Cronyism

Roger, a psychoanalyst, sixty-two, was deeply involved in his psychoanalytic institute for his entire thirty year career as a psychiatrist/psychoanalyst. He served on committees, he taught candidates at the institute, he gave parties, he went to conferences, symposiums, presentations by local and out-of-town speakers. He enjoyed the camaraderie, the intellectual stimulation, the feeling of belonging, similar to the high school experience of “fitting in”. http://shirahvollmermd.wordpress.com/2010/03/10/belonging/. Regimes change, the leadership of the institute began to shift, such that his buddies were no longer in positions of power. As such, the new leaders tapped the shoulders of their friends, their cronies, to do the “work” of the institute. Roger began to feel marginalized and demoralized. His years of voluntary service began to fade away in his colleagues’ mind. He no longer felt he belonged. Understanding the issue is clear to Roger. The adage “it is not what you know, it is who you know” rings loudly for him these days. The emotional overlay of disappointment and abandonment also rings loudly for him. Roger wants to feel appreciated. He is searching for validation. His world has changed; Roger has to adapt. Grief, followed by rebuilding a professional community is his path. Good luck Roger.

Palliative Care

    Taking control over one’s death; why don’t we do that? Lee, fifty-five year old African-American male, heavy smoker for forty years, heavy drinker for twenty years, but now sober for ten years, is dying from metastatic lung cancer. He is in agonizing pain; he has good insurance. The pain doctors, or so they call themselves, are hesitant to give him opiates because he has a substance abuse history. “No way,” I say to the family. “That can’t be true,” I repeat in total disbelief. Yet, it is true. “Well, then get him a new pain doctor” I say, with a demanding tone, realizing that for inpatient pain management, there may not be a lot of choices. Eventually, Lee says “put me down” with such clarity that he realizes that living must be worse than dying, at least as far as he is concerned. Veterinarians heed the call of the animal, when the dog or cat or bird is nearing the end of his days. Physicians on the other hand, tend to be insensitive in this domain. Although palliative care is a growing field, most dying patients do not receive services which help a faster, more peaceful exit. Mental health providers, by and large, have also remained silent. Why don’t psychiatrists, psychologists, and social workers speak out, about how for the sake of the person, for the sake of humanity, let’s help this patient die?  Our silence is deafening. It is time to change health care policy for end of life care. Shortening life, in the face of a terminal illness with chronic pain, is both humane and cost-effective. We have to stop pretending that both issues are not important.

Los Angeles Child Study Team for Mental Health Professionals: Interested?

      For those of you looking for a fictional patient story, this post is not for you. This blog is a solicitation for mental health professionals who are interested in delving more deeply into understanding development and understanding family dynamics. I am interested in starting a study group for professionals who want to read articles about the developing child, about the development of personality. I imagine a group of eight to ten people meeting at my house, or my office, once a month, discussing a theoretical article about development. Perhaps we would talk about the influence of culture, genetics,  and/or socioeconomic issues on the developing child. Maybe we would have guest speakers talk about their experience with a particular patient population. Maybe after a year of meeting, we would develop a position statement, that maybe, just maybe, would influence policy decisions with regards to helping children, our vulnerable population. Maybe we would consult to schools about how best to discuss the mental health needs of their students, maybe. Maybe we would give talks to the community about our ideas of parenting. Maybe we would just make friends with professionals who have similar interests. There are lots of possibilities. Anyone interested?

Thanksgiving Drama

   Javier and Luisa, both in their sixties, married for thirty years, three grown children, have verbally violent confrontations almost every day. Mostly, Javier yells at Luisa about something she is doing wrong: folding the laundry, taking care of the dog, taking care of the fish, working too hard. Mostly, Luisa stands there and takes the verbal assault, with little pushback. Internally, Luisa feels helpless and confused, not angry or revengeful. Javier, by contrast, feels self-righteous; he feels like he is “helping” Luisa lead a better life. Javier and Luisa do not come for marital therapy; they come because they are worried about their thirty-year old daughter, Isabel, who is trying to find her way, but in the meantime, she is financially dependent on Javier and Luisa.

    “How was Thanksgiving?” I asked, just wanting to break the ice after a three week separation from our sessions. Luisa begins, “well, we were an hour late to our friend’s house  because Javier started screaming at me about how I did not feed the dog on time. It was a holiday so instead of feeding Spot at 8:00 am, as I usually do, I did not feed him until 10:00 am.” “Let me get this straight,” I say. “Javier screams at you when you are supposed to be leaving. You stand there for an hour, as he is screaming, then you gather your stuff together, arrive at your host’s home, and then you act as if nothing happened.” “That’s right,” Luisa says flatly. “How do you go from feeling traumatized to being social,” I wonder aloud. “I have  years of practice,” Luisa says with her same flat tone. ”Maybe we should change the focus of our sessions away from Isabel and towards your marriage,” I say with trepidation. ”Javier does not think there is anything wrong with our marriage,” Luisa maintains her flat tone. “Is that true?” I ask Javier. “Yes, that’s true,” he says dryly. “Luisa needs to learn things from me, so I needed to explain to her why it was so wrong that she fed Spot late today,” he stated in a matter of fact way. “Did you need to yell at her?” I ask, thinking that I am defending Luisa, but maybe I need to do that now. “Yes, I needed to yell at her, that is how she listens.” I am feeling bad for Luisa, but I know I need to focus on the task that Luisa and Javier outlined. “Where would you like to go from here?” I ask, hoping they will agree to marital therapy. Javier says bluntly, “I think we have to go back to talking about Isabel.” “OK,” I say, “but if you want to talk about your marriage, we could do that, or I could refer you to someone else,” I say as a further attempt to help them with their dynamics.

The Flashback

    Leanne just turned fifty-five. Her life feels good to her. She is happily married; her kids are grown and happy. She is happy to go to work, although she experiences her life as “somewhat mundane.” Roaming around the internet, she found Leonard,  an old boyfriend; one she dumped for her current husband. On a lark, she reached out to him, and almost instantly he responded. Within minutes, they were on the phone talking about their lives thirty years ago, as if it were yesterday. Unexpectedly, Leanne became “massively depressed,” as she describes a sudden feeling which came over her. “I did not want to get back together with Leonard. That was not it. I did want to go back to that time in my life where I did not experience the overwhelming sadness that I have felt since then.” Leanne’s third child passed away from a brain tumor when he was two; that was twenty years ago. I could feel Leanne’s sadness, the feeling that Leonard reminded her was not always part of her psyche. Leanne has been sad for so long, she almost forgot the time in her life when she did not feel that way. Remembering that, made Leanne even sadder. I wanted to say something, but I was overwhelmed with  feeling sad for Leanne. After a pause, I began, “it is like you have had two lives: one before your baby died and one after,” I say, knowing that this is both obvious and painful, but also knowing that understanding this before and after experience might help Leanne integrate the varied chapters of her life. Leanne begins to sob, “yes, but I did not want two lives.” “I know,” I say with deep understanding about the helplessness that she feels. “When Leonard called you, you were unprepared to be brought back to your old life, in a similar way that you were unprepared to get the dire diagnosis for your baby,” I say. “Sudden, unexpected events, are very jolting, since they bring you back to your baby’s illness,” I say, reinforcing how her vulnerabilities to sudden changes are so understandable. “Flashbacks, even to happy times perturb your mental state; it rocked your boat,” I say, again, trying to help her unpack why her conversation with Leonard was so deeply troubling.  “I don’t know,” Leanne replies, “I just know that I feel really bad since I spoke with him.”

The Parentified Child

    Peter, sixty-two, comes in devastated over Eli’s, his younger brother, life stressors. Eli has three kids, he is unemployed, and he is very depressed. Peter has six younger siblings; Peter was six when Eli was born. There are three siblings in between them. “I understand you are upset about Eli, but why are you SO upset?” I ask, since I have a strong sense that there is a missing piece. Peter’s emotional state did not seem to correspond with his narrative. Peter seemed cut off at the knees over Eli’s long-term struggles. Eli has been unemployed for over six months. Quickly, Peter responded, ” Eli is like my son, not my brother. I took care of him. I changed his diaper. I made sure he got up to go to school. I made sure he did his homework. I helped him with his college applications. Now, I feel so helpless.” Peter sobs. “My mother was really depressed so I had to fill in for her,” he explains. I began to understand the dynamics. Peter, at a tender age, took it upon himself to raise Eli. He never understood the responsibility cognitively, but emotionally he felt that he had to take care of Eli because there was no one else to do that. Of course, there was no one else to take care of Peter, but Peter was forced to accept that abandonment. He compensated, partly, by showing himself that he could care for Eli; maybe that reassured Peter that he could also take care of himself. Now, all these years later, Peter is still plagued by feelings of responsibility and guilt that he cannot quite untangle. All he knows is that when he talks to Eli, he feels really bad about himself. Understanding how the past influences the present helps somewhat, but Peter is still stuck with his old feelings of letting Eli down. He felt that acutely when he went to college. He knew that Eli would suffer when he left, but he also knew he had to leave home and start a life for himself. I do not think Peter has ever forgiven himself for that. We are working on putting that in perspective. Intellectually Peter knows he was entitled to go to university, but emotionally, he feels plagued with guilty feelings. Bringing his emotions in line with his intellectual understanding is our challenge. Each conversation with Eli is our starting point to wrestling with these contradictory feelings. “It is amazing how things that happened so long ago  still deeply impact me,” he says, with childhood wonder. “Yes, it is,” I reply, with equal measure of wonder.

Eva Hesse

Eva Hesse, now on view at the Hammer, http://hammer.ucla.edu/image/5257/590/0.JPG, was hard for me to appreciate until Elizabeth Sussman, http://artscapemedia.com/2010/06/01/elisabeth-sussman-curator-whitney-museum-of-american-art/ came to the Hammer to discuss her work. At the age of two and a half, Eva, and her older sister were placed on the Kindertransport, http://www.kindertransport.org, going from her affluent life in Hamburg, to live with her uncle in the Netherlands. I thought that most kids on the Kindertransport went to England, but apparently, according to Elizabeth Sussman, the Hesse family used the transport to send their children to safety with relatives. A few months later, the parents joined the children and then they left for NY  to ultimately settle in Washington Heights, the home of many German refugees. At seven, Ruth Hesse, Eva’s mother, committed suicide. At eight, Eva’s father remarried.  By Ms. Sussman’s accounts, so many of Eva’s paintings reflect the dyad that she and her sister formed as they were terrified to be sent away and then re-traumatized by their mother’s suicide, and then again by their father’s remarriage (to a woman who came to be known as Eva Hesse, as well). The younger Eva Hesse, as a young adult, found her way into psychotherapy, and according to Ms. Sussman, these psychotherapy notes were given to Oberlin, for public viewing. That first therapist passed away, leading Eva to go to a second psychotherapist who, again according to Ms. Sussman, has refused to release medical records, I assume tomaintain up the privilege of confidentiality which extends after the death of the patient. Eva passed away in 1970 of a brain tumor, at the age of thirty-four.

The painting above has no faces, showing the depersonalization of the war, but perhaps it shows the depersonalization her mother felt from having to go to a life of the élite, with multiple servants and nannies, to a life of persecution, poverty and overwhelming terror. Maybe Eva never knew a warm and loving mother. Maybe she had a warm and loving nanny, but this was for a very short time. The pain in her paintings reflect deprivation; the kind of deprivation that is hard to describe with words, yet is so palpable as a feeling. The loneliness, the emptiness of the painting, might signify the hole in her existence cut so deeply by the Nazis, by how her family coped emotionally with the holocaust. Her brain tumor was tragic too, but not as tragic as the emptiness she seemed to struggle with, while living her life, when her body functioned well.

The Coach

 

 Marjorie, http://shirahvollmermd.wordpress.com/2010/09/21/45-year-old-female-single-never-married-is-something-, dreamed that she was massively disfigured, “like leprosy,” she said. “It was a nightmare,” she said, with force and dismay. “What do you think is going on?” I ask, not sure myself. “I don’t know,” she says. “Has something in your life changed?” I ask, trying to tie this nightmare to a new experience she is having. “Well, I started going to a boot camp and there is a coach there who is really helping me,” she said. With confidence, although not sure where it came from, I said firmly, “maybe having a great coach makes you look at yourself in the way that you imagine he is looking at you, and as such, you have developed a crisis of body image. In other words, you may have unconsciously projected your insecurities about your body on to your coach, and then when you are with him, you feel that he is critical of you. Then, these disturbing feelings come out at night, in your dreams.” I say, thinking that Marjorie might have developed a transference to her coach; feelings that she has experienced from authority figures of her past, she now assumes that her coach has as well.  These feelings are suppressed, until she goes to sleep, at which time, she experiences a haunting sensation. Marjorie was less enthusiastic about the elegance of this understanding than I was. She said with a dry and disturbed voice, “well, maybe, but all I know is that I can’t get this nightmare out of my head.”

Parent/Teacher Conferences

     This time of year has come; the time when parents report to me what teachers report to them. Tricia and Tom, the parents of their fifth grade student, eleven-year old Amy. The previous five years of parent/teacher conferences have been an endless barrage of negativity. She has poor focus. She has no friends. Her reading comprehension is below grade level. She cries in class and disturbs the other children. Tricia and Tom have remained calm through this barrage, asking gently, “what can we do?” Together, Tricia and Tom, took the teachers seriously. Amy received educational therapy, social skills training, individual psychotherapy, psychotropic medication and mindfulness training for children. This year, the parent/teacher conference was “boring”. Amy is doing really well. Her academics are at grade level. She has nice friends. She is happy and cheerful, almost every day. We will never know what helped Amy go from struggling academically and socially, to blossoming into a happy, healthy and successful child. Not knowing the key ingredient to Amy’s progress, even with such a positive trajectory, is strenuous. There is one thing that is clear to me; Tricia and Tom deserve a lot of credit. They were not narcissistically injured by Amy’s weaknesses. They took the emotional aspect out of it and they tried to help Amy with what they thought would be constructive interventions. In other words, they did not seem to feel shame or fear by Amy’s developmental lags; they just wanted to help her.

Zoloft

Jack,  was feeling quite depressed for a sustained period, months. I started him on Wellbutrin, along with twice a week psychotherapy, but he was still tearful, he had concentration problems, he lacked motivation to see his friends, he felt pessimistic about his future. I proposed adding Zoloft, at very low dose to his regimen. He was desperate; he agreed. The next week, I asked him “how is the Zoloft going?” He looked at me as though that were a strange question. “Gee, I have not thought about it. What am I supposed to look for? ” “Well, are you feeling worse? Are you more agitated?” I ask, trying to see if there are negative effects. “I don’t think so,” he responds with some hesitation and surprise at those questions. The following week he comes in and immediately says “I stopped that Zoloft. After you asked me the question, I have been thinking about it. I noticed that I was so agitated and even more depressed. Of course, I did not attribute those feelings to the medication, but then after our last appointment I realize that the timing was such that I was feeling more depressed and more agitated since starting the Zoloft and now that I stopped it I feel much better.” Jack says with relief that he took action which improved his mental state, at least temporarily.

Monitoring of medication is one of the most important jobs of any prescribing physician. Checking in allows both the doctor and the patient to decide if they are on the right course. Too often, medications, particularly psychotropic medications, are prescribed with multiple refills, such that the expectation is that the medication either helps or it does not help, but that observing closely for side effects is not a critical part of the intervention. Of course, when the patient and the doctor pause, observing how the medication interacts with each person’s biochemistry is going to be a unique experience and as such, no generalizations can be made. To some, Zoloft is like it says in my picture; it makes some folks more tolerable. To others, like Jack, Zoloft might be exacerbating his already disturbed mental state. The level of distress is the target; Zoloft, like all psychotropics can help, do nothing, or make it worse. It is that simple. It is also mandatory.  Checking in involves spending time and attention to the patient’s change in mental state. That is not simple, nor is it done as often as it needs to be.