That's Entertainment???

I don't have time to clip my own coupons. Why would anyone ever want to watch someone else shop with coupons? There's a whole segment of life I just don't understand. Roy? Clink? Can someone explain this to me?

Pharmaceuticals in the Information Age--Guest Blogger Dr. Mitchell Newmark

Look, I found Mitch, a classmate of mine from medical school, when he started to follow me on Twitter. Only I don't tweet (or I don't "emit tweets?" Sometimes I squawk, does that count?). I sent an email and while we were catching up, I invited Mitch to be a guest blogger.

Pharmaceuticals in the Information Age

It’s become a standard for me, when prescribing psychiatric medication, to ask patients if they intend to look it up on the internet. I think the internet is often a terrible place to go hunting for information. Either you’ll find a company sponsored site with happy faces, bells and whistles, or you’ll find disgruntled groups of patients denouncing the evils of one pill or another. The “impartial information” sites are frequently as toxic, especially for anxious patients, who can read through a comprehensive list of side effects, with little reference to their frequency or importance. And who knows if the information you’re finding is up to date? If a patient is paying to see me, it would make sense to bring his or her worries (Will my hair fall out?), concerns (Will this make me gain weight?) and fears (My friend took this and had a terrible reaction!) to me, not to the Web. If patients do want to Google their Rx’s, I ask them to send me whatever information they find which disturbs them. At least I can try to address the questions the internet has raised.

Even worse are television commercials for medications, which are unavoidable. I find that I need to watch at least some network TV just to keep up with what patients are seeing. How confusing to see such pained sufferers become spontaneously functional and cheery, while listening to the diabolical audio undercurrent of debilitating side effects. I know the messages are powerful; I frequently meet a new patient who comes in specifically because they saw a commercial for Abilify or Pristiq or something else during their favorite show. At least these drug mini-dramas do patients the courtesy of asking them to “ask their doctors.” Every patient is different; what works for someone, or causes side effects for someone else, is often an unknown. I find commercials send the message that THIS medicine will fix everyone.

Mitchell Newmark, M.D. is a psychiatrist, living and working in Manhattan, who is both a psychotherapist and psychopharmacologist, with a subspecialty in addictions.

Charlie Rose: The Brain Series: Mental Health

In case you missed it, Charlie Rose had quite the guest list this week in Episode 9 of his Brain Series:

Helen Mayberg , Jeffrey Lieberman, Kay Redfield Jamison, Eric Kandel, Stephen Warren and Elyn Saks in Science & Health on Thursday, July 8, 2010

Here is a link with the transcript of the interviews: http://www.charlierose.com/view/interview/11113#frame_top

Nobel Prize winner Dr. Eric R. Kandel co-hosts the show with Charlie Rose, and to quote Dr. Kandel from the transcript:

The whole history of psychiatry, which is a culmination of Emile
Kraepelin, is interesting.  We’ve known about these illnesses since
Hippocrates, the great Greek physician in the 5th century, who not
only spoke about depression and manic-depressive psychosis but
specifically indicated that these are medical illnesses.

But this basic idea was lost on European medicine for the
longest period of time.  During the middle ages, even later in
the Renaissance period, these were thought as demonic disorders,
people possessed by the devil or moral degeneracy.

And people with mental disorders were put away in insane
asylums usually far removed from the center of town and often
they were kept in chains so they don’t move around.

Fortunately, this situation was reversed in about 1800.  The
Paris school of medicine began to really express a very modern
view of medical science.  And Philippe Pinel, a great French
psychiatrist, realized psychiatric disorders, as Hippocrates had
said, are medical illnesses, and he began to institute humane
treatment, the beginning of psychotherapy with mental patients.

But from 1800 to about 1900, no progress was made in
understanding psychiatric disorders.  One couldn’t localize
them specifically so one didn’t know is there one mental illness
or are there many?

And that’s when our mutual hero, Emile Kraepelin, came on the
scene. And his textbooks which began to emerge around 1902 and
continued until he died in 1926, he outlines, for example, in this
book in his first three chapters he defines the fact that mental
illnesses are not unitary.  They affect two different processes,
they affect mood, emotion on the one hand, and affect thinking on
the other.

And he defined the disorders that affect mood -- depression and
manic-depressive disorder, and he defined the disorders of thinking
as schizophrenia.  He called it dementia praecox.  He thought it
was a deterioration of cognitive process in the brain early in life,
praecox.

And as you outlined, we have some insight into the nature of
these diseases.  We know that depression is an illness that involves
mood, which is associated with the feeling of worthlessness, an
inability to enjoy life.  Nothing, it’s all pervasive -- nothing
gives one pleasure.

And there’s a feeling of helplessness, of worthlessness, often
leading to thoughts of suicide and, tragically, to suicide attempts
themselves.

And 25 percent of people that have depression also have manic-
depressive illness.  They have the opposite end of the spectrum.
They feel fantastic at the beginning of the disease.  They feel
better than they’ve ever felt in their life.  But ultimately this
leads to grandiosity and frank psychotic episodes.

Schizophrenia is a thought disorder that has three types of
symptoms-- positive, negative, and cognitive.  The positive symptoms
are characteristic I can of schizophrenia.  It’s the thought disorder,
hallucinations, delusions, the acting crazy.  The negative symptoms
are the social withdrawal, the lack of motivation.  And the cognitive
disorders are the difficulty with organizing one’s life and a
difficulty with a certain kind of memory, called working memory,
short-term memory.

Fortunately, as you indicated, we can now see people who have had
effective treatment who have very productive lives.  And Kay Jamison
and Elyn Saks, despite the fact they suffered the this disorder much
of their life, have rich personal lives, both of them involved in
meaningful interpersonal relationships, marriage, that is very
satisfying to them and having spectacular academic careers.

So there’s tremendous hope for the treatment of the disease.

Clutter Free Reality TV and My Fantasies.

Patients have been talking about a TV show I'd never heard of: Clean House.
It's a reality TV show where they come in and help the clutter bugs get rid of their stuff. I've never watched it (obviously). This is entertainment? My patients say they watch it then go throw some of their stuff out. Entertaining and therapeutic. It's funny (as in kind-of-ironic, not ha ha), but people spend a lot of time in therapy talking about their clutter and the piles of paper they can't part with. I suggest bonfires, but hey.

So I started thinking about this whole reality TV show concept, and the fact that I'm writing about psychotherapy (now done with 2500 words of What Is Psychotherapy). I had this fantasy about having a real life therapy podcast. Roy once talked about how there was bound to be a reality therapy TV show. Couldn't I do a start-to-finish psychotherapy podcast and put it on iTunes? I've got the microphones, and I could probably get Roy to teach me how to use all these gadgets. It might be interesting, it might be something people could use to teach (Gosh, that therapist says dumb things!) or it could be really boring. How does one logistically recruit a patient for such thing? Is it ethical (hmmm...) to offer free psychotherapy in exchange for allowing it to be broadcast on the internet? Could anyone relax and be themselves? What if it got up close and personal and the patient wanted out? Obviously, you stop, but then what becomes of the therapy? Funny, they didn't deal with these issues in medical school.

Okay, it's not happening. It was just a fantasy. I'm going to clean out my closet now. For real.

Making Sense of a Senseless World.

You think this post is about psychiatry. Or life in general. Here is going to be the secret, how to unravel it all so it makes sense.

Ha! Tricked you! I just found an article in the New York Times (from 1.15.09) called The Man Who Makes Sense of 'Lost.' It's about Gregg Nations, a man whose job (he gets paid for this!!!) is to keep track of the plot lines for the TV show LOST, a favorite of both Roy and I. This is the thing though, I watched the first season on DVD on vacation, 2-3 episodes a day, it was riveting, no commercials, no waiting a week to see what happens. I watched a couple more seasons on DVD, but not at the same rate, and the plot started to get a bit confusing. Or rather there were too many different plots going on at the same time and more and more plot lines started with more questions being asked but not enough being answered. And I caught up to the real-life show, and now have to watch it on TV, with the week-long breaks between episodes, noise of regular life, and season breaks. The show travels back and forth through time, I never figured out why Benjamin (the bad guy) was shown for a flash as a security screener in the airport in Australia, or what was with the polar bear on the island, and now we travel back and forth in time in vague and mysterious ways. There are puffs of smoke, bodies lost and found, lovers in countries down the road, and an island that splits and has the magic power to heal cancer and paralysis Nothing quite rivals that first season, with the number sequence that had to be typed into the Dharma station machines ever 108 seconds or else...or else what?

So I'm Lost. It was good to read that other people are Lost, and that even the show's script writers have trouble keeping track of the intricate plot. I didn't realize there were over 100 characters. Will they be my Facebook friends?

And Therapy Patient, there had better not be 20 million people headed to Washington on Tuesday. Shrink Rap will be reporting.

Guest Blogger Eric Kuhn from CBS News on Easing the Pain

Hey, so we got an email from Eric at CBS. He wanted to tell us about a series CBS is doing on pain-- too late to watch, but I'll put up his synopsis and links. Cool stuff. And Eric, remember us when the Shrink Rappers get the book together!

Eric writes:

I have been reading your blog and think it is great. I thought you might be interested in a story that we are doing this week about pain.

EASING THE PAIN
February 19 – 21

Tuesday: NERVE STIMULATORS
Dr. Jon LaPook reported on a new kind of nerve stimulator in the final stage of FDA trials to treat pain. It's a headset that pulses electric currents to the back of the head and users say it works miracles to stop the throbbing. We follow a man with excruciating knee pain for a week of treatment to see firsthand what a difference it makes. It works because electrical currents somehow change the brain's perception of pain. Check it out the story that aired here - http://www.cbsnews.com/stories/2008/02/19/eveningnews/main3849876.shtml

Wednesday: ABUSE PROOF DRUGS
Dr. Jon LaPook examined the newest aspect of pain management, which are drugs that are called "Abuse Deterrent Opiates". These drugs can help prevent people from getting physically dependent on opiates, because they don't work if they're crushed and taken improperly. Doctors face a huge dilemma when trying to balance treatment and risk of addiction at the bedside. We'll meet people you'd never expect to become addicts, but who wound up getting hooked. We'll meet others for whom this new drug relieves the pain without risking addiction. Check it out here - http://www.cbsnews.com/stories/2008/02/20/eveningnews/main3854165.shtml

Thursday: BABIES' PAIN
CNN's Dr. Sanja Gupta reports on how there is no gold standard for measuring pain and discomfort in babies, especially newborns…however there is a clinical trial of a facial recognition technology to identify pain in infants. The initial research used photographs of infant faces but now there is research using video images. Catch this TONIGHT on the CBS Evening News with Katie Couric at 6:30 PM EST.

In Treatment....Episode? Lovely Laura

I'm a day behind and Roy wants me to write about a NY Times article on therapists in therapy. I'll get there.

So yesterday, Laura comes to talk about her sexual experiences with Paul's patient Alex. Way too much information. She is goading him, if I can't have you, then I'll sleep with Alex. Alex might as well be a dirty dish cloth. She returns to her feelings for Paul and pushes him: "Yes or No, Is this an intimate relationship." Paul says yes. She talks about hating herself, and this is where everything turns-- Paul talks about hating himself when he didn't do a good enough job caring for his ill mother when he was a child. They linger a little too closely as they say goodbye. And, oh, she owes him for the appointment.

So I didn't have a problem with Paul saying it was an intimate relationship, only this wasn't really the question. The question was "is this a special relationship?" He could have told her it was an intimate relationship, but that therapy is by it's nature intimate, instead the idea was transmitted that he also loves her.

Sometimes therapists decide it's useful to reveal personal information to patients. Sometimes it's comforting to know your doc has "been there." Here, however, Paul opens up his vulnerabilities to Laura at a time when he should be setting boundaries. He's let her know that he also lost his mother at a young age, he's "been there" but, like he told Gina, it feels like he knows where to press to get what he wants, and what he wants isn't what either of them should have....

In Treatment: Episode ?....Paul Continues In Supervision With Gina, Sort Of

For those of you tired of In Treatment, there's a "real" post below. And Roy promises me he's putting up our heated to-benzo-or-not-to-benzo post today [20:31 ET: I'm working on it now. -R]. The end of this post talks about the differences between psychotherapy and clinical supervision.

So Paul returns to Gina for supervision. Every word out of her mouth, he jumps on. Why is he going? He blames her for encouraging him to terminate with Laura, the patient who wants to sleep with him, and he finally admits what we all knew: that he does, indeed, fantasize about Laura.

Every exchange between Paul and Gina is charged, aggressive, angry. These people want to be in a room together why?? They call it "supervision" and Paul talks about his fears that his urologist will think he has small genitalia. It all seems more like psychotherapy to me, not supervision. Angry psychotherapy without a clear agenda and purpose, at that. Paul is as defensive a supervisee as one could imagine any patient being. It's not fun to have this session on my TV screen, I personally, wouldn't want this guy in my office. Did I once say he, as an actor, is hot? I take it back. He started the series as a warm and likable therapist. Most of what happens on this show, no longer feels like anything that happens in my office. For this, I'm grateful.

One of our readers asked the difference between psychotherapy and supervision. Psychotherapy...well that's hard enough to define, but let's just say it's talk therapy to address a problem. We've been there in lots of posts before. It's all about the patient.

In supervision, a psychotherapists consults with another psychotherapist, usually someone older & wiser, about the treatment of patients. "Supervision" implies to me an ongoing process, while "consultation" can be a one-shot deal. The topic of discussion is generally limited to the patient and the interactions between the two of them. Certainly, the supervisee might bring up issues in his own life that feel relevant, but that's not main focus, and discussions of intimate personal matters aren't generally part of the discussion--- if the therapist needs that, a formal psychotherapy is more appropriate. Supervision isn't, by definition, cold or impersonal-- I always ask people I work with about their personal lives in some form-- how they are, if they have families, where they went for vacation, and they often ask the same of me. If a supervisee has been ill, they may chat about that, but it's generally determined by how much we 'click' and polite conversation.

Paul and Gina, the TV characters, can't decide what they're doing or even why they're doing it.

Mandatory Reporting...more thoughts on Sophie

Okay, I'm still talking about this TV show, the blog post is a response to comments on yesterday's In Treatment episode on Sophie. Please, remember it's fiction.

In Maryland, the law is that mental health professionals must report any child abuse issues. It doesn't matter if it happened 40 years ago, if it happened in another state, if the perpetrator is dead, this is either the law, or the attorney general's interpretation of it, and it's how mental health professionals operate. Okay, it can be silly, I'm not a detective, I'm just telling you law. And on the information sheet I give patients, it has a line that says that there are laws regarding confidentiality and issues of child abuse.

The Sophie issue is more clearcut-- this is recent sexual activity of an adult with a child and the adult continues to have contact with her and with other children. No issue legally. I won't comment on the therapeutic ramifications about trust, because, well, there's no legal ambivalence here. For those who aren't watching the show: Sophie lived with her gymnastics coach for a while, for months his wife was out of state, she cared for their child, had a relationship with coach, slept with him (mentioned that before they had sex, everyone assumed they were), and after the session, Paul calls her mother to ask her to come in.

Throughout the session, Sophie looks childlike and younger than her stated age. I believe the TV folks did this on purpose.

Here are my thoughts:
--Paul should have told Sophie that he's obligated to report this. Yup, given that she loves the coach, this probably would have ended the therapeutic relationship, but preserving the therapeutic relationship is not the most important thing in the world. Remember, this is the coach who picked her up from her last therapy session.
--Paul should not have called Mom without discussing it with Sophie.
--Do we believe this? Kid lives with coach, her parents allow this, his wife is away for 6 months, everyone thinks they've been having sex, which they do, and coach the pedophile-criminal transport kid to therapy where she may snitch on him and get him locked up for years?
It would be interesting to see what Sophie said when Paul told her he had to report it.
Next week, perhaps?

And I have wondered if the show is taking place in the DC suburbs.

I'm still thinking about my response to ClinkShrink's last post.

In Treatment: Episode 13....Sophie

ClinkShrink has asked me to reiterate that this is a "Painfully Silly" show.

Sophie kicks her backpack towards Paul. She has brought him a model boat, he is delighted.

"It must really suck having to listen to other people's problems all day." Oh, I hear some version of that a lot. I remind people that I chose to be a shrink, I actually kind of like it.

Sophie and Paul change seats and she plays Shrink for a while. He treats Sophie with a gentleness and fondness that he doesn't have for his adult patients. It's as though this is the one patient we meet who isn't laden with noise for Paul, he looks younger while he sees Sophie. They talk about "what if I'm a therapy patient" and Paul does a nice role induction. Sophie tells Paul angrily about her parents and how they split and how they told her.

Sophie talks about her relationship with her Coach, Cy, and we aren't surprised to hear they've had a sexual relationship while Sophie was staying there, caring for their daughter, while his wife was away for months. It's all a pretty sad story and Sophie feels responsible for Cy's marital problems. She left their house and had her near-fatal accident.

Sophie goes to the bathroom. We will she kill herself in there? Something shatters. She broke some picture frames, she's worried she'll hurt their relationship. She demands that he determine if her accident was a suicide attempt. She screams and curses at Paul.

These people are worried about the insurance company and whether something that happened weeks ago was a suicide attempt....they don't even mention that she was sleeping with her adult coach-- ummm....she calls him a 'gentleman,' a really good guy. Paul never counters this. Sophie talks about how she messes everything up. They say good bye at the door. He calls Sophie's mother and asks to meet with her. Shouldn't someone be more concerned about this kid's imminent safety and arresting the coach?

In Treatment: Episode 12....the sub-blog

[Posted by Clink (thank you!) Commentary by dinah]

I think I may have reached a new low in blogging. I am posting a blank post.

Dinah called me when I was on my way home from work to ask me to put up a blank "In Treatment" post so that people would have some place to comment on the show until she could get to the blog.

_____________

Okay, so this episode, Alex returns to see Paul with a top-of-the-line Italian espresso maker gift gotten off EBay, well, I found myself dozing.

Alex brings the gift, a dig at Paul's awful coffee from the week before, he walks in, moves a model ship, a family photo, sets it up, starts brewing. Paul clearly feels invaded and uncomfortable, they agree it will stay for the duration of Alex's treatment.

Alex talks about his family: his friendless geek son whom he finally realized is happy with himself, his successful wife, his virtuoso mother, his philandering father. Oh, and he left his wife Michaela. Paul draws parallels between Alex and his father, we see the anxiety this brings out in Paul who is dealing with his own lovelorn marriage.

Guess what? Alex met Laura outside and they went out. Alex figures shrinks don't like that, that there are ethical issues for the shrink (huh?).

So I don't know what this episode was really about, it was pretty boring. Power, I guess, the two men struggle with every aspect of their relationship-- will Paul accept the espresso maker, will Alex date his patient, will Alex accept Paul's interpretations of his family dynamics?

Lacking is substance, is that what ClinkShrink said?? Actually I think the show is a pretty good springboard for discussion. I do hear that some folks are tired of it....we'll try to mix it up. Roy? Roy? What's going on down there.....

In Treatment: Episode 11....the sub-blog

Mike Huckabee was on Meet The Press discussing how he cooked squirrel in a popcorn popper in his college dorm. That is so weird.

Okay, back to our show here:
Paul is sleeping on the couch in his office, fully dressed, rudely awakened by the alarm. His idea or Kate's?

Laura is 25 minutes late, she asks for water (also a common theme on this show, no wonder they all have to go to the bathroom). She's come in a cab and she watched a dog get hit by cars, repeatedly. "I had to get him to a vet. You would have pulled over?" Paul responds, "I wouldn't have pulled over, I'd have assumed he was dead and there was nothing I could do."

He points out that she would have been late, dead dog or not, "I would have appreciated a call." She accuses him of being "anti-me."

"What do you think your being late is trying to say to me? Maybe you think I'm not doing my job?" "Are you angry with me? Maybe we need to talk about what good this therapy is doing you." She talks about her distress at the end of the last session. "You're trying to make me angry. I can't win here." She curses him out. "You don't have to love me in return."

"Now I see why they laugh at shrinks and their ridiculous interpretation." She talks about her helplessness as the patient, about having an idiotic theory thrust on her.

"Maybe I'm not helping you at all," Paul says.

They talk about Laura's upcoming marriage, how she hasn't told her father, though her husband-to-be has blasted his whole e-addressbook. He returns her to the issue of her being late.

"You want to kick me out of therapy." He says absolutely not, but then says they should think about winding down. "You don't want me to treat you as a psychologist (he really garbles this, did he say ologist or iatrist?)....I'm the one who says No, who humiliates you. Therapy should not be a source of constant humiliation for you."

"Am I the first patient to be in love with you, Paul? Maybe you can't treat me because you're in love with me Paul?" She's breached the boundaries. He ends the session despite her pleas for more time and Laura storms off while Paul tries to hand her the bill. Laura bumps into Alex, who has arrived for his session a day early. They flirt on the street and they drive off together.

Oh my, so we've got early patients, late patients, popping squirrels and dead dogs. Patients in love with shrinks ramming unwelcome theories at them, and an uncomfortable doc who wants the patient to leave.

Okay, so I still don't know What Paul is. Laura made a reference to med school, so I thought a psychiatrist, but there's never any mention of meds. Of course, with all that water, one might think everyone has dry mouth from their medications. One of our commenters has said he's a psychoanalyst, but I don't think so, his patients come weekly, not daily, and he doesn't have an analytic set up with a chair behind an analytic couch (these are rather specific couches).
Paul and Laura have a discussion that epitomizes the type of power struggle our commenters often worry about. Another episode where no one feels heard. You know, the whole point of psychotherapy (or at least one major point of psychotherapy) is to feel heard. These people are getting it all wrong, and I don't blame Laura for feeling cornered. Seems like Paul takes turns with his patients being painted against the wall.

Why can't Paul be honest? It's hard to have a patient declare that they're in love with you, the boundaries are a mess, he's feeling uncomfortable and he CAN'T have a relationship with her, it's simply unethical and he would lose his license. So he went to see an old supervisor, to get another opinion of how to handle a situation that's uncomfortable for him and that is obviously uncomfortable and painful for her. The supervisor wondered if they shouldn't consider transferring her care and he feels that now that that option's been brought up, they should look at it. Laura would be mad, she'd feel betrayed, but at least it's honest, it gives the sense of consultation and propriety, and instead he's pushing Laura away, treating her unfairly, being unnecessarily cold.

And a final thought here-- Sarebear asked if anyone here worries about being sued (I think it was Sarebear)--between making tea and having one's wife dress one's patient in their daughter's dry clothes. Really, there's nothing to be sued for here--- there are only a few boundaries that are set in stone (don't sleep with your patient and don't kill them, for starters). A patient could lodge a complaint that her therapist made her tea, but why? And since he makes tea for everyone, and the question is milk or sugar, not Red or White, there isn't a boundary violation. And giving an injured wet and cold young patient dry clothes, well, it's hard to find harm here. The boundary issues become salient if a patient ends feeling injured, and then the doctor's behavior gets scrutinized. If Laura feels jilted, and she sues Paul, then things like whether he extended the time of the sessions, what he gave her to drink, whether they'd ever met outside of the office, then and only then is it an act that has relevance. Even if a patient and a therapist were to go out for a meal, yes this is a boundary violation, but in the absence of something more, a patient can't sue a doctor simply for going out to eat a meal. It's just a suspect thing to do, and becomes a part of the case against the doctor, if the patient then alleges they had sex.
ClinkShrink, I hear, shares her squirrels with her inmates.

In Treatment: Episode 10....the sub-blog

I'm posting after the fact, but I did watch the Paul-returns-to-Gina episode last night.

Can I give this episode a few sub-titles:
1) Why I don't have a home office.
2) Why don't these people listen to each other?

So Paul returns to tell Gina that Kate really is having an affair: an insurance agent/an employment guy/ a supermarket manager. I guess he wasn't listening. He talks about his disconnection from his childrens' lives and how Kate blames him for his neglect. While Paul has mentioned once last week that a patient says she's in love with him, that "erotic transference" thing, he hasn't said much about it, and Gina repeatedly and insistently-- as if by crystal ball-- comes back to the feelings Paul must have towards Laura as the source of his marital woes, and therefore, we can assume, in having some role in Kate's need for another relationship outside the marriage. He does eventually confess that Laura's beautiful and he 'enjoys' the flattery and the feelings. But well before this, Gina was probing him-- Laura could have been the ugliest, most unavailable woman in the world-- but Gina was insisting. I hate it when therapists do that--sure, patients repress things or don't see the obvious, but in real life, you're just testing theories, and if a patient backs away from an idea, you figure that either you (the therapist) were wrong, or that the patient needs more time or a new way to see this, and you back off. You don't ram your theories down their throats. Or I don't. It was interesting that Paul was eventually hammered into looking at the connection between Laura and his feelings, but it could have just as easily turned into a repeat of last week's screaming sessions, and unlike any of my patients, Paul has the benefit of a professional script writer to compose his lines for him.

Paul talks about Kate's jealousy of his home office, of her feeling excluded and not important to him. He mentions that she was in it after the miscarrying couple left (he didn't mention that she was there because he barked an order for her to come help with the damn spot), and he mocks Kate saying "What Happens In this Office?" Nothing in their real life compares to what goes on here and she never feels like his top priority. I ask my husband if he ever feels that my work comes first, and he says "never" (1 point for Dinah, zip for Paul). I hate to offend anyone, but much of what goes on in a therapist's office is mundane, while neat things happen, or there are frequent I-wish-I-could-write-about-this-on-my-blog moments, it's not that magical.

I think about our real life house-- it was built generations ago by a doctor and some form of doctor has always owned it (--we are the first family in which that doctor is the wife, not the husband). There is a separate entrance, and until the owners before us, the first floor was divided into a physician's office. I don't really know what the layout was, but as we
doing the final walk-through, the former owner (a hospitalist who didn't have his practice at home) pointed out that a radiology tank used to be where our TV now is, the bathroom had been relocated, essentially, our "playroom", family room, laundry area, were all somehow a separate physician's suite. It wouldn't be so hard to reconfigure this into a shrink's office, with the separate walkway and door already there, and people have asked why I don't have an office in my house. So if you watched In Treatment the last few days, you know that spending a few bucks on office rent, especially if you have a family and all those bathroom issues Paul seems to have, isn't such a bad idea.

So we move on to learn that Gina's husband David died just a year ago. And here's a fun subplot: Paul had referred his good friend Charlie to Gina for treatment. Charlie fell in love with Gina and he told Paul that Gina was in love with him. We see from her face this is true. Charlie, like David, is now conveniently dead so we can talk about all this with no hope of fixing it. Paul is angry that Gina's response to her feelings for her patient/his friend was to run away to England on sabbatical with her husband. Huh, Charlie was her only patient? No college tuitions or morgates to pay, I suppose. Paul writes her script that THIS was the reason why? There's no room here for other possibilities--- requirement of David's work, once-in-a-lifetime opportunity, nope, without asking, he's told her that she dropped her practice, picked up her hubby, and moved across the big pond to escape Charlie. Gina flinches so we figure it's true, but a little more convincing with the script writing, huh? Why don't these people Ask, try out their theories, consider other options. Paul mentions there sessions are like debate teams where everyone goes in ready to plug for their side without hearing the other's side. Yup. This isn't therapy and it isn't supervision, and it's only by virtue of television that they haven't thrown those pretty water glasses at each other.

Just for the record, Paul says if he transferred every patient he was attracted to, he wouldn't have a practice. Interesting. I don't believe that's the usual.

In Treatment: Episode 7....the sub-blog

[Go to #6]

Alex returns from Iraq where he went to see the damage done by the bomb he'd dropped. First, he criticizes Paul's coffee, asks about Paul's heart (remember, Alex had had a heard attack) and Paul tells him a story of a patient who began every session by popping a pill.

Alex felt nothing as he looked at the people he'd mutilated. He felt nothing. His ability to feel guilt has been removed, like an organ ectomized. Paul talks about how he felt nothing at a friend's funeral...the story does not resonate for Alex.

Alex talks about an old man in Iraq who appears to have recognized him as the bomber. From there they talk about Alex's father, how he'd killed his own father, suffocated him to keep him quiet as they hid from a mob set to kill them. Alex's father had no guilt or he wouldn't have survived.

Alex is here today to talk about his marriage. "I saw my wife, I really looked at her." She was sleeping in front of the TV, he watched her for an hour straight. Does Paul ever watch his wife sleep this long? No, Paul falls asleep first. Alex asks, "Who the hell is she and what am I doing with her." Paul looks tense-- oh Alex is hitting on Paul's own insecurities about his own stale marriage. "She grinds her teeth, she takes it all out on her teeth at night....she is a totally repressed person," Alex says. Alex's wife Michaela is on a mission to get him back to work, everything with her is clockwork. "Michaela's dying for me to go back."

As Paul talks about Alex's marriage, I wonder if he's talking about Alex's marriage or his own. Alex announces he's suddenly realized he was never in love and now he knows he needs to leave the marriage. Will Paul deal with his own issues, will he leave Kate. "There must be tremendous relief in walking away." "Maybe you're leaving yourself not your wife."

"Again, I feel like a rubber stamp for a decision you'd already made. You're really asking me to accept responsibility for your big decisions. These aren't conclusions you've come to here on this couch in the last week with my permission. They've been boiling over inside you for a very long time."

"My time is up." Alex pays in cash and storms off. "I'll keep you posted."

It ends and I asked my husband, "What was that about?"
"He makes up his mind what he wants to do and goes to the doctor for validation."
"Oh," I said, "I thought it was about Paul's marriage."
I wonder what Roy and ClinkShrink think.

In Treatment: Episode Number 6......the sub-blog

[Go to #5]

What is a "sub-blog"? My husband says he invented the term. And Laura, the patient with the erotic transference who sat in the dark for 4 hours waiting for her appointment in a little black dress, will return.

Episode 6 starts with a clogged toilet, an irritable psychotherapist who can't unclog it, an annoyed wife who doesn't get why the patients can use a different bathroom. Bathrooms play a bigger role in this show then they do in life as I know it.

Laura announces she's getting married, she talks about wanting to invite Paul to the wedding, he's a bit uneasy, "a kill joy...that congratulations was a bit labored."

Paul talks about diving, coming to the surface to quickly. Laura is a certified diver, she's happy they have an interest in common. "I don't want a depressing session, I want a happy session, show a little support."

Laura talks about a visit to her fiance's ex-girlfriend's house, her baby, how she breastfeeds the baby and how the ex-girlfriend is now a domesticated animal. Laura talks about sex, she is provocative, she flirts with Paul asking him about post-marital sex, he is clearly uncomfortable.

"You didn't answer my question, Laura. Where did this "yes" come from." Paul wants to know why she's agreed to get married.

"It's because you said "no" to me."

"We're still talking about the reality that I'm in love with you, Paul." She's insulted when he talks about fantasies.

Another uncomfortable session. Roy, Roy, please email me a Xanax. I feel for Paul, for the corner he gets painted into, for the pressure of Laura's flirtation, for his difficulty in not squirming.

Paul takes Laura back to the summer she spent in San Diego when she was 15 after her mother died. She stayed with a couple, the man was a life raft, Laura wanted him to adopt her. "Perhaps I'm an alternative to everything that Andrew represents."

Laura has to pee. The toilet is clogged, Laura wants to use another bathroom in the house. "I prefer my patients to use this bathroom." She is annoyed. She stands next to a bookshelf with a video on it labeled in marker "Wedding."

"Look, I know when I turn somebody on. The first time I saw you I thought you looked like a dead man, I wanted to take your heart in my hands and pump life into it....Just my being here has brought you back to life....and you deny it. I know it happened and you know it happened."

Paul responds...oh so cliche..."I think we're out of time, why don't we talk about this next week when you come back."

"Just tell me, I think you owe it to me, do you want me."
"No."
Oh, but we know he means Yes.
------
Okay, so someone out there is going to ask if this happens in real life. Roy, you have some of Paul's unflappability, his gentle patience that's hard to ruffle: Do your patients announce their love for you? Never mind any patient, Laura is hot, she's a doctor, she's smart and sexy and she scuba dives. She's raw and longing, injured from adolescence, someone I imagine a man might want to repair.

I've never had the male equivalent of Laura come on to me like this. Kind words, a general sense of (often mutual) affection or respect or fondness, but no patient has ever come on with a strong and crass "I want to sleep with you." And if I get through my career without such an event, it will be just fine. Of course, I'm not as hot as Gabriel Byrne.

Paul's office is in his house, it's cluttered with his stuff, he's not a blank screen. He wears a wedding ring. Some psychiatrists don't wear wedding rings-- I've only known of men who don't, yet I've never met a married female psychiatrist who doesn't wear a ring. And maybe it's only been psychoanalysts who don't wear rings, who don't want to open the session to questions about their personal life. If you ask me, it's a dumb idea-- the presence of the ring removes an element of possibility from most people's realities. Laura doesn't care about Paul's marriage and, in a way, her high pressured appeal for love and sex is sociopathic and narcissistic. The whole bathroom thing is weird, but we knew it was coming from the tension between Paul and his wife and his edginess right from the start about what bathroom his patients would use. Laura is on to something when she talks about how Paul doesn't want her to see his wife or his wife to see Laura.

The reality is that male psychotherapists get into trouble with sexual boundaries much more often then women. Perhaps it's simply because more psychiatric patients are women, maybe it's because there are women like Laura who are so seductive, maybe it's because men are more susceptible to....oh my, I'm going to get myself in trouble here.

So a little less plot synopsis, a little more commentary. How'm I doing?

[Go to #7]

In Treatment: Episode 5...the sub-blog

[Go to #4]

Paul returns to therapy. It's been a while, he can't remember where to park, he takes the therapist's chair. She tells him about how awful it is to be 60. She asks for his drink order, offers him a piece of sugar-free cake. They talk about Gina's deceased husband.

We hear about Paul's kids-- Max is 9, Rosy is 17, Ian is at college.
"I called you last night because I needed to talk to somebody. I feel that I'm losing my patience with my patients. There are sessions where I can barely restrain myself from an outburst. I wish everyone would go away.

He talks about how badly he feels for telling the couple to have an abortion, he talks about Laura's erotic transference. "If patients could see what goes on inside my head..."
Paul talks about the fighter pilot who bombed the Iraqi school. All the time I listen as if it's nothing...it's so disgusting."

"Were you insulted that the patient called you a murderer?" Gina asks.

Paul talks about the lack of praise one gets from the lack of an audience, Gina talks about how she meant they had no one to criticize or critique.

Gina talks about how angry Paul was with her when he stopped coming 10 years ago, how he was so angry he didn't come to her husband's funeral. She talks about how Paul had accused her of interfering with his practice. Gina is retired. She's trying to write a novel. Go for it Gina! No wonder I like this show.

Paul tells Gina that he and his wife, Kate, argue non-stop. Kate has taken Max to a class for gifted children behind Paul's back. "If you cared as much about your family as you cared about your patients....she says I don't love her that I'm always a step ahead of her....she says I never have any perspective. All I can see is rupture."

Gina was his supervisor for 8 years. Now they talk about whether he's talking to her as a therapy patient. "You keep saying you didn't come to talk about Kate and you keep talking about her."

So Paul has been so unflappable, here we see him flap. I'm a little disappointed. Paul worries that his wife is lying to him, she doesn't take her sneakers when she says she's going to the gym, she doesn't answer her cell. Shades of his patient Jake. And sex is out of the question. "Once a month if I'm lucky.... I think about it ALL the time."

He makes a Freudian slip and refers to the patient with the erotic transference instead of his wife. Gina says it's a test of his marriage. "Please don't draw any conclusions because there are none to be drawn."

This is a heated session. "What are you trying to prove here Paul, that you won't talk about Laura?" Paul gets angry, "You twist everything." They are fighting. She asks Paul if he slept with Laura. "You're making it really difficult for me to come back here to talk to you....was I that big a disappointment to you?"

"I hope your novel doesn't stink this long.....you're failing at everything."

I take it back, it's not a heated session, it's a Hostile session. I'm tense just watching these two people. "You are not being helpful," Paul says.

"What role have you assigned me?" Gina screams.

This is....therapy? supervision? oy. Gina tells him how hard it's all been on her, how confusing it is.

"You've been waiting for this to happen, Paul the failure."

The two agree this wasn't such a good idea. Gina suggests professional help. Paul doesn't need it. "I'm not angry, I'm really not."

This was hard to watch, nothing about it felt good, nothing about it felt helpful. Therapy, supervision, whatever the hell that was, it needs some warmth, some trust, the anger, if there is overt anger, needs to be a sub-plot, not the fuel for the relationship. These two people need something. I could use a Xanax.

My husband's opinion: "Winner of the most annoying patient of the week award goes to the psychiatrist (Paul)."

[Go to #6]

In Treatment: Episode 4.....the sub-blog

[Go to #3]

Let's be real here: ClinkShrink's been eating donuts without me. I have no idea what Roy is doing, all I can say is that it had better not have anything to do with chocolate. If in doubt: eat dessert first.

I'm having trouble keeping up and my TiVo-todo list now has LOST and 2 episodes of In Treatment. I skipped a dinner & movie invite for tonight to stay home and watch TV, I have now officially become pathetic. Pass the popcorn and hit Play!

------------------------

The patient is on the phone with his son; Paul the therapist listens. "Are you eating fritos?" It's raining outside. He calls his wife, and already we know Jake is one angry dude. "Where the hell are you? Don't f***ing tell me you forgot we have an appointment with Paul."

"Are you comfortable being here with me without Amy?" Paul asks. Oh good, Paul is talking about the therapeutic relationship, and our readers have asked for some comment about this. Even I'm sick of listening to Jake on his cell phone, he's impatient, annoying, tiresome, agitated, aggressive, and pissy. He even screams at his mother-in-law.

Amy shows up. Jake is relieved. Jake is inquisitive, jealous, we know where this is leading. He interrogates her about why she's in a different outfit from the morning, why did it take her so long to get to the appointment. Paul asks, "Is your being late an indicator of your not wanting to be here?" More about the relationship. Is Jake worried that Amy is hiding something? She spilled coffee on herself and bought a new outfit. Jake wants to end the session. "How much do we owe you Paul."

"She went to finalize the abortion."

Jake is suspicious of Amy's relationship with her fertility doc.

"She can't talk to you about this abortion because you suspect anything she says."

"I'm the one at fault here?" Jake is outraged.

She's not sure if she wants to be pregnant again. She's hiding things from Jake. "I'm not sure I'll be able to love another baby....I know I'll have post-partum, I see it coming and it paralyzes me...I scare myself to death."

"You're insane," says Jake.

"I want to make my own decision and if playing the part of a depressed wife will do it, so there."

Amy, we learn, is a self-professed liar. And we hear about Amy's anger about five years of fertility treatments, how violated she felt. Amy was married before, she cheated on her first husband with Jake.

"You're not really talking about a child, you're talking about your inability to accept each other."

Jake rails at Paul, he wants him to tell them what to do about the pregnancy, he doesn't want to talk about the relationship. "We came here to talk about an abortion...How do you sleep at night?" Jake yells.

"Have an abortion," Paul says. Wow. I haven't told anyone to have an abortion recently. Or ever. Even loudmouth Jake falls silent. "Really?"

And now we get to talk about the relationship.

"Do you see what's happened here, how you shoved me into a corner...this is exactly what you do with Amy. I can't tell you whether or not to have an abortion, I don't have an opinion."

Paul gets mad, he emotes for the first time in 4 episodes. He's not as cool as he was last night with Sophie. Jake storms off. Amy leaves silently and sadly. Paul is pensive, he's wondering, I bet, why he failed. Rattled, he calls a doctor named Gina: it's been a while, he leaves a message.
I suppose Paul is rattled into returning to his own therapy.

Stay tuned.

[Go to #5]

Shows I'd Like To See

Since there's been so much interest in HBO's new series "In Treatment", I thought I'd put up a post about the psychiatry-related dramas I'd like to see some network do someday. Let's face it, most television networks only think of psychiatry in terms of a private therapist's office. There's more to it than that, and I think the public has a right to know.

1. Mobile Treatment
A psychiatrist, nurse, social worker and psychologist team up to provide on-site mental health care to the chronically mentally ill, on the streets and in the community. They respond to police emergencies involving the mentally ill and showcase the problems in our current care delivery system. The show addesses ethical dilemmas, legal and financial barriers to care and how people living on the margins work around them.

2. Is There A Shrink In The House?
A spin-off from the series House, this psychiatrist starts out as a consult-liaison doc in the series House. (I know, Dinah hates House, but you have to start somewhere.) There are clashes and confrontations right off the bat as House's brash, sarcastic style comes up against the psychiatrist's more thoughtful, measured approach. The show addresses the intersection of psychiatry and medicine as the consult-liaison doc teaches House how the brain affects the body, and vice versa.

3. Emergency!
An ER doc and an on-call psychiatrist handle the quirky, spooky and overtly odd cases that only seem to come in after 3 am on a Friday night. The latest hit comedy series which will finally put an end to all the reality show shlock.

4. Pimp My Meds
An NIMH research pharmacologist presents a weekly review of psychopharmacology-in-development, with optional references to pharmacogenetics and neuroimaging.

5. Insurance Court
Judge Judy takes on the insurance industry as denied, delayed and neglected psychiatric cases appeal to the insurance commissioner. In lieu of payment, insurance companies found liable for care may choose from a variety of publicly humiliating punishments.

(By the way, the picture at the top of the post looks a lot like my actual TV, rabbit ears and all.)

In Treatment: Episode Number 3....the sub-blog

[Go to #2]

ClinkShrink has a GREAT Story about her day, you've got to scroll down to the Donut post.

Episode 3

It's about shrinks and parents, a theme close to my heart these days.

Paul's psychotherapy office, we discover, is in his home. A small boy, maybe 9 or 10, sits at his desk holding a thermometer to a light bulb while Paul and his wife argue in the background. The boy wants to stay home, but Paul doesn't buy the sick plea or the temp of 103. "We could rent a movie and watch it," the boy says, but Paul is stern. Boy must go to school, dad must go to work. The boy says, "You never believe me." The shrink dad cringes, we know there's more to it (damn it, there'd better be), we'll wait for another episode.

Patient Sophie is 16, an only child, an Olympic-hopeful gymnast. The handshake over first names reveals both her arms are in casts, and she's been referred by her lawyer. "I'm here for your professional opinion." Translates to, 'I'm not here for treatment.' Sophie was hit by a car while riding her bike, the question has been raised by the insurance company as to whether it was a suicide attempt, and in fact, Sophie had tried a friend's motorbike 2 years before and crashed into a car back then.

Paul asks about the accident. "I told you, I don't remember anything." She becomes uncomfortable. She's already seen a social worker and she didn't like the social worker because she thought she knew everything about Sophie.

"Can you help me with this professional opinion?"
"It's not like an XRay," Paul says, "It doesn't quite work like that." Sophie says she'll leave, but she doesn't. "I didn't come to talk about myself."

She gets angry. She wants Paul to ask her "shrink-like questions." She thinks Paul spoke to her mom, and she and mom clearly have issues. She came by bus, she'd never let mom drive her. Sophie's close to her dad, he's always there for her, but she finds him by calling "411" --Information-- because he moves so often. And, oh yeah, there's Cy the gymastics Coach who drew the topless mermaid on her casts and who's children she's babysat for.

Sophie is angry that Paul doesn't jump at the opportunity to read the insurance report she's brought him. He says they need to meet 3 or 4 times and he wants to read it alone. "Otherwise it wouldn't be professional." He echoes her words with such finesse.

Paul reads. Sophie wanders about his office. She comments on his collection of ships. He has asthma, she finds his inhaler. "Did you really read all those books or are you just trying to make an impression?" "They're your f***ing books, Buster." Oh my. And Paul is unflappable.

Sophie asks about Paul's daughter. How did she know? They are in the same grade, they once went to the same school, he was on the PTA.

They talk about a show that even I'm not old enough to know about "This is your Life" or something like that. Paul tells an angry Sophie that everyone thinks about death. "Suicidal tendencies, blah, blah, blah," she says.

"It's 10 of and you probably have to turn on your cell phone now," Sophie says to Paul. She asks Paul about his relationship with his daughter, she must call him at 10 of the hour. My real-life daughter and I laugh, I because I turn on my cell phone at 10 of the hour, my daughter because "I always call you on the hour because that's when you answer." Why aren't we on TV?

Paul gets water for Sophie at her request. He gently places a straw in it and asks if she needs help. For the guy who wouldn't watch a movie with his kid, he is the quintessential daddy to this patient who so desperately needs a parent. He gives them both an assignment-- they will both write an assessment of the insurance company's report.

Paul is good. He's really good. My daughter says he's old, wrinkly, gray. Nothing fazes him, he never says the wrong thing, he ties everything neatly together. His eyes light up when he smiles, sometimes even when he doesn't. He's a better shrink than I am any day, oh and that faint brogue to top it all off. When can I tell him my secrets?

[Go to #4]

In Treatment: Episode Number 2.....the sub-blog

[Go to #1]

Warning: PLOT SPOILER



Today's patient (well, yesterday's patient, I'm playing catchup) is Alex, I assume the therapist will still be Paul. And you know, Paul is kind of hot.


No denim today. Paul's in slacks, though Alex the patient wears jeans and a leather jacket.

It's Alex's first session, it starts at the door with a handshake and first names. Alex asks if there are ground rules. He looks around, touches some books. Paul jests, "In my profession we say that the customer is always wrong... it's a therapist joke."

Alex has done research: he knows Paul is the best. "So, do you recognize me?" Alex always goes to the best. Paul does not recognize him.

Alex explains that he flew a navel mission which accidentally resulted in the deaths of civilian schoolchildren while they studied the Koran, it was all over CNN. Alex is a wanted man by Islamic fundamentalists.

"You're dying to ask how I can sleep at night. Very well thank you. I hit my target, I sleep like a baby." Alex is smooth, cavalier, steeped in denial if you ask me. (You didn't ask, but hey, it's my blog).

Alex talks about how his father handled his mother's death, an event he deems the most traumatic thing in his life. He imitates his father: 'It never ends, Alex, your mother left such a mess.' His father soon remarried. "A whole life together and not a single tear."

Alex talks about running, his way of getting R&R. He runs with a gay friend named Danny, they go for miles. They run farther than ClinkShrink. Alex pushed Danny, who wanted to stop, to go for 26 miles, a marathon pace. At 22 miles, Alex had a heart attack and "died" but was revived from his 'total clinical death' defying all odds. He talks about the end, "the tunnel." Alex tells Paul, "All that time I tried to figure out if I had a hard on." And from there he talks about how his 92 year-old grandfather died with an erection. Danny, the gay runner, is a doctor who resuscitated Alex. Paul wonders if this links to Alex being fearful of being a homosexual. No way.

Alex and Paul tussle a bit. Paul points out that Alex has been testing him since he walked in the door. "You have no patience," Alex tells the therapist.

So now Alex tells Paul his chief complaint: He talks about being 'frozen' for 48 hours in a body suit during his time 'dead.' Paul tells Alex he has a strong will to live. He's come back from the dead, "and if you don't supply the goods...." Paul says, "this is a systems failure that wasn't supposed to happen to you."

Alex says his whole life was perfect, he was born to excel, he is the creme de la creme, "I'm a top gun grad and that training is not for pussies."

Alex wants advise. He continues with his cryptic style. Alex decided to go back to the site where he dropped the bomb on the school. "I don't have a guilty conscious." Paul worries that Alex will not be safe if he returns to the school. "This isn't for me." Alex says of therapy.

Paul talks about how Alex perhaps needs someone to be his commanding officer. Paul is scheduled to leave TONIGHT to go to Baghdad.

"Don't you think there's a strong desire there to atone for your actions?" Paul asks. Something finally hits Alex, he wants a cup of coffee, he doesn't want to leave even though his time is up.

My husband says it's not enough, it's just a plot summary, it needs a Dinah-spin. He wants me to predict where the therapy is headed. What does my husband think I do for a living? I'm a shrink, not a fortune teller!

So I liked this episode better than Laura. It was less predictable. Alex is a narcissist, I think, he's also difficult, constantly challenging and trying to out-smart the doc. He wants advice, but he isn't there to listen, he's there to hear he's right, to get permission in a sense, and to ignore whatever it is he doesn't want to hear. Maybe he's just there to out-best the best.

[Go to #3]