be a Star Blogger. We're doing okay here at Shrink Rap, I think. We've passed the $100 mark on Google Ads (can we go to KoKo's for crabcakes, now???) and we get a couple thousand visitors per week. I'm happy. Oh, I'm on vacation, that always makes me happy.

Gerbil is having a baby soon, and still she took the time to send us This Link about In Treatment. Apparently 38 people are still watching it. I'm one of them. Best wishes for a happy, healthy baby Gerbil.

So for the other 37 people still watching, the show has gotten better. I've only watched through Tuesday, and with vacation, I may be behind for a bit. It ends next week, so I imagine I'll catch up. I'm also working on John Adams, but no blogging on it, and I'm an episode behind on LOST.

At the end of their Couples' session on Friday, Paul's phone rang-- it was clearly something awful and I was worried that Sophie had committed suicide. My husband thought it was Alex. He was right. Oh, he's always right. Monday we meet at Alex's funeral. Paul talks with Alex's son Roy and offers the boy some kind words and support. He then finds Laura there (wait, who goes to a funeral of someone they've had a brief fling with??) Paul knew she'd be there, he'd called her, and he talks about his own childhood losses. Alex's father mistakes Laura for Paul's wife.

Tuesday, Alex's father shows up in Paul's office. He wants to know what drove his son, is fearful of losing connection with Alex. He's just like Alex--- challenging one moment, pleasant the next. He compares psychotherapy to prostitution then later apologizes. He implies that the psychotherapy dredged thinks up and left Alex vulnerable, so vulnerable that he died while on a training mission. A question was raised as to whether the death was a suicide. The session is intense, painful at moments, well acted. Personally, I think Alex's narcissism would have protected him from suicide, I'm voting that it was an accident. I know: it's just a show.

My best to all. Clink, Max misses you.

Wednesday, March 19, 2008

How Dinah Thinks

I just finished Jerome Groopman's book
How Doctors Think. My beloved Co-Blogger, Roy, notes that we talked about this book in our last podcast-- to see those show notes and/or download the podcast, CLICK HERE. They also have a direct link to Dr. Groopman's book, which I'm too lazy to create here.

So Roy mentioned that I said Jerome Groopman purposely avoided talking about psychiatry. Per his footnote on page 7 of my hardcover copy:

I quickly realized that trying to asses how psychiatrists think was beyond my abilities. Therapy of mental illness is a huge field unto itself that encompasses various schools of thought and theories of mind. For that reason, I do not delve into psychiatry in this book.

I read the book and I actually thought all of it applied to psychiatry. Psychiatrists make the same cognitive errors in diagnosis, our thoughts are colored by the patients we just saw, the mistakes we've already made. The time we stopped a medication believing it was safe, only to find it wasn't. The one patient who had a horrible response to a medication. He talks in depth about uncertainty (one of my favorite topics) and oncology. I didn't think the issues one faces about whether to have chemotherapy for cancer-- given the fear of side effects-- was much different from the issues that surround the decision to take medication for mental illnesses. There could be side effects, there could be adverse effects, and in case you forgot how I think about those things or never got there in our now-enormous blog, click here for Medicines: The Good, The Bad & The Ugly. The issues for shrinks are the same. And when you get down to it, much of doctoring, any kind of doctoring, is about hearing the patient and the current pressures placed on doctors squeeze them out of taking the time it takes to do this. I'll grant Dr. Groopman that psychotherapy, one mode of treatment for psychiatric conditions, follows different rules than what he discusses. But in terms of diagnosis, risk, uncertainty, weighing the possible benefits of treatment against the possible harm that treatment can confer, re-thinking the clinical assumptions when things don't go well--- this book is completely relevant to psychiatry.

I loved Groopman's honesty-- he talks about himself as both doctor and patient, he tells stories well, he talks about complicated things simply. I liked that he starts by discussing the work of Debra Roter who studies doctor-patient communication patterns. Why? Because Debra is my friend and neighbor and it's always fun to stumble across someone I know on the pages of a book.

What I didn't quite jive with was the idea that diagnosis is an exact and elusive thing. It felt like there's a gold standard out there, something to compare with, and the reality of medicine is that so much of the time it's about best guesses. Perhaps not so in oncology-- there is a tumor or there isn't a tumor, it's malignant or benign-- even there I can tell some gray-area stories. In infectious disease a bug grows or it doesn't, but maybe we treat even when the bug doesn't grow. Often we don't get answers, and I'd like a dime for every time my childrens' pediatrician has told me over the phone "it's a virus." Oh, but all those illnesses resolved, generally without a prescription or further ado, and so by default, they were viruses. In Groopman's story, there was a diagnosis, one that was missed and then found, and the bottom line to keep thinking critically, to ask questions and not give in our own narcissism, is well worth hearing.

Okay, here's the link to How Doctors Think. I just sent a copy to my aunt.

Tuesday, March 18, 2008

My Three Shrinks Podcast 43: How Doctors Think

[42] . . . [43] . . . [44] . . . [All]

The Benzo Wars are over now, and podcast #43 is much more dispassionate and level-headed. Later this week, we'll also put out podcast #44, with the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo.

The three of us have been busy with other things, so we apologize for not getting these podcasts our more regularly, but please keep coming back for more.

March 18, 2008: #43

Topics include:
  • My Three Shrinks: The Book. We've been talking about writing a book which explains how psychiatrists go about thinking about approaching problems, such as selecting medications or diagnosing illness. We are debating about how to format the chapters in the book. One option is for each of us to write individual chapters about various topics. Another is to maintain the conversational tone so that we each would have some back-and-forth commentary within each chapter. What do you think? Let us know in the comments below, or email us.

  • NYT: Time Off From Electronics. Mark Bittman had an article in last week's New York Times called "I Need a Virtual Break. No, Really." The article talks about forgoing today's electronic trappings for one day each week, similar to some business' "email-free Fridays." No cell phone. No voicemail. No Blackberry. No internet. This provoked anxiety for Dinah (and "what's the point" from Clink and me), who speculates further about "internet addiction" and the risk of death by videogame. Addiction vs compulsion.

  • PT: Why Psychiatrists Should Read the Humanities. Clinkshrink discusses a Psychiatric Times article from the Feb 2008 issue by Cynthia M.A. Geppert, suggesting that more humanities should be taught to medical students and residents. Dinah remembers my first blog post about Tom Cruise.

  • Female Sociopaths in Literature. Clink lists a number of female sociopaths portrayed in operas, books, and other literary works.

  • Brain Maturation Delayed in ADHD. Also in the Feb 2008 issue of Psychiatric Times is this article by Arline Kaplan, describing research suggesting that the brains of kids with ADHD mature a little later than others, bringing into question the medication treatment of this disorder, rather than more behavioral and "tincture of time" methods.

  • How Doctors Think, book by Jerome Groopman MD. Dinah is reading this now and notes that Dr Groopman chose not to discuss how psychiatrists think, because this is "beyond [his] abilities." (We really need to get our book written.)

  • How Psychiatrists Think. Once again, we are starting a book and would like some feedback from our listeners and readers. The question is about the style of writing. Option 1 would be for each of us to take on topics and write a short (1-5 pages) chapter on a given topic. Option 2 would be for each of us to chime in within each topic/chapter, thus more resembling a discussion. Option 1 is more traditional. Option 2 would sound more like our podcast, at the risk of confusing the reader about who is "talking" at any given point.

    Email us with your thoughts about these options at mythreeshrinksATgmailDOTcom.

Find show notes with links at: The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.

Monday, March 17, 2008

Making Crime Pay: The Rest Of The Story

In my post How To Make Crime Pay I blogged about a conversation I overheard in prison between two inmates regarding how to get money from the state for being a crime victim. I was a bit aghast that one had gotten paid more than $5000 for getting shot during the course of an offense. The money came from the state's victim compensation fund.

So this past Sunday our local newspaper published and in-depth story about this problem, written by Josh Mitchell. He reviewed five years worth of records documenting awards from the fund and found that over $1.8 million had been awarded to drug dealers and violent offenders. Interestingly, the state is now trying to pass legislation to close the records regarding payouts.

In an unrelated note, Maryland has come in (once again) in the top ten for the most dangerous states in the country.

Sunday, March 16, 2008

HBO In Treatment...The Rest of Week 7...Couples from Hell and Imago Relational Therapy

Amy uses their psychotherapy session to tell Jake she slept with her boss. Will these people just get divorced already?
Therapist Paul and his wife Kate have their own couples session with Gina. They are still dealing with Kate's infidelity, Paul still treats Gina (his therapist/supervisor) with scorn, and Kate talks about how Paul is out-of-touch with the lives of his children and how she's felt unable to be heard and unable to be a complete and fulfilled person because of her marriage to Paul. I'm not sure why. During the course of this session, they use a technique called "Imago." Gina and Paul both mock it, but Gina insists they start. "Please don't make us do this, Gina," Paul says, but because he doesn't want to, Kate insists, and Paul surprisingly plays along. It's a technique where one person talks and the other listens and reflects back without interpretation or added input. This is very hard for Paul, who can't help but add his own jabs. Kate says she thinks her affair came from something she's been harboring for many years. Paul reflects back that she thinks her affair came from something in her childhood. They both seem to get something out of the act, and Kate finally feels heard by her husband. One of the things she tells us in her own discussion is that while she was opposed to couples' therapy, she came in desperation because she couldn't get Paul to hear her at home, and with Gina she finally feels some sense of validation.

So while I'm tired of Jake and Amy, overall the series is getting interesting again. The session with Gina resonated a bit for me, I didn't have that "Give me a break!" feeling I usually get and Paul, while defensive and even on the edge of hostility at moments, his behavior is more contained, more real. My husband loves when he bickers with Gina. I find it unrealistic and disrespectful.

Okay, so I wondered about this Imago stuff. Sounds like something psychologists and social workers learn, not psychiatrist stuff. Thank you, Google, and in ClinkShrink's honor, Wikipedia.

At I found the Imago Relationships International website.
At Wikipedia, I first learned that Imago is a stage of insect development. Oops, wrong Imago. I tried Imago Therapy and learned that it was founded by Dr. Harville Hendrix, author of Getting the Love You Want, and he lives in New Jersey and New Mexico (two fine places) and Dr. Herdrix has 6 children and 3 grandchildren. About Imago therapy, Wikipedia says:

The core practice of Imago therapy is the "Couple's Dialogue," in which a couple engages in a structured conversation, with or without an Imago Therapist.
  • The Couple's Dialogue consists of Mirroring (repeating) each statement, Summarization, Validation ("That makes sense because ...") and Empathy ("I imagine that makes you feel ..."). This enables each partner to extend themselves to understand the experience of the other as different from their own. If you can work with an Imago therapist, he or she will help to deepen that dialog.
I'm having trouble with the formatting here, but the bottom line is that I learned something new today.

Saturday, March 15, 2008

The Villainess

I'm back. This may be the longest I've ever gone without blogging. I spent four hours yesterday scanning and repairing my laptop to I could avoid an endless loop of error dialogues at startup: "Windows Explorer has encountered and error and must close. We apologize for the inconvenience." Nice of Microsoft to apologize, I just wish it would quit showing me that error box over and over again. Ah well, it's gone thanks to a commandline tool and my original system disk. Thank goodness my ten year old Mac still works.

So anyway, one of the podcasts that will eventually be posted has a segment we did about the use of the humanities in medical education. I talked about some of my favorite female sociopaths in classic literature, and then a friend reminded me later about a couple others in literature and opera. So I decided I'd put my money where my mouth is and write a poem about female sociopaths.

Poetry is not new to Shrink Rap. A while back we had a post, The Cats Go Barefoot With Grace, in which I invited readers to submit poems using that line somewhere. (It originated in a comment on Dinah's post, The Secretary Who Couldn't Stop Talking. She had put up a hypothetical problem and asked for input. I got totally distracted by the sentence 'The cats go barefoot with grace.')

So anyway, the type of poem I used is called a villanelle. It's a very structured form that I've heard is the hardest to write. A villanelle uses two rhyming lines alternately in six stanzas, coupling them together at the end. The most well-known example of a villanelle is Dylan Thomas' "Do Not Go Gentle into That Good Night," which uses the lines:

Do not go gentle into that good night,
Rage, rage against the dying of the light.

My poem is called "Villanelle For The Villaness". I've included wikipedia links (the source of all definitive Internet knowledge) for those of you who want to read about the references I make in the poem. Here it is:


Villanelle For The Villainess

For jealousy, ambition, and greed that will not quell
There is a poisoned cup or a tender knife.
The evil that women do, they do well.

Steinbeck loosed a feminine hell
In Cathy's charms with her liquid death, all
For jealousy, ambition, and greed that will not quell

Shakespeare knew, and could foretell
Through witches a lady's persuasive regicide.
The evil that women do, they do well.

Carmen, the fiery gypsy belle,
Once prison-freed she drove men mad
For jealousy, ambition, and greed that will not quell

Milady was destined for hell when
Dumas beheaded her for the musketeers' revenge.
The evil that women do, they do well.

A man may kill and risk a cell,
No clever plots for him, just shoot and drop. But...
For jealousy, ambition, and greed that will not quell
The evil that women do, they do well.

And no, I'm not quitting my day job.

Thursday, March 13, 2008

All's Quiet On the Shrink Rap Front

There's In Treatment, which I'm actually enjoying a bit more lately, but aside from that, things are kind of quiet with Shrink Rappers. Roy had the flu, and he's taken on a zillion projects (How many Committees can one man be on? I don't know, but I'll call you when Roy finishes changing all the light bulbs), and he's falling behind with my To Do List. He'll get there, he always does, and just to keep you tuned in, we had a great pod casting session this past weekend where we were joined by Dr. Raymond DePaulo, the Chairman of Psychiatry at Johns Hopkins and one of the country's best known experts on Mood Disorders. So, sometime in the next few weeks, look for two episodes of My Three Shrinks where Ray joins Roy and we all ramble about treatment-resistant depression and The New York Times, and oh, we talked and talked.

ClinkShrink has been busy in jail, got a bunch of job stuff going on, and her own committee stuff. I don't know why she's not blogging, but she's not.

Me: Well, I'm trying to catch up on Lost, stay up on In Treatment, Spring sports are starting for my kids, one of them has decided that I'm learning to play squash now, and as of 4 P.M. today, I'm happy to announce that I'm on VaCATIon!!! Plans are still being formed, but one thing I'll be doing is visiting a high school friend whom I haven't seen for years. ArniBeth (a high school nickname) and I e-mail several times a day, every day, and we've only seen each other once in the last ten years, so a short flight and I'll also get to meet her daughter, who is kind enough to be the same age as one of my little charmers.

Okay, so there's this one other little project we're trying to work on: getting some Shrink Rap and My Three Shrinks stuff together in a cohesive way to turn it into a book. We've mentioned it before, and on one of the podcasts Roy will ask for your input. We're getting there, at least in terms of a proposal, and yes, Anon, we know you think we should keep our day jobs. I keep nagging Roy and telling him the book will make him rich. I don't think he cares about fame, but who that we've got Eric our friend at CBS...and Dr. Phil...who knows?

It's lighter later and that's good, at least here in Maryland. Springtime mania hasn't yet begun. Winter depression is dissipating. I hope you are all well, and by all means comment on my non-post.

Wednesday, March 12, 2008

HBO In Treatment....Parents & Children...Week 7 begins

No Laura this week. Her session is filled with Paul's attempts to talk to his teenage kids about....their romantic lives, his marriage. It's like he's never spoken to these people before. His teeny bopper daughter asks, "Are you worried that I'm sleeping with him?" Right, this is what Dads and their teen girls call casual conversation. And then Rosie pops on him that she knows her mom's been to Italy with another man. "Fix it" she cries.

Son Ian drops by in search of his pillow. He's slept with 5 girls. Cool with Dad. And so Paul tells him that he's been thinking of another woman, but he hasn't slept with her and he lies and says she's not a patient. Ian understands, Mom's a martyr, and after 23 years Dad/Paul must need a change. Not a prob for Ian. Oh, but Paul gets angry that Ian is critical of Kate-- she's cared for Ian, put her career on hold to raise him for 15 years, taken him to baseball and guitar, Ian should appreciate this, and he tells Ian how he empathizes with his distress over his parent's marital problems. Paul, I seem to remember, is the child of a divorce after his own doctor dad cheated on his mom with a patient and his mother died when he was 15; he lives feeling he didn't do enough for her. So, Ian doesn't feel his father's empathy, he feels patronized. It's never quite clear in these exchanges who's talking about who.

Next day, enter patient Alex, back to his fighter pilot life now. He talks about his father and his son and power and humiliation. He can out do all the other fighter pilots but he can't beat his son at chess and his own father calls him pathetic, leaving him as the outsider at his son's birthday party.

Sophie is next. She talks about her telepathic bond with her absent father who loves her and is always there for her, her hatred of her mother, the one who remains with her through thick and thin. Funny, she has this dream that she's in a hotel room chatting with Paul, except that he's not her shrink, he's a serial killer waiting to kill her father. And Dad, of course, was unfaithful to her mom, which Sophie discovered when she found him in bed with one of his many nude photography models. We're back to the issue of boundaries, and of course we hear Paul tell teen patient Sophie of his dreams of being stuck in a chair and unable to help his own mother.

So everyone's lives-- doctor and patients-- play out in this ongoing cycle of abandonment, infidelity, failed expectations.

Will they all live happily ever after?

This is Our 709th Post

Just so you know.

Saturday, March 08, 2008

No Cherry Blossoms Yet

Just had to break up the In Treatment monotony here.  Hangin' out at the Omni Shoreham in DC this AM with a friend at the Work, Stress and Health Conference.   Above is the restaurant behind me as I type this out (which has great banana nut French toast, BTW).  We're off to one of the Smithsonians, maybe the American Indian History one or the new butterfly exhibit at the Natural History Museum.  If it stops raining, we'll do the zoo instead, which is just around the corner.

Hey, we did a podcast last Sunday, and I now have time today to get it produced and posted, so stay tuned.   Also, the House version of the Mental Health Parity bill passed a couple days ago (yay!), so now the trick is to get the House and Senate versions reconciled.

Catch ya later.

Friday, March 07, 2008

HBO In Treatment....The Rest of Week 6

The Sophie Episodes are my favorite. The Jake/Amy ones are insufferable as are the Alex ones, though Alex is earlier in the week. It feels like these people spend an awful lot of time talking about the sessions themselves and going at it with the therapist. For what it's worth, in real life-- at least in my real life-- patients are a lot less focused on me and a lot more interested in telling me about their lives outside of the office. Oh, and my patients are much nicer than Paul's. So there are my thoughts.

Sophie orders a pizza to be sent to the session-- how cute is that? Deep dish: you go, girl! They end up talking about weight and eating and control and we get to question if Sophie has anorexia like her dad's Italian model girlfriend thought. Then we hear about good old Dad, Sophie's favorite person in the world, who doesn't know about how she OD'd on her shrink's sleeping meds in his office bathroom (gotta love that bathroom). Paul pushes Sophie on why she's keeping this from her father and he shows her that he's found a book with photos by Sophie's dad-- photos of naked women. Sophie gets mad, she tells Paul to "Eat Shit, Paul" and she's ready to storm out. Then she comes back and she screams at him that she's supposed to control the conversation, basically tells him not to push her too hard. He comes back with more shrinky analysis pushing at her how she needs to look at her relationship with Dad. Sophie weeps, Paul assures her that there are safe places besides on her gymnast's balance beam, and says his office is one of those safe places.

Ha! Talk about bad therapy. This is a kid he pushed her buttons and she overdosed in his bathroom. She's told him loudly and clearly that she needs to keep it where she feels safe, float it on the surface. She comes undone when he pushes her, and I thought that when she sat back down, he'd make an effort to put her back together, to smooth things over, and yet, while she somehow doesn't lose it with him (at least doesn't keep yelling at him), he keeps up his plug to go deeper, to look at the painful stuff. We're supposed to believe he gets his message across because he's now chosen the right words, but if you ask me, he's standing next to the fire with an open vat of gasoline. A patient this fragile needs to control the session, she doesn't need a lot of annoying interpretations or to be pushed to look at things she doesn't want to look at . She tries to kill herself when this happens. We're on session 5, we've had a pizza, we've had an overdose, we've told Mom to f--k off, and now he's shoving naked photos her dad took in her face??? Oy. Assess her symptoms (including the possibility of an eating disorder), make sure she's literally safe, report the damn gymnastics coach who slept with her, treat her Major Depression with medications, and talk about school, how it's going at home (if she wants), what she likes on her pizza, and maybe chat about a movie. How many suicide attempts does it take before the shrink figures out that his office isn't a "safe place" if he pushes her to the the brink? Okay, you get my point. See any good movies this week, Sophie?

Amy shows up alone, no Jake this week. She feels rejected when Paul is a little late and asks her to wait outside for a few minutes. She tells about it. We then hear that she's back together with her controlling husband, and that Jake is now disgustingly tender, she likes it rough. Bad sex with hubby and a fling is set in motion with her boss tonight. She always forgives herself. Oh, and she was a fat and tormented child, dad died when she was 13, her sister was a mean little thing who had to have the red dress. Paul clearly doesn't approve of sex with the boss. Amy goes to the famed bathroom where she blackberries her husband just to hear his voice. And what does that mean?

Is there something to say?
Paul's psychotherapy supervision has turned in to couples therapy. His lovely arachnid wife, Kate, joins the session. Gina kisses Paul and there's a spot of tea waiting. They worry about their daughter. They bicker about Paul's sexy patient Laura. Paul tells Kate what Gina is saying, cuts off Gina, jumps to conclusions. Gina comes up with theories of Kate's role in Paul's life-- they she started the marriage as a dependent "patient" who was never his equal (to be clear here, Kate was never Paul's patient, she just liked that he listened to her, apparently that puts one in a patient role even in a romance). Paul harshly accuses Gina of "jumping to conclusions" and of rushing the therapy by making interpretations that should wait for months if not years. Funny, didn' t I just say he did something similar with his patient Sophie? Kate weeps and storms off. Apparently you can't have psychotherapy without beverages, a few choice obscenities, and someone storming off.

You know, spell check doesn't like "shrinky" or "oy".

Thursday, March 06, 2008

Shrinky Stuff

Behind me, a teenager is watching a Law & Order episode about a dead psychiatrist who was sleeping with one of his child patients. And his wife was a former teenage patient. Great.

Here's a link to a new Psychiatry Blog, Frontier Psychiatry:

Oh, and here's a grassroots mental health organization, check it out:


And from today's New York Times, pointed out by one of our readers, Penelope Green writes about psychotherapists' home offices in What's in a Chair?
and with such a topic, we're brought back to HBO's In Treatment. I'm on hiatus, maybe tomorrow.

TWO Sundays ago, Lewis Aron, director of New York University’s postdoctoral program in psychotherapy and psychoanalysis, organized a salon for his peers. The topic? “In Treatment.” Two hundred analysts showed up. “It went like this,” said Dr. Aron. “Someone would stand up and say, ‘Hi, my name is Judy X and I’m addicted to ‘In Treatment,’ and then everybody would say, ‘Hi, Judy!’ ” For two hours, the analysts discussed the various mistakes Weston makes regarding boundary issues, and one analyst broached the idea that the placement of his office in his home was the cause of his many transgressions.
No, I don't need a self-help group. I'm not sure if the Times article is more interesting in it's mention of the psychiatrist who had nude watercolors of herself in the waiting room, or the doc with the dog, training pads and all, in the office. None of the Shrink Rappers have home offices. Roy, however, does have a 28-inch monitor, and I have monitor envy.

Wednesday, March 05, 2008

HBO In Treatment....Back for More

Laura un-fires Paul as her therapist. She shows up with maple syrup. They sit on the couch together and she talks about her father in the ICU and Paul declares his "very deep feelings" for Laura. She talks about her regret for sleeping with an older man as a teenager, her anger that he'd slept with her at all. Paul holds a distressed Laura, he talks about his own longings for a teacher who agreed to a kiss, but then Paul got scared and left. Paul assures Laura he won't abandon her, he hugs her, offers reassurance and a kiss on the forehead. Laura leaves to go negotiate her father's care. Paul holds his head in his hands. Laura runs into Kate who is taking out the garbage and looking a little less than glamorous. And did I mention that Paul's daughter was in the beginning of the show, upset at finding her father's couch made up as his bed?

Boundaries, boundaries, boundaries. It's a no-no to breach these boundaries with any patient, but there is something particularly distasteful about doing it with a woman who is talking about her distressing past sexual relationship with a male authority figure. Mercifully, the episode was only 23 minutes long.


On Tuesday, we discover that Kate is not happy about seeing Laura outside. "I thought you said she quit therapy." And Alex arrives: "I'm glad you came back" says Paul. Really? He spars with Paul, talks about how he's killed people, offers a dream. And of course he drinks water. It's another therapy/beverage session. I didn't make it through the whole session.....tell me if I missed anything....


So one of our commenters asked:

I really enjoy reading a psychiatrist's impression of the series. I have been following the series and am really shocked! All the patients seem so hostile toward the doctor. In real life, do you see this type of anger when people try to get help and work through problems? I just think it is so weird. Thanks!

Dear Anonymous Commenter: No, in real life people are not hostile towards the doctor. It's not that people never get angry or annoyed, but a) it's occasional b) it's not this kind of instant outrageous hostility. I think this is pretty weird, too.

Saturday, March 01, 2008

HBO's In Treatment: The sub-blog. I Can't Take It Anymore

I finish what I start. Oy. I thought it was over, I thought yesterday's episode was the last. What more is there to say? Paul has hit a patient, couple from hell are divorcing, his wife has broken off her affair, they are now in therapy with Gina (mentor, supervisor, therapist and couple's therapist) where Paul has announced his feelings for Laura. Sophie has done cartwheels on the couch and overdosed on Paul's pills. She's cursed at her mother. Alex made espresso and became as aggressive as one could imagine a patient or anyone else being-- prompting the attack and the famed espresso being thrown on him by his shrink. There was the miscarriage on the couch. Is there more to say? "It's chaotic, disrespectful, and unproductive." That's what Paul said about Jake and Amy's couples' therapy and that about describes all the rest of the sessions.
I thought it was over.

So the judge came for coffee yesterday, curlers carefully in place, Tex barking up a storm. She handed me The New York Times-- "here, they have your show in it."

I link you here to "He Listens. He Cares. He Isn't Real," an article about the dreamy Dr. Weston. Dreamy? Annoying. I got to the last line and realized the show goes on until March 29th. Oy!