Reboot

For a number of reasons, personal and work related, I reached my stress limit...

which began to activate automatic shutdown mode. This requires a weekend brain reboot in order to make it through the next week. The search for mental and emotional refreshment led me to visit the old home place property I purchased last year. My early childhood and much of my adolescence was spent there beginning almost 50 years ago. It seems unreal the way time has flown by. I needed to compare the vivid mental maps from my memory and my frequent dreams to what really existed there today. I expected to look behind the heavy overgrowth and thicket and see the old house. Not a single block or brick remained. The sweet gum quartet that once provided shade for the front yard and porch stood tall after close to 100 years. Even the surface root I walked on as a toddler was not phased by time except for being larger. I noticed that the old cedar tree that was 3rd base during all those ball games had grown immensely. The big oak no longer graced the sky. The septic tank was the only evidence of a house ever being on the property.

I walked to the stream where as a child I couldn't wait to get to and fish for crawfish, chub minnows, tadpoles, salamanders, and baby snakes. There was a slow trickle but no sign of life today. Erosion made it difficult to match any specific part with that in my memory. The garden area seemed so much smaller from what I recalled. Then alas! I noticed a corner foundation pillar of stones of the old barn I once found so intriguing to explore until the wasps repaid me for throwing hot water on their nest. Nothing remained of the structure but the corner pillars and pieces of severely decayed support beams. This was enough for me to re-envision it in my mind. Then something very familiar caught my eye. It was my first basketball goal rim, still painted orange but mostly intact. This image took me back to 1970. I decided to follow the stream back further to see how well my memory matched what was there. I envisioned where my uncle's woodyard once existed. I came upon the old spring where we once drew water to drink and bathe. The spring seemed unchanged. The water still flowed from underground to form a smaller branch that flowed into the larger stream. By this time I decided to find a nice sized stick and proclaim myself explorer, hiker, and archaeologist for a day despite my slacks, dress shirt, and loafers. Except for that it was like being a kid again. I had always been afraid to explore much beyond the spring but today was my opportunity. Not surprisingly, my curiosity about the stream was much easier to quench at age 48 than age 8.

I thought it would be more fun to visit the site where my great grandparents once lived at the top of the hill. This home had been built not too long after the Civil War and even in my childhood memories had decayed almost beyond recognition. I wondered if the place could even be located. It didn't take long to find the spot evidenced by two large stone masonry fireplaces relatively intact. That same trademark of cornerstone foundation pillars was again seen. There were just trace amounts of decayed wood. The tin roof of the out house rested flatly on the ground as its only remain. My great grandmother died at about age 98 when I was less than 2 years old and great grandfather died before I was born. I knew that she loved to grow flowers and had actually picked some with my mother as a kid. Today, it made me happy to see the daffodils and other plants flourishing without being tended for almost 50 years. It felt awesome and an honor to be the only descendant to visit such a place where these people lived so many years ago. My imagination went wild as I envisioned Great Grandfather Job and the men of the day constructing the home and Granny Kissire and the kids sitting by the fireplace or working in the flower garden.

Soon I moved on to find the dirt road that was once so familiar. The mental image did not match but I walked along where I thought the road should be. The road once ended at a now paved state road where the church I used to attend is located. The walk went well and I even thought I found an eroded version of the large stone where I'd always stop to rest when walking to church or to visit my cousins. Eventually, all resemblance of a road had vanished. The pasture where I was once so afraid of the cows came into view and in the distance sat the church, which was good. Had I been thinking like a normal human being I would have climbed the fence and walked the remainder of the distance from within the pasture. But in my quest to win the Lewis and Clark Exploration Award I eventually found myself being attacked by plants in what seemed to be a never ending briar patch. I feel like the deer, racoon, and squirrels were somewhere in the background having a ball laughing at me fighting briars with a stick and yelling ouch. After this exercise in futility I climbed the fence and was on the state road within 5 minutes.The return trip was much less interesting since established routes were used.

This post is one of those personal therapeutic entries that I need to do from time to time to help preserve my own sanity. The take home message is, however, an important part of good mental health hygiene. When your life gets crazy to the point you begin to feel control is slipping away the stage is set to activate your weekend brain reboot by finding something a little crazy to do.

Search for a Silver Lining

         

The past week was a week of sadness and grief...

Less than twenty four hours after the death of my nurses' husband to cancer, my receptionists' grandmother was taken off of life support and pronounced dead. One of the deceased I knew well and the other I'd never met. My practice partner and I made it through the week without support staff the best that we could. I'm glad the week has finally ended. I wanted to find another topic to write on tonight but nothing seems to inspire me. We all wish we could avoid dealing with death and grief but doing so is the greatest form of denial, for death is fully guaranteed for every living creature. It is interesting that this thing we dread and hate so much is the very thing that gives life such value. Were death not a future certainty we would have no reason to be accountable for the life choices we make. It wouldn't matter if we selected a pathway of pure evil and destruction or if we selected the very same pathway we have chosen in our current life. Without death there would not be a past or a future and life would probably resemble that of Bill Murray in the movie Ground Hog's Day. Every day would be like every other day. In that movie, Bill's character eventually prayed for death but since death was impossible he was trapped in his own private hell where he was the only human with a sense of awareness of his reality. All others were only concerned with their own individual realities.

Hardly a day goes by that I don't speak with someone having at least passive thoughts of suicide. At this stage of my career I will ask someone if they want to die with similar casualness as I would ask them if they had any trouble finding the office. It is well known that talking about suicide does not increase the risk that a patient will commit suicide. Though impossible to prove it is probably more likely their suicide risk is reduced by you asking about such thoughts. If the examiner doesn't think to question a depressed person about suicidal ideation the examination is flawed and incomplete, not to mention the fact that if the patient just happened to kill themselves later that day you would probably be sued and would most likely lose the case. It is equally important to be aware of the homicidal potential of a patient since you could be held liable for people killed by an individual you may have recently examined. So I don't have a problem routinely asking people if there are thoughts of murder. It is not believed that doing so will contribute in any way to an individual becoming more homicidal toward anyone other than yourself, maybe.

Despite all the efforts of the mental health care community the suicide rate remains steady in the arena of 30,000 per year since records began over 80 years ago. The most predictable indicator of a rise in suicidal deaths epidemiologically has been the economy. The suicide rate tends to rise when the stock market falls. There was a marked rise during the great depression and a slight rise during the recession of the 1970s. Suicide has been described as a permanent solution to a temporary problem. The greatest deterrent to considering suicide I have found to be fear of going to hell. This question creates a theological dilemma for all after a suicide has occurred. I personally believe that if the persons' mental capacity had failed them then God would no more hold that against them than if their heart had failed them. The confounder that exists sometimes rests within the fact that a large amount of successful suicides involve self induced states of intoxication from alcohol or drugs. I think many of those people would have come to a different conclusion were they not under the influence of a mind altering substance. Alcohol is great at causing one to feel disinhibited and to do things they probably would not do in a sober state of mind. Theologically, I believe that what makes man God's greatest creation is our free will. Being equally able to choose evil is really what makes doing what is right so much more valuable. Usually, the pathway of least resistance passes through the temptation of doing that which is harmful or not right. In my humble opinion, I think that choosing to take life when in a state of mind that the individual clearly knows to do so is wrong predisposes that individual to whatever the consequence may be. That said, i believe that the vast majority of those intentionally killing themselves are totally out of their mind at the time. I believe God gives them a pardon.

Sometimes I feel I should go to rehab to address the hostility I sometimes feel toward most of the cocaine addicts I've encountered. Interestingly, when I treated them in the jail setting there was never a problem. Even now when that rare addict presents that admits to having a problem and is genuinely sincere about accepting help, I have no problem with them. But when I discover several weeks after seeing someone that everything they told me in their history was a lie and their whole agenda was to get a controlled drug I start to feel like Mel Gibson in Lethal Weapon. Over time I have learned to accept that they are very sick individuals who literally have damaged their brains so much that the parts responsible for good judgment, truthfulness, and any degree of common sense has usually been destroyed. Dead Man Walking is an appropriate description. It is often as if the trigger has been pulled and the bullet is on the way to their head in extremely super slow motion. It may actually take a few years for the metaphorical bullet to penetrate the skull and inflict the fatal wound. In the mean time they have an obligation to make everyone else's life as uncomfortable as possible. I don't mean to let those off the hook that prefer drugs different from crack but I have found there to be a significant difference. I am actually pleased to find an ordinary alcoholic to treat because I know what to do for them and what to expect from them. Pure opioid dependent patients can sometimes be perfectly normal and functional except for having that problem. I have yet to meet an individual smoking crack every day that has a normal life.

I know I have rambled and meandered a bit here but I think something useful may have been expressed. At the very least I feel that I have vented a little and feel better than when I started this entry. I suppose that's a good thing given that I have chosen to write about such a dark topic today. To me it proves that some humor can be found in the darkest situations even when little or no control is available. Maybe next week will be a better one.

Hard Out Here...TGIF

Just a few hours ago I found myself at a place where I really didn't want to be, but I was there...

Instead of aborting my session with a 16 y.o. girl with severe conduct disorder and oppositional-defiant behavior when it started to heat up I decided to explore a little further. She picked the wrong psychiatrist to try intimidating though anger and verbal aggression today. I think what got me going was her calling me stupid and a fake. She was the one court ordered to the care of a group home after another assault charge and repeated incidents of anger related aggression, yet I was the one who is stupid and just seeing her to get paid. She felt telling me how much she hated me would really make me go away, but it didn't. I wanted to know how could she hate me so much after only seeing me twice before today. Had there not been a chaperone and witness from the group home it would have been extremely foolish for me to take this any further.

Instinctively, I felt I needed to not let her have this victory for her ego or I would never have a chance to help her. I let her take me to the pits of her anger (which she denied having) and found myself in the awkward position of participating in a brief shouting match with an angry adolescent. I felt it important to not allow her to believe that intimidation is the way to solve any problem. I made it clear that I was not frightened of her and that she could not threaten me away until I was ready for that to happen. Next came her F it strategy which was totally useless because I've already been there and done that when I was much younger. She proclaimed that she didn't care how many level reductions or punitive measures it required she would never talk to this stupid doctor again. She stated she was willing to accept any punishment that could be inflicted. This left me with a perfect confrontation opportunity of asking her if it was really worth all that as a response to just being asked what she was feeling today. Actually, it sort of surprised myself when I didn't back down from the implicit threat of violence and threat of trashing my office. Fortunately, I have done a bit of acting a few years back and I decided to let her know that I am not a total stranger to getting "Ghetto" if I need to. The temptation was far too great and I found myself going there. I had doubts of whether I had handled this situation appropriately until the end of the session after we both had some time to de-escalate. Now, I feel it was the right call and was worth the discomfort to let this play out in a safe environment. In an unsafe environment violence would have been imminent and almost inevitable. Letting her do it in the office allowed me the opportunity to make a point that had already proven futile through the means of normal conversation. I think now she can better accept the fact she has anger management issues, even if she sees it being my fault that she does. She refused to shake my hand as a gesture of a truce at departure and stated she would not be back, but I have a feeling that she will.

I had gone through a similar confrontation with an adult patient yesterday, though much less intense. She was apparently manic and somehow got the brilliant idea to stop by the office unannounced to give me a few pointers on psychopharmacology. When people are experiencing delusions of grandeur it appears to them that it is you the doctor who is an idiot. It is pointless to try convincing them otherwise. Denial is a real B, mainly because it is only the one who denies who sees no denial. With her husband along as a witness, I felt compelled to give a brief but poorly received lecture on the list of symptoms of bipolar disorder being exhibited before our very eyes. She insisted I prove to her how I know she has bipolar disorder. This is a job for Moses I would think. The simplest way I could put it is that most people with bipolar disorder, one way or another, eventually make it to the office of a psychiatrist. There has never been a need to go out looking for patients to treat. From her perspective she did not have bipolar disorder but a more acceptable explanation was that the Depakote prescribed to her started all of her newfound problems. I really love when this happens because it enables me to come back with " well if you figured out the cause of all your problems was taking a sub therapeutic dose of Depakote for a few days then stopping that medication should have fixed all of your problems. Right? What do you need me to do?" She then clarified that it was coming off the sub-therapeutic dose of Depakote and the side effects of "not feeling right" that must be the actual cause of all those problems worsening. For most patients going through this it is inconceivable that it may have been that Klonopin prescribed as needed for anxiety (that is being over taken) that could be the main cause of the not feeling right. When a determined patient continues to come at you with non sense that they are convinced is fact, eventually you have to spring the topper of asking where they received their training to practice medicine? The only option left at that time is for them to devalue you and inform you that you are not worthy of the privilege of treating them any more. By this time, I'm usually ready to show them the door anyway.

Sometimes it gets this bad but usually not. It actually is this uncertainty that keeps the work interesting. The next time I see either of those patients again they may be totally different people or to punish me they may move on to the next psychiatrist or therapist. Even parents occasionally have to let their kids learn things the hard way. I really find it humorous when a difficult patient fires me. It's much like the little kid running away from home with just a back pack and a packed lunch because mama wouldn't give him his way. It's hard out there for one in need of a good and caring therapist. Whether those who self terminate treatment choose to return to me or not, usually I know a day will come when they will see the grass is never greener and there is no such thing as a magic pill that fixes everything.

Update on Mon, April 30, 2007 at 07:31PM by HEADoc

Looks like I received a little bashing from a psychology colleague. I always appreciate any positive input. Unfortunately, most  psychiatrists don't receive a whole lot of training in theory of direct behavioral intervention with adolescents with aggression problems. On the job training is more the norm. I'm sure majority of my colleagues tend to practice avoidance when it comes to potential violent confrontation. I'm a former football player and was once conditioned to seek out the action instead of avoiding it.  To my newfound cohort, I do especially appreciate the inclusion of alternatives to shouting and being reduced to a primitive level of behavior. This form of behavior is of course a last resort and fortunately this situation occurs only rarely for me. I don't think practicing self defense is any indication of illness in this physician. There is a time and place for everything. If I am threatened with violence it is not my nature to run. I certainly won't make exceptions for an aggressor behaving in an antisocial manner. If this is seen as wrong then so be it. I have been face to face with murderers, psychopaths, and common thugs during my work at the County Detention Facility. I have a good instinct for keeping violence in check. I will never allow anyone to abuse me in my own office if there is anything I can do about it. My patience is quite long but limited. Sometimes the textbook must be thrown out the window. My job is to help those who want help and are able to cooperate with that help. If those criteria aren't met it is not necessarily my problem. Logic isn't always effective when confronting ignorance.