Meditation: Does it Do Anything?

Meditation sounds like a great idea from the perspective of a psychiatrist: anything that calms and focuses the mind is a good thing (and without pharmaceuticals: even better!).

Personally, I tried Transcendental Meditation as a kid...more to do with my mother than with me...and found it to be boring. I have trouble keeping my thoughts still. They wander to what I want for dinner and should I write about this on Shrink Rap and will Clink and Victor ever eat crabcakes with me again and did I remember to give my last patient informed consent and a zillion other things. Holding my thoughts still is work.

The New York Times Well blog has an article on Meditation and Brain Changes. In "How Meditation May Change the Brain," Sindya N. Bhanoo writes:

The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

-------Lower stress, lower blood pressure, higher empathy.... I may have to give meditation another try. The cartoon above, by the way, shows Roy leading a meditation session. Now there's a thought.

James Watson Live!

"To succeed in science, you have to avoid dumb people... Even as a child, I never liked to play tag with anyone who was bad as I was. If you win, it gives you no pleasure. And in the game of science-or life-the highest goal isn't simply to win, it's to win at something really difficult. Put another way, it's to go somewhere beyond your ability and come out on top."
-- James Watson, "Succeeding in Science: Some Rules of Thumb", Science, 261, 24 (September 1993): 1812. September 1993.


Snowy here in Maryland.

Yesterday, there was just a little snow, a three-inch surprise in the morning, and schools were closed, things were surprisingly still. My agenda included a trip to Hopkins to hear Nobel prize winner James Watson speak. Was it canceled? Did I really want to risk being caught in the snow coming home? No, it wasn't canceled. And when would I ever get the chance to hear James Watson speak? So yes, I did risk the weather, and it was fine.

I've never seen Hurd Hall so packed. No chandeliers, but people were hanging off the balcony, snow date and all. There weren't a lot of psychiatrists there, even though the lecture was sponsored by the Department of Psychiatry, but this meant I got a front row seat in the reserved section.

Dr. Watson was an entertaining speaker, to say the least. He structured his talk around his "rules" for life, and said there were rules involved in the race to find the structure of DNA. Oh, I wish I written them down. He started something like this, "I was a boy on the South Side of Chicago and the first rule was Don't fight bigger boys or dogs." His second rule of life had something to do with putting a spin on balls. The rules around the story of the discovery of the double helix included things like don't be the smartest person in the room, don't research the same thing that everyone else is researching, leave a job before you get bored with it, speak to your competitors.... it was all told with a sense of humor and I should probably have taken notes for a few good quotes and a better taste of the rules themselves, but who knew? Oh, and I didn't have a pen. I have to do something about that.

Dr. Watson's account of the discovery of the structure of DNA is written in The Double Helix but since the publication of the book, letters have been found that shed more light on the relationships between the players, and Watson quoted some of these letters. They weren't quite what you'd expect from geniuses who were changing the course of science, and I suppose I forget that all stories have interpersonal dynamics and the associated banter as part of their plot.

You knew who Watson liked and who he didn't -- the stories weren't subtle, and oh, he said some things that were a bit off from the politically correct...it made for entertainment. Did he really say that? I won't repeat them, because we try to be a politically correct blog here, but you can get the flavor from the quote above.

Podcast Number 55: What Happens to Shooters with Mental Illnesses?

There has been a lot in the media recently about mental illness and it's relationship to violence.
In this episode we have ClinkShrink walk us through what happens to a mentally ill defendant in a violent crime. First, there is the question of Competence: is the defendant able to meaningfully participate in his/her trial, this is the present mental capacity. If the defendant never becomes competent, he generally remains in a forensic facility indefinitely. At some point (10 years in our state for a capital crime), the law requires a final disposition, and the defendant who is not likely to ever attain competence will be civilly committed and will remain in a forensic facility.

The second question is one of sanity at the time of the crime. ClinkShrink talks about the complexities of insanity evaluations and the rarity of having a Not Criminally Responsible plea. We discuss the idea that incidental mental illness is not enough to be found not guilty by reason of insanity, that the mental illness must have influenced the criminal behavior or obscured the defendant's ability to appreciate the criminality of his behavior. Finally, Clink talks about what happens after an insanity acquittee is released and what type of aftercare planning gets put into place.

The photo is Billy Bob Thornton in Slingblade--he's our example of an insanity acquittee.

Once again, thank you for listening and please do write a review on iTunes.

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This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Guns and the Mentally Ill

On Facebook, I'm a fan of NY Times Reporter Nicholas D. Kristof

Mr. Kristof's status reads today:

Nicholas D. Kristof

Just in case Pres. Obama visits my FB page, what should we suggest for his State of the Union speech? My hope is that he calls for banning oversize ammo magazines, like the 33-round one used in Tucson. Even Cheney favors a ban on them. And gun serial numbers that are harder to scratch out. And tighter restrictions on the mentally ill obtaining weapons. Your thoughts? Other suggestions for the President?

I'm not an NRA member (this is my disclaimer here) and I've never had much use for guns. But I had thoughts about the issue of "tighter restrictions on the mentally ill obtaining weapons."
I wondered what that meant and how one defines "the mentally ill." Oh, and my second disclaimer here is that I don't know how current regulations work in determining who is mentally ill with regards to purchasing a weapon. I've never reported to any central source any information about who I'm treating so they can't buy guns and no one has ever asked me to sign off on a gun permit. I'm not sure how it's determined that someone has a mental illness and shouldn't own a gun.

It doesn't take very much to get yourself into the range of being 'mentally ill.' Knock-on-door community studies, known as the ECA studies-- meaning Epidimeologic Catchment Area-- show that over half of all people have an episode of mental illness at some point. This includes phobias and anxiety disorders. NAMI tells us that one in five people have a serious mental illness.

Some of the people who commit crimes with legal guns haven't sought treatment. If you haven't gotten a diagnosis, how can you be designated mentally ill for gun ownership? Does gun ownership get designated by diagnosis? Certainly, owning a gun is not a great idea for a person with brittle bipolar disorder who gets violent and impulsive. But we all know that the diagnosis of 'bipolar' disorder has become a bit loose and over-inclusive. An angsty teenager sees a psychiatrist and is diagnosed with bipolar disorder. If he does well later, should he be forbidden from buying a gun at the age of 40? I believe one standard is a psychiatric hospitalization for over 30 days, but I'm not certain how--or if-- that's reported.

I suppose we worry about the Big Brother aspect here. Maybe instead of "mental illness" the standard should be that if college student is expelled, or an employee is fired, for certain behaviors then they are reported to a 'no-guns' data bank. Then you'd capture violent and threatening people who have not sought treatment but may well be dangerous. Oh, I'm just mouthing off here about something I admit that I know little about. But I hate finding one more thing to stigmatize mental illness over in a way that is not likely to effectively decrease gun violence.

Have a happy Facebook day, Mr. Kristof.

Any thoughts?

Is This Fish Happy or Toxic?

Thank you to Anon who sent us a clip to this interesting article in the Montreal Gazette about all the fish in the St. Lawrence River who are being exposed to anti-depressants though human waste.

William Marsden writes in "Antidepressants Found in Fish":

"It's very hard," Sauve said. "The question itself is quite interesting. You can't ask a fish whether it is happier or not. One of things they can do is use cameras to look at the male behaviour. Will it have the same behaviour in mating or feeding? Then you have to go back and look at its normal behaviour. It's quite tedious work and difficult."

Quebecers purchase about 555 million antidepressants a year. That works out to about one in four Quebecers taking one pill a day. That does not include the amount prescribed by psychiatric hospitals.

Hmm... I'm not sure what to say. Should we be more alarmed about what the meds are doing to the fish (and just how happy should a fish be?) or the idea that Quebecers average a one in four rate of taking anti-depressants?

This Medicine Might Kill You, But....

We all believe in Informed Consent and ClinkShrink likes to write about it. See Is It Malpractice to Lie...or better yet, read our book when it comes out where Clink talks all about the history of Informed Consent and many other such things. And one of the things people get angry at doctors for (? and shrinks in particular?) is when they have side effects or adverse reactions, and the doctor hadn't told them this might happen. People seem to get really mad about this, especially on blogs or on anti-psychiatry sites (sorry, no links here, find your own anti-psychiatry sites).

So I've wondered, does it matter if a patient is forewarned that they may get a side effect? There are many icky responses people have to meds, some are not very common, and sometimes it's hard to tell if it's the medicine causing the problem. And side effects can be uncomfortable, are they less uncomfortable if you were forewarned? You need a procedure and they make you sign a form saying that you know you could get an infection, hemorrhage, or die. Everyone has to sign or no procedure. If something bad happens, you can still sue, but if you're dead, you're dead. It's become so rote that it almost lacks meaning.

I do tell people about the more common side effects of medications. The pharmacist gives them a longer list. Google has it all for the curious, and I certainly don't discourage Googling, I sometimes suggest it. But I've wondered, does informed consent change things? Here's what my non-scientific observations have revealed.

There a medication that is associated with a rash that can be fatal. I tell people this, and the precautions they need to take to avoid croaking---slow titration, stop med/call if there is any rash at all. A shrink friend prescribed the medication to a patient who had a rare ?never heard of reaction and ended up in an ICU with liver toxicity and nearly died. The patient didn't die, made a full recovery, but the shrink was pretty traumatized and said she wouldn't use the medication again. After my friend's patient had this problem, I told every patient I prescribed this medication to this story. No one flinches. No one has said, "I don't want to take that medication that nearly killed someone." On the other hand, if I say, "This medication is associated with weight gain in some people," the resistance becomes huge. Even though weight gain is gradual and can be monitored, and I tell people they must get weighed twice a week and we can stop the medication if their weight increases by 4 pounds (that's my non-scientific cutoff for beyond the realm of fluid fluctuations). And I know skinny people who take lithium and zyprexa and stay skinny; not everyone gains weight. And I know people who feel so much better that they are willing to tolerate some weight gain.

Just my thoughts this chilly Saturday morning. By all means, tell us your stories.

On Health Care Reform: Stolen from the APA's Announcements

Verbatim:

Moments ago, as expected, the U.S. House of Representatives approved H.R. 2, legislation to repeal last year's health reform law. The final tally was 245-189, with 3 Democrats joining Republicans to vote for repeal. No House Republicans voted against repeal. The impact of the vote appears to be largely symbolic, since Senate Majority Leader Harry Reid (D-NV) has already said he will not bring the bill to the Senate floor for a vote, and it appears unlikely that Senate Republicans will be able to attract enough Senate Democrats to force a vote. Even if the Senate does approve H.R. 2, President Obama has already indicated that he will veto the bill, and there are insufficient votes in Congress to override a veto should it occur.

Tomorrow, the House is scheduled to debate legislation that instructs key committees to develop proposals to replace the reform law. While the President has indicated he is not opposed to modifying existing law, it is difficult to predict how likely such action is to succeed. In the meantime, the House GOP majority is also expected to seek to defund or otherwise delay implementation of the law. Numerous court challenges to the law remain in process and most likely will be up to the Supreme Court to resolve.

Genetic Friendships

Here's an interesting article I came across about the role of genetics in friendships. Two researchers studied genetics found in social networks. They asked people in two longitudinal studies to name their friends, then they compared certain genetic markers. They found that the DRD2 gene, which is associated with alcoholism, tends to cluster among friends. In other words, DRD2 positive people tend to be friends with other DRD2 people. Conversely, the CYP2A6 gene carriers tended to make friends with CYP2A6 negative people. This gene is associated with people who have open personality styles. In other words, a tendency to seek out variety and new ideas.

I'm not sure what to make of all this except to say I think it's interesting that there may be a biologically driven reason why Dinah and I are friends. In many ways we're the exact opposite. Dinah is a whirling dervish of multi-tasking in a way that I find exhausting, yet she seems to thrive on it. I'm an obsessionally detail-oriented and data-driven person who never loses her car keys (or drowns a cell phone). I enjoy living this way but have no doubt that Dinah would go mad from boredom within hours if we ever woke up and found our lives had been switched. I can guess which one of us has the CYP2A6 gene. The scientists would say that we are friends because we have complimentary genetics---traits that balance off and help one another. And I guess that's true. Our book might not ever have been finished if Dinah hadn't kept us moving and on task. And it wouldn't have been as organized and readable if I hadn't followed up with the editing. So it all works out in the end.

Now we just need to find a gene that protects against cell phone loss.

Do We Need Insight?

In the comment section of my post How Do You Switch Docs? readers Moviedoc and Kate have been having their own discussion ( perhaps to be called The Blog Within The Blog?) about the virtues, or lack thereof, of psychoanalytically-oriented psychotherapy. I've been staying out of it. I'm not a psychoanalyst and I've never been in psychoanalysis. My sense is that since psychoanalysis is so specialized and done by so few, and takes so much time and money, that in today's world, the contribution is more one of technique and assumptions that flavor most psychotherapies. Things like that the idea that there exists an unconscious mind, or that feelings that were part of past important relationships might surface in current relationships, including the one the patient has with the doctor. What role all this has in the treatment of mental illness seems to depend on the patient and the doctor. Some people find it very helpful to look at their lives and their illness and their problems as part of a continuum, and even those that don't, often find great solace in the therapeutic relationship. There is something so lonely about being mentally sick, and something so comforting about having someone to talk to about the pain without the judgments or fears that go into ordinary conversations.

That said, psychiatrist Richard Friedman was kind enough to talk about the role of insight in treatment today in the New York Times. I feel like he really meant to chime in with Moviedoc and Kate in our comment section, but I guess he lost his way and ended up in New York instead.
In Does Insight in Therapy Equal Happiness? Dr. Friedman writes:

Psychoanalysts and other therapists have argued for years about this question, which gets to the heart of how therapy works (when it does) to relieve psychological distress.

Theoretical debates have not settled the question, but one interesting clue about the possible relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

In fact, when two different types of psychotherapies have been directly compared — and there are more than 100 such studies — it has often been hard to find any differences between them.

Researchers aptly call this phenomenon the Dodo effect, referring to the Dodo bird in Lewis Carroll’s “Alice in Wonderland” who, having presided over a most whimsical race, pronounces everyone a winner.

The meaning for patients is clear. If you’re depressed, for example, you are likely to feel better whether your therapist uses a cognitive-behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.

Identity Crisis!

So I was born a Gemini. It's been part of my identity, always. I'm not much for astrology, and I don't check my horoscope, but it's something everyone knows about themselves, and sometimes it's fun. And interestingly enough, Gemini fits me to a tee.

Here, see if you agree. From Ganeshaspeaks.com:

Ruled as they are by the Planet Budha (Mercury), Mithuna ( Gemini ) exhibit a delicious brand of mercurial energy. They are quick thinking, quick-witted and fast on their feet. It's their curiousity and cleverness that make them such a hit at cocktail parties. But they are not just good talkers - they also love to listen and learn. However, any social setting is good enough for a Mithuna ( Gemini ) since these folks are charming, congenial, and love to share themselves with their friends. Mithuna ( Gemini ) mind drives them to talk, to converse and it is not always just idle chatter. They need more and more information to feed their intellectual inclinations. They probe endlessly for more information as the more it collects the better. They are supremely interested in developing their relationships. Sharing that knowledge later on with those they love is also a lot of fun. Mithuna ( Gemini ) are bright, quick-witted and is at the centre-stage in any party. Although rational and practical, they also have a surplus of imagination. However the fact that they are unsure which twin will show up half the time they are often considered fickle and restless. They can be moody and act on simple whims. While their effusiveness may be misconstrued as scheming by some, Mithuna ( Gemini ) generally have their hearts in the right place. It is this ample energy, which can also paint them as scatterbrained and unfocused but, behind all that restlessness, they are usually busy filing all that information away. Funny, brimming with life, full of ideas, adorable, inconsistent, capricious, superficial, they are a bundle of maddening contradictions. They may deal in everything and are 'know-alls', but at the same time they also have the ability to master skills. Mithuna ( Gemini ) are versatile and have an amazing grasp of the subject they choose, although it may not interest them for long. They prize intellect and consider it to be the key to all things. At work, they are the clearest of thinkers, suggesting logical and well-thought-out ideas which make them an asset to any team. Their greatest strength lies in their ability to communicate effectively and to think clearly. Adventures of the mind are what the Twins are all about. Bestowed with a cheerful face easily detectable from signs of anxiety, tension or unhappiness the Gemini face is a dead give-away when they try to hide sorrow behind their brand of wit and humour. If even for a short while, romancing a Gemini is likely to be interesting, adventurous and fun, but the fickle, almost uncaring attitude will manage to break many hearts before they finally settle down. Although affectionate Mithuna ( Gemini ) can be extreme flirts, But be sure that the partner shares the Mithuna ( Gemini ) sense of humour. Mithuna ( Gemini ) never stray if the family life is satisfying. However it is best not to rush headlong into marriage; give adequate thought before popping the question.

So apparently, Parke Kunkle, some guy in Minnesota (homeland of ClinkShrink, no less) decides that it's all wrong. Everything is off. Now I'm a Taurus. But I'm not a Taurus, I'm a Gemini. They want to stick me and ClinkShrink under the same stars? No way.

And here are the new dates:
Here are the new zodiac dates:

Capricorn: Jan. 20-Feb. 16
Aquarius: Feb. 16-March 11
Pisces: March 11-April 18
Aries: April 18-May 13
Taurus: May 13-June 21
Gemini: June 21-July 20
Cancer: July 20-Aug. 10
Leo: Aug. 10-Sept. 16
Virgo: Sept. 16-Oct. 30
Libra: Oct. 30-Nov. 23
Scorpio: Nov. 23-29
Ophiuchus: Nov. 29-Dec. 17
Sagittarius: Dec. 17-Jan. 20

Have you been blown away, too?

What will this mean in psychiatric practice? Will everyone's personality change? Will people come to talk about the shift between who they are and who they thought they were? Will they fight back? I know that I'm staying a Gemini.

Shooter Psychology, Part II

Here's an aspect of shooter psychology you don't often hear about. It's from an article written by the mother of Dylan Klebold, one of the Columbine killers. It's hard to imagine how one's child could do something so horrific, harder still to imagine that a shooter could keep his plans so well hidden even from those who knew him best. He was a bright child with few previous problems. Certainly fewer problems than the Tucson shooter and less evidence of mental illness. How did things go wrong?

In her own words:

"Those of us who cared for Dylan felt responsible for his death. We thought, "If I had been a better (mother, father, brother, friend, aunt, uncle, cousin), I would have known this was coming." We perceived his actions to be our failure. I tried to identify a pivotal event in his upbringing that could account for his anger. Had I been too strict? Not strict enough? Had I pushed too hard, or not hard enough? In the days before he died, I had hugged him and told him how much I loved him. I held his scratchy face between my palms and told him that he was a wonderful person and that I was proud of him. Had he felt pressured by this? Did he feel that he could not live up to my expectations?"

It's hard enough being a parent, wondering if you're doing things 'right' or 'good enough', even you're kid isn't a spree killer. The parents of the Tucson shooter are probably asking the same questions.

Peter Kramer on Slate.

While we're waiting on ClinkShrink, I'll steal a link to a Slate article on paranoia by Peter Kramer. He won't mind.

Fanning the flames of paranoia

A psychiatrist wonders how a culture of Birthers and Truthers feeds the delusions of people like Jared Loughner

Dr. Kramer writes:

The experience in my training years made me comfortable with paranoia. As a result, I have always had one or two paranoid patients on the roster in my private practice here in Providence, R.I. I should stress that no one I see resembles Jared Lee Loughner. I travel a good deal, and I can't leave the covering doctor with potentially violent patients. When my patients have schizophrenia or related conditions, they tend to be the most accomplished, most reliable, and nicest people to suffer these terrible afflictions. Their needs are serious enough.

Not much specific is known about how to treat paranoid patients. Generally, they don't come in hoping to lessen their delusions, which can be wholly convincing to them. They want relief from depression or insomnia -- or from an employer who has insisted they get help. Their mood symptoms may respond to medication, and they may even become less isolative, but generally the system of thought does not budge. After months of trials of different drugs, the patient will be less agitated and less pained but still solidly convinced that he is being watched and threatened. Always, too, there are prices to be paid in terms of medication side effects.

One thing we all seem to agree on with mental illness of this magnitude is that violence of this extreme and horrific nature is rare. It's all pretty horrible.

What I Want From ClinkShrink, by Dinah

Dear ClinkShrink,

Thank you for writing your post yesterday in response to requests for your input on the tragedy in Arizona. I liked reading about The Killers I've Known (or rather the killers you've known) and certainly I enjoyed revisiting your article on Shooter Psychology. And it does seem to be true that we all pester you every time there is a mass shooting.

I know you can't really comment on the motives of a mass murderer whom you've never examined.

Here is what I think it would be interesting for you to write about, if you want to. Or maybe if our readers bother you because they seem to have more influence than I do.

I'd like to read about the process of what will happen to the man who committed this heinous act. The descriptions in the news paint a picture of a man who may have been mentally ill or under the influence of drugs, or both. So what happens from here? Does he go to jail or to a psychiatric facility? How is it determined if he was mentally ill? What sorts of documents are examined and what sorts of people (if any) are interviewed? If he's found to be unable to stand trial, how does that work? Will he be treated with medicines? If he's very psychotic, might the medicines make him much better, and how would play out? Could he then stand trial? I'm going to assume that there's no chance (I hope) that he will be released back into free society, at least not now. What factors influence whether he is found not guilty by reason of insanity (does that designation even exist anymore?) And where does he go if he's found to be a) mentally ill and unable to understand the consequences of his actions, b) mentally ill but able to understand that what he did was wrong, c) that drugs were part of the picture or d) not mentally ill and fully able to understand what he did. How much difference does it make as to which state someone lives in who does something like this in terms of where he might end up? And in death penalty cases, does his mental state matter at the time of the crime? At the time of the trial? At the time of execution?

So perhaps I want you to give us a full forensic fellowship in a blog post. You are a good sport. It seems we're going to hear a lot about gun control and tea party's and political agendas and obstacles to treatment of the mentally ill and what obligation society has to prevent such atrocities. You have something different and important to add.

Cheers,
Dinah

The Killers I've Known

Some blog readers have been asking for a post about the Arizona shooting incident. The issue of spree killing has come up on the blog before, after the Amish killings in Pennsylvania, after Virginia Tech and the Fort Hood incidents. This will officially be my third poster about shooter psychology and it's getting hard to find something new to say.

First of all, most murderers don't have multiple victims. According to the Uniform Crime Reports, the number of multiple-victim killings has remained pretty stable over the last five or so years, at about 350 per year. Almost all multiple victim killings are committed using guns, although in 1987 there was an anomaly in which 24 people were killed by poison. More about that later.

In most cases, the killer knows the victim and that's true both for single and multiple victim offenses. The nature of the relationship varies with the setting and type of killing: spree shooters most often kill co-workers or other students, while single victim killers murder their partners or drug acquaintances. Psychotic killers will usually murder a caretaker, a mother or wife, but only if the killer is a young male. Female psychotic killers tend to kill their children. It's rare for a psychotic killer to murder multiple strangers. Locally I can recall only one case like this over the last twenty years. In this case the killer suffered from a grandiose delusion, and the victims were killed in a car crash. Psychotic people can stalk or threaten political or other high profile figures, but this usually doesn't result in violence. Typically what motivates psychotic political stalkers is a delusion of some type, for example the belief that a political (or other stranger victim) is threatening them in some way. For example, one political stalker I examined believed that a U.S. Senator was a devil worshiper, and that he was destined to kill all devil worshippers. Another psychotic letter writer had a delusion about the president, although he was so thought disordered it was a little hard to sort out the "logic" behind the delusional motivation.

Multiple victim killers could be spree killers or serial killers. That 1987 anomaly with the poison deaths was partly due to Donald Harvey, a serial killer in Ohio who poisoned patients at the hospital where he worked.

Non-psychotic spree killers have the same motivations as "regular" single victim murderers: frustration over the loss of a job, the loss of a relationship, loss of a living situation, lack of money or friends, alienation from family and substance abuse. Killing is an act of desperation whether you're killing one person or many. Political motivations may come into play, but without the "nothing left to lose" factor political motivation isn't enough.

So why did the Tucson shooter act? Ya got me, I haven't examined him so we can only speculate based on what's in the news. All I can tell you about is the usual characteristics of the killers I've known.

How Do You Switch Docs?

We got a very thought-provoking question:

I was wondering if you could address the issue of switching from a long standing psychiatrist (who provides regular psychotherapy - the ideal which garnered so much controversy in one of your other posts!) following a scheduled medical leave because the covering doctor seemed to be a better fit. What sorts of issues could be involved in that? I know both parties are professional, but I would still be worried about hurting one's feelings. Or what if the covering doctor did not want to continue to see the person; would that then ruin a dynamic of going back to the original doctor? How can this even be addressed?

Wow. Where do I begin.

1) In a long-standing psychotherapy, one of the issues that might be addressed is the therapeutic relationship and how that plays out as a mirror of other relationships, a process known as transference. The question of what else is going on here should be addressed. Is switching doctors a way of avoiding a problem that should be examined? Is leaving adaptive or a way of not addressing an issue.

2) Sometimes in the course of the therapeutic relationship, we forget that the goal is the treatment of psychiatric disorders and the alleviation of symptoms. Before changing doctors it would be important to take stock: why did you go to treatment? What were the symptoms and difficulties, and how are they doing now. If you're doing better, then I don't think it makes sense to leave a treatment that has been helpful because someone else is an easier person to talk to or a better fit. The goal of treatment is to get better, not to find a good friend. This isn't to say that people don't feel helped by a comfortable therapeutic relationship: they do. It is to say Take Stock first.

3) If this is an insight-oriented psychotherapy with frequent sessions, honesty demands that you at least mention the fantasy of leaving to the old doctor. If it is not that type of treatment, you may want to call the covering doctor and have a brief discussion: Will she take you on? She may feel like she's stealing patients and that may not be cool with her. She may have no openings. She will likely say to discuss it with your old doc first. Before you actually leave the first doctor, it makes sense to have a phone conversation with the new doctor, or even a single one-time appointment to discuss why you want to change, whether she will see you, and if that makes sense. Are there insurance or fee issues? Can she see you at a time you are available? Since you're someone who's needed to see a covering doc, what are her policies on emergencies?

4) If you're not getting better with your first doctor and you've followed treatment recommendations and given it a long enough period of time, then switching doctors is reasonable. If you're worried about hurting someone's feelings, then hopefully it means there has been something positive in the relationship. It may be worth taking stock with your first doctor. These are things that have been helpful. This is why I'm thinking I may want to try seeing someone else. If there's nothing positive, then leave and see someone else, even if it's not the covering doc. If there are positive things, then point them out. If the doctor's feelings are hurt, they will live (I promise). It may not, however, make sense to return to someone you've fired if things don't go so well with the second doctor, and leaving may indeed include closing a door.

Thanks for the great question and I hope that was helpful.