Wednesday, February 27, 2008

War is Agressive

I know we're doing what we can to end the war in Iraq.

Last week I listened to the news and puttered in the kitchen while FD attended the synagogue in the morning. He attends every day. When he came home for breakfast all smiles, I reconsidered telling him. But a couple of minutes later I solemnly reported, "Three boys were killed in a bomb this morning in Iraq."

He groaned. I groaned. We hate hearing about boys killed anywhere.

Then the very next morning he came home from shul and said, "You know those three boys you told me about, the ones killed in Iraq? One of them belonged to our synagogue."

That first degree of separation. The funeral was yesterday, at our shul, but we couldn't go.

I wasn't going to tell you this, but I'm out of the country. I took off for Switzerland on Sunday, left Dov and Cham to watch my fish. There's a lot to say about Switzerland, but it's peaceful and pleasant there, so it can wait.

What I want to tell you about is what it's like living in Israel, now that we have this peace with the Palestinians. For as you may know, we gave up a significant stretch of land for peace relatively recently, a long stretch of beach property, a place called Gaza. Jews left their homes and their synagogues in Gaza and now live in tents because, as you must know, this is a step in the right direction, a step for peace. Yes, read the sarcasm. You don't need an interpreter.

No, this is not a political blog. And I had no intention of posting about my trip while away, certainly no intention to talk Israeli politics with you. I had several drafts in Blogger to pick and choose from that I could have posted instead of this.

I did post one this morning, ironically, about determining when to be passive, when to be assertive, when to be aggressive. And now I see that here in Israel, that is exactly what needs to be determined.

Why not just tell the story? Because I'm in a bad mood, and that's never a good thing. But I want you to think about this passive, assertive, aggressive thing. Assertiveness, speaking just the facts, has always been my default.

We have a son learning in a yeshiva in the south of Israel, not terribly far from Gaza. Gaza, the land the Israeli's gave the Palestinians for their very own last year, is where Hamas takes credit, although sometimes competes with Hezbollah for credit, for shooting rockets into Israel. These rockets, Kassams, are fired every day. Thousands of rockets a year. We don't have this problem in America. If the Canadians shot Kassams at us, or if the Mexicans shot Kassams at us, there would be some explaining to do.

At the very least, some asserting, at worst, some aggressing.

When they take out an Israeli citizen here in Israel, the terrorist organizations cheer. I think of Hamas and Hezbollah as gang-bangers, but instead of using pistols they use rockets.

The story.

We picked up our littlest (19) at his school yesterday and shlepped him up to his aunt's apartment in a town north of Tel Aviv, where we'll be staying for a couple of days. We took him out for dinner and caught up, and this morning, after a great pancake breakfast that my sister-in-law had no right to make us, since this is a work day for her, took off in my nephew's Fiat. Little One had to get back to school.

Well, he didn't have to get back, but that's the kind of kid he is. We'll steal him back soon enough for a little more vacation.

Anyway, he's a kid and you have to feed them regularly, so on our way back to his school out in the country, we stopped in one of the coastal cities for a slice of pizza. We carried out the food to eat in the car, a bit in a hurry to get back in time for afternoon prayers. You have no idea what it's like, constantly having to be back for the praying.

No sooner had we turned onto the highway when we realized we were going nowhere. Nowhere. Cars were backed up EVERYWHERE. This didn't feel good, sitting in traffic. And for some reason my nephew does not keep his radio in his car (something tells me he worries it will be stolen). It's a scaled-down five-speed, a stick shift, white, like all the cars in Israel. Did I say stick shift? One day remind me to tell you what I do to clutches. Not pretty.

Anyway, we sat in traffic for about an hour when we finally made it to an intersection and could turn off the main highway. FD gunned the motor to get us anywhere but there. At the next intersection, same thing. Another parking lot of cars, all idling, nowhere to go. He started driving in the only direction that didn't have traffic, towards the coast.

Fine, fine. The coast is safe, but you can't just go ANYWHERE in Israel. Anywhere isn't necessarily safe. He drove south a bit (toward Ashkelon and Gaza) and I nagged him, Let's not end up in Gaza, PLEASE. I can assert with the best of them.

He turned around and headed north towards Tel Aviv, then found a stretch west to my son's school, and then south again, and eventually we dropped him off, safe and sound.

The highway we would have ordinarily taken back to FD's sister's apartment was cut-off to the south at this point, but we were going north. We still had no idea why everything had shut down. With me behind the wheel now, and heading away from whatever was going on, it didn't take long to get back home.

I'm not going out again, I told him. I'm in for the night. FD drove off to see another nephew. He's borrowing my nephew's piano for a gig in Israel. Incredible, that.

My brother-in-law is cooking and I ask for help. He says, Not now, and I'm out of there! The t.v. and the elyptical machine are free! In a better mood already, I flip through channels and find a movie in English with Hebrew subtitles, something about a mule and basketball and Chicago. I'm really pumped. Just as I'm getting into a groove b-i-l steps into the room.

Uh, can I turn on the news? There were 40 rockets landing in Sederot this afternoon. At least one person is dead. That's why you were delayed. All the traffic south, didn't go anywhere. You were right there, you know.

Well, not right there, at all. But the range of these rockets seems to get longer and longer.

I watched the news. If you've never seen footage of a decent explosion, how the walls and ceilings cave in and people bleed and sirens sound and people cry, and if you've never seen missiles take off into the sky in pillars of smoke through the clouds, well, you've missed out, I suppose, assuming you like this sort of thing.

WHY? I ask the chef.

He tells me that the police had stopped a car of terrorists at the border this morning with explosives and killed all of them. The 40 kassam rockets, this mess, these casualties, these deaths, are revenge.

The Israelis have to decide, although it's likely they've already decided, do they reciprocate in kind? The chef turns to me and says, almost tearfully, because here life is so precious, each life:
We give them land and from this land they shoot rockets at our hospitals. We never turn down anyone in a hospital, no Arab, no Jew, no one (the insurance issue isn't like it is in the U.S.) But they shoot missiles at our hospitals. They shouldn't even show this footage (we are looking at the wreckage of a cafeteria outside the hospital at Sederot, the Israeli city nearest to Gaza).

They cheer in the streets, celebrate. They LIKE to see this. They don't care about human life. We treat their wounds. They shoot rockets at us. We should retaliate. We wait like sheep for these attacks. We stop them at our borders with explosives, and kill them before they murder us. Then it is an excuse for them to try to kill us again.

For them, it's a win-win situation. If we don't kill them, they blow us up. If we do kill them, they fire missiles and hope to kill us.


Always a problem. Passive? Assertive? or Aggressive? The Israelis have never gone after Palestinians in the past, knowing they would kill innocent civilians. They won't start now. The kassams are fired from civilian neighborhoods. They don't send missiles into civilian neighborhoods.

What's a country to do?

therapydoc

Tuesday, February 26, 2008

Asserting at the Bar: The Con

Maybe it happened to you. You were conned out of money but you never quite could forget about it. This happens in drug transactions all of the time.

A dealer sees a guy seeking drugs and asks, Looking for something? I've got something.

He brings you to a bar and the bartender is amazingly nice, knows the dealer. She gives you free drinks. You're starting to enjoy yourself.

The dealer defines the drug deal, asks you for money so he can get you your drugs. You tell yourself, Don't do this. Your rule is, always get the drugs first, THEN pay. But he insists on money up front and you're drunk, so you give him the money with that funny feeling that you've been duped.

And you never see him again.

Until one day you do. You're at a bar and he's there.

What do you do? Ah, such a marvelous variation on assertiveness. You don't always find such examples in the literature, do you?

So seriously. What do you do?

You're thinking,

Do I deck him? Do I talk to him? Do I say nothing? Do I run?
Do I make small talk? Can't I deck him?
Don't look at me. I don't know. I'm serious in that I don't know. I should say, NO, of course you don't hurt him, you don't hurt anyone, but there are some places where people do aggress and they seem to gain respect for aggression. Sure, they're gang-bangers, but perhaps that's the culture we're in right now, in this example.

But let's say you don't want to be in that culture, that perhaps although you've been conned, you've been done wrong, you're a little reluctant to act as they act, to do as they do. Should you say something?

Ordinarily the therapeutic directive would be a resounding YES! Be assertive! Sure you should say something, perhaps something meaningful that teaches a lesson, as in, I know you conned me once, but FYO, I'm a nice guy and I won't risk going to jail to punish you for that. But the next guy might, so you should clean up your act, get a real job.

But I feel that in that case, if you say that, you might get decked. It's a dangerous thing, dealing with dangerous people. Assertiveness isn't the law everywhere, and it's not understood everywhere.

So just as I've suggested before, that you don't tell a big scary guy who cuts in front of you while you're in line waiting for a show, Excuse me, sir, but I'll bet you didn't know that the end of the line is actually back there (pointing to the end of the line), likewise I would suggest, Don't start with a drug dealer.

And why are we dealing with drug dealers, again?


therapydoc

Friday, February 22, 2008

Constructive Criticism

Most of the time I post your comments.

But what would you do if you got this one?

No need to post this, Mom -- but you know what you should never do? Write a lengthy, complicated piece about how complex an issue is... and then make a blanket, black-and-white statement along the lines of "no guns, no killing." You would hate if someone simplified the NIU tragedy, by saying people with schizophrenia are dangerous, so they should all be locked up. Why simplify it for your own political views?

Love ya!
Well, needless to say, the comment didn't make the cut. But we talked, and he explained that he liked the post, but that my adding a political view (about which you really don't know much, Mom) took away from the substance, the subject, which should have remained mental illness.

And he's totally right. I don't know all that much about gun control as a political issue. And you can get the gun control pitch in a thousand other places. You're not here for that.

Generally I look to my kids for advice. I figure, I'm old. They're young. I'm lost in a sea of issues and problems and threads that can take me virtually anywhere. If I stay on one topic in a post it's a minor miracle.

But it can sting when they lay into me, you know, and like most people, I can be a little sensitive. Still, it's good to get constructive criticism and I'm glad that my kids feel they have permission to dish it out. If you make it through a doctoral program you can make it through virutally any kind of criticism. Profs are vicious in graduate school.

So it's not hard to step back, think about it, accept/reject/thank/regroup.

You know that process, right?

Someone criticizes you. It's constructive (but of course). You have to listen to it because you're all grown up. You ponder, try not to be defensive. You hem/haw. You might tell it over to a friend, a relative. Your therapist.

(You might BLOG on it and tell half the world).

Then you get to the accepting or rejecting phase, which shouldn't happen within the first few minutes of receiving. It's a thoughtful process. You accept what's good about the criticism, possibly after clarifying what the sender meant by checking it out with the sender.

And you reject what you don't like.

You thank the sender. After all, much of what others have to say really is interesting, if not always constructive, and people don't usually mean any harm. Not your friends. Not your family. (Okay, so some people do, it's true, but they can't help it.)

But at the end of the day, you regroup. You get back your sense of self. You determine it's a good idea to change, or that you're fine the way you are. You regroup and in the process, you grow. It's a gift when someone helps you do that, especially if they can do it in a nice way.

An even finer gift to be able to take it.

So okay. He's right. The post on schizophrenia (differential diagnosis) was a strong post. It didn't need that bit about guns. And for all we know, reading it upset NRA members who read the blog! Who knows? Perhaps Republicans or Democrats, even Libertarians! As a conflict avoider (default position), that's the last thing I'd ever want to do.

But here's the catch. Now, I've got to respond to his comment. Let's do it in a letter, right now. And you should know, the two of us do this only to have something to talk about, except perhaps how I stop mid-sentence and wonder what any of the kids are doing at any given moment. This is universal for parents? I don't know.

Dear Son,

In reference to your comment and what we talked about on the phone, you're right, I'm not a political blogger. ENT is about mental health and mental illness, except for when I throw in an occasional story about you :) and your sibs and my grandkids, my parents, Safta, and of course, old FD.

But about not knowing much about gun control, well, my job description includes hearing firsthand about murder, involuntary, voluntary, it doesn't matter, this isn't Law and Order, suicide, and accidental death. These senseless acts all have one thing in common, guns.

And in under a year we have had two grisley stories about mentally ill people who probably (certainly in Cho's case, we're waiting to hear about Kazmierczak) had expressed the wish to kill others and themselves, and were sold guns, sometimes two or more at a time, by reputable dealers.

I have to sit within three feet of relatives of victims of murder who are sure they'll never recover from their losses. I have to hold back any of my personal indignation and political views (lame, I know, I know). I have to wait, week after week, until my patients feel better, knowing that they have been robbed.

And it's not fun.

So although you may not feel I'm very educated about the issue . . .

I don't really think there's all that much to know. We have to do something. Maybe it's education about mental illness. So we'll stick to that for the most part. For the most part.

Love ya',

Mom


We're good.

therapydoc

Monday, February 18, 2008

Retraction and Stopping the Forward Madness



What's a post without at least one pictures, really?




I understand that I wrongly accused the University of Kentucky in my last post and humbly retract the accusation about a Holocaust curriculum decision.

I apologise and feel pretty gullible about that.

Do you think I should take down the post?

I can reply to the forward to try to stop damaging gossip like this, and we can and should talk about it.

Do read it and let me know. Keep in mind, the University of Kentucky still has a Holocaust studies program.

The American South has a tradition, interestingly, of keeping this memory alive.

See the documentary, Paper Clips, about a small rural town of less than two thousand people (Whitwell, Tennessee, predominantly white and Christian) and a school principal who wanted to expose her students to diversity. They memorialized the Holocaust with paper clips.

You can rent the video. Or better yet, take a drive down to Whitwell to see the memorial. It's unbelievable.

therapydoc

Sunday, February 17, 2008

Eisenhower and the Holocaust



Dear Friends,

I feel pretty gullible, but can't bring myself to take down this post. I apologise in advance to the University of Kentucky for ever publishing it last night. The good news is that the email subscription feed didn't go out yet.

Aparently the email forward that I re-published below is a lie. The original UK, United Kingdom, rumor had been transposed to U of K, University of Kentucky, by an overzealous individual, obviously someone who worries too much. But there are Holocause deniers who hold positions of power.

So. Can we worry too much about this topic? I don't know. I'll let you decide. I own my paranoid thinking. Is it functional? It's a good example, perhaps, of how that kind of thinking CAN be functional, in the end can generalize warranted concern. You decide.

The only truth to the forward is that President Eisenhower did say what he said, did what he did. And we shouldn't forget what he said. Or did I get that wrong, too?

Conflicted,

therapydoc


I tell myself, Don't blog, get something done, get something constructive done, pull away from the computer. File receipts, do your taxes. Just do it, pull away. You have to prepare for class on Thursday and it's a busy week. You could fold some laundry. Get on that treadmill that you use to hang your sweaters.

And then I get an email like the one I'll show you in a minute.

A little context. Sunday is a work day for me. I take off Saturday, so I'm at the office by 9:00 on Sunday and I'm lucky if I leave by 2:00. I see patients from the minute I walk in the door until I leave. There's none of this 10 minutes between patients to chart and think or eat peanutbutter.

In good weather I ride my bike, but we're still thawing out here in Chicago, and today was a mess of rain on snow. FD drove me to work and he picked me up. The plan was to make two shiva calls before returning home to shovel in some food.

Do you know what a shiva call is? It's a visit to someone who has recently lost a 1st degree relative, meaning a parent, a child, a spouse, or a sibling. The mourner has seven days of staying home, meeting with visitors. The community visits. It's never fun, this visit, but it's one of those things that you do because you know it's the right thing to do.

And you often learn from it.

Today, on these two calls, we saw friends who had both lost parents. Both parents had survived the Holocaust. Between them, I believe they'd been in four concentration camps, two labor camps, had walked the Death March, and survived the war by the skin of their teeth. Or do we say the grace of G-d.

One friend told me that her mother never talked to her or anyone else about what happened to her. The only story she ever told about her years in the camps was a "good" one, in which a guard hid a piece of bread in her sewing drawer, daily, at a work camp. Having lost parents, siblings, aunts, uncles, and grandparents in the Holocaust, this woman spent the rest of her life in social service, helping the elderly.

Another friend told of how her parents had met one another as orphans after the war, lone survivors of their respective families. Her father had survived the camps and escaped the ovens only to die in a fire late in life, and her mother couldn't take the abandonment, never recovered emotionally. She died of a broken heart.

After each visit, as we made our way to the car dodging puddles and slush, FD remarked that these people, this population would one day soon no longer be among us.

Survivors. The survivors of World War II are dying out. Their memories will die with them. It's very scary.
And I nodded, worried that harm could come to the memorials, the museums (we live in a violent world), and that no one 200 years from now, might believe what had happened in Europe to six to ten (or is it 9 to 11) million Jews, gypsies, prisoners of war, Russians, ethnic Poles, Slavs, Jehovahs witnesses, religious and political dissidents, the disabled, gays, lesbians. . .

Then, as if to validate his thesis, tonight I get this forward. Generally I don't like forwards. But the friend who sent it is special so I opened it up and I read it.

Here you go. You read it, too.

Eisenhower in Dachau

It is a matter of history that when Supreme Commander of the Allied Forces, General Dwight Eisenhower, found the victims of the death camps, he ordered all possible photographs to be taken, and for the German people from surrounding villages to be ushered through the camps and even made to bury the dead.

He did this because he said in words to this effect: "Get it all on record now - get the films - get the witnesses - because somewhere down the track of history some bastard will get up and say that this never happened".. All that is necessary for the triumph of evil is for good men to do nothing.

Edmund Burke
In Memorial

This week, the University of Kentucky removed The Holocaust from its school curriculum because it 'offended' the Muslim population which claims it never occurred.

This is a frightening portent of the fear that is gripping the world and how easily each country is giving into it. It is now more than 60 years after the Second World War in Europe ended.


This e-mail is being sent as a memorial chain, in memory of the 6 million Jews, 20 million Russians, 10 million Christians and 1,900 Catholic priests who were murdered, massacred, raped, burned, starved and humiliated with the German and Russian peoples looking the other way!

Now, more than ever, with Iran , among others, claiming the Holocaust to be 'a myth,' it is imperative to make sure the world never forgets.

This e-mail is intended to reach 40 million people worldwide!

Be a link in the memorial chain and help distribute this around the world.

Don't just delete this. It will only take a minute to pass this along.

So I passed it along. Do what you feel you should do. Don't like chain letters? Hey, I don't either. But at some point you have to be proactive in life.

It skips by pretty fast.

therapydoc

Saturday, February 16, 2008

Schizophrenia can be silent: Stephen Kazmierczak

The illness is, at the very least, quiet.

It is an illness that features psychosis, delusions and auditory or visual hallucinations, thoughts beyond reason (the FBI is listening into my conversations, or I actually AM G-d). It is a blurring of the boundary between what we think of as sensate reality, and thought.

One with this disorder has difficulty knowing with certainty where certain thoughts come from, the origins of voices, ideas. A person with paranoid schizophrenia might assign his or her own negative thoughts to another person in the same room, will assume that the other is thinking certain things, even saying things that have never been said.

It's very confusing, this cognitive dysfunction.

And people wonder why I don't get all excited when they say that they're forgetting things lately, that their cognitive functioning is a little off.

Try having schizophrenia.

Among the more disturbing features of severe paranoid schizophrenia are the delusions, which are never happy. It's not the kind of thing whereby the person thinks, Oh, yes! I just heard that I'm going to get that job! I heard it on the radio!

It's more like,
G-d told me that The World is Coming to an END and He ordered me to tell everyone. You're all, every last one of you, sinners.
It's about hearing voices that no one else can hear, seeing things that no one else can see.

And yet you know that others think you're crazy when you mention these events. Your logical conclusion? Don't talk about them. Don't tell others. This is obviously the topic that we don't talk about in company.

I believe that this is how it is in the initial phases of the illness. Later on you might become more boistrous, perhaps even an individual carrying a placard that says, The World is Coming to an End. But initially, before it gets too scary, before the voices in the head are irrepressible, before faces of others change into monsters, smiles into demonic raging, a person suffering from this type (paranoid) schizophrenia is likely to be incommunicative about the illness and what is going on his head.

Hallucinations are rare, but voices or delusional thoughts, usually obsessions with death, sin, violence, and knives, are more common in severe types of paranoid schizophrenia. It's no wonder that an individual haunted by voices or negative thoughts might pay attention to firearms.

A person with schizophrenia who is obsessed with death might inadvertently see guns, perhaps on a walk past a gun shop, or see weapons on television. The visual imagery triggers a voice or a thought, channels a message to acquire them. The mind says, Buy them. Buy the guns. Kill someone. Kill yourself. You are scum. You should die. And so should they.And the voice may not shut up. It is very painful.

And the guns, well, they're so plentiful!

A person who suffers from severe bi-polar (manic-depressive) disorder might also blur boundaries, reach the pale of psychosis. But we hear from them when they're depressed. They tell us how sad things are, how exhausting, how impossible. And we hear from them when floridly manic. They do not stop talking, words never stop, and the range of severity can be remarkable between episodes, remarkable between patients, too. Only the very few with this disorder have a compulsion to shoot off firearms, and that's often for the sheer stimulation, or when stressed to the maximum.

Policemen with this disorder have to be watched because they carry firearms. Of course, we could say that anyone with firearms should be watched. Anyone.

When people with bi-polar disorder get delusional, hear voices, or see things that no one else can see, we call the disorder schizo-affective disorder. Individuals with bi-polar disorder who manifest psychotic features like these really don't have bi-polar disorder at all. It may have seemed, perhaps, that they had bi-polar disorder, and the medications that work for bi-polar disorder worked for them at one time, but at some point during the course of the illness, the hard features of psychosis predominated.

Those who suffer with schizophrenia or schizo-affective disorder are often turned inward, much more-so even, than individuals suffering from the severe insular depressive withdrawal characteristic of unipolar depression or bi-polar disorder. But they can hold their own in the pre-morbid stages, fake being okay. And on medication, they are okay, or can be.

A person suffering from schizophrenia who has been treated successfully is just like you and me: thoughtful, caring, interested in people, life. Better than you and me, for this person has accepted a disability, suffered, worked to change, to rewire, so to speak.

How many times do you and I say, Oh, I have to change! But we don't. We don't hurt enough, you see.

In answer to those questions, when the symptoms of people with bi-polar disorder reach psychosis, when we call it schizo-affective, then yes, the disorder can be very dangerous. I couldn't tell you that Mr. Kazmierczak did not suffer from schizo-affective disorder, except that his tattoo, a tricycle in a pool of blood, indicates paranoid schizophrenia to me, not schizo-affective disorder.

I wonder if some people who present with bi-polar disorder that manifests under stress as schizo-affective disorder is really schizo-affective disorder, period. But the schizophrenic piece, the shattered ego that is definitive schizophrenia, is silent, predominantly, so it never captures attention. Then under marked stress, like skin stretched too far, it tears through the surface.

In severe paranoid schizophrenia the voices might say things like:
Don’t tell anyone else about us! Don’t tell anyone! We’re your only friends. Do what we say. Take that knife. Take it. Cut yourself. And then, when you are finished, cut . . .(name).

Shoot . . . (name). Get a gun and shoot. Shoot them all.
Yes, like in a horror movie.

The onset of schizophrenia is late adolescence, sometimes early adulthood.

The onset of Stephen Kazmierczak's mental illness seems to have been post-high school, coinciding perhaps with the stress of leaving home, facing college, or coping with social rejections or relationships.

His parents didn't cause it, unless you can blame genetics. They're not to blame for their parenting. They knew he was sick and sought treatment. He had been hospitalized for cutting, had an extended hospital stay. He could not be controlled at home, so he lived at Thresholds post-hospitalization, a half-way house for individuals suffering from psychotic disorders. Residents of half-way houses usually are no longer benefiting from the hospital (and it's too expensive) and cannot live at home. Yet they're not ready to be on their own. Too suicidal, usually.

It is very painful and very embarrassing to have this problem. You're not so different from anyone else in so many ways until you get really sick. Until you get really sick, you can study, you can learn. You understand social cues. You aim to please others, tell them what they want to hear, strive to do well in all that you do. People with the illness who haven't become very sick might harbor certain symptoms, negative feelings, might have a dreamlike grasp of reality. But they perform well, seem well to most everyone.

The first psychotic episode is news, and can be violent. It might be the voices or audible thoughts, ordering harm to one's self or others. It may be a tantrum. If it's voices that torment, they're not something that's necessarily or willingly talked about, shared with others. The negative thoughts, the paranoia, can keep a person up at night, all that noise in the head, yet one can’t tell others, won't tell others, won't talk about it, usually.

People with schizophrenia know that they suffer, but don’t want to tell anyone. They really can't tell anyone because it is so hard to put thoughts together, to put them into words, to perform socially. This is real illness.

Schizophrenia is a stress sensitive disorder. We try very hard to keep life quiet for people who suffer from it. We dial down the anger, the conflict, the worry, the problems of life. These patients are delicate. They’re sensitive. We think they have fractured egos.

What’s a fractured ego?

Your ego is you. It’s your identity. It’s who you say you are . I like ice cream. Ego. I can ride a bike. Ego. I can do well in school. Ego. I relate well to others. Ego. I don’t relate well to others. Still ego. I feel happy. Ego. I feel sad. Ego. I am a member of this family. Ego. I am voting for Hillary. Ego.

It's all about the "I" and it's definable. Can a person have too much? Too much ego really means conceit, or self-centeredness in our ordinary lexicon. But in the psychological lexicon, in some ways, no, a person can't have too much ego. It's good to be multi-faceted, complicated, complex, to have much identity, much that one can say is Me. Many skills, many ideas, many friends, relationships.

When the ego is fractured, the “I” is confused with the “I” of everyone around, even people who don’t exist, voices in a head are self. Who is it who is telling me these things if not me? Or they are my people, for sure, they're always with me. They're me.

Therapy is about gluing identity back together again, if that’s possible, and dissociating unwelcome people in that soup of identity.

A boy like Stephen Kazmierczak had an identity and lost it when he got sick. His parents missed him, I’m sure, the little boy that they knew. He “changed.”

You know that Seung-Hui Cho, the young man who murdered 33 people at Virginia Tech on April 16, 2007, was not autistic. He did not suffer from Asperger’s. He suffered from paranoid schizophrenia, although it does seem that he had his illness from early childhood, had childhood schizophrenia. You can find links to my posts on Mr. Cho if you scroll down at the sidebar, all the way down. It was a topic I had hoped to forget about.

So yes, we have another case of schizophrenia and another case of too many guns, too easy access to too many guns.

When, oh when, will our legislatures make it a crime to sell guns to individuals who have had a history of mental illness? When will they take people who sell guns to people who have suffered from mental illnesses and throw them in jail? Like they do with child molesters? It is a molestation, handing someone with schizophrenia a gun.

Someone please tell me this is changing. The face of schizophrenia is the same as it always has been.

And sure, Stephen Kazmierczak's crime could have been committed because he was angry, jilted by a girlfriend, perhaps. But how many people do you know who have been jilted by girlfriends who buy guns and attack an entire lecture hall of students? Has the face of anger suddenly changed?

People get angry. People stalk. People get violent. But THIS violent?

This is mental illness combined with guns. Guns kill people and they are accessible. We have to collect them and throw them all away.

therapydoc

Friday, February 15, 2008

Stephen Kazmierczak

He killed himself, too. A quick correction to the previous post. Stephen Kazmierczak sauntered into a university building and hid in a lecture hall. He carried several handguns and a fully loaded shotgun hidden in a guitar case. He fired from the auditorium stage and killed 6, injured 17 others.

A student at another state school, the University of Illinois, Champaign-Urbana, this troubled young man had gone off his medication. He grew up in that college town, was one of what we would have called, the Champaign "townies."

The campus police today said that he was a top-notch student, not a disturbed student. No one could have seen this coming. He gave no prior warnings.

The details will role in, and again, we'll be glued to the the television, captivated by senseless violence. Well, I will.

The university police said that there was nothing they could have done to prevent this from happening. He had been a student previously in Dekalb with no obvious problems. And even in Champaign, he gave no warning, no cry for help.

No warning.

I just want to say that in Israel, one does not enter a university or other public building, not even a large grocery store, without passing through metal detectors. Most guns are made out of metal, you see.

So when they say,
There's nothing we could have done to prevent this. We had no warning.
They're wrong. And short-sighted.


therapydoc

Thursday, February 14, 2008

Kathryn Faughey and the Northern Illinois University killing rampage, an ordinary day

This is the homepage for Kathryn Faughey. Above the picture it says:
psychotherapy in new york
Just below it:

February 15, 2008

Emotional help for adaptation to change

Solution Oriented Psychotherapy

Last night I had Dov and Cham over for dinner, and as we slurped our vegetarian lasagna (a little soupy, but good and hot), I looked up at Cham and asked, "What was that link Pat sent me? I didn't have a chance to open it."

"Oh, it was about some therapist who got murdered by a patient in New York City," she murmurs, not looking up from her food.

I raise one eyebrow. "Really."

"Uh, yeah. She's just worried about you, is all. Thinks you should be careful."

Cham's studying to be a therapydoc. I'm sure she heard the same directive.

"I don't want to hear about it," I say.

"Me neither. Could you pass the salad please?"

With pleasure.

So I let it drop. But today I have time on my hands as I wait on the telephone for perhaps an hour or more, and speak with the third, no exaggeration, third, customer service rep from ATandT who is determined to resolve the mystery of my telephone bill. You should know that the customer service representatives at ATandT are very kind, patient, and full of time, if mystified at the enormity of their task and not altogether sure how, exactly, they can help you.

Thus while I wait for these well-intended individuals to work it out amongst themselves, between several games of spider solitaire, jotting notes, and filing bits of paper into charts, I open the dreaded email.

Kathryn Faughey, 57, a lovely, compassionate, hard-working Manhattan psychologist, is slashed to death, stabbed with a meat cleaver in her office. She will not be coming back to work tomorrow.

The New York Daily News:
"No one is helping me! No one is helping me!" the balding butcher yelled as he . . .(I can't say it!)

"She helped so many people, rich and poor," Adam, a retired lawyer, told the Daily News, as a cop stood guard outside his apartment door. (Adam is her husband)

"She was a very good and decent person. She saw herself as the child of immigrants. Both of her parents came from Ireland. She was one of seven and the first in her family to go to college. She worked very hard to become what she was."


Police said it's unlikely Faughey was slain by someone who just snapped during a therapy session. "It wasn't a sudden burst of temper. It was planned."

She specialized in domestic violence.

I haven't heard from my mom yet, but for sure she'll be listening to the news and reading that paper, watching the phone, wondering if I'll call her. She knows I teach tonight. She'll be thinking . .Should I tell her. . .Be careful?

FD, of course, went to the drill. "You take your chair and hurl it at him and get out of there."

Or, I say, I could whack him with that 5 # dumbbell that I keep on my desk, the one that I have never, ever used for exercise, but can point to and say, should someone ask,

See? I keep weights right here at my desk, in case I get bored. Never waste
time, life's short.

Or what about that hammer that I keep in my desk?

I tell FD, "I sit right next to the door for a reason, dude. I'm a runner."

Are all therapists wondering what they would do? Are all of you in the business thinking, Who in my practice might do that to me? Isn't this the secondary trauma that they write about in mental health blogs? (yeah, look in the sidebar, it's there somewhere). We therapydocs are traumatized (oh, just a little, seriously) merely hearing the traumas of others. And so are you.

I know we're supposed to say, when someone passes away, either "naturally" or tragically, that there's a reason, that it's for the best somehow, who knows how. And yet it's surely a tragedy, it has to be. Think of the family, the incompleteness, the roads not traveled, the jobs not done. And in Ms. Faughey's case, think of all of those patients, the people who looked to her for comfort, ideas, smiles, support, help.

And then, when it couldn't get any worse (the news), we hear that five (now I hear seven) students are slain, seventeen injured, many seriously, as a gunman fires off several rounds of ammunition in a crowded geography classroom at Northern Illinois University.

NIU is only about an hour and a half away from my house. A short trip, really. Dekalb. Think women's basketball. Huskies. Nice people, now scared to go to school.
It's Valentine's Day. A quick and dirty: Another peer rejected kid. With mental illness.

A dangerous world we live in, perverse. We're going to need more mental health professionals, my friends, not fewer, in the coming years. So don't listen to people tell you that there's a glut of psychologists, social workers, psychiatric nurses, and counselors, or that psychiatrists don't get to do psychotherapy anymore, all they do is push medicine.

Don't be discouraged, don't be skittish about the field, or worried that a sociopath or otherwise sick individual will surely cross your path one day, that thought driving you to think . . .Real estate. We need you. Something tells me, we need you.

Oh and Pat, thanks. Honest. You just beat Mom to it, is all.

therapydoc

Wednesday, February 13, 2008

Including the Pri-cares

Just a quick adjoiner to the post on choosing your therapist. I'll have a few of these, and will be discussing it at length regarding children at MomInIsrael.

Shauna (a myelin challenged woman) reminded me. Thanks so much, Shauna.

It's remarkable that I forgot that, (a) because I live with a family practitioner and consult with him and other physicians regularly, and (b) EAP referrals are the salt and pepper of my practice. And I'm not even a certified EAP therapist (another subspecialty you guys can go into to make a decent living).

One of the reasons the pri-cares know the quality of the therapists in the neighborhood is that they hear from us. We communicate. Or we should. In some states, it's the law.

So when your therapist says,

Can I speak with your primary care doc? Sign here, if you don't mind.
Say YES. It's nice when one hand knows what the other hand is doing. It really makes a difference in your quality of care.

therapydoc

Sunday, February 10, 2008

Heath Ledger


I hesitated to post on him. I felt so badly.
So much talent, so young.

But I kept reading negative things about Mr. Ledger on the Internet. You can't help it, you know. You're surfing around and the celebs get the most press. Even up here.

Bloggers, generally a tolerant lot, chimed in with negativity, anger. Of course we know that's a stage of grieving.
Shame on him! Wasted his life. Everything to live for. Money, women, fame.

And shame on all the people who knew, who didn't do anything. What were THEY thinking, huh?
Caught on video using drugs. They knew. People knew he had a terrible problem.

So I just have to say this. And I know it's grim, and I apologize for the grimness. But you know, my business can be a downer.

We have this expression in addictions treatment. A person has to hit bottom to want to get help. It's not always the case, indeed, one does not have to hit bottom to want to get help. We can learn from the mistakes of others. Most of us prefer our denial, however. It's easier to go with the flow.

And when things get a little out of control, or very out of control, accidents happen, people land in jail, or the hospital. Some people would call landing in jail or a hospital hitting bottom. Some people have to do that more than once, and sometimes it's not bottom.

But hitting bottom chips denial in the best and worst possible way. There's nothing like real, sincere pain to motivate people to change.

Positive reinforcement: I'll give you a thousand dollars to stop drinking/using.

That just won't cut it sometimes. A million dollars, maybe. But not if you make millions. Therapy, too, helps, for sure. But when things go badly, really badly, you start to reconsider your humanity, what you're doing with your life.

Wake up in the park, cold and wet, the rain pouring down on your face. You stop and wonder.

And when you lose your job, even misplace a paycheck, you stop and wonder.

And when your wife walks out on you, you stop and wonder.

Or disappoint your children to the point that they won't talk to you anymore, you stop and wonder.

Or get cirrhosis, cancer, hepatitis, malnutrition, HIV, or another disabling, potentially life-threatening illness, you stop and wonder.

Or kill someone while driving drunk. You stop and wonder.

Or publicly embarrass your family. You stop and wonder.

Or publicly embarrass yourself. You stop and wonder.

If you get the chance, you stop and wonder.

therapydoc

Saturday, February 09, 2008

The Heart Has Its Reasons

Just when I was beginning to think that the Wall Street Journal is becoming bad for my mental health (think economy), Colin McGinn reviews Eric G. Wilson's book, Against Happiness, a treatise against the happiness movement.

In America, if it's not happy, it's bad. So I'm glad to see that book get the attention it deserves. I think.

Then today, Kevin Helliker writes this wonderful piece, the one we're about to discuss. Front page story, deservedly.

Now quickly, for I've got a date for the movies. (Juno, if you must know; the previews made it out to have heart).

Mr. Helliker's WSJ story, The Heart Has Its' Reasons, has so much heart.

Toby Phalen Young, 48, a "goody two-shoes" all her life, business professional, dog-trainer, philanthropist, prison-volunteer, married with children, arranges inmate John Manard's escape from prison. And runs off with him.
Mr. Manard's age at the time, 28.

Ms. Young met Mr. Manard in the prison. A community leader, she had designed and executed a program for inmates at the Lansing penitentiary to teach inmates with exempliary behavior to train animals. The prisoners saved strays that would otherwise have been exterminated. These "best" prison inmates vied to have the dogs stay with them in their cells at the facility. No question, the dogs made the prisoners kinder, gentler people.

The program achieved a certain notoriety, and Ms. Young became something of a household name in penitentiary circles in the Midwest. People came from far and near to her pet adoption fairs to rescue well-trained, loving dogs.

Prior to this she had held a six figure job at Sprint. When the cellular company suffered a failed merger with MCI, Sprint killed her project. She bounced around after that, and suffered an illness. Recovering from thyroid cancer she determined to do something more meaningful with her life so she started a dog rescue/adoption program. A friend told her that cell-dog programs in prisons seem to be catching on, that they seem to reduce inmate violence.

Toby Phalem Young found her niche.

The prisoners loved her. She walked freely, unafraid in the prison hallways, interacted with inmates, no guards to protect her, not usually. At one point she did receive a threat, and Mr. Manard shadowed her. He found her engaging, and they got to know one another. He marvelled at her innocence, how she had never even dated anyone but her husband, had never been drunk, never smoked, never had a traffic ticket. They talked of her unhappiness, how her husband, a good, solid man, couldn't show affection. Mr. Manard, who is well over six feet tall, good-looking, lean, and strong, couldn't believe a remarkable woman like Ms. Young could see anything good in him. But she did. And she fell in love, too.

One day I'll talk to you about how important seeing the good, especially in children, really means.

John Manard, at 17, had received a life sentence for his involvement in a car-jacking that left one dead. He didn't pull the trigger or even hold the gun. Felony murder in Kansas assumes guilt all around, fair or not, all suspects share the sentence. So he was incarcerated. Mr. Manard became a model prisoner. He earned his high school diploma in prison and taught himself several musical instruments. He read poetry and books.

The story's got everything, violence, sex, love. An unhappy marriage, an unhappy ending. Yet hopeful.

Ms. Young, who will complete her sentence in May, is still in the Leavenworth Detention Center, separated from her flame at Lansing Correctional Facility, is the one who quotes Pascal, by the way:
The heart has its reasons that reason knows nothing of.
What's marvelous about Mr. Helliker's telling is that he doesn't buy into the reasons that most Kansans proffer to explain how a truly straight arrow falls in love with a convict and then runs off as an innocent Bonnie with Clyde.

The town people who know her, unwilling to believe Ms. Young would do this, blame her bad judgment on a mid-life crisis. They blame Mr. Manard, who supposedly conned her, didn't love her, used her to escape.

The couple, you should know, were caught within days after the escape, lovers at a honeymoon cottage in a small town in Tennessee, shopping.

Mr. Helliker says that the reason Ms. Young couldn't stay in her loveless marriage, the reason that she couldn't continue with the status quo, the reason she let herself fall in love, is that she never complained. Her father, who suffered severe burns in a fire that burned off his ears and nearly killed him, chose the most painful ways to heal, crawling on his belly at a job to stretch the skin.

She learned from her father to suffer in silence, to be strong.

Oh, my. We could have helped her, couldn't we? For all we know, had Ms. Young asserted herself, told her spouse that she needed more, insisted that he give more, that that marriage didn't have to end this way.

But I don't think so, actually. I think that her husband's petition for an emergency divorce only days after her arrest, says it all about that marriage.

And the real victims, let's face it, are the pets.


therapydoc

Thursday, February 07, 2008

SADS is GETTING to ME




Okay, it's not really getting to me. But it sure does get to some who haven't seen the sun in 8 days. We're weather weary, friends, here in the northern latitudes.



So you're not alone if the short days and lack of sunlight are contributing to your alternatively cranky/sad otherwise cheerful disposition.

FD is so sick of SADS he's named it something else,
HLWD, Higher Latitude Winter Dysphoria. One day we should rename all of the disorders. That would be fun. For want of anything better to do.
I for one am feeling a little pent up moving from the house to the car to the office to the car, to the car to the house, the house to the car to the office to the car, with an occasional stop at the grocery store for provisions.

As a younger person, having a winter sport helped. It's a default thing that a person who grew up making snow-people simply doesn't think twice about. If you can't afford a week or two in a warm, sunny climate, then you HAVE to have a winter sport. Hockey, ice skating, snow ball down the back, snow boarding, skiing, not to mention the indoor sports like basketball, volleyball, tennis, racketball, swimming, golf. Okay, not golf.

I think I told you about the last time I skied. Up in Utah, staring at the sky, horizontal. One ski about ten feet away, another nowhere to be found. The clouds looked nice. And the sky in Utah is an unforgettable shade of blue.

There are evergreens in Utah. So although snow tends to be white (and we're talking WHITE white, not slush-white, not gray, not tar-sullied-salt-grainy ochre), the forest-green aspen, those happy blue skies, the sunshine bursting off of snowflakes, well, it doesn't even seem like winter.
It's more like Disneyland without those scary cartoon figures that dance around and shake hands with crying babies.

But most of us can't afford to do that, chase off to Park City or Aspen to ski. We can't even ditch school to drive up to Wisconsin (Alpine Valley) to shake the lead out. So we hate people who do. They're tan!

We've seen you guys with the tans. It hurts, honest, seeing you people looking so healthy, out on a winters days having FUN, coming home from that winter junket looking so INVIGORATED and healthy. Hey, too much sun in Bermuda isn't healthy, either, according to Gentle Doc, my brother the dermatologist. Remind me to tell you one day what he says about skin creams. (Use one, it doesn't matter which one).

So one might think that a winter sport is good for Seasonal Affective Disorder (SADS) the disorder some say is associated with too little vitamin D, the sunshine vitamin. Someone once told me that there IS an association, but I'll be honest, it's hard to be vitamin deficient in America unless you're eating disordered or a substance abuser. So I don't buy the vitamin deficiency explanation, although too lazy to look it up right now.

I remember telling a man who had a terrible case of Seasonal Affective Disorder that he ought to get his kids out on a tray and go sledding before it melted. Chicagoans understand that a person doesn't need to buy a real sled to slide down a hill. Since we have only a handful of hills in Chicago, this assignment isn't as easy as it sounds.

The natives here, however, "sled" on lunch trays, newspapers, winter coats, plastic swimming pools, even those colorful plastic disks and sleds sold at Toys R Us that are intended for sledding, if they want to play it safe. Wooden sleds, ala Citizen Kane, aren't even valued. What they lack in originality they make up for with metal glides, not terribly safe, really. Rosebud, that's the name of that sled.

I asked FD if he wanted a snow-blower. He acted as if I had asked if he wanted strep throat. Why would anyone want to give in to that, a snow-blower?

What he's saying is there's something very wonderful about shoveling snow, assuming you don't drop dead doing it (check with your local physician, please, before shoveling snow). There's no hurry to get it done, really the walk.
We're all pretty mellow when it's snowing. If we drive too fast we'll skid and hit someone. If we walk to fast, we'll slip and fall on a hidden patch of ice. When it's coming down, it's best to simply watch. Outside, preferably.

The clean-up, certainly, quite the challenge. Oh, but the quiet of snow! It puts a buffer on the noise of the city, absorbs so many sounds, sounds we don't even realize that we hate! And there we are, carefully moving snow from the sidewalk, making sure we don't break our backs or pull a muscle. And all around, silence.

It's usually a 3-4 Advil affair!

And your neighbors are out, you know, shoveling their walks, saying Howdy. Haven't seen you since the summer. How's the family?

Indeed, if it weren't for snow, no one would stop to talk to anyone in Chicago in the winter. Too darn cold half the time to waste the time. You want to hurry up and get inside so you can do something important like watch TV.

Oh, you wanted to know about SADS, Seasonal Affective Disorder. I think there's something on it somewhere in the archives, but basically, YES, you need to light that house up like a Christmas tree if you can. Pay Com Ed, not your therapist. Use flourescent bulbs to keep the cost of the wattage down.

And yes, diet. Don't let yourself eat too much. On the other hand, a person should gain about five pounds in snowbound climes in the winter. That's just the way it is. We're a little like bears and squirrels, storing it up against the cold. Exceptions are people who are making a simcha (a happy occasion) like a wedding, cotillion, or a bar mitzvah for their kids. That kind of stress, you're allowed to lose weight.

The rest of us have a responsibility to eat more, socialize while eating, and do our best to exercise a little so we don't totally hate ourselves by spring.

Which is why I finally did it, hearkened to Ebay's call and scored the cross-country skis I've threatened to find for years. They haven't arrived yet, and I still have to buy boots (those I just can't bring myself to buy used). And hopefully Z (the vendor, that's really his name!) will remember to send me the poles. Empath Daught says she'd give anything to see me traipse around the city in skis.

Just my luck, this will be the last snow storm of the winter.

Or should I say, just your luck.

therapydoc

Tuesday, February 05, 2008

The Family On-Line Together, Stays Together

Every once in awhile something happens that breaks you up in the GOOD way,
meaning you laugh until the tears are rolling down your cheeks.

So last night I'm on-line, reading email. I get an email from Michelle.

You know Michelle. Michelle Obama.

She wants me to see Barack's new video on YouTube, Yes We Can. The video is truly slick, a wonderful example of how a confluence of art, politics, entertainment, and emotion can produce something that will probably be the next President of the United States.

But this isn't a political blog, as one astute reader has assiduously reminded me, so I'm not going there. It's just a part of the story.

Michelle writes to me, and Barack does, too, for the record. Today he reminds me to vote, and while I'm on the way to the polls, to grab a friend to come along.

Go out for a sandwich.

Anyway, our immediate family emails as a group. I realize that there are better ways to communicate these days, Skype conference calls, Face Book, Twitter, etc., but we've managed to get a charge out of old fashioned email. I started this thread going with the following:

Subject: Well, I think it's funny

http://health-in-action.blogspot.com/2008/02/jeder-braucht-therapie-whlen-eine.htmlHow to Choose a Therapist in. . .German????

All I sent was the link. A blogger translated my post, How to Choose a Therapist, into German. I thought it was pretty cool.

Son #1 chimes in with:
Wha? Wha? What does it mean???
I write back:
I'm telling you. I think it's a direct translation of a post I did just the other day on how to choose a good therapist. But since I don't know German, so I'm not sure. But the paragraphs look the same, and I saw the word OY! which I used in the post
Son #1:
Gut een hemmil!

Me:

I just got an email from Michelle, Michelle Obama, of course, who sent me to the
following link. If this is what we get the next 4 years, man, o man. Can you
imagine?

http://www.blogger.com/I

Son #1:
Does Michelle read your blog?

Son # 2:
Anyone else notice that Israeli girl at 1:46 who says “Anu Y’Cholim”?

Son # 2:

Okay, let’s play I Spy…

John Legend
“Michael” from Lost
Scarlett Johansen
“Ashley” from Fresh Prince
Xena Warrior Princess
I think one of the guys from Black-eyed Peas

Anyone else?

(These are the performers on the video.)

Son #1:

B-actress Aisha Tyler
Annoying actress Kate Walsh
Kareem Abdul Jabar (I
think)
Barack Obama (I think)

Me: Should I be afraid?

Then, the coup de gras', from we're not sure whom, but we know his name. He shares the very same name as a son who HASN'T joined the conversation.

Jonathan:

who are you people? and why are you putting me on your email list?

I apparently spelled Son #3's name wrong when I sent out the original group email . So this OTHER Jonathan got it by mistake. Son #3's name isn't really Jonathan, but I felt that I should change it for our purposes here and keep the family anonymity.

Before I can correct the situation, Empath Daught has posted:

Jon, all you have to say is YES WE CAN!
(Oh!)
YES WE CAN
(hmm!)
YES WE CAN
(we can, we can)...
I quickly write to the other Jonathan, the one who is not in our family:

Sorry Jonathan. We have a Jonathan (last name) in our family with a gmail account, and I mistook you for him. Forget you ever met us. If that's possible.

Son #1:
Truth is, I'm so sick of the candidates, I'd vote for King Abdullah before ...
I've corrected the addresses so that Son #3, our Jonathan, is now on the list. I write to all, since all of us get all of this,

Do you believe this? Someone ELSE named Jonathan (last name) got this entire
thread by mistake! I am capable of worse, but not sure how. There are great
things lying ahead for you people. I think I've corrected the error.

Son #1:
OMG that is hilarious!

I vote we just keep sending him our (stuff).
And Rac chimes in:

LOL I think it's very funny! Poor Jonathan. LOL
And Empath Daught:

OH MY OH MY OH MY .
That is the funniest thing EVVVVER. Did you guys see what I wrote back to him?!
And Cham:

LOLOL oh man good stuff
#2 son:

I second #1's motion in adopting a second Jonathan. If you read his email
carefully, he clearly seems interested in being part of our family. Empath's
response was hysterical.

Okay. I should stop here. I really should.

IS THIS A GREAT WAY TO KEEP FAMILY TOGETHER OR WHAT?

Oh, they'll be so mad at me for posting this, I just know it. So perhaps not.

I have to get to the polls. There's for sure an extra beat in my step. Yes We Can?

NOT A POLITICAL BLOG, NOT A POLITICAL BLOG, NOT A POLITICAL BLOG. Honest.

It's a free country. Go out and vote.

therapydoc

Monday, February 04, 2008

Connecting the Dots

In this wonderful land of opportunity, many second generation Americans have parents who prefer to speak their native tongue, the language of the old country.

When I was little my parents did that but only at particular times, when they didn't want us kids to understand.

And to curse, which was very, very rare. They certainly cursed in Yiddish.

Under one's breath. Gey in dr'erd. Drop dead.
But they didn't mean it.

If they called someone a name, it was in Yiddish. A schleper (one who doesn't get anywhere). A mishuganah (a lunatic). A shlamiel (one who is down on his luck, never seems to have any luck).
If they gossiped, they gossiped in Yiddish. We kids didn't know the language, and it was insinuated that we shouldn't know the language. How else could they speak their secret language?

Which brings us to our first picture of the day.

Diagram #1 Healthy Families

What you see here are three healthy couples in committed relationships. The two couples in the top ellipses to the left and right have one child each. The first, a boy (rectangle-below, left); the second, a girl (circle- below, right).

These three couples are all heterosexual, all rectangles and squares, just to get that out front right away. We could have used ellipses with committed double circles, double squares. There are no differences in family systems of gay and lesbian couples.

The parents and kids are either married or in committed life-partnerships, or they have spouses, husbands, wives. We'll use married for convenience sake in this post.

Notice that nice solid lines make up the ellipses in this diagram. If you remember from previous family diagrams, nice, solid ellipses around couples increase the odds that they'll make nice, solid executive decisions about their children or other things.

What's this got to do with speaking Yiddish, Spanish, German, or Portugese?

Well, one of the more common types of family dysfunction starts with dotted ellipses (see Diagram #2 below). And many times that particular type of dysfunction begins with dependency, parents dependent upon children of all things.

Immigrant families, no disrespect intended, can be prone to such role reversal. Middle-aged newcomers to a country can have some difficulty with the new language. Their children, however, pick up language quickly (see that post on neuroplasticity). They use their children to translate and mediate with the culture at large.

This can be a set-up for marital conflict when that second generation commits to raising a family of its own.

When a child has the role of cultural liaison, i.e., talks to doctors, beaurocrats, cable guys, bill collectors, school teachers, in lieu of his parents, the job doesn't necessarily terminate under the chupah, at city hall, or in the chapel. A son or daughter may not resent this liaison role. It's the least he can do for the people he loves, the people who have struggled for him.

Parents do, by the way, generally speak some English, sometimes very good English, enough to benefit from family therapy. A therapist need not be bi-lingual to respectfully work with this population. The important dialog, after all, is between family members.

Sometimes when a dutiful son marries a girl who does not speak his family's language it can be a problem at family dinners or at coffee in the sitting room. (We could be using "dutiful daughter" married to a boy who doesn't speak the family language, or a girl, for that matter).

The in-law child is left out of the conversation. In this case, his parents may or may not like their daughter-in-law, but it's not usually about that. It's most often about communicating more comfortably in the native tongue.

The daughter-in-law, after a time, tires of this. She will mention feeling left out to the son.

Why can't his parents speak English when she's around? They know enough English to converse fairly well.

At first she suggests this quietly. Then her reminders become something of a rant as she gets used to nagging. Then a big complaint, a serious complaint, building to a roar or even a tantrum. She doesn't like not knowing what's going on, reading magazines while they're talking, perhaps about her for all she knows.

He says, "What am I supposed to do? They're my parents. Teach them English?"

She says, "They know English. I can't stand this. They have to try a little harder. Do it for me. Or have them do it for me."

And around and around. In the end someone sees a therapist like me, usually her, then she brings him in as soon as possible (that's how I do it, at least). The games begin. Diagrams like you see in this post end up in every chart at some time or another, assuming you have a family therapist.

It's not only about psychoeducation and pictures, obviously. The couple therapy here is mostly about empathy and communication. But for this post, let's focus on the psychoeducation piece.

"THIS is healthy," I say, roughly sketching Diagram #1 (above), emphasizing the nice, bold boundaries.

"THIS is not." I'm sketching Diagram #2 (below).

"You two are working Diagrams #2 and #3 (most probably). My crystal ball does not bode well for the two of you. Change this system and pay at the door.

Diagram #2, Not good. Now you should know that when the couple on the left captures their son (note the larger ellipse with the three of them in Diagram #3), when they steal him away from his primary dyad (wife, main squeeze, significant other), it's not usually intentional. But it can be.

And the reason for enmeshing him doesn't have to be because they need him to chat about the weather in Swahili. It can be because he functioned in their marriage on numerous levels. A different lesson for a different day.

Here his parents have become one point of a triangle that leaves the daughter-in-law out on the fringes (see Diagram #3 below). The daughter-in-law is effectively triangled out. Notice that the distance between the son and his parents is shorter than the distance between him and his main squeeze.

Diagram #3, Really not good at all.

They might operationalize this procedure by having him come over to watch the Super Bowl while she stays home to putter around the house. They might do this by having him come over to change a light bulb. Or they might do this by simply not including her in the conversation.

In this case he has to tell his parents, in any language, that they have to make the effort to speak English when his girl is around. If they refuse, he says, he will take her home. He has to tell them that he thinks it's impolite to leave her out. He feels badly for her, and they should, too.

Then, when the four of them are together, he has to sit with her, show his parents that they're a tight couple. Or they won't be. Not forever. These marital grudges don't go away and as the years go by, they can get stronger and angrier, and there you are, at fifty, living with your parents because she's told you, as she forced that pen into your hands,

"This is what you wanted anyway."

And you know, she didn't say it in Yiddish.

Copyright 2008, therapydoc

Sunday, February 03, 2008

Choosing a Therapy Doc, or is that Dodo Bird?

A mom requested this one awhile ago.

How should a person go about finding a good mental health professional?

I think I've sent you all subliminal messages about what to look for when looking for help, but perhaps it is time to get a little more specific.

It's very hard. Just admitting that you want help can feel so uncomfortable, so dependent.

But if you look at it like, Nobody gets into Pre-K without immunization for measles, mumps, and rhubella, yet here I am, working at being a grown-up, and I've never had my emotional temperature taken, not by someone who can really read it. So perhaps it's time.

Oh, man, you think, and this is going to cost me.

That can be bad. But if you have no insurance or no money, that can be good. You're likely to seek services at a community mental health center or a social service agency, and it won't cost much at all.

What will you find? Probably caring, well-intentioned, well-trained professionals, young and old, who have the means to consult with other caring, well-intentioned, well-trained, experienced mental health professionals. These are people who like people, usually. Consultants and supervisors swarm agencies and mental health centers. And the training for interns in MSW, PhD, and PsyD programs is better than ever before.

So using community resources is certainly a good idea for starts. Your family doctor is another good option.

And if you have insurance, most insurance companies have some mental health benefits package, and provide affiliated provider lists that point you to licensed social workers, psychologists, and psychiatrists. Good people.

Eeny, meeny, miny, moe. Catch a tiger by the toe.

How do you pick from that list? It's not easy. You can try finding someone with a nice name and then google to see if the provider has a web site. But the likelihood is that your average Joe or Sally Mental Health Provider doesn't have a website.

Which is ridiculous, of course. Those of you who are going to become therapy docs should, absolutely should, put up a website that describes the type of therapy you do, the types of people you see, your specialties, preferences, fee schedule, etc. You'll probably not want to explain who you are and what you do on the telephone.

But if you have a website, you avoid the following telephone conversation:

New patient (catches me between patients): Uh, Dr. Therapydoc, My name is _____and I got your name from _______ and I was wondering if we could talk awhile about your practice and how you work, and the kinds of problems you treat, and how you treat them, perhaps where you went to school, who mentored you, do you have any certification in . . .

I'm listening as the list goes on, and inside I'm thinking:

This can't be good! I'm TERRIBLE at these interviews! I always fail! There's no summing up these things just to dismiss a patient's anxiety. And no time. There's the scheduling, the billing, the calls to the pri-cares, psychiatrists, teachers, and principals. There are the ex-spouses, divorce lawyers, childrens advocates, all needing a consult, too. And a therapist has her own appointments, her own children, in-laws, parents, friends, and hair-dresser to consider. Where's the time?

Oy, such an attitude. It's not good. There's no heart in it, and I've never actually said these things to anyone but FD, only recited that list to him while describing previously failed interviews, the ones in which I fumbled trying to answer the questions. The ones in which the patient-in-need-of-doctor at the end of the line has said, after listening to me patiently explain what it is that I do,

"Well, thanks very much, but I'll keep looking."

Of course.

But people do need to know what we do. Not every therapist does the same thing. We're a very mixed bunch. How are you supposed to pick one? How do you know if a doc is right or wrong for you if you can't even get an interview on the phone?

It might not matter, truthfully. The outcome research on therapy docs is that a dodo bird is a dodo bird is a dodo bird (except the CBT dodo birds, who are special). If patients like their therapist, if they get a rapport going, if there's a good feeling, good karma, call it what you will. If you get along just fine that first visit, it's likely to become a therapeutic relationship.

We're all Dodo birds.

But you can't tell people that on the telephone.

Me (armed with cybertechnology): No, I don't do interviews anymore on the phone. I suggest you take a look at my website, though. Got a pencil? Okay? Great, write this down. Hope to hear from you. Give me a call back if you still want to see me after reading through the material on the web. Terrific.

But let's say the therapists on your list aren't equipped with that technology, haven't got a kid who is a graphic designer. You can still get at least some information, usually, from the busiest therapy docs if you ask a specific question or two.

Like you can ask, By any chance, do you happen to do a particular therapy, uh, ________therapy?

Some therapies are better than others for certain problems and you can go into treatment knowing something about them.

For example, if you want to see your life and your problems through the lens of learning theory and past relationships, including family, lovers, and friends, and you have the time to sit on the couch awhile, a psychosocial approach might feel good. Almost all social workers learn that style of therapy in foundation courses and it can be extremely powerful.

But if you know that there are serious repairs that need to happen in relationships right now, or you think that someone in the family is truly suffering because of the behavior of someone else in the family, you might ask a therapist if he or she has some post-graduate training in relationship, family, or marital therapy.

If you have an addiction, you might ask if the doc has certification in addictions therapies. Although it's not always necessary, it really helps.

If you like problem solving, and don't feel your problem really warrants an overview of your entire life story down to your toilet training (psychoanalytic therapy) you might ask if the therapist comes from a problem-solving, task-centered, or behavioral background.

Or perhaps you're struggling with depression and/or anxiety and your thoughts tend to go negative and irrational. You should surely ask about cognitive-behavioral expertise.

If you just saw someone murder someone, you might ask for experience in crisis counseling or exposure therapies for post-traumatic stress.

I particularly like acceptance-commitment therapy, an outgrowth of cognitive behavioral therapy. In ACT you accept where you're at and commit to changing, growing, and trying to become a different, more complicated, more lovable human being.

But ACT is so different from bemoaning that past child abuse and blaming the stars, although you can do that, too, in ACT.

And you know I think in terms of family systems.

But sometimes it's good to have a therapist who knows how to play well with kids. Children won't necessarily talk to you unless you know how to play. A deck of cards, a box of dominoes, a few dolls. A therapist who treats kids and doesn't do just a little play therapy might not cut it for your particular little angel. On the other hand, a child's therapist who ONLY does play therapy is potentially stealing your money.

If you have terrible post-traumatic stress from a violent or cataclismic episode or three, then you might benefit from an exposure therapy.

Hypnosis
sometimes works for eating and smoking. Not always.

Feminist and empowerment therapies are really good for issues that have roots in oppression or social inequality.

So you see, it's handy to have an eclectic therapist. Use whatever model works with a particular patient, I say.

Bottom line? If you don't feel a connection with your therapist after the second visit, if you don't feel you can relate, then you probably should discuss it to see why you may not make a good team. There isn't a therapist on earth who relates to everyone, and that's as it should be.

Now. Armed with that very limited treatment overview, that first phone call should go as follow:

Patient: Hi, I got your name from ________ and wondered if you were taking new patients.

Therapist: Sure, but first, very briefly, tell me what you're looking for.

Then the patient provides a brief summary of the problem, i.e., I want to save my marriage, or I lost my mother, or My wife if cheating on me, or My kid is thirty and won't leave home, that sort of thing. Whatever it is. Brief.

The therapist then hopefully responds with an empathetic remark, like, Oh, dear. That must not feel so good. Let me see what I have for you, see if our schedules match up, if I can get you in. When did you want to come in? What day/time is best for you?

IT DOESN'T HAVE TO BE ANY MORE COMPLICATED THAN THAT.

Then, at the set appointment time, the patient discusses the problem and the goals and objectives of the therapy, assuming that these are actually important to him. Sometimes they're not. Sometimes people really do just want to talk, and talk, for weeks and months, indefinitely, and that's fine, too.

But if a patient has something in mind, certain goals to accomplish, the therapist should somehow communicate that these can be accomplish. The therapist should have a clue as to how. Because face it, the patient doesn't.

It's like a first and second date. You really don't have to see a person a second or third time if you know, deep down, that it's not a good fit. Therapy is a good place to work on NOT being co-dependent. It's a good place to put yourself and your family first.

Okay. Go get 'em.

Copyright 2008, therapydoc