Tuesday, November 16, 2010

In Treatment: Sunil, Week 4


Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Sunil remains kind of creepy. He sneeked into his daughter-in-law's private study and found her birth control pills---proof, he says, that she's having an affair. Is he delusional? And he had this disturbing dream where he was burying an animal, one that had fallen from a cliff, and when he awoke, he went to his son's bedroom and watched him and his wife sleep. For fifteen minutes. Really creepy.

We learn that Sunil's former lover broke off their relationship on the library steps and then threw herself off a bridge. He was questioned when the police investigated her death, an apparent suicide.

Paul continues to confront Sunil. The birth control pills might not be proof of an affair. Sunil wants to change the subject and Paul stops him. The relationship Sunil had with his lover is similar to his son's relationship with his wife, and this is why Sunil is so troubled by it. When the patient disagrees, Paul does not back down--- he tells Sunil how it is. Does anyone else find it insulting when a therapist insists that a patient feels something he says he doesn't? Sunil considers Paul's theory, thanks him and leaves.

Paul is clearly worried about what Sunil may do. Call if you have disturbing thoughts. The frustration of both parties is palpable--- at times, Sunil raises his voice in an effort to be heard, especially about his right to snoop in his daughter-in-law's study. And Paul....well, Paul always looks frustrated.

Monday, November 15, 2010

Guest Blogger Dr. Darell on Not Being Funny in Psychotherapy


A while back, I put up a YouTube video that I thought was funny. A commenter didn't like it and felt it promoted stigma. So I took a vote, and while most people were fine with it, a number did not like it, and I took the post down. We received this note, and I thought it was substantial enough to be it's own guest post (with permission, of course).
------------------

Hi. I am a practicing psychiatrist based in New York City. I find your blog interesting, informative, and, at times, funny. Now, can you guess which entry I'd like to comment on?
Mel Brooks once said, (paraphrased), that if you slip on a banana peel and land on your butt, it's comedy. If I fall down a flight of stairs, it's tragedy.
I've had a long-term interest in humor, and a brief career as an unpaid stand-up comic in L.A. (Brief because my bombing to "killing" ratio was about 15 to one.)
With respect to my experience as a therapist, I now occasionally utilize humor in my treatment, but only extremely judiciously, once I have gotten to know my client.
I learned my lesson early. At the beginning of my residency training, during my second session with a client, I commented that perhaps he felt like Groucho Marx when Groucho said that he wouldn't want to be a member of any club with standards low enough to accept him. I sat back, feeling as if I had made the interpretation of the century, and waited for a reaction. I got one. The client stormed out of my office and never returned. My supervisor later told me that, as I suspected, I had screwed up royally.
This memory resonates with Dinah's statement that it's the recipient's reaction to a joke or a comment that counts. So know thy audience, and know thyself. You're obviously on much safer ground if you make a joke about a community or an ethnic group that you belong to. We do, however, live in an era of enhanced sensitivities and political correctness, and need to be extra careful not to anger or offend.
With respect to the Youtube audio, I, like a number of your readers, have heard other versions and have become desensitized to it. Ironically, I read about a version of it being told by a psychiatrist moonlighting as a standup comic years ago. My immediate reaction was, "Keep your day job, doc!"
Since "Psychiatry Hotline" is available to a large and varied audience, including people suffering from mental illness, I would not personally have posted it. Although it appears comparatively innocuous, I voted for it as offensive from a psychiatrist's point of view because it trivializes mental illness and is potentially hurtful to many.
Warmest regards,
Edward W. Darell, M.D.
Blog: ShrinqueRap (on Wordpad). Very soon to be updated. Please do not sue me. I registered the domain name before hearing of your blog, and my pockets are extremely shallow. (just short of being inside-out).
URL: www.shrinqerap.com

----------------
And while we're on the subject of humor---- a nice break before I start writing about In Treatment tonight--- Sarebear sent us a link on A Proposal to Classify Happiness as a Psychiatric Disorder. Hmmm...it's a joke, right?
And don't worry, Dr. Darell, we're not going to sue you, but do keep your day job.

Saturday, November 13, 2010

Just Like Someone Without Mental Illness Only More So





I'll cut to the chase: I loved this book.
Five stars. Two thumbs up.

When I read books, especially psychiatry books that I write about on Shrink Rap, I often read more carefully and sometimes more critically. I was so immersed in reading
Just Like Someone Without Mental Illness Only More So that I didn't stop to think, I just went on the journey.

Mark Vonnegut is a pediatrician and he is also the son of my favorite author from when I was in junior high school. His memoir is a poignant and candid account of his struggles with...well... life in general, and life with a psychotic illness in particular. Schizophrenia, bipolar disorder---who knows (I'll vote for bipolar disorder)? Some illness where he had three episodes in his twenties, then another episode 14 years later. Thorazine and lithium and megavitamins and psych wards. Xanax and alcohol and how humiliating it is to be psychotic on a stretcher in the ER hallway of the hospital where he works. Divorce and remarriage. First and second families. Childhood as the son of a financially struggling, not-yet-famous, eccentric writer, and adulthood as the son of an icon. Vonnegut is a hippy, a mainstream doctor, a middle-aged softball player, then finally a guy who accidentally poisons himself with wild mushrooms.

Dr. Vonnegut's struggles are those of vulnerability, fragility, hope, and resilience. He comes back from these life-altering episodes of psychosis and applies to 20 medical schools. He gets in to Harvard, and only Harvard. If you're going to apply to med school with a 1.8 science GPA from college, then I imagine it's helpful to have a very famous dad who teaches at Harvard. Vonnegut does well enough that he stays for residency and teaches there after. His illness and the possibility of its return hang on him--once you've heard voices, he says, you're never like someone who hasn't. As serious as the topic is, the author is able to make light of himself and the writing is funny and tragic all at once. It's a quick and engrossing read.

In case I didn't like this memoir
enough, Vonnegut makes intermittent jabs about the tedious things that weigh down life as a doctor-- paperwork (my favorite rant), the influence of big pharma, and insurance companies.

So would I like Mark Vonnegut in real life? I liked him in his book. And so it goes.

Thursday, November 11, 2010

In Treatment: Adele, Week 3.



Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

 Paul is upset that Adele doesn't have any Motrin to treat his headache. Adele doesn't recall his son's name fast enough. On the scoreboard, Adele is losing.

Paul gets up and walks around the room. Adele wants him to sit. He doesn't, at least not at first. He tells her a little about his patient, "You know what's going on here, it's perfectly obvious." But she doesn't. He wants her suggestions and Adele doesn't want to be both therapist and supervisor.

Paul talks about Max (his son, not my dog). He makes a lot of assumptions about....everything. Adele sums up the session by telling Paul that he has been pushing her to take care of him. She cites the evidence to prove her case.

WWFD?


Would Sigmund Freud or Carl Jung read Shrink Rap? Somehow, I'm not so sure. Tracey Cleantis seems a bit more certain. Check out her article on Blog.com of Top 10 Psychoanalysis Blogs (Jung and Freud would read).
Thanks for the should out, Tracey, and we're always happy to be deemed accessible!

Wednesday, November 10, 2010

In Treatment: Jesse, Week 3


Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele
Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Why is Paul always chasing people?

Jesse brings his mother to the session, but he doesn't want it known that he wanted her to come. Jesse continues to alternate between being a gentle, vulnerable boy and being a provocative, hurtful monster. He tells his mother about the sexual event, in all it's glorious detail, that got him beaten up and suspended from school, and just in case that's not enough, he announces that his birth mother wants him back. Mom gets upset and leaves the room. Paul asks her to stay. Why does he do that? When someone says "enough" or "I need space," maybe it makes sense to listen.

Paul tells Jesse he's creative, an artist. I like that, he's saying something to build the kid up. He tells Jesse that his own son is an artist and that sometimes he doesn't understand him and feels distant. Is this the right thing to do? At first it seemed kind, like an attempt to connect with Jesse, but for a moment I wondered who was the patient. The revelation doesn't seem to have an impact on Jesse, who is drowning in his own complicated life and problems. He wants so much to be loved and valued as he pushes the world away.

Paul asks Jesse if he's heard from, or contacted his birth mother, and Jesse abruptly stands and leaves. Paul follows him to the door, not just to say goodbye, but to continue the session as Jesse is trying to end.
And Mom, who Jesse had believed would leave, is still in the waiting room.

Monday, November 08, 2010

In Treatment: Frances, Week 3



Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele


Meet Edgar. He's Roy's dog. My best bet is that Edgar secretly watches In Treatment.

Paul asks his girlfriend if he has 'happiness deficit.' She hasn't seemed to notice what a miserable creature he is.

Frances is a hurricane of stories about her mother, her daughter, and her sister. The sister, you'll recall, was once a patient of Paul's and the entire session is a play of who is having a relationship with whom and of competing jealousies. Mom liked sister more, even from infancy, and now daughter likes her dying sister more. Frances is always on the outside, always the one abandoned by everyone else, and on cue, Paul recalls how the patient used to put lipstick on her dying mother until the very end. Oops, Paul got the wrong patient, it's a story that the sister had told him 18 years ago! One more jealousy. And Frances wants Paul to help rehearse her lines, like her ex-husband used to do. He refuses and she storms out. Somehow, he feels more like the patient in this episode as he fumbles to apologize and cover his mistakes. Ah, the episode started that way when he fell asleep and the patient's knocking woke him--and he lied to conceal that he'd been asleep.

Usually, I find it easy to criticize Paul as a therapist. In this episode, however, I felt like I could relate to his mistakes. We all have moments where we slip--forget the name of a patient's spouse, confuse a story with one another patient told...he's put on the spot, and somehow I know how he feels. Yes, Clink, I know, it's just a TV show and they're not real.

In Treatment: Sunil, Week 3


Week 1: Sunil - Frances - Jesse - Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

So last week, I took my kid to the doctor. He knows I'm a psychiatrist and greeted me with "Have you ever watched In Treatment?" Oy. He wanted to talk about Sunil.

Sunil continues to develop as a character. He and Paul have tea. They talk about dignity and passion and living a principled life. Sunil is animated when he talks about Survivor and about his daughter-in-law as she exercises. He's overheard his son having sex with her, he thinks she's having an affair, and we learn that Sunil was secretly in love briefly, before he met his wife in an arranged marriage. Maybe he is jealous of his son, Paul suggests, or maybe he feels the daughter-in-law is betraying Sunil personally.

Who is Sunil? Is he laughing or is he crying? Is he wise or is he insane? There is a mystery to him--- he wants to know exactly what might cause Paul to break his confidence, and as Paul tells him that the circumstances would have to be extreme, that someone would have to be in danger, it's hard not to wonder if someone might be. Sunil is compelling, yet creepy, and one might wonder if he's attracted to his daughter-in-law, or if he's thinking of killing her? Did anyone else wonder this?

Sunday, November 07, 2010

The Sunday Morning Shrink Rapper Update.



I've decided to start reading the Sunday New York Times in bed--- no electronic distractions and I actually sort of read. I love the internet, but I think it makes me crazy.

The NY Times has a feature on Debra Winger and talks about her acting come back in the role of Frances on In Treatment. Click here if you'd like to read it.

I'm reading a wonderful book, a memoir by Dr. Mark Vonnegut called Just Like Someone With Mental Illness Only More So. When I was a kid, I loved Kurt Vonnegut's novels. Unusual family with lots of genius and mental illness. I will write more about the book when I finish it, maybe later today?

Tried a great new pizza place last night. Trouble parking and I thought I'd never go there again, and then we ordered a boring pizza because we have topping-issues in my marriage. Great spinach salad, and as we waited for the pie, I coveted the pizza's around us with sausage, veggies, mushrooms, oh.... but then our Four Cheese Pizza arrived and it was amazing. We didn't even mind that we were by far the oldest people in the place, and I will definitely go again, maybe on a weekday. So here's a plug for Iggy's.

As for the rest of my day? Roy wanted me to go to lunch with him so he could convert me into someone who fully understands the details of an issue that has come up in our state with hospital reimbursements. The restaurant he chose isn't open on Sundays. Oh, and he's decided he's busy with one of his many other projects. Clink wanted to work on posting another podcast with me, but got a last minute invite to a birthday party and has blown me off. I've pointed out to her that she was on my "A" list as a first-choice friend for a Sunday afternoon. The day-before birthday party invite and she was clearly on that person's "B" list. Apparently, my company doesn't compare to the prospect of birthday cake.

Our little dog, Kobe, the hyperactive one, was shaved down yesterday in an event called grooming. I suggested husband take him to the Ravens Game (Kobe would like that) but was told, "As a comfort dog? Kobe is the farthest thing from a comfort dog."

Friday, November 05, 2010

Surprise! I'm A Shrink and I'm Here to See ME!



The title of this post is a take off on the title of my last post, Suprise! I'm a Shrink and I'm Here to See You!

Today, I went to work at my office, and mostly, I saw me. All of my patients either didn't show up or canceled their appointments, except, of course, for my last patient. It was a really weird day.

I don't have an internet connection in the office and I don't have a TV. I don't even have a desk. My office mates weren't there. It was me. I made phone calls. I texted my friends. I vacuumed the carpet. I made hot tea. I talked to Clink. I thought about Roy. I listened to NPR on the radio in the waiting room. I went to lunch at a cafe in the neighborhood, chatted with the owners and checked my email on the free WiFi. I rested on the couch. It was all kind of serene. In my younger days, I would have been upset, and if I had my car, I probably would have gone home and fiddled on the Internet and done housework. I saw my last patient who said, "You should go home now, it's Friday." I did. As I locked up the office, I thought, well I didn't have to cook and I didn't have to do laundry and with limited on-line access, it was sort of like being on vacation.

Thursday, November 04, 2010

Surprise! I'm A Shrink and I'm Here to See You!


Lockup Doc has a post up on KevinMD.

He talks about how awkward it is to be a called to consult on a patient who is on a medical or surgical unit of a hospital when the patient hasn't been told that a psychiatric consult has been requested. The Shrink gets to announce to the surprised patient that they were called and the patient may be insulted.


What’s troubling about this all-to-common scenario is that when consultations are requested of psychiatrists, two key ingredients are often missing. First, the reason for the consultation is often unclear. Second, the consultation is often requested either without the patient’s permission or knowledge, or, the patient is informed of the consultation but an inadequate or even inaccurate, potentially insulting explanation is given.

Roy is our C-L Psychiatrist here at Shrink Rap, so I'll let him add to the comments. As an outpatient psychiatrist, I'm just never a surprise.

Wednesday, November 03, 2010

Special Election Issue of Grand Rounds is Up at Dr Wes


Dr Wes hosts a special election issue of medical grand rounds this week, with a red and blue clicky map of the coverage.

Highlights:

  • Video of Tennessee Gubernatorial candidate Basil Marceaux: "I'd like to plant grass, or vegetation, in vacant lots all across the state, and sell it for gas."
  • Arkansas' Dr Ramona Bates blogs about Carly Fiona's infection.
  • A cartoon about Why Health Insurance Sucks.

Repealed: Kansas voters repeal law that could block people with mental illness from right to vote

Back in the 1970s, Kansas passed a law that could prevent people with mental illness from voting. The law was never used, but advocates were successful in getting an amendment passed that revoked that law.

This law was passed at a time when stigma against mental illness was much higher than now. I'm guessing it was presumed that folks with a mental illness could not reason enough to exercise an informed vote, which is not true, of course. If 1outta5 have a psychiatric illness, including anxiety, depression, and substance abuse, then there could have been a huge swath of disenfranchised voters.

And there already exists, to a degree, a basic cognitive test for voting -- navigating the whole ballot process.  In Maryland, ours was electronic and no harder to use than an iPad, but I could still imaging some with severe dementia unable to navigate the system.  But there should never be a cognitive bar one must pass to vote; the challenge would be where you draw the line.

Tuesday, November 02, 2010

In Treatment: Jesse. Adele. Week 2.



Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele



Jesse is obnoxious. Paul is obnoxious.
----------------

Paul has his second therapy session with Adele. She sits stiffly and while she listens with interest, she isn't warm and fuzzy. Paul tells her that Max showed up on his doorstep. He talks about having Parkinson's Disease--- his fears of disability and decline and of passing it along to his children. The neurologist said he didn't have enough symptoms to meet criteria for Parkinson's, but that doesn't give Paul any relief-- he's going for a second opinion, as though he must hear that he has Parkinson's. He even talks about telling Max that he has the disease, the one he hasn't been diagnosed with, and he finally tells Adele about the dream. Oh, and Paul is reading Gina's book and he's angry: he feels that he was is the self-defeating character in the novel and Gina hasn't returned his phone calls.

Paul's session with Adele is not as contentious as the first session, but it's still tense and full of one-upmanship.

Is this what real-life therapy is like? Would anyone ever be a psychotherapist if therapy was anything like what is portrayed on In Treatment? Would anyone voluntarily subject themselves to this? No & no & no. These episodes are compelling, and certainly there are moments of confrontation in real life treatment, but Paul is morose, depressed, takes himself way too seriously, and all the sessions lack the interpersonal warmth that happens when someone confides in a therapist.
----

Speaking of Max: today is our older dog's 9th birthday (approximately). Bowls of liver all around!

In Treatment: Frances, Week 2


Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Paul starts off the episode at the neurologist. We watch the exam, no dialogue, and we won't find out why he has a tremor or if he has Parkinson's Disease, at least not during this episode.

Frances is a little less obnoxious this session and a little more sympathetic. She talks about her courtship and marriage, her teenage daughter, and her dying sister. She is provocative with her questions and her sexuality. She's scheduled an appointment to see if she has the breast cancer gene --the BRCA breast cancer susceptibility gene. Finally, it seems she lied to Paul when she told him she'd asked her sister--his former patient-- for the referral and said it was fine with sis if she came to see the same therapist.

Last week, when Paul heard that the sister had stage 4 breast cancer and was dying, he immediately asked if she was in therapy. Today, we hear he's spoken to the sister and she is, indeed, in therapy. I found whole line of thinking interesting-- that the process of dying should necessarily be accompanied by a psychotherapist, with no other questions asked. Do certain stressful life events get negotiated better if one is in therapy? Is it a given that they need therapy? Do we, as psychiatrists, want this assumption supported, even by a fictional character on a fictional show?