How About a Little Inspiration?

Anyone who knows me as a therapist knows that I believe that change is difficult, and that for the most part, people come flawed.  We seem to spend an inordinate amount of time identifying and trying to fix our flaws so that we conform to some standard of how we're supposed to be, and this leads people to feel badly about themselves and have the infamous  Low Self-Esteem.  Or to feel badly that they aren't richer, prettier, smarter, tougher, whatever.  

I think people should come to terms with who they are and say Yup, I suck at this.  And then they should not spend much time thinking about what they are bad at and they should figure out what things they like and how to grow those aspects of themselves and make those characteristics work for them so they can live a more fulfilling life.  

Obviously, there are exceptions, and I don't think people should say, "Yup I'm a sociopath and I kill people, get used to it,"  Nor do I think people should embrace their mental illness without trying to get help.

That said, and with minimal relevance to what I really want to share, I really enjoyed this TED talk by Dan Gilbert on the pursuit of happiness, and I hope you will too.  I wish I could speak like this (maybe with a little bit more air exchange).  And I stole the Seuss cartoon from Kathy's facebook page.  Enjoy.

Psych Meds are THE Problem: A Post for Duane Sherry

Shrink Rap prides itself on being a take-all-comers place for open dialogue about the issues and controversies in psychiatry.  Five plus years, and the feel of our blog has gone through many evolutions.  In the last 6-8 weeks, things have gotten very heated around the topics of involuntary hospitalizations and the question of whether medications cause illness or treat illness.  

I see patients who walk in the door in distress.  The only people who walk in feeling well are those who have been treated by someone else and are coming to continue treatment, either because their shrink moved, they moved, something changed.

Once in a while, someone comes in and they are in distress and they are already on psych meds and I look at the regimen and say "No wonder you feel badly, you're on way too much medicine" and I stop things.  Mostly though, I start new medicines and I see people who were sick get better.  Some people have problems with medicines, but not like I hear people talk about in our comments section.  Here at Shrink Rap, people hate anti-psychotics. Very few patients tell me  that very low dose anti-psychotics bother them.  Medicines need to be added carefully, at low doses, and increased gradually.  The patient is supposed to get better: it they don't, the medicine should be stopped.  Sometimes people end up on a zillion medications, no better, and it's not clear why they are on them.  See: Medications: The Good, Bad & Ugly, and  You're Supposed to Get Better.  These are some of my views on treatment and medications.

It's not unusual that patients come in and casually mention in the course of a therapy session, "oh, I stopped taking the meds."  I ask why.  Side effects?  Felt they were no longer necessary?  I ask if they feel better without them (some do, some don't).  I'm here to help, and since I work in a totally voluntary setting, I may spout statistics, especially to someone with a high risk of relapse who was having no side effects and no problems with the meds and feels no differently off them-- but hey, you don't want to take medicines-- it's fine with me, and I'll hang out with you in therapy anyway. 

Duane Sherry has been visiting us for a while now in the comment sections and he feels strongly that medications are the problem, not the answer, and that people who think they are better are wrong.  He and I are seeing different before & after shots.  He asks if I give informed consent (funny, I do) and thinks people should explore different options such as orthomolecular therapies.  He's posted many links, and something gets troubling about the repetitive nature of it (at least to me) and something gets troubling about the accusatory tone, though he has really toned down the blatant --you're an idiot-- comments. Thank you, Duane, this has meant a lot to me.

So let me give Duane a moment here to get out his message of Meds are Harmful / Psychiatry Sucks here on the main page of Shrink Rap.  Duane, you're still welcome to comment, but please stop with the repetitive links, and please keep the tone respectful.  You might want to consider getting your own blog where like minded people can have a forum.

Duane says:

The drugs numb.
They provide temporary relief.
And that's all they do.

The greatest injury happens in their long-term use... They are addictive, because they meet the medical definition of physiological addiction in two vital areas:

a) Increased tolerance
b) Measurable effects during withdrawal

Have your patients look at the "side effects" more closely... Really look at what the drugs do.

Then see how many want to be placed on them.

Here is Duane's website...funny, no place for comments:
http://discoverandrecover.wordpress.com/wellness

Here are some links Duane likes:

http://www.foodforthebrain.org/content.asp?id_Content=1635
http://www.vitamindcouncil.org/health-conditions/mental-health-and-learning-disorders/depression/
http://www.townsendletter.com/Nov2009/hoffer1109.html
http://www.youtube.com/watch?v=aBjIvnRFja4&feature=channel_video_title
http://www.madinamerica.com/madinamerica.com/Timeline.html
http://breggin.com/index.php?option=com_content&task=view&id=40&Itemid=52
 http://recoveryfromschizophrenia.org/therapists-guide-to-reducing-medications/

Duane, Please put any other links you'd like in the comment section of this post: your personal space on Shrink Rap.  If you'd like, in future comments you can say "I'm putting links up in my space on Shrink Rap" and link back to this post and put them in the comment section here.
 
For the most part, we need to agree to disagree.  I don't believe I am going to sell Duane on the idea that medications sometimes help people live better lives.  And I don't think he's going to sell me on the idea that they should never be used. 

To my co-bloggers: please forgive me. 

Like Looking in a Mirror

Sometimes, I treat people who have the same problems I have in my personal life. It's hard. Oh, it's really hard. If I'm really distraught about something and a patient calls seeking treatment with a similar life circumstance, I will sometimes turn them away and recommend another shrink. But I don't always screen so carefully on the phone, and often "I'd like to make an appointment," will simply get a time and date.

The feelings get really complicated here.

If I feel I've had a role in creating my circumstances, then I wonder as my patients seek my counsel, Who am I to be making any suggestions, much less giving advice? Why are you looking to me, I've screwed up the same situations. Oh, you say, Dr. Jeff said on KevinMD that Psychiatrist's Shouldn't Give Advice, but you know, some of us do, and even when we don't, our feelings are often relayed through the questions we ask or the comments we make or don't make, or perhaps by the expressions on our faces, even if we don't say "You should do X." I told a friend once that I feel uneasy, guilty even, in these situations, and he replied, "How do you think I feel?" Did I mention he does family work and was in the midst of a stressful divorce? And I have yet to ask a colleague who also does family work how he managed during the years his own children wouldn't speak to him. Oy, life can be tough, for shrinks just like everyone else.

So perhaps I listen to someone talking about his most personal feelings about a situation, and you know, if I've been there before, perhaps it's good that I can empathize. If I'm in the middle of it, sometimes I listen and the patient's words seem so unreasonable, so unjustified, and yet I recognize them as being exactly my own--it's like having my own anxieties bounced off a wall only to ricochet straight back into my face.

Do I tell the patient that I've been in the same place before? Generally, no. Therapy is about his problems, not mine, and I think in these situations my empathy is clear. I say things that are more poignant and resonant than I might in circumstances where I feel removed. And patients never ask if I've been in the exact same place. On some of the harder things-- things that have no precise quick and easy answer-- I've taken to saying, "Not only don't I know what will fix this, I don't know anyone else who does have the answer." This I can say because I've done my own searching.

I hope I'm reassuring and comforting to people who find themselves in the same places I dwell. Certainly, tripping over a few stones on the path makes one walk a little more gingerly and judge a little less harshly those who walk more slowly. Mostly, though, I worry that I'm a little bit of a fraud just for being in the room.

I Haven't Gotten There (Yet)

A psychiatrist I know is going through a phase-of-life change. It's one you only get to once. He's made the comment that in looking back, he made some mistakes and said some things he shouldn't have to patients who were going through this same phase-of-life change, long before he did. The event of it has made him more empathic to what his patients were feeling, something he didn't comprehend until he was in the same shoes.

I know the feeling. People look to their psychiatrists for wisdom, and you know, we don't always have it. Patients will ask for suggestions about marriage or child-rearing from psychiatrists who may be single, childless, or on their eighth divorce. It doesn't mean we don't have the answers-- sometimes these things are better dealt with from a safe distance-- but sometimes it might. I look back at some of the things I said to the parents of teenagers, back when mine were oh-so-cute-and-loving toddlers...and I wince...oh, my, I was so clueless back in the day. Can I recall my patients? I'm sorry, I said some stupid things back then. I shrug a lot more than I used to. I don't know if it's helpful, but I do know it's more honest.

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.

We're All Going To Die

I heard Irvin Yalom speak today. He's a psychiatrist/writer/ very famous shrink at Stanford, and he was at Johns Hopkins today to give the Jerome Frank lecture. The title of his talk was "Staring at The Sun: Overcoming the Terror of Death." It's also the title of his latest book. The auditorium was packed---no surprise here. When I heard Dr. Yalom was coming, maybe a month ago, I made a point to block off the time to be there-- I've never heard him speak and I was looking forward to this. Please let me share the experience with you.

Dr. Yalom is a gifted writer. He writes about his work in colorful and accessible ways, and he speaks about it this way as well. He lectures an audience of hundreds as though he is talking to a single friend. No notes, no hesitation, and he seems so at ease as he talks openly about work that is quite intimate. His specialties are group psychotherapy and existential psychotherapy, and he classifies the existential issues as death, isolation, freedom (as in freedom to make decisions and to steer the course of one's life, not political freedom), and meaning. "We are unfortunately meaning-seeking creatures heralded into a universe that has no meaning." Now he tells me!

Dr. Yalom started by talking about Dr. Jerome Frank (for whom the lecture is titled)--one of his mentors --and talked about a poignant visit with him near the end of Dr. Frank's life. Dr. Frank was also one of my psychotherapy supervisors, perhaps at a time in my training when I took such things for granted and had no true appreciation of what an amazing gift it was to be his student. Dr. Yalom talked about his memories, and I revisited my own.

Dr. Yalom talked about his own psychotherapy experiences: his three years in psychoanalysis in Baltimore "There was so much attention to the distant past and so little to the future and our death." Later in life, in California, he spent two years in therapy with Rollo May.

Death anxiety, Yalom contends, is an issue for many people--one patients won't necessarily bring up on their own, one they avoid if they sense the therapist is uncomfortable, one that, indeed, makes therapists uneasy as they, too, have their own death anxiety to face. Perhaps it's easier to avoid the topic; after all, there's nothing to do about it. We're all going to die. The therapist, he says, has a role in discussing death, and therapy can diminish the anxiety.

He talked a little about his work with cancer patients and how facing death can have a transforming effect; people get a better sense of priorities. "What a pity I had to wait until now to learn how to live," one dying patient told Dr. Yalom.

By far, the most interesting parts of the talk were when Yalom talked about specific examples of his own work with patients and the interactions that transpired. He talked about a patient--a psychotherapist--- who asked him about his own death anxiety (he responded) and who talked about his concerns about how Dr. Yalom might judge him. One nice thing about being Irvin Yalom is that you can get up in front of an audience of hundreds and talk openly about your work, boundary violations and all. He ended with the statement, "To become wise, you must listen to the wild dogs barking in your cellar." --a version of a quote by Nietzsche. I'm still thinking about that one.

It's been a while since I've heard a lecture like this. We've become so focused on psychiatry as the treatment of illnesses, of which drug at what dose, for how long, or which type of psychotherapy, and certainly we assume that what goes on in therapy includes talking about issues that having meaning to patients--including things that evoke anxiety, and the nuances of life that include meaning. We know we talk about these things behind closed doors--but we don't often talk about the process of such transactions.

Electronic Hair Records!

Roy has Electronic Medical Records on his mind lately and if you'd like to hear him, oh, he'd love to tell you his thoughts. Or read his last post here. I'm still not sure how I feel about Electronic Records-- I worry about confidentiality and the propagation of incorrect information.

So why are medical records oh so important? What about making other important things into Electronic Records so that information can be shared and referred to? Never mind Electronic Medical Records, what I need are Electronic Hair Records!

Hair, you ask? Hair! Let me tell you about my hair. I am a user of hair chemicals and it's no picnic when I'm away and need an emergency procedure. What could electronic hair records do?
Well there was the two year period where I saw a very nice hair dresser and somehow my hair was always too light. I had her switch chemical brands, but to no avail. Finally, I switched salons, and my hair is darker. There was the time that I wanted to have a chemical procedure done with a gift certificate at another salon and was told that if I'd had a certain process done previously, my hair might break off or fall out. If there was an EHairR, my hair dresser could have checked this-- instead we had to call my home salon and determined that it wasn't safe....my hair, indeed, could have fallen out. Oh, and because of all the processes, I must use a sulphate-free shampoo. No EHairR: I have to be the one to remind the shampoo person of this issue each and every time. No one even asks.

So what could an Electronic Hair Record do?

• Keep track of all chemical processes, brand names, colors, and dates of application.
• Coordinate dates of chemical processes to prevent interactions.
• Include panoramic photos of all haircuts so that patron could walk in and say, I liked the way it looked after the last cut and that cut could be reviewed.
• Include standardization of lengths: bangs to a half inch above the eyebrows would be precise.
• For those with thinning hair or balding, track hair loss.
• Include computer generated growth photos to help schedule haircuts with important life events.
• Download onto a iPhone app so the patron could, at last, own their own EHairR!
• Compare costs and ratings for different salons and hairdressers.

I think I'm on to something here.

What Doesn't Kill Us Makes Us Stronger....

So I was bitching to Roy (What, me bitch?) and he responded with "What doesn't kill us makes us stronger." Or some version thereof. Roy, Nietzsche, one of those smart guys said something like that. They actually even kind of look alike.

One thing about being a psychiatrist is that most of us believe that what we do, or hope to do, relieves suffering. We believe that the treatments psychiatry has to offer make people better and relieve their psychic torment. Sometimes they work, sometimes they don't, and sometimes "the remedy is worse than the disease" (--Francis Bacon).

In medicine, the patient's history begins with the "chief complaint." As doctors, we often view our job as being to address that complaint: hopefully to make it go away. Often it is an ache or a pain, physical or mental. And yet, our society clearly values Growth through suffering. What doesn't kill us makes us stronger. When we take away the torment, do we stifle the soul?