Entries in Weekly Entry (41)

Thursday
Mar012007

Hard Out Here...TGIF

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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.

Thursday
Feb222007

The Bigger Picture

    

I really hate being the prophet of doom and gloom as the things I sometimes write about seem to represent...

It is all relative to one's overall world view I suppose. I can still recall as a kid my older sister telling me that there would come a day in the far distant future when the polar ice caps would melt and the land would eventually be covered by water. That thought was frightening but I always felt it was hundreds of years into the future. Today's scientific data is suggesting that it will definitely happen in this century if we don't succeed in finding alternate energy sources to burning fossil fuels to curb the rate of the greenhouse effect and global warming. Satellite imaging has shown a section of ice the size of the United States totally melted in one arctic region after several thousands of years of stability. The Greenland glaciers of the North can be seen to be rapidly vanishing. So far Mother Earth has been able to compensate but I've learned that scientists believe that a point of no return can be reached where the ice that melts continues to progressively melt and not return to the previous total amount of ice again. When and if this happens we will lose most of Florida and most of the coastal cities of the east. This isn't science fiction.

A relatively pessimistic person might argue the scientific fact that every few thousand years the orbit of the earth around the sun changes from circular to elliptical and sets off another ice age, thus making the occurrence of global warming irrelevant. I once heard that scientists of this school of thought have been advising the Bush administration about the environment. An ultra pessimistic individual might conform to the argument that in a few million years the sun will run out of fuel anyway and swell in size and heat so much that it will engulf the earth and burn it to a cinder long after all life is gone. This view makes the case of absolute inevitability of destruction. If this isn't enough, the argument may digress to that millions of years before the sun dies there is close to a 99.9 % chance that at some unknown point the earth will be struck by at least one of the millions of the deadly asteroids now moving about the solar system in the asteroid belt located between Mars and Jupiter. So mankind may go the way of the dinosaurs long before the planet is cooked by the sun. According to an ultra optimist, we will have colonized space long before any of these things happen. Whatever is left of mankind may have moved on to other parts of this and other galaxies when the technology advances enough to make it feasible.

I sometimes allow myself to mentally trip this way to try and find some type of context to help me understand thoughts or situations that may be troubling me at the time. Some people do the same through religion, and I know that they would not hesitate to label me as using heretic thinking. Galileo spent the last years of his life locked up by the church of his day for teaching that the world was round when all the wise and God fearing men of the day knew that it was still flat. Eventually, most of the religious community accepted that the world is indeed round after all. I see myself as a highly spiritual and open minded individual, and am more educated in religion than the average Joe but I too believe that God gave us a brain for a reason. Part of that reason includes learning and using science for the advancement of mankind. I do not wish to attempt any discussion of the slippery slope of religion. I know that it would eventually end up as usual with a tip from a concerned individual that I am going to hell.

What led me to today's topic was facing a week with numerous cocaine related issues. Most of the people encountered don't even know what cocaine looks like but they have a spouse, child, or relative totally strung out on the stuff. I can't help but ask myself why is this happening and why does no one really seem to care? I start to wonder if I'm blowing things out of proportion because of the special population I'm exposed to, then the conclusion is reached that I probably am not. Why is this problem not a higher priority? Why are most budgets for the prevention and treatment of drug abuse being reduced or eliminated? How can tons of drugs come through our borders undetected continuously? Is our homeland security that bad? Is someone being paid to look the other way? What good does it do to arrest the users and do nothing to deter the suppliers? We can never lock all of them up. It seems to just assure that the addict will be banned from the work force for good because with a record they will probably never be hired for a decent job. I know that these questions won't be answered until the problem becomes so severe that it can no longer be overlooked, and that will eventually happen. For now, it really bothers me to see people go to the justice system for help for a family member spiraling out of control to the point of endangering themselves, others, and the home and be told by the magistrate not to contact the police anymore because they cannot do anything to help. An involuntary substance abuse commitment taken out for an addict by a doctor who considers that person to be dangerous is not really worth the paper it is written on. Usually within 72 hours or less that person is right back on the streets using and committing crimes again.

We, as a society, have witnessed this problem spill over from the inner cities to rural America where it now affects middle and upper middle class people of every ethnic group. I believe that this epidemic will hurt us as a nation far greater than terrorism. Having a front row seat yet having little or no power to effectively intervene saddens and worries me often. In one way or another this problem will impose among most of us at some point. At that time we won't be able to run hide or look the other way any more. I wish I had some answers.

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