Mid Week Ramble: Advanced Psychotherapy 102

  My last two entries have been total losses. . . 

battling at Battle of the Blogs, essentially losing every battle to every genre. I'm not really sure how to take that but probably best with a grain of salt. I suppose in the blogosphere every author, self included, feels their topics are of the utmost importance. Often I recall my youth when I was totally oblivious to current world events or any topic outside of popular media culture of Hollywood tabloids and the sports world. With age my interests have changed 180 degrees and the space in my brain reserved for starting line up rosters and stats of my favorite teams have been replaced by the Democratic and Republican Candidates for the next Presidential election. I've taken interest in 9/11 conspiracy theories and have even tried the stock market and reached a point where I could care less for the Super Bowl or the Final Four. I find myself turned on by excerpts from Jon Stewart, Stephen Colbert, and Bill Mauer. I've learned to love to hate O'Rielly, Ann Coulter, and Sean Hannity. Maybe such changes are normal for the fifth decade of life. I believe the ability to change or evolve is one thing that makes life more interesting.

I think I have the most interesting job in the world but also am aware that others may beg to disagree. It's probably the fact that I have the privilege of actually intervening, where appropriate, into the lives of others that makes it more interesting for me. What I have found to be most fascinating is observing people change over time and resolve problems once seen as unsolvable by that individual. Milton Erickson was a gifted psychologist that possessed super human insight and interpretive abilities. I learned of him from a former colleague. My potential and abilities pale in comparison to such a great professional but I have found my own gift of making accurate psychodynamic interpretations. There is a certain pleasure in the experience of seeing a persons' face light up when they understand their situation in a more hopeful light for the first time. Providing even a modest degree of clarity to what was once viewed as chaos can be exhilarating as a part of psychotherapy. Confronting a patient still anchored in denial is the most crucial phase of effective psychotherapy but also the part where I do not feel gifted at all. There is often no pleasurable way of doing denial demolition. Sometimes if the countertransference is negative toward the person, presenting a little painful truth may not be as problematic. If a good therapist to patient alliance exists the risk of an undesired or ineffective response to confronting one in need of confrontation has a better chance of success.  

To the average reader this entry may seem senseless or hard to follow. As you may have noticed, sometimes I tend to make these self therapeutic entries that may only have clear meaning to me. By blowing this stuff out of my brain I usually seem to replenish my creativity and passion and produce one or two following entries that may be worth reading to more people. Or at least that's my perception. I know if my narcissism starts to exceed its boundaries I can just visit Battle of the Blogs to have my ego rapidly and thoroughly deflated and return to reality.

This entry is actually premature but my day was filled with so many interesting cases that I felt a need to record something for future reflection. Any information written here will always be in a manner within compliance of HIPAA regulations and with absolute privacy protection of any person mentioned. I never thought working with adolescent patients could be so fascinating but when the proper support system is in place some of them can be amazing to work with. Because the young have limited vocabularies they become masters of the art of acting out most everything. Many times their behavior can be a direct reflection of the inappropriate behavior of parents or other adults they associate with. The mind of many kids can be compared to a lump of clay being molded by experiences and emotions.

All of the things the child cannot say are observed in behaviors. The range of behaviors is very broad. Today brought a child between the age of 9 and 11 years old displacing anger at his sociopathic mother, who abandoned him a few years ago, onto his paternal grandmother who has taken on the mother role. The hostility has progressed to where the child saw it fit to call grandmother a bitch and even physically assault her. The mother who abandoned him and continues to terrorize the family unit on occasion, interestingly, is viewed as a virtual saint by the child. It really is a shame that a kid this age has had to be exposed to such a world but confrontation as to why he is so abusive to the one who has shown him the most love is essential. He will not have a logical answer but part of establishing and enforcing limits and boundaries requires that he give this contradictory behavior some thought. His grades have fallen from A's to F's. Eventually, a diagnosis of PTSD with an overcompensation through displaced hostile aggression had to be considered. His pronounced verbal denial of fear, "I ain't afraid of nobody," later followed by the revelation of being terrified of sleeping alone pretty much confirmed my suspicions. Failed trials of Ritalin and Risperdal by his pediatrician also suggested more than Oppositional Defiant Disorder and ADHD as previously thought. Bipolar Disorder must also be considered. Despite this high degree of anger and hostility this kid was likeable and clearly was suffering severely. His mother continues to radiate pain into his life. All he ever wanted was her love. He possessed the assets of being verbal and able to identify with the misdirected explosive emotions. I'm so glad I could see him at age 10 rather than at age 35 after incarceration and crack addiction. The treatment team and I may or may not succeed at helping him but he has a fighting chance against a world that isn't always fair.

In another story there were two young brothers who really touched me. The younger brother had played with matches and accidentally set the grandparents' house on fire. Everyone had safely escaped from the flames except the elderly grandfather. Heroically, the older brother ran back into the home and helped grandfather through the smoke and blazes to safety. I spoke with their mother several minutes before seeing the boys and was amazed at how well she seemed to be handling things. I felt thankful no one lost their life but felt horrible for the guilt the younger kid was probably feeling. He wasn't given a break from end of grade exams by the school and not surprisingly he did poorly. The mother then told me of how the older brother gave his younger brother much needed encouragement at the lowest point in his short life. They both made the gesture of offering the money from their partially burnt wallets to the grand parents to help them back on their feet during the grief and rebuilding period. Tragedies tend to bring out the best or worst in us. This story was so touching and inspiring, especially how the family accepted the event as an accident and focused on the value of life and the need to maintain love as top priorities. The community did rally to help the grandparents who had always been known for their own generosity throughout the years. There were many silver linings here. After it seemed nothing else could add to the story the mother revealed to me the family lineage connecting to a world renoun breakfast food icon who had left an inheritance in the past to the grandparents but they were deprived of receiving any money by legal maneuvers by a closer relative. The mother spoke of how her father never showed animosity toward the person depriving him of what was willed to him. I suppose it is the forgiving nature of this family that touched me so. Fortunately, the home had fire insurance and will eventually be replaced. More importantly, thank God no life was lost partially due to the bravery of a very modest 12 year old. I am happy to be a part of trying to help put things back together.

Several weeks ago I was somewhat harshly critiqued by a reader on my post Hard Out Here for my handling of a session gone awry with an angry 16 yo. Sometimes we cannot know our response to certain situations until that time actually arises for us personally. I've learned a lot from books and training but find that what is learned is not practical for each and every situation. For this particular case, given the circumstances, I still stand by my response though I am in no way proud of it. About certain things, I am from the old school and always will be. I took into consideration that this young woman was quite street smart. She did push my buttons. She felt she could punk me because that tactic had been successful for her in certain other situations. I carry the title of Psychiatrist but can play a number of roles if necessary. Without that potential, I could have not made it this far in life. No one will ever come into my office and blatantly disrespect and threaten me without a firm and direct response in return. I will give them a pass if they have a psychotic illness or they sincerely don't know any better. But, as far as I am concerned, isolated sociopathic behavior is not a legitimate mental disorder, it is a special behavioral problem that is mostly learned and practiced. Adolescents with certain conduct disorders and normal intelligence are often just sociopaths in training. If they are not forced to change they will not change. In my short run I have met enough sociopaths to know that I do not like the behavior of many. With some I have found myself not liking them period.

I may be a doctor but I am a human and a man first. I make no apologies for my behavior in the situation previously mentioned given that there was a chaperone/witness present for observation. In this business it becomes blatantly obvious that only a percentage of those encountered will have what it takes to benefit from treatment. Each day I try and concentrate what I have to offer on that percentage with reasonable promise. It doesn't bother me if an individual sees me as not having what they seek or need. I love all people. I like all people except sociopaths and sociopathic crack addicts in particular. I draw the line here.

Rest In Peace

Yolanda "Yoki" King

11/17/1955 - 05/15/2007

Update on Sun, June 3, 2007 at 03:19AM by HEADoc

 

Thinking Bloggers Unite

Thanks to Carwyn for tagging Quest 4 Sanity for the Thinking Blogger Award. My site has never attracted much attention for design or graphics since so many other bloggers have the edge on that talent. I'm more at home in the arena of ideas and play with words. Thanks to the creator of this award for developing a means of recognition for bloggers who might go less noticed and lost in the shuffle otherwise. As the rules require I will nominate my five choices.

1 Blue Panther http://www.blogexplosion.com/show_page.php?SiteID=78791

2  Sin and Curse  http://www.blogexplosion.com/show_page.php?SiteID=102859

3  If Luck Runs Out  http://www.blogexplosion.com/show_page.php?SiteID=103732

4  Stewart Consortium  http://www.blogexplosion.com/show_page.php?SiteID=97994

5  Aquire Wisdom and Live With Passion  http://www.blogexplosion.com/show_page.php?SiteID=95230

The participation rules are simple:

1. If, and only if, you get tagged, write a post with links to 5 blogs that make you think,
2. Link to this post so that people can easily find the exact origin of the meme,
3. Optional: Proudly display the 'Thinking Blogger Award' with a link to the post that you wrote (here is an alternative silver version if gold doesn't fit your blog).

Mental Health Care Reform: Update

This week was a busy one...

Certain revelations about the delivery system I found to be most concerning and troubling to consider giving thought to. I want sometimes to be able to just say that I don't care anymore and discover a way to turn a profit and forget about the ethical and sociological dilemmas that face the future of public mental health care delivery. No matter how frustrated I become with the realities I'm faced with I expect to always maintain a certain social consciousness and not sell out. At a dinner meeting last night I was chatting with a colleague who made an insightful comment that rang so true; "our patients don't vote" meaning that they don't really matter to the politicians. I then listened to a story of a professional who organized a voting rally specifically for the mentally ill and took a bus load to vote at a recent election. For this act he almost lost his job.

Often I get tired of mentioning mental health care reform because very few people care about it unless they work in the field. I become angry when I think of what happens to a vulnerable group of citizens, especially knowing that the general public is not aware of the whole truth.  For several years there has been knowledge of this reform which translates basically to "we don't want to spend this much money from the budget to pay for these services." The essence of the plan has been to phase out virtually all Mental Health Centers from the role of providing substantial services and refer the clients out to a make believe private sector for services. The four state inpatient facilities are to be closed and replaced by a single facility. The transformation from theory to reality seems to have occurred. Lately, I have learned that the local county Mental Health Center will no longer accept new patients. Also I've learned that other than myself no local providers are accepting Medicare or Medicaid patients. This is a problem of great magnitude because it leaves a large part of the population without access to care, not to mention the uninsured.

I quit my consultant job at a metropolitan pretrial detention center a couple of years ago partly because of not being able to tolerate some of what I was witnessing. On several occasions there would be a severely mentally ill inmate I was asked to see after several days or weeks of laying on the jail room floor without treatment. This person may have been experiencing severe hallucinations and paranoia from receiving no treatment. Usually they would be refusing oral medications and it wasn't legal to give intramuscular forced medications which is exactly what was needed. The jail cleared themselves by being able to document the person was seen by a psychiatrist within the 14 day limit as required by law, but in essence nothing was really done for the individual. Sometimes they could be transferred to the state prison mental health unit for safekeeping but this was not a guarantee. Usually the person had been charged with a misdemeanor and fell into the category of public nuisance more so than dangerous criminal. Due to pressure to close the local state hospital this type of person was now a part of the criminal justice system instead of the public health system. Now they can never vote nor will they ever be eligible for Medicaid. As the mental health centers close down there is report of a rise in the number of jails and prisons being constructed. Is this what we as a society really want?

Sometimes I feel like I may care a little too much since there is little or nothing I have been able to contribute to help the situation directly. I feel I am a good clinician but that does nothing in the way of policy making and legislation. Often I wonder if the cause is worth fighting for. At times the forces within the public sector seem undefeatable. I see a disability system that defines people as either totally disabled or totally healthy when in most cases they are neither extreme. Those applicants who might be rehabilitatable or partially disabled seem to be encouraged to appear as ill as possible as they file one appeal after another for sometimes up to more than 2 years. The Social Services Department is so overloaded with cases that often it seems to function as a triage and cases not labeled as life threatening are placed on the back burner. Two parents of small children positive for cocaine in their urine is not even grounds for investigation. Now I see public mental health care on the brink of extinction and it seems that very few are concerned about what this could mean for our society. Maybe I'm the one that doesn't get it. I really don't think so. I don't think the Virginia Tech tragedy served as the wake up call it should have been. Individual emotional and spiritual illness when neglected eventually morphs into social sickness.

In my opinion, the cocaine and opioid epidemic will eventually reach a point of no return. Everyone is affected by the illness of addiction by just being part of the addicts' social or family network. Based on my experiences, I have no problem with locking up sociopathic drug addicts because majority of them seem to become incorrigible menaces to society and without a desire for recovery that is sincere there is very little hope for a good outcome. I do not feel this way about those with primary mental illnesses or even alcohol dependence that is not complicated with polysubstance abuse. I don't think these people should be thought of much different from the person who has cancer or cardiovascular disease since effective treatments are available. At this point it is not at all apparent in my state that those with a severe mental illness will be looked out for as the reform meets its cryptic future goals. I do like the idea of those who have similar views to my own organizing a bus load of mentally ill voters from your district and making sure they cast a vote in the next election. This could begin to build needed political clout. You'll probably lose your job, but you are going to lose it anyway eventually if you are employed in the public sector. This idea seems to be the only viable solution to avoiding a future disaster.

Dope to Cope Kills Hope: Update

 

Suffering from a bad case of writer's block for the past few days...

All I know to do is keep hitting the keys in hopes that some inspiration will come. Today was not a bad day as far as the types of cases seen. The only drug addict to enter the building today was not allowed access to me after reporting the theft of medications prescribed 3 days prior. It's hard to believe they try the same old tricks over and over. It is usually a good day when there are no addicts to see. I don't dislike dealing with all people that abuse drugs but if I had to choose one group to avoid this would definitely be it.

Sometimes in the next few months the 100th dismissal mark for the past year and a half  for non-compliant substance abusers should be reached. I wish this meant that something great was due to happen but it is just another reminder of a limit for helping people. Three out of ten serious substance abusers have a realistic chance of a complete and productive recovery, no matter what approach is taken at treating them. Though genetic factors are significant, environmental conditioning seems to be the greatest barrier to overcome. When dope is used to cope their is little hope.

I'm trying to accept that the drug culture has always been among us and expected to always be. The U.S. is the greatest consumer of cocaine, opioid products, and alcohol on the planet. This really bothers me sometimes. I find that the real truth boils down to "who really cares?" There is no War on Drugs and never has been and I doubt there ever will be an effective one. I also find there to be two separate societies and economies. One is legitimate and the other more of a syndicate nature. Tons of drugs enter our country daily without much consequence. With all of the emphasis and modern technology available to fight the so called War on Terror it baffles me as to why the transporting of illegal drugs is not given some type of priority. This makes me more suspicious and likely to question whether economic gains are not at the root of both wars. Several political analysts have suggested evidence that naming a cause a war is primarily a means of legitimizing something to be milked financially. There is never any intent of winning from day one. Those of us in the legitimate branch of society must be extra careful to follow all of the rules because we can be regulated or punished with such ease if necessary since all of our demographic data is readily available via computer. This may not be so for big time criminals and what frightens me most about corruption in government.

Having a DEA license is really the only reason these matters have been introduced to me. Small time criminals are constantly on the hunt for doctors they may be able to extort drugs from since prescription drugs are currency for illegal drugs. At the bottom of the food chain are abusers of crack cocaine and crystal methamphetamine. These are the ultimate losers in society. Many are incorrigable and absolutely hopeless, in my opinion. I have found this addiction to be more devastating than terminal cancer or AIDs. These drugs attack the soul in a way that is unprecidented, stripping the individual of basic personality traits and eventually all values and morals. Biochemically, the nervous system is wrecked leaving the individual with the template for a paranoid schizophrenic in the untreated state. They become a hollow shell, caring about nothing but the next rock. They will steal the rent money, the food money, the money to care for the baby, the money in grandmother's purse; there are no limits at this stage of addiction. I know of mothers giving their children away and selling their bodies. The words from their mouths are worthless. Their urine drug screen will be positive though they will swear they do not use. Even seeing the evidence on the paper and being confronted with a 50 lb weight loss will not break through the denial and the lying. The death of friends also does not register in many for they truly believe death happens to someone else but not them. Everyone this person comes in contact with is affected negatively. Those who care are viewed as prey by the individual. This illustration represents the spiral downward of the crack addict. I am convinced that this particular drug stands alone in the havock it wreaks.

Opioid dependent people usually have a physiological dependence that can be safely managed. The social deterioration seen with cocaine is not always present with opioid dependence. Although I find that the patients who snort Tylox through a straw are often equivalent to crack addicts in behaviors and have few limits to what they might do. Many opioid dependent individuals can be maintained on methadone or bupenorphrine and are able to lead relatively normal lives. With the proper treatment the focus of their lives is no longer on obtaining drugs and the problem of involvement with a detrimental social circle can be eliminated. I find that many people self medicating with pain pills actually have underlying conditions that are treatable such as ADHD, PTSD, or a depressive or anxiety disorder. With addition of the proper treatment they can be tapered off the opioid medication sooner. Learning that the primary problem is not addiction sometimes can be a motivating factor for the patient.

Garden variety alcohol dependence is welcomed for treatment as opposed to treating cocaine addiction. Today there are clinically proven treatments that can greatly curb alcohol intake and essentially cure the disease in a highly motivated individual willing to participate in a reasonably comprehensive treatment program. Support groups and spiritual support are crucial components of a successful recovery. A monthly injectable form of naltrexone is available and proven to be effective in treating alcohol consumption. Campral and oral naltrexone also work if the patient can adhere to treatment. These drugs offer hope where there once was little hope for some with alcohol dependence.

Crack and Antisocial behavior are deadly in combination. There is no effective treatment to offer them. No one is safe around them. Our world has never before seen a chemical compound so ruthless and predictable in its effect. I have never been a judgmental individual but have developed a strong personal belief that a person choosing to smoke this drug repeatedly has signed their own death warrant and have sunk to the level of a common felon even before they start to regularly commit crimes. The drug seems to activate a gene of self destruction. I know of nothing more devastating than crack and crystal meth. Do you?