Ducking Around

Ooooh, let me tell you: I love vacation.  I really love vacation.  I'm back.  It's cold here, and I spent the day unpacking and doing laundry, and getting ready to start my week.  I returned calls, went in to the office and checked my mail, emailed, postal mailed, and watched the Ducks win the Rose Bowl.  Sad, because even though we Shrink Rappers like ducks, I have my own personal Badger out in Pasadena cheering for Wisconsin, and it's a sad football day for him, I'm sure. 


Roy did a great job of holding down the blog.  Please give him a hand.  Clink was off on another one of her adventures.  For some reason, vacation is not fun for her if there isn't the possibility that she'll fall thousands of feet, get eaten by some form of wildlife, or have her life depend on properly functioning equipment while she gurgles beneath the sea.  She's the only person I know where "I had a fantastic time" is followed by an injury report.


Roy's Happy New Year duck was taken from the Havre de Grace annual New Year's Duck Drop.  From the Aegis:

It was a glorious night for ringing in a new year. Temperatures, unusually inviting for a New Year's Eve in Harford County, hovered around 43. Wind was non-existent. And many people had gathered around the Havre de Grace Middle School grounds for the annual Duck Drop and fireworks to welcome another new year.

In other stories around the web, if you're a distracted duck, you might have notice that it's hard to find Ritalin or Adderall-- perhaps another example of DEA limits allowing Big Pharma to be being overly ducky about reducing supply of the cheaper, generic medications.  From the The New York Times, do check out "A.D.H.D. Drug Shortage Has Patients Scrambling."  


And if you're a duck contemplating filing for Social Security Disability, do read Dr. Steve's post on Thought Broadcast about The Curious Psychology of "Disability."  With 41 comments on that post, I'm going to swim away from the temptation to comment myself. 

And finally, for those ducks who want to know the latest on Electronic Medical Records, check out Shrink Rap News over on CPN for "Notes from SAMHSA's EHR Summit."  If that doesn't make you want to be served up with orange sauce, then nothing will.

So I love vacation, but I did miss all the Shrink Rappin.'  Happy New Year to everyone!  

From Clink: I don't have a duck in this race, so I thought folks might enjoy a seahorse instead. He's black with white stripes and seems to be perched on top of the green moray eel's head. Yes, the eel was that close.

No significant injuries this time.  A slight jellyfish sting and lots of no-see-'ums, that's it.

The History of The Duck, etc....

Those of you who are regular Shrink Rap readers know we are rather attached to the image of the yellow rubber duck.  It started with an article on Emotional Support Animals that was in the New York Times right after we started our blog, and we latched on to the imagine of airline passengers who brought ducks (one dressed in clothing) on to flights, and then Clink began her years-long hobby of animating ducks!  And of course there was the lovely reader, DrivingMissMolly, who donated a flock of ducks to Heifer International in our behalf.  The duck appears on our blog, it was the subject of heated debate and designated committee meetings when our book was in press (see They Nixed the Duck!) and it's on our logo in the print version of our column on Clinical Psychiatry New.  We distribute candy ducks at all Shrink Rap public events. 


Needless to say, I was quite pleased to see an article in this morning's New York Times Magazine on the history of rubber ducks.  In "The Rubber Duck Knows No Frontiers,'  Hilary Greenbaum and Dana Rubinstein write:

This yellow, doe-eyed icon — a preferred bathtub ornament of toddlers and royals alike — would have never existed were it not for Charles Goodyear. The Massachusetts inventor discovered the chemical process that renders rubber more malleable (and thus appropriate for toys) by, as legend has it, inadvertently dropping a mixture of rubber and sulfur into a potbelly stove. Goodyear, who died in 1860, never benefited from this discovery, but his vulcanization process revolutionized the rubber trade.

Greenbaum and Rubinstein go on to note:

Still, it was only when Ernie, of Bert and Ernie fame, took a bubble bath with a rubber duckie in 1969 that the toy became inescapable. According to Tim Carter, a senior producer at “Sesame Street,” the story goes like this: Someone gave a rubber duckie to a “Sesame Street” writer named Jeff Moss, who put it in his bathroom window. One night while taking a bath, Moss looked over and had an epiphany. And “Rubber Duckie” subsequently reached No. 16 on the Billboard chart. “It wasn’t until ‘Sesame Street,’ ” says Charlotte Lee, a Seattle-based engineering professor who holds the Guinness World Record for the largest collection of rubber duckies, “that a rubber duck became a special thing.”  

For those who would like a psychodynamic interpretation of Ernie's relationship with his duckie, Shrink Rap provides one Here. 
--------------------
In other Shrink Rap events:

• Clink has an article up on Shrink Rap News on how social media does a lousy job of representing Forensic Psychiatry.  Please do read What Follows Is Fiction: What Orson Welles Can Teach Us About Social Media.   
• We enjoyed our book signing at Baltimore's Ivy Book Shop on Friday evening and met some great people.  We posted a photo of ourselves with author Gilbert Sandler-- he says he needs all the help he get.  He's a charming man!  Do visit our Facebook page at http://www.facebook.com/shrinkrapbook to see event photos, and do click the link to "follow" us on Facebook for the latest Shrink Rap updates.
• We are podcasting later today, we should have new episodes of My Three Shrinks up in the coming weeks.
• Jesse tells me he's planning to submit a guest post about factors that keep people from reporting heinous crimes, so do check back later today.  The events at Penn State seem to have everyone stirred up.

Right About Now, We Need A Duck Break

I showed up at my community's organic vegetable garden to work yesterday morning. I was a little late and people had begun to disperse. A neighbor tossed some spinach my way. Another said, "Larry says we need ducks."

We need ducks? We have a patch of land by some athletic fields. No pond. Are we going to eat the ducks? No, they are going to eat the bugs off the vegetables. Interesting. I'd never heard of this. Larry's raised ducks before? Last week he was talking about chickens. It's all so confusing.
Apparently Larry wants us to research ducks, and so here is what I found:

http://www.grit.com/Livestock/Raising-Ducks-Helps-Your-Garden-Patch.aspx

The photo above, by the way is a picture of ClinkShrink and I together in Hawaii. I'm the duckier duck.

We Got Our Duck!

Jackie, our wonder editor, told me there was a duck surprise. Oh, good. I like surprises. And Shrink Rap likes ducks. And then I forgot.

So this morning I went to check out the Johns Hopkins University Press booth at the Exhibit Hall here in Honolulu at the APA. Lots of books, lots of people, and they have a poster up for Shrink Rap in a corner. And a big screen with images that change. Then I noticed it: the Shrink Rap stuff all has ducks on it! This, after they denied us a duck on our cover and said it made us look like quacks.

Ok, so it's beautiful here in Oahu and I'm off to soak up some sun.
I woke up at 5:20 this morning and have been learning about psychiatry all day!

Just a quick note to myself and a to-blog-about list. We've been so busy lately that time has been short for blogging and podcasting, but I still have ideas, so coming posts will (some day!) be:

--Response to the med student who wanted to know how to deal with negativity when she says she wants to be a psychiatrist.
--What is anti-psychiatry and why does it bother me. (Please pray for me if I go there).
--The chapter I wish I'd written, inspired by Jesse's comments.
--We got a request to talk about how autism may mimic psychiatric symptoms on our next podcast. Maybe we'll respond to the medical student on a podcast instead.

Ever feel like life gets just too busy? Okay, having fun at APA, gotta catch some rays now.
--

Which duck?

I'm making a change in the left top header [update: already changed]. Instead of the star in the orange field, I'm replacing it with Dinah's duck. I've made three design options. Our readers get to pick which one to use.

Update (4/5/2011): Thank you for everyone who voted over the weekend. The middle (yellow) duck won out. We received 132 votes; Google Forms does not provide any mechanism to prevent multiple votes from one IP address, so it is probably less than 132 individuals. Just sayin'.

Roy is Driving Me Crazy!

I'm at my office today and I turn on my phone between patients. There's a text and a message, both from the same person. "Where is Roy, he's supposed to be here at a meeting? Can you contact him?"

Interesting. I scratch some body part or the other. Am I Roy's mother? Did someone forget to tell me? I forward the text to Roy, and welcome in the next patient. After that session, I check messages again. Roy has texted me, "I can't talk, I'm in a meeting." I guess he got there. Oh good.

And the blog. We have a rule about the sidebar: Dinah doesn't touch it. It's Roy's rule, but I've had a few problems, so mostly it's okay. But then, I decided I wanted a duck on the side bar. I put one up. That I can do. Roy took it down, because if I say Earth, Roy says Mars. Duck> No duck. No duck> Duck. Should I start reverting to reverse psychology? What was wrong with the duck? I liked it. Roy put up a link to our book's Facebook page---you remember, that book we've been writing for about a zillion decades that never actually materializes. I promise (I hope) that it isn't just a pipe dream. So the book's Facebook page has a whopping 8 fans and their photos are shown on our sidebar. Does Jesse the Chinchilla Lover want his photo on Shrink Rap? Do we want to advertise our 8 fans? I take it down. And Roy tells me he's frustrated that I undo things he does without talking to him first. But my duck-- he took down my duck! And he didn't talk to me first.

Why does Roy want the Facebook page up anyway? Does it matter? How will our Shrink Rap Book FB page change the world? Oh, we had tried a Shrink Rap friend page, but that was too hard to manage. I had to sign out of my own account and confirm new friends, and interact with them, and I'm a bit on overload (in case you couldn't tell!). We tried a "fan" page and that was fine. Only it was linked and combined with the friend page and who knew what was what. I was pretty confused and I created them! So Roy made us a FB book page, only the book's not out, so he doesn't want anyone to know. But he does want 25 people to be fans so he can reserve a specific URL for it. HuH? And then he put his twitter feed in to it which would be good---Shrink Rap posts would populate the wall, but then he had a twitter conference and all sorts of random tweets went twitting away on the wall and in my News Feed. I think I'm way too old for this. Anyway, Roy is driving me crazy.

Please join our Shrink Rap Book page so Roy can drive you crazy, too.

And Clink has a new "old" post up on Shrink Rap Today over at Psychology Today.

The Duck Was Nixed!

As our publisher was designing the cover for our book, we put in a request. We'd like a duck on the cover. No Duck, we were told. As we dusted ourselves off, our editor came back and said the design department had agreed to put a duck on the spine of the book. We rejoiced! Here and there, Roy would mutter about the duck. Remind them, don't let them forget about the duck. As the cover was finalized and the galleys were finished, we received a note from our beloved editor. Are you sure? Of course! People will think you are quacks. But we're not quacks, anyone who reads our book will know that. Roy was convinced that it would add to the idea that this isn't just another dry reference textbook, it's an easy to read, ducky kind of book. I thought a little duck would be fine. Our editor sent the picture of "our duck:Now let me tell you.
I did not like this duck.
I did not like this duck at all.

The duck had long lashes, looked way too happy for a psychiatry book, and looked like a toddler's bath toy. We're shrink rappers, but we don't squeak! Oh, and we're not quacks.

Here is the duck I wanted. Very small, very subtle. Think of the penguin logo for Putnam Books.
Only think of it as a duck. Here is the duck I wanted. Our editor agreed, I think, that it was a better duck:


And happy with our duck (though ClinkShrink thought the first duck with the flirty eyelashes was fine)... I get an email from the marketing department. It is a very serious email about how well they think our book will do, and how packaging is important to the overall product. The upshot: there will be no duck. Our opinions were not wanted, the duck was gone, it was a done deal.

Quack?

Oh, the duck would have been just fine....

Happy New Year!

Happy New Year to all our readers. Can you believe it's 2011? I remember being a kid and thinking how long it would be until 2000 and thinking I'd never actually be that old.

I almost saw out the Old Year with Roy. We went out to a local pub for the best of Baltimore's crab cakes, and Clink didn't join us, but she did text in that there was a Duck in her Jacuzzi at what ever wonderful vacation spot she's in. A duck in the Jacuzzi and we didn't even get a picture? This from the woman who texts me photos of every mushroom she runs across? We parted around 10, and for the first time in years, I was awake at midnight, drinking champagne and eating chocolate by the fire with family and friends (non-Shrink Rappers)...who came over to see the year out with us.

Shrink Rap will turn five in April. This is our zillionth post (well, not quite, but we're somewhere over 1,300 posts). Our book will be coming out around the same time, if you'd like a preview, it's up on Amazon, but not yet available. We're scheduled to talk at APA in Honolulu this year, but our talk, The Public Face of Psychiatry, has been scheduled at 7 AM on the last day of the conference. Will anyone come? 7 AM???

Finally, this past week, we were mentioned on The Psychiatric Nurse Practitioner Blog as one of the Top 50 Psychiatry Blogs (I didn't know there were 50 Psychiatry Blogs!)-- do check it out-- and we had a guest post up on Kevin MD, a revised version of our post on How to Find a Shrink.

What I Learned: Part 2

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 1, click here.

Day Two began with a section on PTSD as a criminal defense in military criminal cases. There was a presentation of a murder case committed by several military personnel in Iraq, followed by a discussion of the uniform code of military justice (UCMJ) rules of criminal procedure. The limitations of PTSD as a diagnosis was discussed, specifically the fact that many symptoms of PTSD overlap with other psychiatric diagnoses and that some people meet symptom criteria for PTSD without ever being exposed to a traumatic event. In 2008, 2.9 million veterans were receiving compensation for PTSD.

In criminal cases, defendants can claim self-defense if they have a reasonable belief that they are in imminent danger of serious bodily injury or death, if the force used in self-defense was reasonable, if the defendant was not the aggressor and if the defendant had no opportunity to retreat. Problems happen when the defendant reasonably believes he is in danger, but there is no objective evidence of imminence. (Eg. battered spouse syndrome and "burning bed" cases: a woman believes she is in danger and pre-meditates violence in self defense.) Soldiers with exposure to traumatic events may base a PTSD defense on a reasonable belief of danger, in the absence of imminence. Although the term "battered soldier syndrome" is not actually used in these military cases, they are clearly drawing an analogy.

As an aside, the UCMJ is interesting in that in courts martial, the military panel (analagous to a jury) decides guilt and also passes sentence. Judges have no role in sentencing. Also, there is no option for bail at the pretrial stage. Defendants have a right to a trial within 120 days, which is not much time to prepare a case for a felony offense.

In a presentation about zolpidem (Ambien) I learned that there were 22 criminal cases at the appellate level in which this medication was used as a defense. Ten were driving cases, seven were violent offenses. Zolpidem has been associated with sleep disordered behavior when combined with an SSRI. There have been 16 cases reports of zolpidem causing improvement in a chronic vegetative state.

There was a fascinating talk about tasers given by a guy from Utah. Apparently tasers have a USB data port that is used to gather stored information about when the taser was used and how many tasing cycles were triggered on a defendant. The presenter collected data from many police departments around the country regarding taser use and the nature of the defendant. He found out that in two-thirds of the cases the taser is never actually fired---merely pointing the taser at a defendant is enough to cause the defendant to surrender. When a taser is used, 82.2% of people required a single cycle. The majority of the cases in which a taser was used was on a defendant who was mentally ill and/or intoxicated. According to 1999 Justice Department data, only 2.1% of arrests actually require the use of a police weapon.

I went to the forensic sciences lecture, which is usually my favorite presentation. The American Academy of Forensic Sciences is a companion organization to AAPL and some of our members are shared between the two organizations. Anyway, this year's presentation was about computer crime. Sadly, it was bad. While the investigator was a good speaker, he didn't say much of anything about the techniques of how computer crime is actually investigated. There was no case presentation. The only crime discussed was online child pornography. The mental health professional talked about child porn users, but made at least three pretty outrageous anti-feminist statements. (Eg. women who made late accusations of child sexual abuse had been 'brainwashed by the feminist movement.') A female forensic psychiatrist audibly blurted out "that's bullshit!" and I could hear the silent dropping of jaws. The most enjoyable part of this talk was when the computer investigator had trouble getting the audience survey system to work.

Lastly, I went to a talk about a survey given to 492 members of the South Carolina bar. 83% of the lawyers said they felt their law school training about mental health law was inadequate. Two-thirds had personal or close experience with mental illness. Judges were the least knowledgable about mental health law compared to public defenders, private attorneys and prosecutors.

Tidbits from the poster session:

• 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.
• One poster studied inpatient threats in a state hospital over one year. Only one-quarter of the threats were deemed credible by the treatment team, and only one-half of these threats were thought to meet criteria to carry out a Tarasoff warning.
• There was an interesting review of the Maurice Clemmons case in which public information was used to assess his risk of violence. I blogged about the case here, and provided links to the published clemency materials. Using two violence risk assessment instruments, the poster found Clemmons to be a high risk offender. Easy to say based on his history, but of course the limitation of static risk assessment instruments is that your base risk never lowers. You can get worse, but never better.
• A national household survey of substance abuse, done annually with tens of thousands of people, showed that 3.8% off all women had used methamphetamine at least twice in the past year. Female meth users were more likely than users of other substances to be involved with the law, but not necessarily for violent offenses.
• Two states automatically drop misdemeanor charges against incompetent defendants, as required by their statutes.
• One study found no correlation between a history of childhood sexual abuse and being a perpetrator or victim of inpatient violence.
• Prisoners over the age of 65 are twice as likely to have at least one chronic medical condition compared to an age-matched sample in free society.
• Medical students from UCSD who rotate in a jail for their psychiatry experience consistently rate this rotation as their favorite. One quote from the medical student survey stated: "I love jail!"

Finally, my favorite poster: THE FORENSIC ASPECTS OF SERVICE ANIMALS!

YES!!! EMOTIONAL SUPPORT DUCKS HAVE COME TO AAPL!

This is the poster that won my heart. We've discussed this on the blog and we mention it in the book. Now, the "official" word. A poster entitled "Noah's Ark: A Forensic Review of Service Animals in Psychiatric Settings" provided an overview of ADA requirements for service animals in hospitals and clinics. In addition to guide dogs for the blind, other service animal cases involved monkeys, chimpanzees, miniature horses and parrots. Animals may be excluded from operating rooms but not any other general treatment setting. Potential for infection cannot be used to exclude animals, nor can mere concern about safety separate from an actual safety-related incident. Animals have to be able to meet minimal expectations for cleanliness, orderliness, nonaggression and "unnecessary vocalization". The sole determinant of whether an animal is a service animal versus a pet is the patient's declaration: a health care facility cannot demand documentation that an animal is certified or trained as a service animal. Finally, there have been cases of fraudulent service animals: people who put homemade "vests" on their animals and falsely identified them as a service animal. In California this is a crime punishable by six months of incarceration and a thousand dollar fine. I'm not sure how you'd get a vest on a fake service parrot.

So there you have it. I'm bringing my duck to the next session.

What Do You Want To Know About Psychiatry?

When you work in any setting, your view of it becomes distorted. Your vision becomes tunneled, and the world looks small. My husband came home one day upset because a client had burst into tears while they were talking. "Why does that bother you?" I asked. Apparently it's not something that happens a few times a day for him. And when I was a medical student on an oncology ward, one of the doctors came in for rounds late---on her to way to work she'd seen a young man get knocked off his bicycle by a automobile. She'd stopped to help, and her first question to the young man was, "Are you a smoker?" She quickly realized that it was not a particularly relevant question in that setting.

So do people in the real world have questions about psychiatry? What are they? What a time to ask: just as our book goes for it's final draft. I should have asked before-- What do you want to know? Maybe we're wrong about what we thought people want to know. Maybe we need to write a second book.

The good news is that after several requests, the jacket designer has agreed to add a duck. Bless our editor for asking--- no clue how she explained that one.

Why do I feel like we've been working on this book forever? Clink will tell you, "because we have."

So what questions do you think the general public has about psychiatry? Go for it.

Emotion versus Mental Illness

My favorite commenter, "Anonymous," wrote in to my Duckiness post to say that it was good I could post something totally silly without being told I need more meds. Oh, if life were that simple. And it is true that once someone has a diagnosis of bipolar disorder, not only does the world question their emotions in a black & white "are you sick again?" kind of way, but patients don't trust themselves to feel for it's own sake.

If you're not sick, then being asked if you took your meds is insulting and degrading. And so I thought I'd put together some guidelines for Emotion versus Mental Illness. I'm inventing this as I go, with no evidence-based anything, so take my suggestions at your own risk.

• If you are ultra-successful, rich, brilliant, gorgeous, famous, and comfortable with your diagnosis, you may want to consider telling people you have a mental illness because it decreases stigma and people like being with the ultra-successful rich, famous, brilliant and gorgeous and won't care that you have a mental disorder. It helps even more if you're charming.

• If you're not ultra-successful, you may want to pick and choose who you tell that you've been ill and are on medications. This isn't always possible, especially if your illness is evident to others or if the presentation of your symptoms resulted in a hospitalization. It's good to tell close family members.

• If multiple people are looking at you strangely, or commenting on your behavior, or saying you need medications, you might want to at least entertain the option that you could be sick. Unfortunately, poor insight and judgment are symptoms of mania.

• Tell the people close to you not to make medication jokes. It confuses the issue if you seriously do need medication changes, and it's rude, degrading, dismissive, and disrespectful. There, I said it.

• If you want to be silly, go for it. Be silly when you're well so that being silly is part of your baseline personality and no one equates this with being out-of-character. You'll note the duck invaders did not come after me, rather they said, "There's Dinah posting yet another stupid duck post." If I'd posted about why chocolate should be outlawed and made into a controlled substance, those same duck invaders would be asking "What's wrong with Dinah?"

• Mental illnesses come as constellations of symptoms. There is no "Sending out silly duck stuff" as a symptom. People think about mania when the ducks are combined with more energy, racing thoughts, a decreased need for sleep, increased mood OR irritability, and other symptoms of mania. Know the list and if someone bothers you, say, "I posted about ducks, I do not have any other associated symptoms." Recite them if necessary. If you do have the other symptoms, refrain from posting about ducks. I don't want Posts Duck Blog Posts to show up anywhere in DSM-V and these days you just never know.

• No one controls how any other person thinks of them or judges them and it's not reasonable to live life ruled by a desire to be perceived in a certain way . It's another form of poultry, but Don't Let the Turkeys Get You Down. There are a lot of turkeys out there.

Moods happen on a spectrum. Some people have large variations in their mood---large enough or severe enough such that it causes suffering, and we call it an illness. Some people don't have much variety to their moods and live in a calm, even-keel place, and it's great that we have such people. But, I absolutely promise you that if we lived in a world where everyone had a very narrow range of mood, this would be one terribly boring planet. We should celebrate our diversity, not condemn those who like ducky stuff.

Too Much Duckiness to Ignore.

Let the facts of the case present themselves:

1

In the early pre-dawn morning (approximately 4:00 a. m.) of June 18, 1972, the windshield of the automobile which appellant was driving along North Columbia Boulevard in Town X, suddenly shattered causing a splinter of glass to enter Smith's right eye, which resulted in permanent impairment of sight in that eye. Investigation proved that the cause of this unfortunate mishap was that Smith's car had struck an airborne mallard duck or conversely that the mallard had struck Smith's car. The rationale for this conclusion was the finding of the body of a deceased mallard at the scene of the accident and duck feathers and other parts inside car. The question of negligence, or the degree thereof, attributable to the only participants involved in the accident, namely, the mallard and Smith, is not before us.

2

The scene of the accident was that portion of North Columbia somewhat adjacent to the plant of defendant-appellee, Malarkey Company (Malarkey). Since Smith is a citizen of Washington, Malarkey is an Oregon corporation and the amount in controversy exceeds $10,000, the federal courts have been chosen as the forum in which Smith seeks recoupment for his injury.

3

His complaint, a model of brevity, contains two counts: (1) negligent maintenance of a duck pond on the Malarkey property, near North Columbia, a public thoroughfare; and (2) creating thereby an unreasonably dangerous condition to the public using that thoroughfare.

4

After several unsuccessful attempts by Malarkey to dispose of the matter by motions to dismiss for failure to state a claim, for partial summary judgment and for summary judgment, the case came on for trial before the Court without a jury. Subsequent to the trial, the Court delivered its opinion1 finding for the defendant.

5

The Court refused to conclude that the maintenance of the pond by Malarkey was an "ultra-hazardous activity" and referred to parks and places, public and private, in the vicinity where waterfowl might congregate. As to negligence, the Court held that there was "no showing that the defendant knew, or reasonably ought to have known", that such a pond "was likely to lead to harm of the general character involved in this case" or that the fact that dead ducks had been found on the highway was notice to Malarkey that ducks were a hazard to motorists. In short, the Court could not find "the vital element of foreseeability" in relating the Malarkey pond to the accident. Accordingly, judgment was issued dismissing the complaint.

6

Plaintiff called as witnesses persons who, while driving along North Columbia, near the Malarkey property, had seen dead ducks at the side of the road, ducks walking across the road, ducks sitting in the middle of the road and ducks flying at low levels across the road. In one instance, the front of a motorist's car had struck a duck, with unfortunate consequences for the duck. If ducks chose to walk across a well-traveled public highway used by motorists instead of using less dangerous aerial routes better suited to flying ducks, they might well have subjected themselves to such an eventuality. The roadside dead ducks certainly indicated that motorists were a hazard to road crossing ducks, but by no means that such ducks would be likely to be the cause of the type of injury incurred here. Furthermore, even if it had been, one would have expected the record to have been replete with incidents of ducks crashing into motorists with notice thereof to Malarkey.

7

Appellant also adverts to the Malarkey habit of putting food and grit around the pond about 4 o'clock in the afternoon and argues that even if the pond itself was not the well-spring of the dead duck's conduct, Malarkey was still culpable because of these other lures with which it seduced the birds to come to the pond. However, once again, even assuming appellant's premise that mallards find food and grit irresistible, there is no way of knowing whether the Malarkey provender was the aim of this duck's low trajectory. And there is no evidence which would indicate that the duck was in the area for a midnight snack twelve hours ahead of schedule or that the pond was the duck's intended destination. Further speculation along these lines would be pointless. But even if this feeding practice caused an undue assemblage to partake of Malarkey largesse, it would not account for the unexpected flight of a single duck in pre-dawn darkness. Furthermore, the pond was 100 yards from the highway, surrounded by a seven foot fence with railroad tracks between highway and pond.

8

The area is a game reserve and should be naturally attractive and conducive to migratory birds. In addition to the parks and open areas previously mentioned, there is somewhat nearby the Columbia River, the Columbia River Slough and green fields where ducks have been observed to congregate and feed.

9

The waters of the Malarkey pond might well be said to be alluring to ducks but by no stretch of the imagination is the maintenance of an artificial pond an ultrahazardous activity or a foreseeable cause of an injury of the unusual nature suffered here. The activity is neither abnormal, unusual, or especially dangerous see, Reter v. Talent Irrigation District, 258 Or. 140, 482 P.2d 170 (1971) at least not in an area which is already rife with waterfowl and water.

10

Appellant says "Nothing short of removal of the pond could eliminate the risk" (Appellant's Brief, p. 6). But query, would elimination of Malarkey's rather minute pond remove the risk? Complete protection of motorists might well require the elimination of the game refuge, the surrounding green fields, the Columbia River Slough and possibly the diversion of the Columbia and Willamette Rivers as well, if flying ducks were to be recognized as a constant peril to motorists.

11

The parties here both have proceeded in a well-accepted format of argumentation, namely, an almost biological analysis of cases and the Torts Restatement. They have dissected and then put under the microscope each and every element stated therein. Tort cases, however, so much dependent on their own particular facts, are not suited to such treatment. The Trial Court here heard and reviewed the evidence presented and then, in finding for the defendant, held that the maintenance of the Malarkey duck pond was not an "ultra-hazardous" activity and that the type of accident here suffered was not foreseeable. The law and the facts support this conclusion.2

12

Judgment affirmed.

*

Honorable Leonard P. Moore, Senior United States Circuit Judge, Second Circuit Court of Appeals, sitting by designation

1

The oral opinion dated March 14, 1974 has been transcribed as an opinion, filed as findings of fact, and conclusions of law and order pursuant to Rule 52, and is to be found at pages 149-155 of the record on appeal

2

There is an indication in the record that the Judge and counsel planned to visit the Malarkey property on the afternoon the trial ended, thus giving the Court and counsel the advantage of visual inspection

Rats!

Posted for ClinkShrink:


OK, so here's the rat story:

Dinah, Roy and I were walking down Bourbon Street at midnight during the APA conference. (Three psychiatrists REALLY didn't fit in down there, even though we were wearing duck necklaces.) All of the sudden this huge rat ran out of an alley about two feet in front of us. Dinah screamed and did one of those cartoon-like "peddling in the air" jumps, then turned and ran. Roy and I were in hysterics. We all got back safely. Not sure what happened to the rat.

The Stressed Out Shrink Rapper

http://psychiatrist-blog.blogspot.com/2010/05/stressed-out-shrink-rapper.html

Yes, shrinks get stressed out, too. Can I tell you about it?

I hate paperwork, in case I never mentioned it. And I hate dumb things that are mandated by institutions and don't make sense. So I'm getting ready to go to APA this weekend ( see you there?) and I'm trying to tie things up. It's not going so well. Here's my list:

MEDICARE.
Remember I told you that I moved and tried to change my address with Medicare? Ah, 221 downloadable forms on the Medicare website, and not one of them is a change of address form. To change my address, I had to re-enroll. 27 pages. Then they wanted my office utility bills. But I don't have utility bills, they are included in my rent. I faxed my rent invoice--it has my address, and it says "office rent" on it. It's a very nice office. I figured I was done.
Two days ago, I got a letter from Medicare. I've been denied my application as a Doctor of Medicine. I can appeal. Why? I didn't send in three things: 1) Downloadable form 558 giving access to my bank account so they could pay me. Only I'm not an in-network doc. They don't pay me. Ever. 2) my participating agreement. I'm non par and wish to stay that way. 3) my utility bills as proof of address. Am I the only doctor who rents space with utilities included?
I called. Twice. If I won't give them my bank account numbers and routing information, I'm out. Which means I have to leave my clinic job where I've been for 12 years. I don't have to fill out a participating agreement. And they'll take another copy of my rent invoice. I have 30 days to appeal. From the date on the letter which came 2 days ago. The letter is dated in April (it's now May 20th). And I'm really not happy about giving them my bank account information---what happens when they pay me for patients I see at the clinic? I'm salaried there, I don't get paid by the patient, the clinic does. If I do nothing, I'm quickly opted out, and that's a good thing...unless you're my Medicare patient and you no longer can get reimbursement or you're the clinic that wants me there. Have other people had to give their bank account info to change their address? Never done this before. Time expended: who knows. Hours. If you're a non-par provider could you offer some words of wisdom here/?

Next problem:
Clinic says I need to be tested for TB along with all the other employees. So I get a ppd placed, no big deal. Only I work there one morning a week, and in the past, I've read it myself or had a dr. friend sign off on it, because it's a hassle to get to the hospital, park, and take off work for this. Now I'm told I can't read it myself or have another doctor read it, unless it's an internist, pediatrician, or pulmonologist. Okay, found a friend, still have to get the form faxed in. Time expended: 2 hours.

Next problem:
My cell phone blitzed last night. I called. They said I needed updates and they'd push them through. Whatever. The phone worked, I thanked them, and half an hour later, I was on my merry way. Only then the phone didn't work. And my kid's phone didn't work. I called back I held. I powered off, I powered on, I removed the sim cards, I read the numbers, I switched the sim cards, I powered on and off and ate the batteries and prayed for ducks to come. The phones aren't reading the sim cards. I need to get new ones. Okay. Hours. I got to work today. The phone works fine. I called AT&T. Can't be the sim card. Husband's phone works fine. Must be the degrading tower. What's a degrading tower? Does it crumble? Why does husband's phone work? Very strange, no explanation, but tonight, all the phones work. Time expended: 2.5 hours.

I suppose the last thing is the book. Time expended 4,237 hours. Our editor wants it in Mid May. I think that happened. It's almost there. We still need a little polish on the last few chapters and a table of contents and Suggested Reading . If you know a shrink book that's been helpful to you, please let us know in the comments===we'll try to stick it in.

Hanging on for: http://www.patobriens.com/patobriens/havefun/hrricane.asp

Thank you for humoring me tonight, please send a bill

Three Years and 1000 Shrink Rap Posts!

It's our blogiversary, if that's a word, and we've timed 3 years to coincide with 1000 posts. Well, sort of, Roy pointed out that we have a few unposted things in "drafts," but blogger says this is 1000, so I'm happy with that. I'm pretty happy that our little project has lasted so long, has grown to include 50 podcast episodes with more to come, and our book contract is signed, and that we're all still friends.

To three more years of things to think about....

Thanks for reading Shrink Rap!

From Roy: Thank you to my blogmates for keeping things fun and interesting. And to all our readers and commenters (and listeners) for your interest and participation. Y'all rock!

From Clink: My blogmates are wonderful, our readers are wonderful, life is good. I'm trying to post more often, I really am.

Links:

First post (2006).

2007 anniversary post.

2008 anniversary post.

Just As I Was Thinking About You

I think I have ESP. Last week, I was thinking about a patient I hadn't seen in a couple of months, and he called, just as I was thinking about him. It's happened before with this patient. Today, I was walking to my car (where I'd left my cell phone, unsubmergered), and I started to think about a patient I haven't seen or thought about in some time. I've been treating her for over ten years, and issues of age and health have made it hard for her to get in to see me. It's been a year, maybe more, but every once in a while, she surfaces. So I'm thinking about her, wondering how she is, and I get to my car and there's a voicemail from her. Sort of eerie. I have ESP.

What I don't understand is the whole ShrinkRap with Bacon thing on our sidebar. I guess Roy did this. Why does anyone want bacon with our blog? It's just sort of weird. He couldn't have put ducks up?

And for a final thought: my husband is leaving on a jet plane. He texted to say there is a comfort dog in the next row. I can't wait to hear how the flight goes.

Thanks to everyone who's commented on our pre-draft of a chapter. I like the diversity of opinions. And to anyone who thinks their middle schooler might get something out of it, that would be wonderful!

I'll get a photo in later: let me know if you have any special requests....

I Need ---Non-Human--- Help!

In "Creature Comforts" (the NYTimes mag, of course), Rebecca Skloot discusses all forms of comfort and service animals. There's a difference, and yup, Ducks make the cut. There are miniature guide horses for the blind, monkeys for quadriplegics, and an assistance parrot for a man with bipolar disorder who is subject to tempter outbursts.
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What qualifies as a service animal? .... Can any species be eligible?

There are two categories of animals that help people. “Therapy animals” (also known as “comfort animals”) have been used for decades in hospitals and homes for the elderly or disabled. Their job is essentially to be themselves — to let humans pet and play with them, which calms people, lowers their blood pressure and makes them feel better. There are also therapy horses, which people ride to help with balance and muscle building.

These animals are valuable, but they have no special legal rights because they aren’t considered service animals, the second category, which the A.D.A. defines as “any guide dog, signal dog or other animal individually trained to do work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a wheelchair or fetching dropped items.”

Since the 1920s, when guide dogs first started working with blind World War I veterans, service animals have been trained to do everything from helping people balance on stairs to opening doors to calling 911. In the early ’80s, small capuchin monkeys started helping quadriplegics with basic day-to-day functions like eating and drinking, and there was no question about whether­ they counted as service animals. Things got more complicated in the ’90s, when “psychiatric service animals” started fetching pills and water, alerting owners to panic attacks and helping autistic children socialize.
-----

The article includes issues about disease transmission, especially forms of hepatitis from monkeys, to issues of aggression, citing one service dog who killed another service dog on a bus. People, apparently, are not always comfortable seeing ducks walking down grocery store aisles (can someone explain that to me?)

The article concludes with:

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“Many people try to make this issue black and white — this service animal is good; that one is bad — but that’s not possible, because disability extends through an enormous realm of human behavior and anatomy and human condition,” Frieden told me. In the end, according to him, the important thing to remember is this: “The public used to be put off by the very sight of a person with a disability. That state of mind delayed productivity and caused irreparable harm to many people for decades. We’ve now said, by law, that regardless of their disability, people must have equal opportunity, and we can’t discriminate. In order to seek the opportunities and benefits they have as citizens, if a person needs a cane, they should be able to use one. If they need a wheelchair, a dog, a miniature horse or any other device or animal, society has to accept that, because those things are, in fact, part of that person.”

Over at the Well blog....

You know I like all the Service Animal stuff the New York Times writes about. In fact, the Emotional Support Duck started off our duck obsession here at Shrink Rap.

From the NYTimes Well blog, Dogs and Autism:

A legal battle in New York City highlights the healing power of dogs for children with autism and Asperger’s syndrome.

Manhattan federal prosecutors have accused the owners of an Upper East Side residence of discriminating against 11-year-old Aaron S by preventing him from having a dog, The New York Daily News reports.
The report goes on to explain:

According to the newspaper, a lawsuit claims the building owners violated the Fair Housing Act by imposing unreasonable demands on Aaron’s parents before allowing a dog. Among the restrictions reportedly imposed by the building: the dog couldn’t be left alone for more than two hours, it would have to be taken in and out of the building on a service elevator, monitoring of dog walkers who might take it for a stroll, and $1 million in liability insurance for any injury or property damage caused by the dog. A company-hired doctor reportedly agreed the dog was medically necessary.

Oh, I'll let you all do the commenting.






NOTE from Clink: Now the duck works.

A New Use For Gangs

(A BGF tattoo)

I found a new use for prison gangs today. It was completely unexpected.

The patient was a very large, somewhat scarey-looking guy with a history of bipolar disorder. When manic (and psychotic) he got violent. He was transferred back to my facility for refusing to take his meds in a lower security setting. I forget what happened there, but he just wasn't doing well. Back in my facility he was among his associates from the Black Guerilla Family, a well-known prison gang. They respected his size and definitely didn't want him getting sick. They made sure he went down from the tier to the pill line to get his medication.

You'd never guess he had a mental illness when he was well. He was still big and scarey-looking, but he was also articulate. He talked about being able to haul someone into a shower and "mess him up" without guilt or remorse. He talked about staying vigilant, knowing that being part of the BGF made him a target for other gangs. He talked about being bothered by the fact that his violence and lack of conscience didn't bother him. He talked about "wearing a mask" and passing as normal. I could have listened to him forever, and it would have made a good documentary about sociopathy.

But anyway, back to the gang. In psychiatry you hear a lot about the importance of social networks and family support and how this can prevent relapse for people with psychotic disorders. What you don't always think about is how a prison gang can serve this same function. The BGF helped keep my patient well.

He finished the appointment by asking how I was doing and if I was OK, which I thought was rather interesting. It was a bit like Tony Soprano, someone who could execute a guy without batting an eye, being concerned about the ducks in his pool. And I was the duck.

Failed Heroism and the Shrink Rappers Pursue the Perfect Pizza

The Shrink Rappers have a new quest: to find the best pizza in Baltimore. Don't get me wrong, we still like ducks, but this is a culinary adventure.

So, Victor started it: he read about Matthew's Pizza in a Laura Lippman novel. Clinkshrink couldn't wait, she went without us. Roy says Carmine's is the best, and he's currently in Las Vegas trying to win the big bucks to pay for new recording equipment for our My Three Shrinks podcast. We started without him.

So it was a bit of an adventure getting to Matthew's. First there was the parking space issue, and then, as we walked the few blocks to the restaurant, we came across what appeared to be a dead body in front of a church. People sleep on sidewalks on church steps
all the time, this gentleman was in the middle of the sidewalk. Clink asked him if he was okay, and as he raised his head, there was a small pool of blood on the concrete. We called for an ambulance, and Clink asked the man a few questions, she had him move all his extremities, he seemed coherent, and Clink was relieved that he didn't seem to be one of her patient/inmates. He said he'd been jumped and someone tried to take his money. The blood was coming from a small laceration on his forehead and it seemed to have stopped bleeding. I called his wife.

"I'm looking for..." oops. Excuse me, sir, what's your name?
"I'm looking for John's wife (not his real name)."
"I'm his EX-WIFE." I told her we'd found him, that he seemed to be okay, that the paramedics were here wrapping his wound, that he'd been mugged and hit his head and was going to be taken to a hospital.
"He had too much to drink," she said. And judging by the smell of things, she may have been right.

My second attempt to be a hero this weekend happened when I was walking with Max. We were far from home on a quiet road when we met a wet, slightly bedraggled little dog standing in the middle of the street. I guess I think that when people or dogs actually belong somewhere, they move towards the curb. I would have assumed he lived there, but I looked at his tag and it gave an address that was miles away. Poor little thing. I tethered him onto Max's leash and walked around the block to a friend's house. Their kitchen door was open, so I walked in with two dogs in tow, and asked for a phone.

The tag identified the dog as Louis Vuitton Adams. This is his real name, I've decided that anyone who names their dog Loius Vuitton should expect to find their pet on someone's blog. That's the Adams' dog, I was told. Apparently his owners have divorced and the address on the tag is the ex-wife's address.

I thought I was rescuing a dog, instead I had stolen one.

So Matthew's Pizza was wonderful. When Roy comes back, we'll try Carmine's. If he's lost all his money, it's okay, ClinkShrink will treat. If you know of any great Pizza places you'd like to us to try, please write in. I'm up for a pizza project.

Oh, was this supposed to have something to do with psychiatry?