Is There An App for Stress?

 

 

http://www.latimes.com/world/asia/la-fg-india-mental-health-20150819-story.html

 

Using a mobile application to help with stress? Very exciting. Anyone in the world with a smart phone can tap into a fund of knowledge that reminds him the value of self-care. Many of my readers might be shocked at my enthusiasm for this technology because there is no doctor/patient relationship to bring about hope and lasting change. Yet, I am excited about these applications because there is no pretense of a relationship. Unlike my issue with short-term, cookbook therapies (the Ts, as I call them), which has a person serve the role of therapist, but in fact, their role is one of “facilitator”, in the case of using a mobile app, the patient knows there is no human interaction. The patient is not teased with a relationship which could help them, only to be told after six to twelve sessions that they are “better” or “not better, but either way the care must be transitioned away from that dyad. I see these mobile apps as the modern-day “self-help” book, as the person knows they need a reminder about what they probably already know, but reading it, on the screen or in print, penetrates their defenses enough to facilitate change, and maybe to inspire deeper work with a psychotherapist, one day. Some innovations in mental health care are exciting and game changing. These mobile apps hold that promise.

Hidden Pain

Pain, at least the pain that I deal with, is mostly hidden; hidden from others, and, at times, hidden from the patient having the pain. The trappings of a good life, food, shelter, friends, careers,  do not speak to the internal world of anxiety and insecurity which plague people, resulting in the inevitable shock when that person “throws his life away” by picking harmful relationships and/or spiraling down into substance abuse. The surprise is not that the person has given up all that he has worked for, the surprise is that no one saw it coming; or at least no one said they saw it coming. Steely, twenty-year old female, comes to mind. Her family is “good” meaning that her parents work hard and they have a nice house. Her older sister is a physician and “doing well” by Steely’s account. Steely, on the other hand, has painful memories of her father hitting her mother and her mother hitting her father, in return. Although her sister seemed to “not care” this was happening, Steely felt like she lead a double life; the life her friends thought she had and the life she actually lived. She could not disclose her parents’ behavior because that would shame her whole family. She was alone and isolated in her fears and her confusion. “Why would people who are married hurt each other like that?” She would ask herself, but have no answer. As a result, Steely learned not to trust anyone and so she led a double life. She pretended to care about her friends, while at the same time, she kept herself at arm’s distance. As time went on, Steely dropped out of college, chose a series of “loser boyfriends” and to the surprise of her family, she has no future plans. Steely feels, as she reports to me, that witnessing her parents be physically and emotionally abusive to one another has left permanent scars of distrust and pessimism. “Life is never what it seems,” she says, with a coldness that is penetrating. Working with her inner pain, with her history of childhood trauma, is the beginning of unraveling her double life, and making it a single, honest life, with deep struggles and confusion. The unfolding honesty of her childhood is a healing step, even though the harsh reality does not change. Once again, the power of listening deeply allows for a beginning to the journey of creating a cohesive narrative, and in so doing the beginning of healing.

When Your Father Is A Bully

 

What happens when your father is a bully? Does this mean that you will be bullied on the playground? Or, does this mean you live a life fearful of humiliation? Or, does this mean that fear dominates your existence such that your imagination is killed? These are the questions I ask myself as I think about Sue, thirty-three who is timid and fragmented in her thinking. Her problem solving skills are limited. She constantly tells me that she has few choices in her life, but looking from the outside it seems she has more opportunities than most people will ever have. The father-bully is a particular kind of child abuse which, on the one hand is subtle, in that there is no evidence to anyone, other than her mother, that this abuse is taking place. On the other hand, the father-bully makes it clear that Sue has no mind of her own, and she must do what father-bully demands of her. As a result, Sue, not only feels inhibited, she has no idea what she feels inhibited from doing, because she has never nurtured her mind to see what ideas pop in. It is sad, but there is hope that Sue can come to understand this obstacle to her growth and then get past it.

Should Society Expect More From Mothers Than Fathers?

Mom changes her name to Ricki, leaves her children, moves to California from Indiana, and plays in a rock band, making little money and has  little fame. Her children are deeply hurt. Her ex-husband remarries a woman who the children now consider their mom. She is called back to her adult children when one of them has an emotional crisis. The story unfolds from there. Ricki is filled with guilt and shame over her behavior and as a result is inclined to withdraw, but at the same time, she feels the pull to help out her children. Her children, both angry and grateful that she has come to help, give her painful mixed messages. Her ex-husband still seems to love her, and so he too, is filled with mixed and painful feelings. What is amazing about this movie is how Meryl Streep portrays the complicated and contradictory feelings, leaving me, the audience member, feeling as much for her, as I do for her innocent children who suffered from maternal abandonment. It is hard to “show up” for your children in ways that are meaningful, but it is even harder to do that after you have hurt them deeply. To face the damage she has done, while at the same time, attempt to repair a small piece of it, is the torment of this movie. Should Ricki never see her children again to spare herself and her children the complicated nature of hurt and forgiveness? Or, should she attempt to “mother” them despite the years and years she missed as they grew and developed into adults? These are difficult waters to navigate. The more primitive side of Ricki wants to stay away and say she has no money to see her children. The more sophisticated side of Ricki knows that where there is a will, there is a way, and so she can show up for them, in the way that she knows how to. Every parent can relate to the judgmental comment of, “how could a mother do that,” knowing the inherent gender disparity of that statement. Mothers can be hurt people who hurt their children and mothers can want to repair that. Embracing the complexity of that repair is the beauty of Meryl Streep’s acting. In the end, no one feels good, and that is not the goal. Less bad is “good enough” and after all, “good enough” is all any parent can hope for.

Specialty Certifications

 

Addiction Medicine, eating disorders, geriatric, child, psychoanalysis all suggest additional psychiatric training and yet the meaning of each certification is very different. There is an addiction medicine board which requires one year in an addiction medicine fellowship, followed by an examination with an 87% pass rate, and if you have worked in the field, that can count as your fellowship. With eating disorders, there is no board examination, but there are letters one can get after one’s name which says they are “certified” to treat eating disorders. Geriatric and child boards both imply a 1-2 year fellowship program along with a board examination. Yet, how much of this extra training is necessary, versus learning about these areas on the job? I am a board certified psychiatrist and I am a psychoanalyst. I do carry a bias that these two areas of extra training has widened my scope of practice and has given me the tools and the confidence to treat all patients, from cradle to grave. At the same time, I now work in the addiction world, and I also feel confident that my skill set is very useful there, and that I could sit for the addiction boards, but I am not sure I see the point. Would my colleagues respect me for it? Maybe. Is this worth the time and expense for board preparation? Maybe. Would my work with my substance abuse patients be more insightful, if I disciplined myself to study for this exam? Maybe. Typically, I am up for the challenge of a new certificate. I enjoy learning new things and I appreciate the neuronal stimulation this activity would give me. On the other hand, after 25 years in practice, I feel confident in my skill set and I see addiction, as with all of the human condition, as part of the self-destructive behaviors which in the short-term alleviate pain, but in the long-term create misery and hopelessness for the patient and for those around him. That argument is not very compelling. Knowledge is helpful and deepening my understanding of addiction is crucial to helping my patients. I think I should go for it.

Hurt People, Hurt People

cliché?  Maybe. One of my favorites, though. A strong reminder that the aggressor has been a victim, giving compassion for the perpetrator. The movie “The End Of the Tour” chronicles the last four days of David Foster Wallace’s book tour. More to the point, the movie is a 4 day “affair” between the reporter, David Lipsky and the highly acclaimed author. Like “Bridges of Madison County,” in a short time frame, a connection is made which lasts a lifetime. David Foster Wallace and David Lipsky struggle to bond, while fearing what the other thinks. The rivalry is intense. David Lipsky wants to be David Foster Wallace. David Foster Wallace finds no joy in being David Foster Wallace, but he understands that he is being envied. When two women enter into the story, the tensions mount. David Foster Wallace feels betrayed by David Lipsky’s flirtatiousness, and he lashes out, resulting in a mute stand-off, where the silent treatment is felt with intense pain. Hurt people, hurt people, I kept thinking. David Foster Wallace was hurt because this woman was an ex-girlfriend. He was clearly still hurting from that. David Lipsky was struggling with his relationship, back home. He was hurting too. His unconscious flirtation hurt David Foster Wallace, but this was a result of David Lipsky’s loneliness and insecurity. Ultimately, ten years later, David Foster Wallace commits suicide. He was hurt, and so were many of his fans, including David Lipsky.

Should Eating Disordered Patients Know Their Weight?

Doctors weigh their patients. Patients own their charts. For some sensitive people, knowing their weight is a trigger to disordered eating. As such, should doctors not weigh patients who could be prompted to re-start their disorder, or should doctors make a point of weighing eating disordered patients as a way of desensitizing them about weight? Once again, there is no answer, only strongly held beliefs which get promoted by “experts”. My opinion: the doctor should obtain consent for weighing the patient so that the patient can take control of his or her mental health. Blood tests, although certainly more expensive than weight checks, can give health information and so obtaining weight is not critical to medical care for these patients. On the other hand, eating disordered patients do need to heal and accept themselves and that includes accepting their weight. However, in the course of the illness, patients may be too sensitive to deal with their weight and so it might make more sense to avoid that trigger, if possible. Should the psychotherapist inform the primary care doctor about whether to weigh the patient? Maybe, but I would prefer that the therapist work with the patient directly so that the patient can inform the physician about whether it makes sense to be weighed. After all, eating disorders are so often about control, returning control to the patient, in big ways and in small ways, is a major step of healing the disorder, in that the more control the patient has in his life, the less important it is to control eating. Like all self-abusive behaviors, we have no clear path of intervention. We have to use our best guess. That is the state of the art. Big data does not help us here. I can live with that.

See Saw Of Life

Unconscious Prejudice: Freud Lives

 

http://www.scpr.org/news/2015/03/09/50259/police-agencies-line-up-to-learn-about-unconscious/

http://www.pbs.org/newshour/bb/biases-back-mind-affect-feel-race/

 

We treat people differently based on reasons we would adamantly deny. We live lives of contradiction and confusion. The one slight benefit to all of these racially based shootings is that we can now acknowledge that, although we do not like to admit it, first impressions cause us to make conscious and unconscious assumptions about people, which cause us to act, at times, in unkind, and hostile ways. The story in this report of a white mother with her African American son who is slowly crawling out of anesthesia, where she sees her son as scared, and the staff see him as threatening. This disparity, clearly racially driven, highlights the notion that, under stress we work off assumptions which may have historical value, but in the current context is inappropriate. The staff perceived this young man’s anxiety as potentially violent, because in their minds, agitation could result in aggression, whereas if he were female, and/or white, they may have been inclined to try to soothe, as opposed to ignoring and avoiding. The bad news is not about unconscious assumptions, since we are all “guilty” of that, but the bad news is that we, as a society, deny that we behave that way. It is only with the advent of hand-held video cameras can we begin to penetrate this denial, and say, hey, the person in authority reacted out of proportion to the situation at hand. Let’s be honest that we have prejudice, which is rooted deeply within us. Then, we can attack the problem. Otherwise, we repeat. Geez. It sounds a lot like psychotherapy. Freud lives. Here is our “evidence”.