Tell Me About Your Mother

It's the typical shrinky line, so I'm using it to introduce a new website on Mother-Daughter relationships (and all their angsty stuff). Check it out at Motherrr.com ! Ah, the site is run by my sweet Cousin B and her friend, and no, they aren't shrinks.

I'll leave it to Clink to tell you about the Shrink Rapper holiday dinner last night at Mr. Rain's Fun House. Oh, why not: I threw red sea salt at Clink and Roy ate a gourmet dog biscuit that Clink had brought from the Ben & Jerry's store in Vermont. The food was good, too. Purple soup and cotton candy baked alaska, anyone?

The Snake Trail Test

Psychiatrists have a way of assessing judgment during the mental status examination. Typically they'll ask a question like, "If you found an envelope lying on the sidewalk and it was addressed and stamped, what would you do with it?" The typical answer, the one that will get you a 'good' rating on the judgment line, is: "I'd mail it." Duh. There are other possible responses, some of them more interesting or creative than others, but that's the response you get most of the time.

I had a chance to come up with a new "judging judgment" type question this week. I call it the Snake Trail Test. Here's how I came up with it:

As coincidence would have it, one of the best local climbing spots near here also happens to be a repository for copperhead snakes. Since I've taken up climbing I've now seen more copperheads in the wild than I've ever seen in any zoo. Whenever I see a snake, I warn any hikers I happen to see in the area. Many hikers are parents with small children. It's been interesting to see the wide variety of responses.

One parent immediately grabbed the kid and said, "No no honey, don't go down that way. We'll go on this trail instead." Another parent still went down the trail, but cautioned the kids and made sure they stayed on the far side of the path, away from where the snake was spotted. The most interesting reaction came yesterday, from a young tattooed woman hiking with four kids under the age of ten. After I gave her the warning she shrugged, pointed back over her shoulder at the trail she had just come down, and said, "Yeah there's another one back there." Not a word to the kids and they all scrambled on without a care.

The psychiatrist within me thought: "Checkmark for 'poor' judgment." Then I thought again: "Maybe she's an herpetologist. Maybe she comes from a charismatic poisonous snake-handling cult. Maybe she's been hiking here for 20 years, has seen lots of snakes and never had a bad outcome." There were a lot of reasons why someone might not be freaked out by the idea of a poisonous snake in the trail.

My new Snake Trail Test has got me thinking about how we interpret judgment.

Judgment is formed through learning, experience, culture and a multitude of other personal idiosyncratic factors that a psychiatrist might or might not be aware of. The best way to sort out 'normal' and 'impaired' judgment is to ask followup questions. "Why would you do that?" is a good one. "Why not do this?" is another good followup question.

I didn't have a chance to ask the tattooed lady more questions, but I bet if I did she might have given me a good education about snakes.
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Note from Dinah: Here's a post from Edwin Leap about what Not to bring to the ER with you, and it includes the snake that bit you.

It's Your Mother's Fault

Moms and psychiatry have a long history.

Freudian psychoanalysts like to talk about moms. "Tell me about your mother." Oh, those Oedipal sexual longings....

Winnecott, who gave us the concepts of the "holding environment" and the "transitional object" talked of the "Good enough mother"-- an imperfect creature who could still raise normal children.

Melanie Klein gave us the good breast, a way for the infant to internalize dear mama.

Bruno Bettleheim gave us those Refrigerator Mothers who caused their children to be autistic while Theodore Lidz gave us Schizophrenogenic Mothers. Oy.

I could go on and on, if only Roy would let me. While we've moved beyond blaming mothers for autism (now we have vaccines to blame until we name the next culprit-- please don't let it be chocolate), we still believe that mothering is a key ingredient in who a person becomes. Good mothers have good kids, bad kids must have bad mothers. No matter how you dice it, we all believe in cause and effect, and we all can write the script backwards. An entitled, self-centered criminal must have had a mother who spoiled him and didn't set limits. I remember my own mother saying, "When you see a child hitting someone, you know someone is hitting that child at home." (My mother read Dr. Spock, she wasn't a scientist).

It's really easy to write the story backwards, and in fact, as psychiatrists, that's what we do. As a mother (have I mentioned that I have two teenagers?) it's not so easy to write the story forwards. If I do "X" my child will become this type of person and if I do "Y" my child will become that type of person. It doesn't work that way, trust me. If it did, we'd all read the instruction manual and have a perfect world.

So this, I've decided, is the paradox of today's world, now that we are relieved of refrigerator mothers but not bad breasts: There are lots of things that society tells us we need to do for our children to grow them good. Mozart in the womb, and that's where it starts. No drugs, no tobacco, no caffeine, no artificial sweeteners, no alcohol: the perfect internal environment. And once they pop out, there are all sorts of do's and don'ts: what chemicals they inhale, what they watch (pg, pg-13, violence and sex and how long have you been sitting in front of that boob tube, junior?), how they behave, say please and thank you, not those violent video games and what are you watching on U-Tube? Montessori this, Rebounders that, chicken nuggets are good, chicken nuggets are bad, make sure they get enough sleep and not too much MySpace, quality time, licensed day care providers who build self-esteem, car seats and safety gates and all the right influences and none of the wrong. Talk to your kids, the TV says so, the billboards say so, talk to them about sex and drugs and God and country and the earlier the better (--see, I can go on and on).

Then they turn in to teenagers and they figure out that the word "controlling" is extremely pejorative in our culture. What's worse than a Controlling Mother? Even a bad breast doesn't sound so bad. Are you a controlling mother? What do you mean I have to eat vegetables? Or be home when? And that's the paradox.

In the world of teenagers and psychiatrists, it's hard to win as a mom.


You know you've been blogging a long time when....Roy followed me and added links in this post to past blog posts I've written-- I clicked on some of them and realized I don't even remember having written them. How does he? A man who needs a longer ToDo List!

Who's Your Mama?

You know it's a bit confabulated.....

So one of my patients happened to mention today that her son is a coach in a league one of my kids plays in. I must have known this, she must have mentioned it when I first took her history, eighteen months and two playing seasons ago. Today, at the end of the day, hours after she left and as I was writing progress notes, it suddenly hit me: her son is my kid's coach. It was this funny, disconcerting feeling.

Now the fact that a patient's son coaches my kid isn't really a big deal. Only I wish I could say that my kid is the ideal player, the coach is a wonderful coach, that I've never actually had reason to speak with the coach, or if I did, that it was a warm and rewarding experience. Let's just say that's not the case, the coach is a little weird, my kid once had an issue and I'd felt a need to intervene.

And now I can wonder, who knows what? This particular patient has no qualms about announcing her struggles with psychiatric illness. I know the son knows she has shrink, I can't imagine my name doesn't get uttered here and there-- she comes to sessions and sometimes says "Little Howie said to be sure I tell you such-and-such." Only I have a fairly common last name and like my patient, my family members all seem to have different last names (--Max has requested that I not publish his last name on the blog). I now can wonder if Coach related to me, Neurotic Mom, all the while thinking You're My Mom's Shrink. Or maybe he worried that she tells me personal things about him. Maybe we've had a whole unspoken relationship that I just missed. So, Coach Howie, if you're out there, rest assured that Mom says all nice things about you.

It's fine that I treat Coach Howie's Mom. This is the part that's disconcerting-- I realized that I relate a bit differently to different people in different places in my life. With patients and their families, I keep it pretty even and I try to remain professional (I hope). No ducks at all. Without even trying, I'm a slightly different person when I'm the doc than when I'm the mom. In my non-doc role, I talk more, I listen less, and I tell raunchier jokes. I might look to Coach Howie for wisdom or understanding. If I'm frustrated I might be more sarcastic than I'd ever be with the family member of a patient. I'd never complain to the family member of a patient, even in a non-clinical setting, that he was an idiot for not starting my kid when the kid he did start was clearly an inferior player. (--oh, I didn't really do that, but it was fun to confabulate).

Coach Howie, you have a lovely mom.

Dr. Crippen, Blog Fodder

Oh he's done it now. He has truly done it. I have spent several years of my life working to become a doctor, only to have Dr. Crippen suggest that perhaps I and other women physicians don't have a right to certain specialties or job flexibility. He quotes a Dr. Sarah Blayney, who writes:

"The training jobs as they stand are all or nothing. You either do all the hours or don't get the post. I want to pursue a career in hospital medicine, which will mean me committing to a minimum of five years of fairly hefty on-calls. "

At the moment I am 24, single and am enjoying life. But in four or five years time my situation may have changed and I may not want to work those hours."

She said flexible working would be particularly relevant to female colleagues wanting to start a family, but said male colleagues were also interested in changing their hours. For example, some wanted to take time out to travel, she added."

Note that the need for flexible job hours is cited as a concern for both men and women. However, Dr. Crippen takes it upon himself to limit this issue to women:

"It is right and proper that women can pursue a career in medicine. But at what stage do we decide that the needs of medical training can no longer be subsumed by the needs of working mothers?"

Perhaps Dr. Crippen would do well to remember that not all women are, or are planning to be, mothers. Perhaps he would do well to remember that here are many other reasons for limiting on-call and extended working hours---like retaining one's sanity. But that's OK because he also suggests that: "Sarah lives in cloud-cuckoo land. She wants the job but she is not prepared to do the hours....You need to grow up a little.... Just because you are a girlie, you can’t expect medical training to be turned on its head."

Good God. I thought we had grown beyond that. I thought I had left thinking like that behind on my surgery rotation, along with the bra-snapping resident and the resident who once complained about me scrubbing in: "I found a medical student to help, but she's a girl." Given that over half of all medical students in training today are female, it's truly time for this discrimination to be over.

So please feel free to visit NHS Blog Doctor today and leave a comment. The only comment I have to say right now is: "Sic 'em!"


[From Clink: Sigh...she insists on modifying my post again...At least I can modify her awful color choice.]
Guess What? The first half of Chapter 10 is up on Double Billing.

My Three Shrinks Podcast 20: Mother Talkshoe

[19] . . . [20] . . . [21] . . . [All]

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We had to do something a little different this week. We three shrinks were all busy ... Mother's Day weekend, yard work, Longwood Gardens, and luaus kept us too busy to get together to do a podcast. I insisted that we find a way to do it online, so I FINALLY convinced Dinah that even she could do it ;-)

Ten o'clock last night, it all came together, and we were able to do a podcast, thanks to Talkshoe. (If you haven't checked out Talkshoe, do it. It lets you podcast by phone!) As luck would have it, a storm came through and turned the transformer down the street into a Fourth of July celebration. Despite being without power, we still managed to get it done. Is that dedication, or what?

So, here ya go. It is a little rough, as we weren't sure what we were doing (what else is new?), and recording it via cell phone caused occasional lags and silent periods... hmm, just like psychotherapy.

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May 13, 2007: #20 Mother Talkshoe

Topics include:

• Happy Mother's Day!
• Turkewicz law blog a hit with Clinkshrink. Her recommendations? Malpractice Primer and Economics.
  
• Q&A: Zoe Brain asks "Is there a Standard of Care for GIDNOS in the case where the patient is intersexed? And does the degree of intersex affect the therapeutic regime, and if so, how? I'm familiar with the WPATH (Formerly HBIGDA) v6 SOC for GID. But once a diagnosis of GIDNOS is established, the SOC does not appear to apply."
  Answer: Huh? (We did the best we could.) Also, see Farmer v. Brennan.
  
• APA says people with Medicare Part D having trouble getting their psychiatric medications. Also, discussion of the "donut hole."
  
• Medical Truth in Advertising bill: Is your "doctor" really a doctor?
• Ethical conundrums: trains and Tarasoffs and guns (oh my!). Also, Maryland's problematic law requiring reporting of childhood abuse, even if you are now 90 or you don't know who the perpetrator is. And, what do you do with a dead astronaut on the way to Mars?
• If Dinah had Lost It in Space, she Wishes she would have a Crystal Ball.
  
• A shrink like me?
  

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Because It Feels Good

See other Savage Chicken cartoons here

The Psychology Of Altruism

I saw a story in our local newspaper recently that summarized the results of a Johns Hopkins survey of people who volunteer for research projects. The projects they were looking at were Phase I clinical drug trials, in other words studies that are done using drugs on humans (as opposed to animal) subjects for the first time.

It led to the obvious question: Who the heck would do something like that?

Now, I knew a couple people who volunteered for studies when I was an intern. They were both rather adventurous, young, and somewhat in need of money. Looking back on it I could say that they were trusting people who believed that the researchers wouldn't do anything to seriously put them in harm's way and that they were also fully armed with the youthful denial of any possibility of death, disability or adverse consequences to many things they did.

Some of the subjects in the survey reported that they essentially became professional guinea pigs, even travelling from state to state to make a relatively lucrative living (lying to the investigator in the meantime about their extracurricular research activities). However, about half the volunteers were employed at the institutions where the research was being done. They reported that volunteering made them feel good that they were helping people.

That got me thinking about altruism in general. We have many examples of altruists in our society: parents, volunteer firefighters, soldiers, people who sign organ donor cards or send money to charitable organizations. What leads people to give up something when there is no immediate benefit to the giver? Or worse yet, when there are always people ready to take the benefit without ever making a sacrifice in return?

There are religious motivations for altruism, but this being a psychiatry blog I thought it would be more relevant to look at the psychology and evolutionary biology of altruistic behavior. (Don't worry, I'll keep it short to avoid being snooze-worthy.)

In The Ego And The Mechanisms Of Defense Anna Freud described the concept of "atruistic surrender". I'm admittedly nowhere near being an analyst, so if any reader out there has a better handle on this than I do feel free to enlighten me. As best as I can figure it out, altruistic surrender takes place when a patient's unconscious conflicts are triggered by superego suppression of impulses. To manage the resultant anxiety the patient projects the forbidden impulse onto someone else, identifies with that person, then works to help that person satisfy the impulse. For example: someone feels the urge to eat lots of gourmet food but this impulse triggers an unconscious conflict. The impulse is attributed externally: "I am not hungry. They are hungry," and the person throws herself into feeding the hungry or cooking extravagant meals for friends and family.

Whew. This must be why analytic training takes years.

The evolutionary perspective is much more simple-minded (lucky for me). A behavior survives for one of a few reasons: it's good for your relatives, it helps you have more kids or it improves your standing in the community. The weird thing about altruism is that it doesn't seem to do any of those things, yet you see the behavior in non-human species as well as insects. And if altruism didn't do something to enhance survival then all altruists would be extinct by now. What gives?

This is where I get to refer to an economist---probably the only time we've mentioned economists on the blog even though the few I've known have been pretty terrific people. Robert Aumann and Thomas Schelling developed game theory in order to understand economic cooperation and conflict, but they ended up enlightening human behavior. They used mathematical models to prove that given enough time and enough opportunities for strangers to interact the altruists come out ahead economically the majority of the time. Later researchers showed that the "cheaters" (people who don't sacrifice) eventually get punished by the group by being denied opportunities to interact---no one wants to do business with them.

And finally, now that we have this gee-whiz cool fMRI technique you can pretty much count on the fact that someone somewhere has taken a picture of an altruistic brain in action. One study showed that increased activity in the posterior superior temporal sulcus strongly predicted a person's likelihood for altruistic behavior. (And now that I've volunteered my time to write this summary I can practically feel my posterior superior temporal sulcus glowing.)

So now when someone asks you why you volunteered for that activity that everyone else in the neighborhood is hiding in the attic to avoid, you can say: "Because given X number of trials involving Y individuals there's approximately Z percentage likelihood that I'll come out ahead by doing it." Or you can keep it simple: because it feels good.

Mother's Day

[posted by dinah]

In psychotherapy, Mother's Day is a two week long event. People talk about it the week before and the week after. For mothers in intact families, it gets a brief mention-- there was a nice meal or even some flowers. For those who've lost their mothers, however, it is a rough time, a day when grief re-surfaces, when old wounds get spiced.

In honor of Mother's Day, Shrinkette has posted some cool pics: The Secret Lives of Our Parents

My best to everyone and , of course,

Happy Mother's Day