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.

Holiday Greetings, Approved by Our Lawyers and Institutional Review Boards

Best wishes for an environmentally conscious, socially responsible, low stress, nonaddictive, gender neutral, winter solstice holiday, practiced within the most joyous traditions of the religious persuasion of your choice, and with respect for the religious persuasions of others or their choice not to practice a religion at all; a fiscally successful, personally fulfilling, and medically uncomplicated recognition of the generally accepted calendar year 2011, but not without due respect for the calendars of choice of other cultures whose contributions to our society have helped make our country great.  This greeting is being sent to all without regard to political party, race, creed, color, religion, nationality, immigration status, sexual preferences, gender identity roles, physical or mental capacity, literacy, or marital & civil union status. 

This greeting is subject to clarification or withdrawal. It implies no promise by the wisher to actually implement any of the wishes for her/himself or for others.  The implementation of those wishes, however, should be done in a manner that is compatible with the policies set forth by the Americans with Disabilities Act.  It is in no way to be construed as effecting a contractual obligation of any sort on the part of either the wisher or wishee.

This winter greeting is HIPAA compliant.  Your acceptance of our greeting will not be released to parties other than insurers, pharmaceutical companies, and market research institutions. If you wish to accept our holiday greeting, please read the six page document that accompanies this greeting and check the box that says "I have read and accept the terms of this winter greeting."  Please note that these terms are not negotiable, but they can be exchanged for another holiday greeting for a 10% restocking fee.   

What to Get Your Psychiatrist for the Holidays

This is an update of a Shrink Rap post that originally was posted in 2006.  Seems like a good time for a re-run.

Sarebear mentioned some time ago that she didn't know what to get her psychiatrist for the holidays. I thought about this and decided the answer is easy:

Give your psychiatrist a holiday card and write something meaningful and kind in it. Say, "Thanks for helping me." Or "I'm glad you're in my life." "You're the best psychiatrist in the world" works nicely, too. If you hate your psychiatrist and for inexplicable reasons feel compelled to get them something anyway, then skip the note and just give a generic Seasons Greetings card.

Don't get your psychiatrist an expensive gift. And don't, not even as a joke, give your psychiatrist money-- unless you're paying an overdue bill-- and don't  make comments about a holiday "tip."

So gifts and shrinks are often an unsettling combination. As psychiatrists, we're taught that treatment is offered for a fee. End of discussion and anything more represents a violation of boundaries. Psychiatrists-in-training are told not to accept gifts, and psychotherapists as a whole are taught to try to understand behaviors that skim the usual boundaries. So, theoretically, the psychiatrist should refuse the gift and explore with the patient what meaning the gift, the refusal, the whole exchange, has to the patient.

When residents ask me what to do when patients want to give them gifts, I say "Tell them the program has rules that say you're not allowed to accept gifts." This is the truth and the resident risks getting in trouble if they do accept gifts. If you can't take a pen from a drug rep anymore, why should you be allowed to take a timeshare from a patient? Okay, I made that up, I've never heard of a patient gifting a resident with a timeshare, but we can all have fantasies, right?

I'm in private practice, there's no program director, I make the rules. When a patient gives me a gift, I accept it and say, "Thank you." Why? Because it seems intentionally hurtful to do otherwise-- I assume it has meaning to the patient, that their feelings will be hurt if I refuse the gift, that the patient has taken the time, effort, and money to pick out a gift and this represents something meaningful to him and that it might be painful to have this refused. While the act of giving a gift might have a multitude of meanings, depending on the gift, depending on the patient's illness, depending on the circumstances, I just can't find a way to say No that would feel anything other than rejecting. So I accept the gift and thank the patient, and if the gift is edible, I eat it. This is the thing though: while I've decided that this is the way to go, at least so far for me within the realm of my own practice, I always feel like I'm doing something wrong by accepting a gift.  Training issues remain in the back of my head, and I'd really rather just have a card that says I'm the best psychiatrist in the world.

Disclaimer in honor of other non-shrink physicians: Doctors in other specialties have no such concerns with accepting gifts. They probably don't want anything that taxes your budget. Food is usually good, a bottle of wine, a plant, candles, all will do nicely, and no doctor expects gifts from their patients.  

'Tis the Season

Stolen from the facebook page of another shrink:

Why Isn't There an Anti-Oncology Movement?

Happy Fourth of July to all of our readers!

We will be posting a podcast later today--we kept this one short and sweet at just over 15 minutes.


We've talked quite a bit here about Anti-Psychiatry sentiment, and I keep wondering why psychiatry alone gets such controversy.  Oh, I think people are frustrated with other areas of medicine, and doctor bashing has become a popular past time, but I'm not aware that any other sub-specialty has an organized "anti" movement.  

Here's why I think that oncology might be a good candidate:


Like psychiatry, the treatments are not guaranteed: they may work, they may not.  

The treatments have horrible side effects: vomiting, hair loss, nerve damage, chemo brain, organ damage, cardiotoxicity, loss of body parts from surgery, infertility, and the list goes on.

They are never given involuntarily, you say, but I assure you there are patients who are cajoled and guilted into some pretty toxic treatments even when their chances of meaningful recovery may be quite low.  And a patient in a hospital who tries to refuse care and check out may well end up having a psychiatry consult called to assess their competence to make decisions.

Treatment is extremely expensive.   If you thought Abilify costs a lot, try Avastin at $88,000 a year, or Provenge which prolongs life by an average of 4 months and costs $93,000.


My best guess?  I think we're so conditioned to think of Cancer as deadly and terrifying that those who survive the illness and the treatment are 'programmed' to believe they must be thankful, and those who don't are too dead to complain.  Leslie will tell us it's because there is no formalized mechanism for involuntary treatment, and Rob will tell us that it's because there are known pathological mechanisms which dictate that cancer is real.  Is that totally true?  Don't we think that there are people who have early-stage breast and prostate cancers that likely won't progress to fatal diseases who are still subjected to disfiguring and toxic treatments in a mass sweep to decrease mortality rates?


Oh, my, not a very holiday-esque post!  And I don't have it in for the oncologists at all, I was just wondering. 










 

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.

Most Popular Shrink Rap Posts of 2010

This is Roy's job, but he's otherwise occupied. He'd do a better job, I promise. Here's my quick and dirty list of our most popular posts this year:

What's a Psychiatric Emergency? 2/8/10

Prescribing Psychotherapy 12/13/10

ObamaMama it's Health Care Reform 3/27/10

Is it Malpractice to Lie? 3/17/10

Are In-Network Shrinks Better Shrinks? 2/14/10

What's Your Favorite Shrink Book? 5/21/10

What Makes Mental Illness Bad? 10/13/10

Shopping Spree 4/8/10

Unhinged: The Trouble With Psychiatry: Book Review 5/10/10

Saving Normal 3/3/10

Unrelated to the New Year, but the all-time most popular Shrink Rap post:

Why Docs Don't Like Xanax (some of us)

Making Mango Margaritas as a Metaphor for Life

Roy came to a cookout at my house this weekend. He came late, and probably only because I sent him a text message at noon that said, "Remember, you're coming to dinner at my house tonight."

So here comes Roy, and as I'm schmoozing with guests, he tells me he's brought the makings for mango margaritas and where is my blender? By the sink. He goes inside. He comes back outside-- can't find the blender. I go inside and point to the blender next to the sink. He never noticed that sink. Will it chop ice? Will it chop anything? It's not a very good blender. He fills it with mango stuff and I start smashing ice with a crab mallet. The blender goes grrrr and nothing happens. I dump everything into the food processor and go back outside.

The food processor is leaking. Roy has come to find me. Are food processors supposed to handle liquids without leaking? I make gazpacho in it, but it leaks and I do it near the sink, pour fast, and wipe up the spillage. So it's no surprise at all to me that the food processor is leaking mango margaritas. But wait, Roy says, we have to find the source of the leak. What? Why? Who cares where the source of the leak is? In a million years, it wouldn't occur to me to ask this. I pour the mush into a pitcher. Oh, only it's not mushed enough. Roy wants me to regrind half. I toss the whole thing back in and push the button. Orange junk explodes everywhere. The whole episode feels exactly like writing a book with Roy. I just want to get it done, and he's dealing with the details of the second sentence when there are chapters to go before we sleep. Who the hell cares if there is a comma there? Or orange goo on the counter.

Can we leave the alcohol out of some of the mix so the kids can have some? That, I'm told, will mess up the proportions. Proportions? I cook and bake by adding "some"....Roy reminds me of my mother who seemed to think I should measure, or be able to tell her how she could make the muffins I'd made. Measure? Proofread? Proportions? A cocktail needs proportions? Look, no one has ever left one of my cocktails unhappy. You add cranberry juice until the color is right: voila, Cosmo! Roy will want me to figure out how to get blogger to add the accent squeal over the 'a' in voila.

Okay, so Roy's mango margaritas were a hit. Very good. A little later in the evening, I looked down at myself and realized my black shirt was splattered with large orange flecks all over it, but hey. And in his honor, we threw out the blender.

So I haven't quite figured it out: Roy is meticulous and a bit obsessive and very detail-oriented, except when he isn't. The time before when he made the drinks, he texted me asking if he could borrow triple sec...when I was out, he actually made them without it-- a recipe made with one ingredient missing! (--years of psychoanalysis, I'm sure) And the meeting he was supposed to be at this morning at 9 am? Let's just say he texted back, "Yikes!"

Please, God, don't let Roy write a post about me.

From foodnetwork.com:

Ingredients

For the Mango Margarita Mix:

• 1 1/4 pounds fresh mangoes
• 1 cup water
• 1/2 cup sugar
• Gray salt

For the drink:

• 3 cups ice
• 1 1/2 cups Mango Margarita Mix
• 4 ounces tequila
• 2 ounces triple sec
• Lime wedges
• Mint Salt, recipe follows

Directions

Peel and pit the mangoes and cut them into large chunks. Place the mango in a blender with the water, sugar, and a pinch of salt. Blend until smooth. Taste and add more sugar, if necessary.

Fill the blender with ice and add the Mango Margarita Mix, tequila, and triple sec. Blend until smooth. Rub the rim of a margarita glass with a lime wedge and dip into Mint Salt to coat rim. Fill glass and enjoy!

The Good Old Days

Dr. Psychobabble is a new intern in New York and she's reading the manual on how to work her pager. Her pager? They don't just call/text housestaff on their cell phones, they still need hospital pagers? It got me thinking about my old pager back when I was an intern in New York.....

I saw my first cell phone when I was in medical school. It was in a suitcase. I didn't see another one for years, and I didn't get my own until 1996. My entire training occurred in the virtually pre-cell error. As an intern, I was given a pager. It beeped, then shouted out the number I was being paged to call. The owner of the pager had to listen, it was a auditory thing, not something you could read. In the bathroom, the voice of pager woman reverberated off the tile walls in an particularly intrusive tone. For months after I no longer carried the thing, I jumped when the microwave went off (post-traumatic pager disorder). Talk about an object to hate!

PCs showed up when I was in college, but few people had them. A research team I worked with did, and so I learned Volkswriter (? a predecessor of Word) fairly early. Mostly I remember the group panic when the computer lost an 80-page original research document. I did think it was fascinating that you could push one button and have the thing blast out 80 of the same letter addressed to different people. For my own papers, I still used a smith corona and I remember being up all night writing a paper my senior year on bulimia. Mostly I remember that the professor pointed out to me that I'd misspelled bulimia (and Roy says....sigh...and wishes I were obsessional and detail-oriented). I can't imagine what college would have been like for me with internet access. I may not have made it: Facebook might have diverted me from any goal-oriented behavior. How would I would have sat in class and texted my heart out. Oy. But all the professors I was too intimidated to speak to-- I would have emailed them my every thought and it might have been a richer experience...or not?

By med school, word processors were more widely available---there was a whole bank of computers in the library and the night before a paper was due, we'd all be there typing...er, keyboarding. No real Internet yet, and I never had much use for the computer beyond the word processing capability.

I did get an answering machine in medical school, something that truly freed society from sitting by the phone waiting for a boy, a job, a residency interview.

A few years after I finished residency, the Internet really caught on and I had no real idea. Clink of course, knew it all. I asked her to come show me, so she comes with a laptop and plugs it in to my phone line. She loaded a page and waited. And waited. This was not for me. I wanted to try email. One of her contacts was a mutual friend, a man who'd trained with us and then moved to Minnesota. I sent him an email. He wrote back: he and his wife and two small children were coming to visit, could they stay with my family (in my very small house, with our two small children) for a week? I wasn't so sure about this email stuff.

So now we have a blog, a sometimes podcast, I have a desktop, laptop, iTouch, husband has an iPad and blackberry, kids have laptops and iTouches, everyone has a cell with a zillion minutes and unlimited texting. TV with satellite and DVR and four remotes and a sound system. There's a bunch of digital cameras in the mix, two types of speaker docs for music, voicemails and emails. listservs, and things to check out the wazoo....we all have Facebook pages and some days we're friends and most days we're not. Twitter me this, send me the link to that, YouTube, MySpace, ITunes, oy. When's Roy gonna make a Shrink Rap iPhone app?


______
And now for announcements:
Happy Fourth of July weekend, Everybody!!!
Happy Birthday, David. I love you and you were great on TV this week.
Welcome home, DB, two delayed flights, days of travel and I'll be glad to have you home and out of Africa, can't wait to see your pics and I love you, too.
Roy? Has anyone seen Roy? Did he eat the beauty queen podcast???
And finally:
Congratulations, Clink and Victor!

The Art of Being A Homebody

After Dinah and I got trapped temporarily at Roy's place I had this sudden mental image of all three Shrink Rappers homebound together in a snowstorm: Dinah baking cookies, Roy tweaking the blog template and me climbing the walls.

It occurred to me that we have a diagnosis for people who have trouble leaving the house (agoraphobia) but we don't call it an illness if somebody goes crazy being at home for a long time.

I know people who always have to be on the go. After a day or two of hanging around the house, or sometimes a few hours, they have to get up and move around or at least take a walk. They're out shopping with friends or going out to lunch or otherwise on the move.

Me, I have learned the art of being a homebody. It was a necessary skill in my early days when a really good blizzard could strand you, doors drifted shut, for two or three days at a time. I'm convinced that upper Mid-Westerners became laid back and easy-going through natural selection---anyone who couldn't handle several days together in close quarters just killed each other off. Regardless, it's now an innate trait for some of us.

Some people describe themselves as homebound---the stay-at-home mom for example---but I know from my parent friends that stay-at-home moms are rarely at home. They're on the road constantly to and from doctor's appointments, school, sporting events and children's social activities. We also now have the 'stay-cation', people who spend their vacations at home because of the economic downtown. However, even stay-cationers aren't in the house the entire time. They're taking day trips or sightseeing local attractions they don't usually go to. They're just not going as far as they usually go.

We've even invented gender-based words for being a homebody: women "nest", men retreat to their "man-caves". (I cringe a bit at this, with the implication that for women to justify nesting they have to have kids, or that men need a place presumably to grunt, watch sports and scratch places they wouldn't scratch in public.) But there you have it, that's our culture, and mainly I was just amused when the pleasure of being at home became a fad. My innate instincts had become trendy.

The key to being happy at home is to first relieve yourself from the guilt of doing nothing. If you look around and all you see are the dust bunnies and a kitchen that needs to be renovated, that's a problem. If you can't rid your mind of all the errands---the dusting, the bills to be paid, the unpacked boxes leftover from your move several years ago---it's going to be hard to be comfortable in your nest.

Personally, all I need is a quilt, a good book and a place to curl up.

And a good snowstorm.

Changes......

My farewell post to 2008 was a bit gloomy. If that wasn't enough, I came upon this article in the New York Times by Alex Williams: New Year. New You? Nice Try.

It starts with Oprah's re-gained weight (please, everyone, leave poor Oprah alone...she's great at all weights). Nail biters, drinkers, dieters, even those with heart disease trying for healthier diets don't make much progress in Williams' article:
“Most of us think that we can change our lives if we just summon the willpower and try even harder this time around,” said Alan Deutschman, the former executive director of Unboundary, a firm that counsels corporations on how to navigate change, and the author of “Change or Die,” a book that asserts that even though most people have the ability to change, they rarely do. “It’s exceptionally hard to make life changes,” Mr. Deutschman said, “and our efforts are usually doomed to failure when we try to do it on our own.”

There are cases cited of someone who vows to learn to cook, and someone who wants to get a drivers' license.

Is it really all that hopeless? Ranting without data, I don't think so. Weight change is hard-- it's a battle against biology. But in the course of talking with patient about their history, it's not so unusual to hear that someone quit smoking or drinking many years ago, or made a change only after years of deliberation. The woman Williams talks about who vows year after year to learn to cook but still subsists on Honey Bunches of Oats--- my guess is she either likes the cereal better or she doesn't really want to learn to cook. Please forgive me this once for discussing the motivations of someone I've never met, but this was hard to resist, especially given my own preference for Honey Nut Cheerios.

Are our efforts to change really "doomed to failure when we try to do it on our own" as Deutschman, quoted above, suggests? I think it's a skewed population: if you vow to change and do, you don't seek help. You don't enter a study. You just make a change.

And your New Years' resolutions?

The Frazzled Holiday Season

So Clink, I think, is climbing somewhere. Roy is working, a lot. I'm on vacation (mostly---if you have an appointment with me this week, keep it, I'll be there) and I don't have much to say about psychiatry at the moment. I've had a few thoughts to write about sliding fees, but it's the holidays and a recession, do we really want to talk about money? No. I've thought of writing about the limits of 'evidence-based medicine' in psychiatry. But it's the holidays.

Instead, I'll tell you about my trip to New England last week. I posted from the airport, so you know my plane was delayed-- there was a blizzard where we were landing and the airport closed. One of my kids was pleased that the delay gave her time to get Starbucks, the other remained plugged into an iPod and read a book. I blogged, Starbucks'd, and read the Sunday NY Times, then tried to re-route us, only to be informed that we'd be taking off shortly.

So across the aisle on the delayed and not-quite-full flight, there was a young mom with two very sweet girls. The mom was frazzled. For starters, she was traveling alone with the girls, one of whom had to use the restroom just as the flight was about to take off... a no-no in these post 9/11 days but this family was so...well, let's just say she made it, scooped up in mom's arms.

But the big story was the globe, a big talking globe in a great big box. Mom was trying to navigate the globe, navigate the children, put the globe away. A gift from an aunt...oh, I've been there with the way-too-big to travel with gifts. So mom tries to maneuver the globe into the overhead luggage bin. It does fit. She pushes and pushes and pushes some more, but the talking globe just doesn't fit and I wonder if she's going to break the airplane. It doesn't fit under the seat. She asks the people in the row in front of us if the talking globe can have the empty seat between them. The globe gets buckled in, with it's tray table in the upright and locked position. The flight attendant starts to scold the people sitting next to the globe, who look at her a bit cluelessly, and ultimately, just this once, the talking globe is permitted to have it's own seat, just as the little girl is permitted to use the restroom facilities. Mom borrows a pen from my husband. Twice. She mentions that she's going to Vermont and that she hasn't driven a car in twenty years-- I don't know the details, just that we'll be landing in a blizzard. Mom borrows my husband's cell phone just as we land.

Okay, it would be nice to say I didn't laugh out loud, but as I watched her try to get that talking globe gift from the aunt into different overhead luggage compartments.....

May your holidays be peaceful and filled with joy. May your gifts all fit in your bags. May you enjoy the company of fine friends and fine food.

And a Partridge in a Pear Tree

'Tis the season. In the past, I've talked about What to Get Your Psychiatrist for Christmas, Hanukkah, or Kwanzaa. Today, I'm going to talk about gift-giving and gift-getting in general. But this is Shrink Rap, you say, what do presents have to do with psychiatry? Pretty much nothing, except that gifts are often a topic people talk about in psychotherapy. Over the years, as both the listener of many gift-related stories, and outside the office as both a gift-giver and gift-receiver, I've made some observations. If you wanted psychiatry, try another blog and check again tomorrow with Shrink Rap...

Okay, so gifts are always a complicated issue. Before you buy anyone a gift (with very few exceptions, the major one being sweet young children who sometimes actually are excited and surprised), here's what you need to know: you're damned if you do and you're damned if you don't. I'm sorry if I sound kind of cynical. I read an email today from a dear friend and when I mentioned I might bring a local specialty food that I've mailed her before, she responded "We don't really like the Maryland thing." Okay, I guess it's good that I'm not wasting my money and time, but it kind of came off as "I didn' like the gift you sent last year." It got me feeling a bit snarky.

I've collected a lot of gift stories over the years, including one guy I knew who would only give his mother gifts embroidered with her initials so she couldn't return them, only to be disappointed when she never wore them. Oy. Gifts often have an edge of control about them.
Sometimes people feel the gift is something the giver thinks the receiver should want, or be interested in, or learn about, or have for his or her own good. The other spin on that would be that the giver has an interest he wants to share with the receiver.

So here is what I've learned:

• Some people like to be surprised, and mostly they want to be surprised with the thing they want, and if the gifter doesn't know what the giftee wants, that's hard.

• Some people want practical gifts and hate the frivolous.

• Some people want frivolous gifts and hate the practical.

• It's awkward for many people if you give them a gift that is more elaborate or expensive than what you gave them.

• Gift-giving often gets saddled with all kinds of unspoken expectations
• If your wife wears a size 18, don't give her a size 4.
  

I don't have any really great suggestions about gift giving. I do have one suggestion about receiving gifts-- there is one response and only one response that works: "Thank you." Oh, a little more effusive is fine, too. I believe that if you don't like a gift, you should quietly return it, and not mention that fact. If someone is in your face asking if you like it, well.... that's difficult. If it's not returnable, re-gift it to someone on Mars (--and yes, I've had someone casually mention to me that they re-gifted a gift I'd given them...was that necessary?) If it's not returnable, if it's not re-giftable, if it can't be donated to a charity that might appreciate it, then quietly throw it out. If you already have one, if it's the wrong size, if you're allergic to it and will die if you open the box, the safest thing is still to leave it at "thank you."

And if you'd like to check out an amusing clip, try:
http://bewareofthedoghouse.com/videoPage.aspx

Happy Thanksgiving!

From the Shrink Rappers to you.



(And don't forget, Roy wants you to have a happy holiday discussion about your end of life issues!)

My Wish List For 2008

Dinah is off to a warm sunny place this week, leaving Roy and I to care for the blog.

Uh oh.

Much as we (I) like to tease Dinah about talking too much, the fact of the matter is that it's nice to know she's here taking care of the blog when real life intrudes on my blogging capacity, which lately has been pretty often. So in her absence I thought I'd put together a list of things I would like for 2008:

I'd like a never-ending list of topics to blog about that really catch my interest.

I'd like Dinah to have good-hair days, every day, all year round.

I'd like Roy to keep getting the latest and coolest Mac gadgets so I can enjoy his geekhood vicariously.

I'd like Dinah to have her own iPod. Really, she deserves one.

I'd like to have an organized and coherent podcast. I really believe this can be done and that we should do it, or try to do it, at least once.

I'd like a list of good non-crunchy food to eat during our podcast tapings.

I'd like pet-sized mikes for Monkey and Max so they don't feel left out during our podcasts.

I'd like Blogger to start showing our little icon pictures again when we comment. I miss seeing my little guinea pig behind bars.

I wish my patients would behave every day, all day, for a full year. (Hey, I can dream can't I?)

I wish someone would give me an office. Or maybe just a telephone. (I did get the heat turned on a few weeks ago---I'm making progress.)

I wish someone would explain to me how "pregnant pigs" came to be one of our post labels.

I wish all our listeners and readers would continue to find My Three Shrinks a comfortable place to learn, ramble and rant. It certainly has been for me.

Finally, I wish the best of all good things to both of my co-bloggers. I've had a wonderful time with both of you.

My Recycled Post, Back Again After Technical Difficulties

Don't ask, this is recycled from last year. It was gone, now it's back, unfortunately the three new comments were lost.

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What To Get Your Psychiatrist For Christmas, Hanukkah, or Kwanzaa

One commenter (was it Sarebear?) mentioned some time ago that she didn't know what to get her psychiatrist for the holidays. I thought about this and decided the answer is easy:
Give your psychiatrist a holiday card and write something meaningful and kind in it. Say, "Thanks for helping me." Or "I'm glad you're in my life." "You're the best psychiatrist in the world" works nicely, too. If you hate your psychiatrist and for inexplicable reasons feel compelled to get them something anyway, then skip the note and just give a generic Seasons Greetings card.

Don't get your psychiatrist an expensive gift. And don't, not even as a joke, give your psychiatrist money or make comments about a holiday "tip."

So gifts and shrinks are often an unsettling combination. As psychiatrists, we're taught that treatment is offered for a fee. End of discussion and anything more represents a violation of boundaries. Psychiatrists in training are told not to accept gifts, and psychotherapists as a whole are taught to try to understand behaviors that skim the usual boundaries. So, theoretically, the psychiatrist should refuse the gift and explore with the patient what meaning the gift, the refusal, the whole exchange, has to the patient.

When residents ask me what to do when patients want to give them gifts, I say "Tell them the program has rules that say you're not allowed to accept gifts." This is the truth and the resident risks getting in trouble if they do accept gifts. If you can't take a pen from a drug rep anymore, why should you be allowed to take a timeshare from a patient? (Okay, I made that up, I've never heard of a patient gifting a resident with a timeshare, but we can all have fantasies, right?)

I'm in private practice, there's no program director, I make the rules. When a patient gives me a gift, I accept it and say, "Thank you." Why? Because it seems intentionally hurtful to do otherwise-- I assume it has meaning to the patient, that their feelings will be hurt if I refuse the gift, that the patient has taken the time, effort, and money to pick out a gift and this represents something meaningful to him and that it might be painful to have this refused. While the act of giving a gift might have a multitude of meanings, depending on the gift, depending on the patient's illness, depending on the circumstances, I just can't find a way to say No that would feel anything other than rejecting. So I accept the gift and thank the patient, and if the gift is edible, I eat it. This is the thing though: while I've decided that this is the way to go, at least so far for me within the realm of my own practice, I always feel like I'm doing something wrong by accepting a gift, training issues remain in the back of my head, and I'd really rather just have a card that says I'm the best psychiatrist in the world.

Disclaimer in honor of Dr. A, Fat Doctor, Flea, Midwife with a Knife and other non-shrink physicians: Doctors in other specialties have no such concerns with accepting gifts. They probably don't want anything that taxes your budget. Food is usually good, a bottle of wine, a plant, candles, all will do nicely. Fat Doctor, I hear, is in need of some good toe nail polish remover.

24 comments:

Sarebear said...

It was someone else, actually, but I'm tickled to be mentioned in a Shrink Rap post! I commented under that person about wondering about holiday cards and such.

Oh, another thing I thought of, is there is a website, where you can pick which program you want to donate to, and do it in someone's name even.

The programs are various ones like getting geese for people to raise (in third world countries) to make some income for them, and many other things that provide purpose and opportunity and other helpful things for people in difficult times in countries like that. I think you can even just buy one chick towards the program for someone . . . Anyway, doing that in someone's name, say, $10 towards improving someone's life in another country, and then put that on a certificate inside a card you give your mental health professional, I thought would be a way to give a gift to your ologist, iatrist, what have you, and yet it's a , well, it's a gift that's non-refuseable, and I don't think, inappropriate under these or most any other circumstances, either.

Plus, it feels good. I'll haveta look up that site and post it here, and you can put it in your post if you look into it and like it and find it a useful solution to the gift problem.

I must say, as a patient, being so grateful for the help my ologist gives me, that there's just times where I wish I could mark say the anniversary of starting therapy, or something, in a meaningful way that I can share with him (aside from working on myself, which I know is what he would like the most). So a small donation to that sort of thing I thought would be copacetic. (I hope I used that word right, lol).

Oh, and is that sareBARE a Freudian slip on your part? Hee hee.

November 04, 2006

Roy said...

WHAT A GREAT IDEA!

Sarebear, this is just the best thing. I've heard of these "microloans", where you loan someone money to buy a goat, they turn it into a cheese- & milk-selling business in their village, and pay back the money over time, plus a small amount of interest. There are others that just give the money away.

But combining these idea with that of a gift to someone else is great. Especially if one can somehow track the individual's success (how cool is that to check out your goat-guy's site 2 years later to see that he now owns 50 goats and employs 12 villagers).

I haven't completely checked these out, but here are a few sites which appear to do something like this...

Universal Giving
Kiva
Village Banking

November 04, 2006

ClinkShrink said...

When I was a resident I had a psychotic inpatient who wanted a pass to leave the unit. The nurses were really busy and the policy said that patients had to be escorted whenever they left the unit. I was going stir crazy, so I volunteered to escort him. We went across the street to the drug store where he bought cigarettes (yes, he heard about that from me) then on the way back we stopped at the hospital library so he could return a book. (The librarian recognized him and called him by name, which I thought was a good sign.) When we got back to the unit he pulled a playing card out of his pocket (the eight of clubs) and handed to me, thanking him for the time off the unit.

To this day I don't know for sure what that playing card represented. I had a vague sense then that it served some protective function, but for all I know he could have meant "you are cursed and will turn into a duck within three days". I'm not sure if I accepted a gift or not.

Regardless, periodically since then when I've been in risky or uncomfortable situations I sometimes think to myself, "It's OK, I've got my eight of clubs." The magic may have worn off by now, but at least I haven't turned into a duck.

November 04, 2006

Roy said...

According to this site, the eight of clubs signifies "INSTABILITY - Internal strife; the foundations within are crumbling.".

Perhaps he was trying to tell you something?

(Okay, maybe not the most reliable site... tarot.com's interpretation seems less ominous.)

November 04, 2006

Dinah said...

Sarebear: oops! I fixed your name.

Wow! What an idea. Can I feed someone in a third world country a dinner of duck in cherry sauce and give this as a gift to Clink? I can hear her asking why I didn't feed her....

And Roy, should I donate Macs and IPODs to someone in third world countries in you name?

So I started thinking, can I make a donation in honor of my patients? Then I realized I can't use their names.

For those who want to stay closer to home, there are Foodbanks to feed the hungry locals, in Baltimore there is HealthCare for the Homeless.

Clink, hang on to that card, you never know.

November 04, 2006

ClinkShrink said...

Eight? Did I say eight? I meant six. The six of clubs is much better:

"SIX OF CLUBS: INNOCENCE
Naivete; failure to attempt to understand the world around one."

Yeah, that's it. Much better than instability.

Dinah you always feed me great. As long as you don't feed me to the homeless I'll never complain.

November 04, 2006

Anonymous said...

I gave mine a rechargeable flashlight with a note that expressed my thanks for his help in illuminating a difficult path I was walking. Corny, but less than $10, and my appreciation was real.

November 04, 2006

Sarebear said...

Glad you like the idea!

Feeling more secure, and less drafty in here in my sarebearishness. Hee hee.

November 04, 2006

Dreaming again said...

My therapists birthday was in October. She'd recently moved offices ...so I gave her a gift for her office. A decorative candle.

I have been wondering about the holidays and my psychiatrist this year. Last year, Thanksgiving time, I mailed him a letter, first time, rather intense, about some childhood memories that I'd realized carried more significance than I'd given them credit for.

He'd gotten the letter, and because it came Thanksgiving week, just figured it was a Thanksgiving letter (he'd gotten several Thanksgiving cards). When I had an appointment the next week and had to have him read the letter in front of me ...I realized NEVER send through the mail an emergency letter at holiday time!!!!

Maybe this year, I'll just give him an autographed copy of my book when it comes out ...hmmmm

November 04, 2006

Midwife with a Knife said...

Hm... you know, a card that says, "You're the best obstetrician in the world" would go a long way. My favorite "gift" hass always been baby pictures, even if by email, of babies I've delivered.

Even though I'm still in training, and with student loans and all am kind of "poor", now my patients are much poorer than I am, and recieving a gift from someone who couldn't really afford it would just make me feel weird.

Pictures of moms and/or babies who are alive and doing well, however, is something I can save and look at when I've had a hard day (like a maternal or fetal/neonatal death) to remind myself that sometimes moms and/or babies are alive and well, mabe even because of my involvement in a case. I think that giving someone a goat is great (especially
under the circumstances sarebear detailed), but if you're looking to give me something that I will get maximum enjoyment, peace of mind, courage, and...well... courage and peace, just give me some baby pictures. :)

I don't really know what the psychiatric equivalent of baby pictures is, really... unless it actually is a card that says, "You're the best psychiatrist in the world!"; you know, something that you can look at when you've had a day where everything seems really bad, and feel like you're OK.

I think that people don't appreciate what a precious gift those baby pictures can be sometimes. So, everybody, give your OB those cute baby pictures, even if you think they might be annoying, they're not. Your obstetrician probably looks at them in the middle of the night while delivering a stillborn child and thinks that maybe they can come and do this job another day.

November 05, 2006

healthpsych said...

When I was on internship, one of my patients gave me a framed photograph she'd taken herself. It was great, I loved it and really appreciated the thought behind it but I was very uncomfortable. It didn't seem appropriate to take it because of the boundaries reasons yet I also felt that it was offered with good intentions and would be potentially hurtful to refuse. I knew the no gift rule but my supervisor said it really was dependent on the nature of the gift. A box of chocolates - not so bad - something more personal like this, trickier. In the end, she advised me to accept it. After that, I think they elaborated on the 'no gifts' policy in their intake information - that would definitely make it easier to explain away refusal and reduce the likelihood of offence.

One of the other interns got given some sexy lingerie by one of her famle patients...I'm glad I didn't have that particular dilemma!

November 05, 2006

jw said...

Well, you give a Canadian psych timmies! (Tim Horton's Coffee, Canada's national food).

November 05, 2006

Anonymous said...

As a BPD masochist, my psychiatrist dropped me from his practice in October 2005. For Christmas last year I gave him a $50 gift certificate to a cool Indian restaurant near his office.

I would have liked a thank you--even if it was scrawled on a PostIt note.

November 06, 2006

DrivingMissMolly said...

I'm glad to see this addressed here. Before I gave my last psychiatrist a gift, I researched gift appropriateness on the Internet. There are some strong admonishments for not accepting, but there are strong reasons to accept as well, especially those involving rejection causing hurt to a patient.

After much deliberation I decided it would be alright to bring him a gift at our last session (he was a resident), since it was a termination gift and of modest value.

I ordered two moleskine notebooks for him because I liked the symbolism of blank notebooks for a resident/baby psychoanalyst.

I wrapped them in black organza ribbon and sewed gold tassels to the ribbon ends. I expressed my gratitude and my best wishes for a happy career and personal life in a blank card I attached behind the notebooks. I then shoved it all into a paper bag.

At the end of our last session I pulled the bag out and said; "I got you something." He turned red. I handed it to him and said something brief. Then I got up and fled as quickly as I could because I was afraid he would reject it and I wanted the card to speak for itself.

I heard him call my name as I got on the elevator but I kept going...

This holiday I have a new shrink. I know he is Jewish. I don't know what, if anything I'll get him. He is so new to me. I was thinking of a charitable donation in his name accompanied by my usual UNICEF card.

Last year I got therapist a huge poinsettia for the office. I think items for the office aren't as personal feeling so they may be more acceptable to patient and therapist or psychiatrist.

Thanks for the post, Dinah.

Thanks Dr. R

November 07, 2006

NeoNurseChic said...

I like the poinsettia thing... My current doctor's office is so barren - he seriously needs a picture on the wall or SOMEthing! Not that I will do anything - but that would be nice. His old office had a picture on the wall and he had a nice comfy couch in there. Must've been a permanent office fixture because now his office has your standard teacher's desk, a desk chair, another standard desk chair for patients to sit in, a computer, and 2 shelves that he's filled with books. That's it. Of course, in his last office, he had no window - and now he has a really nice big window - that looks over a parking lot but still. Perfect window for people watching I guess!

I've always known about the receiving gifts thing because honestly they hammer nurses about it (and anyone who works in a hospital) quite a bit, too. I can see where it is a bigger issue in psychiatry than in other specialties because if you accept or refuse the gift, it means different things and both could be good or bad...and that's completely discounting what the gift even is.



Guess that's certainly a different way of accepting a gift, whether it be something physical or something that I might say about our work together.

Just an interesting insight to me!

November 07, 2006

Dinah said...

Actually, I would like to suggest that giving a photo of a baby you gave birth to, or a CD of yourself performing, isn't really a "gift" in that it's not something you've gone to the store and purchased of monetary value to give someone for only their benefit, but that as sweet and touching as it is, it is really more a gift of sharing yourself, and that even the pickiest of psychiatrists would be hard pressed to refuse or be anything but honored by such a gift.

I'm not sure what to say about office gifts. I have a book in my waiting room that a patient gave me for it, I think she wanted to share this with others in distress (it's called The Blue Day Book) and I've had many comments about the book, all positive, and I've told her that people have liked it. I'm not sure what I would do if a patient gave me something I didn't like, but I would probably feel obligated to display it if that's what the patient wanted.

Still, the card saying I'm the best psychiatrist in the world would make my day, if anyone wants (I've never gotten one). A charity contribution (I like HealthCare for the Homeless) would be great, and I'd be pleased to be honored with financing someone's goat in a developing country. I may get this for Roy for the holidays. Clink gets a used playing card, maybe the ace of spades.

November 07, 2006

Sarebear said...

The Blue Day book . . . is that one of those ones w/funny animal pics and great captions to go with them?

Someone mailed me this book, years ago, and it's the beginnings of my "rainy day" kit, for when I'm having a really bad day.

Course, I don't know where I put the basket I was starting to put stuff in, like Sense and Sensibility, The Blue Day book, and a few other things.

If that's the book I'm thinking of, the same guy has done other ones, that I wish my family and friends would give me to cheer me up. They really give me a giggle.

If I was waiting in a psychiatrist's waiting area and saw that book, I'd instantly know, or rather, think I know, that they had a sense of fun and humor.

November 07, 2006

NeoNurseChic said...

But I still bought the cds I used to record my recitals on...and paid $200 and $150 respectively to have them professionally recorded. Come to think of it, I should be charging people for copies of it, no? LOL

Just kidding around here...

I do like the Blue Day book. My mom gave it to me when I was a student at Penn State - during one of my times when I wasn't doing so hot. I saw another one by the same author recently and really wanted to purchase it, but I haven't yet! I even have the blue day journal - my blue day journal is filled with quotes and song lyrics that I like. Then I started writing about my headaches in it at one point - just personal thoughts I'd had... I also have a list of friends and phone numbers in the back of it - whenever I made that list, it was a list of people I knew I could call and count on when I needed a friend. :)

November 07, 2006

Fat Doctor said...

Dinah: My silence was unintentional. I check in here daily but for some reason must have missed the day you posted this.

As for the toenail polish, I took a reader's advice and bought some pure acetone. Worked like a charm!

By the way, I want to thank you for picking up on some identifying information in one of my posts and alerting me to it. I fixed the post, as you can see, and didn't post your comment. I figured you'd understand. Sincere thanks!

November 08, 2006

guinness girl said...

Oh, yay! I give my therapist a nice card every year at Christmas, thanking her for helping me to enrich, improve, and understand my life. Glad I wasn't supposed to include a sweater or a gift card or, oh, say, a timeshare, too. :)

I'm new to Shrink Rap, but I came over from Fat Doctor's site. Any friend of hers is a friend of mine. :)

November 08, 2006

DrivingMissMolly said...

HEIFER INTERNATIONAL! That's the name of the place I used to get a catalog from that sells the animals! You can give bees, a water buffalo, a knitting basket, and many other things.

I wouldn't feel comfortable sending a "Your the best psychiarist in the world" card because well, as a borderline patient, I will hate him the next day anyway....Haahhahhaha. Sorry.

I noticed that my therapist has three "stick ups" on his bookshelf. I have wanted to tease him about them, but I am pretty reserved in RL. A good office gift would be a candle and warmer. Yankee Candle Company makes nice little holiday sets in various holiday-ish scents such as cinammon and balsam that might be enjoyable.

November 08, 2006

DrivingMissMolly said...

Dinah, Clink and Roy, Heifer International will allow you, for $20 to purchase a flock of ducks!!

Lily

http://www.heifer.org/site/apps/ka/ec/product.asp?c=edJRKQNiFiG&b=477887&ProductID=164780

November 08, 2006

jcat said...

I'm in South Africa, and I think we're a bit more relaxed about doctors accepting gifts from patients, as long as they aren't too costly.
I've been seeing my current psychiatrist for 18 months now. Didn't get him anything last xmas, cos I didn't feel like I knew him well enough. We have a kind of standing joke about his ultimate bribe being a Porsche Turbo Convertible, so for the anniversary of seeing him this year, I went to the Porshe dealer, and asked for the cheapest, identifiably Porsche Turbo part that they had - turned out to be a thing for the centre of the wheel, and cost very little, and gave that to him with a card that said that the best thing about a really horrid year had been seeing him.
For christmas this year, I bought a feng shui frog, that I really liked, and wrote a soppy card. I would be really hurt if he wouldn't accept something - it doesn't matter to me whether he displays it or not, but it means a lot to me to be able to acknowledge his help and caring, with a gift of something that I have put thought into.

Been seeing my psychologist for 3 years now, and our relationship is a lot less formal, especially seeing as she practices from home. So I know her pets, have met her fiance in passing - I buy birthday and christmas gifts for her, and we're both comfortable with that. Sometimes I'll take dog treats with me, or fresh biscuits - just small things to thank her for being there for me. She's gone out of her way to help me at times, like visiting me in hospital, and bringing things that she knew I needed. So it goes both ways.
I don't think that shrinks should have too much of a moral crisis over accepting presents - as long as they aren't way too personal (the underwear!!) or expensive. And as long as they are given without expectation, just to say thanks for caring.

December 21, 2006