The Power of Listening

 

 

https://www.google.com/webhp?source=search_app#q=school+shooting+prevented+by+talking

http://www.npr.org/templates/story/story.php?storyId=214000118

“He told me he was sorry for what he was doing. He was willing to die,” Tuff told ABC. Antoinette Tuff demonstrates the power of human connection in preventing antisocial behavior. She approached Michael Hill, an almost school shooter, with dignity and compassion, thereby preventing an enormous tragedy. Ms. Tuff gave Mr. Hill and ear, a compassionate audience, allowing Mr. Hill to reflect on his behavior before he proceeded to hurt innocent children. This story illustrates the value of human kindness in the prevention of serious human destruction. It parallels the work of psychotherapy, where human to human understanding helps people think about their behavior, rather than act impulsively. There is no checklist, or automated treatment, but rather a sense of understanding human suffering, because, as Ms. Tuff, explained to Mr. Hill, she too, has gone through hard times. This remarkable empathy led to heroism that was celebrated by President Obama. I imagine that instinctively, Ms. Tuff knew, that if she could see this 20 year old gentleman, as a man in pain, and not a horrible murderer, then she had a chance to help him. Her instincts proved right, as she was a compassionate person, believing that with a little self-revelation, she could change the course of history. It seems to me that she saw Mr. Hill as a man looking for help, but not knowing how to ask for it, and so she supplied an ear, giving him the intervention he needed, but did not know how to elicit. This story should be our model for how to help the mentally ill. They need understanding and caring, and sometimes, not all the time, this simple modality, will prevent violent behavior.

Sociopathy

 

George Vaillant MD, a Harvard Psychiatry professor, a hero of mine for many years, wrote an article, published in 1975, entitled “Sociopathy as a Human Process.” I have read and studied this article numerous times, but now, as I review for a Journal Club with my Psychiatry Residents tomorrow, I am touched by this article, yet again. Like watching a movie for the fifth time, or listening to a podcast for the second or third time, I am always stunned by what I missed in the first few exposures. The repetition brings new understanding; the hallmark of a good piece. For example, he says “in an outpatient setting the management of these disorders produces therapeutic frustration.” Somehow I did not catch the phrase “therapeutic frustration” but the two words together capture the energy put into a treatment relationship which hits up against apparent walls. Dr. Vaillant helps us to understand that these walls are not a result of the hopelessness of these patients who appear not to have a moral compass, but that these walls are a function of the deeply traumatic experiences of these patients, leading them to need a more intensive intervention than outpatient psychotherapy can provide. In essence, the tool is limited, not the patient. That’s brilliant. It is easy to  lapse into thinking that if I could just listen harder, and more thoughtfully, then I could be helpful, but in point of fact, there are patients who require a more comprehensive treatment program, in that their reluctance to outpatient treatment does not mean that they could not benefit from a therapeutic residential environment. On the one hand this is obvious, but on the other hand, the default assumption is that resistance to outpatient treatment would mean even more resistance to residential treatment. Dr. Vaillant reminds us that if we could provide a benevolent cage for sociopathic individuals, then we could help them learn from their peers about how to grow in the world, with empathy, motivation and a moral compass. His theory is that these patients lacked the family structure which helped them learn delayed gratification, and as such, they never learned to tolerate the anxiety of waiting their turn, or allowing others their point of view. Only a group environment, in which the patient has to get along with their peers will begin to help them to relate, and hence care, about their fellowship. This is brilliant again. Psychotherapy is the wrong tool. Group living, not prison, is the right tool. I do not know where one can find residential treatment for adults where the focus is on forming a functional group, but it strikes me like it is like a wilderness program, where all participants have to chip in, to survive in the woods. This would be a relatively low-cost intervention with a high yield-keeping them out of prison. The point for my residents-sometimes you have to read the old literature to know what to do in the future! Again, an obvious point that is often forgotten.

Tribute to a Peer: William Glasser MD

 

 

“Glasser was the developer of reality therapy and choice theory. His ideas, which focus on personal choice, personal responsibility and personal transformation, are considered controversial by mainstream psychiatrists, who focus instead on classifying psychiatric syndromes, and who often prescribe psychotropic medications to treat mental disorders. Glasser was also notable for applying his theories to broader social issues, such as education, management, and marriage, to name a few. Glasser notably deviated from conventional psychiatrists by warning the general public about the potential detriments caused by the profession of psychiatry in its traditional form because of the common goal to diagnose a patient with a mental illness and prescribe medications to treat the particular illness when, in fact, the patient may simply be acting out of unhappiness, not a brain disorder. Glasser advocated the consideration of mental health as a public health issue.”

 

http://en.wikipedia.org/wiki/William_Glasser

 

http://www.latimes.com/obituaries/la-me-william-glasser-20130828,0,654300.story

 

Dr. Glasser was on the ball, and yet, he was not mainstream. He and I part company about the importance of past experience, but we join forces in advocating for understanding the individual, as opposed to pushing them into a checklist. We also join forces in understanding that learning and education, like psychotherapy, come out of caring relationships, which are not suitable for metrics. We again join forces in understanding that the individual can help himself, despite overwhelming trauma and neglect, provided that he has the helping hand of caring mentors. We also agree that the environment contributes to mental health, and as such, mental health is a public health issue. Work hours, quality of education, and quality of child care, are examples in which our society can improve the mental health of large populations. I just wish he did not call his treatment “reality therapy” as that dismisses the important concept that “reality” is subjective. What would I call his therapy? “Working therapy” to imply that the work of wellness is effortful, but rewarding. This would push back the notion that there are quick fixes to deeply disturbing mental worlds. Maybe this would not be good branding, but setting expectations is a good first step.

 

 

Caring About Our Kids

http://www.latimes.com/local/la-me-foster-care-overflow-20130826,0,6981379.story

 

 

“A number of factors has exacerbated the foster bed shortage. For one, the county lacks an accurate, real-time database of foster home vacancies. The system, updated just once a month, lists the licensed capacity of a home but not the number of beds a foster parent now is willing to fill.”

 

This LA Times article, detailing the lack of foster homes available in LA County, hurts me deeply, as I ponder the implications. In particular, technology today has made tracking systems ubiquitous. We can track birds, flowers, stocks, and weather, but knowing the number of available foster beds, seems beyond our capacity. This, to me, seems like evidence of LA County’s priorities, of which our children, are not included. The system is large, but keeps failing. Yes, we do not hear about the successes, so perhaps I am being too harsh. Yet, taken together with my previous post, https://shirahvollmermd.wordpress.com/2011/12/01/shame-foster-kids-given-psychiatric-drugs-at-higher-rates/, the data mounts to suggest that LA County prioritizes other County services, at the expense of the welfare of our children. Perhaps political dollars do not float towards foster care, since these children, even when they grow up, do not present a major voting force. Advocacy is needed, as so many of these children will have mental health needs which will overwhelm the healthcare system. The more we can do to mitigate the trauma these children have already experienced, the more we can help to have a stronger society. Instead, we layer trauma over trauma for these children, leading to over-medication, and a life path which is dark and destructive. Children who require foster care deserve better. They are victims of being brought into  a world which betrays them. Then, our County warehouses them, furthering their feeling of abandonment, making an understandable feeling of deep hopelessness. How can such an affluent city let these children down? I am ashamed.

New Yorker Cartoon Contest Entry

“It is nice to be on the other side.”

“What Do You Blog About?”

 

“I blog about things that make me enraged. I blog about stories that I want to tell. I blog to go on record about all the changes in health care that I am fearful about. I blog to report on my witnessing the changes in my field, many of which I am not happy about. ” That’s what I tell people, when they ask, seeming to be surprised that I post so frequently. I blog to express myself to those who might take an interest. I have thoughts, ideas, emotions about things I read, experiences in my day, and people I see, that with the utmost caution of confidentiality, I want to share with others. I am delighted by the feedback, both public and private. I have ideas and I am interested in how others see things, as well. I am thankful that I live in a time where we have the technology that makes this communication forum easy and fun. I consider it a hobby, an activity that keeps me interested and engaged, without any expectation of commerce. Does that answer the question?

Media Consumption

 

Vivian, forty-two, stresses over what media to consume. She used to avoid television, as she was bored by most of it, but recently, she finds herself drawn to series such as ‘Mad Men,’ ‘Homeland’ and ‘Newsroom’. She also loves her podcasts which she feels give her great pleasure. On the other hand, she misses reading books, an activity that seems to have fallen away.  She says “I am just disgusted with myself that I cannot read a book,” Vivian says with such intensity that if I only listen to the tone, I would think that she did some heinous act. “I wonder why you are so mad at yourself all of the time,” I say, thinking that her preoccupation with media consumption is yet another way for her to do serious emotional self-injury. ” I just do not remember a time before where there were so many things to stay on top of,” she says, now with a sound of fear, that someone she is falling behind. “Are you frightened that you are losing touch with the younger generation, since their cultural references are so different than yours?” I ask, thinking that a part of this beratement is a result of her  realization that she is entering a new phase of life. “Yes, that is so right on,” she says with great enthusiasm. “I am just so shaken by how fast technology is changing and how hard it is to keep up,”  she says with dismay. “You sound like there will be some test at the end of the week,” I respond, pointing out that Vivian treats life like an academic challenge, where she is constantly competing to be the best, but that competition comes from a deeply insecure core.  “It must be really hard to accept all that you don’t know and  all that you can’t consume, ” hoping that she will begin to see that accepting limitations is part of an ongoing maturation. “Yes, that is hard for me, but on the other hand, wanting to stay current motivates me to explore new media,” Vivian says, reminding me that her competitive side has some benefits and it is not all about insecurity. “Yes, it would be great if you could bottle the part that propels you forward and discard the part that makes you hate yourself.” I say, trying to parse out the components of her personality.  “Maybe I will try to read a book,” Vivian says as she leaves,  as if she is winking at me to suggest that she is still on her own case.

Understanding Transformation

 

 

“Literature provides a framework for understanding this transformation. Harold Bloom, the Sterling Professor of Humanities and English at Yale University, said that Shakespeare’s characters were “free artists to themselves” in his soliloquies. As the characters self-overheard their life’s stories, they were able to take control of their narrative and change their existential trajectories, whether good or bad. Likewise, as I accumulated more experience with the physical pains associated with the non-integrated memories that resurfaced while I told my story, I was able to eventually emerge from the restraints and walk back out into the world”

Read more: http://www.psychcongress.com/blogs/eric-arauz/august-10-2013-1235pm/addressing-trauma-treatment-serious-mental-illness#ixzz2by9068Fz

Art Of Listening

 

 

 

“How is your marriage?” I ask. “We are getting new floors,” Nomi responds. “Am I supposed to make a connection?” I ask. “Well, we have been fighting about upgrading our house, and so now we are finally taking some action.” Nomi answers. “Yes, but does this tell me about your marriage?” I repeat, thinking that Nomi has reduced her marriage into winning a battle about floor coverings. “Well, I guess I am trying to say that my husband does compromise, but it takes a long time,” she says. “By compromise, you mean that you got your way?” I say, highlighting that she was pushing to spend money on home improvements and he was resistant. She laughs with acknowledgment. “I can understand that your marriage brings up such complicated feelings that you were searching for a way to capture the landscape and so you landed on your victory over the floors.” I say, helping her to see that her answer speaks to how unresolved she is about her feelings towards her mate. 

Childhood Medications: Time To Wake Up

 

http://online.wsj.com/article/SB10001424127887323477604578654130865747470.html

 

Now we have data to support my long-running rant that many child psychiatrists, working in community settings, are prescribing antipsychotics to children, not because they are psychotic, but because they are angry, traumatized and very difficult to manage. This is an “off-label” use of medications as these medications are not indicated to control difficult behavior, but as a side effect, they do help kids and adults calm down. The disparity among the privately insured versus the publicly funded children could be explained by the fact that these two populations have very different mental health issues. Generally speaking, publicly funded children have more social stressors, and hence they have more traumatic experiences in which they have to deal with, often with a limited environment that does not give them the opportunity to discover the language of feelings and hardship. Plus, many of the children in foster care need to stay in foster care, so there is a strong push to use all available tools to prevent a child from yet, another traumatic transition. Still, to get these medications, there is a doctor prescribing them, and this is where I want to focus. Child psychiatrists are often hired out of training, where they have been primed to think about how psychotropic medications impact children. They need jobs out of training and community jobs both provide employment, but also an opportunity to serve the under-served. Yet, when these young physicians land in their first job, they are confronted with an ethical dilemma. The staff at these agencies want these kids to calm down. Atypical antipsychotics can do this. For a short time, an atypical could calm down a tough situation, and so that might make sense. The problem is that this “short time” becomes year after year, and placement after placement, leaving these children in a compromised mental space. These atypicals dull thinking, and cause the metabolic syndrome, meaning truncal weight gain, and a high likelihood of type II diabetes. So, do we deal with the short-term crisis of aggressive behavior, or do we think more long-term about the exposure to detrimental side-effects? I think we need to understand these children, as most of them falling under the umbrella of trauma, and as such, they need to cope with their trauma through understanding and modeling. Psychotropics present short-term gain, for long-term pain. It is not worth it. Child Psychiatrists should use this data as a point of advocacy. We have to be part of the solution, not the problem.