“I Want Someone In My Life I Can Call When I Go To Trader Joe’s”

Thais, https://shirahvollmermd.wordpress.com/2012/02/22/i-should-have-had-a-manicure/ bemoans the fact that “no one cares about me.” I raise my hand in opposition. “Well, yea, but I mean, I want someone in my life I can call when I go to Trader Joe’s. I want someone to be in my orbit.” I paused to understand her loneliness. I began to see the need to chat about little things, like finding the frozen food or the irritating person ahead of her in line, and that without someone who cares about those things, life can feel so empty, so deserted. As another patient said to me, “no one really cares if I had trouble finding a parking space and that makes me sad.” The sweetness in wanting to exchange life’s little annoyances is so touching, and the lack of a village in which to do that, is so exquisitely painful. Sometimes I wonder if social media, the constant postings on Facebook or Twitter, serves this need-creates this village. Most people need to be heard, not just about the life-changing events of death, divorce or a new job, but more often, for the small, everyday experiences of living life. Thais did not say anything that I had not pondered before, but I was impressed that she was in touch with what was missing in her life. She understood where the hole is, and as such, she knows what she is looking for in a relationship. In the past, Thais would say she wanted “better friends,” but the vagueness of this comment did not articulate what exactly she felt was missing in her life. As she matures, she sees how relationships, both male and female, help her cope with life’s challenges. She no longer “needs friends” in order to be in the “right group,” as she had felt in the past. Now, she needs friends to share her experiences. This is a sea change, and yet subtle at the same time. It is a sea change because she is looking for more depth in relationships. It is subtle because she wants what we all want: she wants to be heard.

The OBGyn Finds High Cholesterol: Now What?

Continuing on our discussion about referrals, https://shirahvollmermd.wordpress.com/2010/07/07/the-referral/ and https://shirahvollmermd.wordpress.com/2012/02/27/why-dont-pediatricians-refer-to-child-psychiatrists/, Olivia, seventy-two, presents to me for issues of depression and anxiety. In the course of thorough history taking, we review her medical problems. She is remarkably healthy, absent major medical issues and she is trim and fit and active with a good energy level. We review her treating physicians. Dr. Lesley Lee, a prominent female OBGyn in the community has followed her for years for routine gynecological examinations. Twenty years ago, Dr. Lee noticed on the laboratory tests that her fasting cholesterol was high so Dr. Lee referred her to Dr. Jay, a prominent female cardiologist. “Why did Dr. Lee send you to a cardiologist?” I asked, shocked that Dr. Lee did not send Olivia to a primary care physician. “Well, I don’t know, that is just who she sent me to,” Olivia replies, indicating that she never considered this question before. “Do you have a primary care physician?” I ask, trying to mute my concern for this referral pattern. “No, I did not think I needed one,” Olivia replies, again, seemingly disturbed that I am intruding on her medical issues. Over time, we discuss the importance of primary care and over time, Olivia agrees to go to a primary care doctor that her friend raves about.

I am left to imagine why Dr. Lee sent Olivia to the cardiologist, Dr. Jay. Both physicians are female. Maybe they are friends. Maybe they go to female networking breakfasts. Beyond that, I cannot imagine why a healthy woman, with the only abnormality being an elevated cholesterol should not be referred to a primary care physician, so that diet, exercise, and maybe statins can be discussed in the treatment plan. Clearly a primary care physician can screen for heart disease, diabetes and other metabolic issues. The public health aspect of this referral also concerns me. Dr. Jay as a cardiologist needs to spend her precious time on those who need specialty care, not on those who can be handled by Internists of Family Medicine physicians. Are we, as physicians, not obligated to be concerned about how we use our resources in the best possible way, not just for the patient, but for the population as well? Sometimes, I feel so old-fashioned. Still, old ideas are not necessarily bad ones, as I have said many times.

What can I do? I ask myself. I can try to persuade Olivia to develop a relationship with a primary care doctor. Yep, I did that. Should I call Dr. Lee and discuss my issue with her? I don’t think so. I don’t have a relationship with Dr. Lee and I am not sure I know how to make that call without making her defensive. Should I call Dr. Jay and discuss my issue with her? Again, without a personal relationship, I only stand to make her angry and upset. So, this post serves as my outlet for my discontent. Thanks readers for allowing me to vent.

Why Don’t Pediatricians Refer to Child Psychiatrists?

Neal, thirty-two, a long-term patient of mine is concerned about his five-year old daughter who is having behavior problems in kindergarten. He and his wife are told by the school that she is uncooperative at school and that she needs to be “evaluated.” Neal and Sophie, his wife, take Chelsea, his daughter to Dr. Firth, their highly regarded Westside pediatrician. Dr. Firth, hearing the concerns from the parents, advises Neal and Sophie to take Chelsea to an occupational therapist. The occupational therapist evaluates Chelsea and she tells Neal and Sophie to take Chelsea to an optometrist because she seems to be having “balance issues”. My heart is having palpitations. “Maybe you should consult a child development specialist or a child psychiatrist,” I suggest, hoping that Neal does not feel that I am dismissing Dr. Firth. “Well, I know you see kids,” he says, “but my wife and I associate you with medication and there is no way that we want to put Chelsea on medication.” Again, I pause in distress. “Chelsea needs an evaluation, so it is no way clear whether medication in on the table or not. First thing is first.” I say, reminded that in these days, people only think of child psychiatrists as “medication doctors” and they forget that their expertise is also in assessment. I think about Dr. Firth. Why did he refer Chelsea to an occupational therapist when the report from the teachers was that she was having behavior problems. Should I call the pediatrician and ask him? Of course, I could not do that without both Neal and Sophie’s permission. Why did Dr. Firth not think of referring Chelsea to a child psychiatrist? I really wish I knew the answer to that question. My hunch is that Dr. Firth has a professional relationship with this particular occupational therapist and that he is not aware of the variety of professionals who do  mental health assessments for children, even though he is a well established pediatrician. On the one hand, if what I am suspecting is true, it is unbelievable. On the other hand, if what I am suspecting is true, then Child Psychiatrists have done a poor job of marketing their talents. Maybe both are true.

Talkin’ To Teachers

Sometimes I have the pleasure of going to a high school to talk to teachers about ADHD. This fictionalized story illustrates a moment which made me pause. During the lunch session that I had with teachers, one teacher told me about a student who was hyperactive, although not severely, causing this teacher to pause in her discussion. When I inquired if she had told the parents about this student, she said I did not want to  “worry them”. She made me realize that when a teacher reports a behavior to parents, they are faced with the uncertainty of how these parents will react. Some might get extremely anxious, and some might get angry. There is always the fear of the “kill the messenger” response. I never really thought before as to why teachers may not be communicating to parents about the concerns they have in their students. In the past, I had attributed poor communication to the fact that the teacher had too many students, or that the teacher was unaware of what was going on in the classroom. Now, I realize that teachers, like therapists, are faced with the sensitivity of parents who cringe at the idea that their child may not be “normal”. No one wants to make a parent cringe. We all would rather have a narcissistic festival where the teacher and the student are thriving in this academic environment that we call school. A “problem” in that environment opens the discussion to a blame game, where the injured, in this case the parents, might throw the blame away from their child and on to the school. Sometimes, of course, the parents may appropriately assess that the school is failing their child. Other times, though, the parents are blaming the school, blaming the teacher, as a way of avoiding dealing with the problems in their child. It is obvious that everyone benefits from open communication and parents should be told when their child is a behavior problem in the classroom. It is now also obvious to me, another reason this open communication may be inhibited. As I said, it is a pleasure talking to teachers.

‘I Should Have Had A Manicure’

Thais, twenty-one, says “I should have had a manicure,” referring to her drunken stupor last evening. “The guy I liked was flirting with another girl, and I felt terrible, so I wish I had done something nice to myself instead of drinking too much,” Thais continues. “I like the fact that you can reflect on your behavior and see how you might handle that difficult situation in the future. That shows tremendous growth and development. I can see how your feelings were hurt and that you needed to numb them with alcohol, but I also hear that you can also deal with hurt feelings by being especially nice to yourself.” I say, reinforcing how much Thais has progressed in her thinking and reflection over her self-destructive behaviors. Sometimes, psychotherapy is so hopeful.

Familial Mental Illness: The Anxiety of Genetics

Joseph, fifty-two, has bipolar disorder, as does his brother, his mother and his maternal grandmother. His daughter, Elsa, age six, has some really bad temper tantrums and he is worried, I mean really worried, that Elsa also has bipolar disorder. “I just can’t sleep at night. Every time she gets upset I am asking myself if this is normal, or if this is the beginning of this dreaded disease.” Joseph says with terror in his voice. “We will have to keep an eye on Elsa and see how she handles stress,” I say, stating that I understand his fears, but it is premature to say that Elsa has bipolar disease. Dealing with Joseph’s anxiety is now my focus, although I also see the importance of monitoring Elsa’s behavior. I feel for Joseph in his fear that he has transmitted his illness, however unwillingly, to his daughter. There is this sense that Joseph would feel responsible for this genetic transmission, which although is not rational, I understand. My job is to help Joseph cope with  and his fear of Elsa’s future. Worrying about his daughter is sweet and concerning in one way, but if it exceeds his ability to enjoy her, can be detrimental to her development. Joseph and I look together for that sweet spot of concern without negativity. It is a challenge.

The Holding Environment: Chicken Style

The French Art of Saying “No”: The Holding Environment-The French Way

Pamela Druckerman captures Winnicott’s holding environment concept well, as she describes how French parents are comfortable saying “no” to their children and thereby giving them the containment which is necessary for self-confidence and a feeling of internal security. In our overly child-centered culture, “kindergarchy” creates kids that are prone to anxiety because they do not know where the limits are. Knowing that the authority figures, the parents, are setting a frame, allows the child to have boundaries in which he/she can push up against in order to form a strong personality foundation. Without limits, anxiety can set in, causing the child to feel insecure and inhibited in their world. This insecurity, in turn, causes the child to miss out on experiences which could enhance his self-esteem. Old ways of parenting are not necessarily bad, and new ways are not necessarily good. No matter how much we know that, our brains tilt towards wanting to believe that new is somehow improved, and that old is outdated. In the case of parenting, Ms. Druckerman reminds us, by looking at French culture, that parental authority for young children, when done lovingly and consistently, is a good thing. I support that.  

 

http://online.wsj.com/article/SB10001424052970204740904577196931457473816.html

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The Anxious Kid/The Disorganized Mom-Chicken or Egg?

   Leanne, fifty-one, is always confusing appointments, losing pieces of paper, and is in general a very disorganized person and a disorganized mom. Lesley, her twelve-year old daughter, feels she can’t count on her mom to follow-through in a timely fashion on scheduling doctor visits, or picking up things she needs so that she can be in the school play. Lesley compensates for Leanne’s unreliability by making a multitude of lists in which she tracks what needs to get done. At the same time, Lesley is constantly in a state of anxiety in which she is worried that she will not complete her task list. Lesley’s dad has suggested that she take medication for her anxiety. I question Lesley, “do you think you would be so anxious if your mom was more organized?” I wondered if Leanne’s unreliability made Lesley feel fearful that so much of the responsibility of moving forward in her life now fell on Lesley since her mom was not providing a safety net for her. In other words, the maternal role for an adolescent child is in large measure the job of making sure that the teenager can go to their various activities and that they have the right supplies. Without this infrastructure, teenagers are going to be impaired in their ability to engage in multiple life experiences.

 Lack of reliability can create anxiety in someone who is dependent on them. That is straightforward. Am I “blaming” Leanne for Lesley’s mental state, or am I understanding what Lesley is up against? Am I stepping on the therapist’s toes, by suggesting that the more Lesley understands that she is anxious because her mom is disorganized, the better Lesley will be able to cope with the demands of her life. The nature/nurture debate continues. Lesley is probably wired to tilt towards anxiety-an internalizer as we say. Her environment exacerbates her condition. She can learn coping skills and she can probably also benefit from medication. This is not a binary system. Yet, our brains wish for binary. We want answer, and sometimes that answer is medication. Multiple answers are usually harder to grasp, especially in crisis. Staying broad-minded is the goal. Lesley is going to do well. She needs help understanding her mom and her mom’s frailties, and she also needs help understanding the vulnerability in her brain to be anxious. She is up for both of those tasks. So, chicken/egg, does not matter.

The Interpretation

  “You are feeling terror because my comment about how you self-sabotage relationships reminds you of how your mom criticized you for having your own thoughts,” I say, giving what psychoanalysts call a “genetic interpretation” because I am talking about how the past is bringing up the present. On the one hand, the patient, in this case, Sarah from my previous post https://shirahvollmermd.wordpress.com/2012/02/14/hate-me-now-love-me-later/ , got angry with the idea that I was not taking responsibility for my actions, but rather I was shifting the “blame” to her mother. On the other hand, this kind of comment provides an opportunity for reflection to see how expectations from authority figures stems from one’s early experiences with his/her caretakers.

The word “interpretation” has always annoyed me in its’ implied certainty. The word sounds too much like a decree or a diagnosis. I prefer the term “thought balloon” to suggest that my comment is an idea, something to chew on, as a way of understanding the influence of the past on the present. Sarah came to see how her relationship with her mom made her fearful of criticism, in that her mom would tell her how her ideas, thoughts, preferences were “wrong”. Consequently, when she gets feedback from others in authority, including her prior teachers and her current boss, she immediately feels like her character is being assassinated and so she becomes defensive. My interpretations have allowed her to reflect on how she confuses feedback with criticism. Hence, interpreting, or explaining my perception of her internal process, is an agent of therapeutic change. Although annoyed by the word, the concept of interpretation is my antibiotic: it can eradicate the disease.