Monday, July 18, 2016

Snapshots: Baton Rouge, Nice

First, Baton Rouge.

Three police officers, shot down. One, just vacuuming his car. I saw the video, the reenactment. The shooter, an ex-Marine, hides behind the corner of a convenience store at a gas station, peeks out, eyes his target, an expert marksman, takes them down.

What is this?

At first you think, Oh, another reverse racism thing, Race in America, the unsolved puzzle, the ultimate in displacement, the psychological defense, placing one's negativity, anger, on someone, something else. If I come home angry and slam a door, or kick the dog, my anger is now in the door, it is the dog's problem. I feel better, momentarily

An immature defense, and too simple an explanation for recent murders in Dallas, five policemen were killed, nine injured, and now . . . more dead in Baton Rouge.

But this massacre is different; one of the policemen, one of the victims is not white, his skin tone is closer to black, so there must be some mistake.

The perpetrator, Gavin Eugene Long, reached 29 short years of age yesterday, the day of the shooting, a birthday, death-day celebration. He self-identifies as Cosmo Setepenra on YouTube, an author of three self-published books, a life coach, and the leader of an extremist group, the Sovereign Citizens.

Protests are not enough, preached Cosmo. Violence is what is called for in the struggle against the government of these United States, a war against the police. He thought the violence in Dallas a good first step.

To me, first glance, this is a man in a florid manic episode, full-blown, psychotic and narcissistic, a person whose reality testing has likely been compromised by mental illness. His words:

If anything happens to me is a reference to his suicide-homicide. Youtube took down his videos, but they're nested in the link above.

An ex-Marine, he had military training. This would be an asset, should one become paranoid, want to take a society, even one with democratic ideals, down.

A therapist would maybe say, "They are only ideals, the government is the means to realize them. It may another two hundred twenty years to create a perfect society. Let's strive for better. How can you make it better? Let's talk about your ideals."

But most probably Cosmo needed another kind of doctor, too, one to give him something that would help him sleep a little, take off that trigger-happy edge.

Nice, France     
Fire Works, Evanston, IL


But first, a story.

Always a fireworks fan, the Fourth of July has become a bit much the past few years. Alley displays are out of control, fire crackers and rockets explode throughout the night, usually a lovely summer night in Chicago.

You want to keep the windows open. The dog covers his ears with his paws and moans.

But watching the faces of the children at an authorized beachfront festival is irresistible, and the music, so,patriotic, upbeat. This year my grandson invited us to join him and his parents to see fireworks. FD suggested we skip the crowd, watch from the top level of the hospital garage near the lake. Perfect for me.

We hadn't counted on security chasing us away.

As an alternative, FD drove us as close as he could to the beachfront, dropped us off a few blocks from the action. We would be in the thick of things (the child among us wanted to do this, anyway, hadn't particularly liked the garage rooftop).

Every street to the Evanston, Illinois beach cordoned off, saw-horses blocking traffic, blinking red, pink beams flashing from flashlights. No vehicle entry to the lake.

You don't think, Well, a truck could plow through that.

But now you do.

When I told a friend that it hadn't been my first choice, going to see fireworks where hundreds of people would be gathering, a jihadist's dream location, and a symbolic gesture, too, this being a national holiday, she told me,
"You can't stop living. That means they won!"
I thought that ironic. They stop others from living.
He had a history of mental illness, according to his father, two nervous breakdowns in Tunisia. Neighbors said he often acted nervous and angry.

Mohammed Lahouaiej Bouhlel murdered people enjoying their holiday, punished others for being happy, for having something he didn't have, maybe. Happiness.
Oddly enough, he flaunted the Koran, scoffing Islamic law, beat his wife, took drugs, drank alcohol and ate pork, according to his cousin. He did not, as far as anyone knows, act as an ISIS puppet.

What could have been done to stop this? He told police that he was delivering ice cream to the beach, so they let him park the refrigerated vehicle over night. They didn't bother to ask for a sample, we suppose. That might have changed everything.

Authorities had him days before that. French police intervened as he threw a heavy board at a motorist during a traffic altercation. He had priors for theft and violence.

Mental health professionals had him, too, the ones treating those nervous breakdowns, and his family knew he could be violent, the potential was there.

Nobody reeled him in, however, when it mattered, when that divorce went through.

Sometimes these things aren't as complicated as they seem.

Great, but what's a professional to do? And law enforcement can't deprive citizens of their rights. We've all watched Law and Order. 

It becomes what might each contact have done, each person who comes into contact with a Mohammed Bouhliel, or a Gavin Long.

What would I have done, had the Bastille Day terrorist in Nice come to see me?  We'd have talked about that marriage, and his anger.

Gavin Eugene Long wouldn't see a mental health professional. He would be the problem of his commanding officer, and likely a military wildcard. But he had a commander, once, who might have picked up on that mania, had he a bit more training.

And we haven't even talked about Bowe Bergdahl, a very different story, an American soldier who walked off his post in Afghanistan, only to be captured by the Taliban and released in exchange for five Taliban leaders in Guantanamo Bay.

(Spoiler alert, if you haven't listened to the podcast, Serial).

What possessed Bowe to walk off, we want to know, ultimately costing the world, not only the US, perhaps hundreds of lives in the future? Do Taliban leaders return home and take up knitting?

Bowe had schizotypal disorder, we learn on that second season of Serial, and should never have been in combat. He had been diagnosed, then sent off to war, couldn't take camp, and the hypocrisy of command. Took off.

O're the rockets red glare, the bombs bursting in air, gave proof, through the night, that our flag was still there.

I don't care what anyone says. Next year, I'm staying home.

therapydoc



Friday, July 08, 2016

Taking Notes

When I told one of my friends that there's no way I would remember the most important, the most salient details of a therapy visit if I didn't take notes right then and there, she said, "Well, you wouldn't be my therapist. I need someone totally looking me in the eye."

I didn't tell her that I could type ninety words a minute and never have to look at the screen.

I'm not exactly sure how they teach note-taking in graduate schools anymore, hopefully the importance of a good genogram (family tree diagram that indicates alliances), among other things. In some Masters programs, surely, the old process recording is still taught.

A process recording is what is done in the courtroom. You write down, verbatim, word for word, what the client said, although he's not on the stand. It is useful in many ways, not the least of which is that when there's a need for clarification, nothing's more powerful than telling the patient, "Let me see what we talked about last time. Oh. Here it says, in your words. . . ."

People forget.

I've been deposed a few times, and in that process the lawyers on both sides of a case review your notes before the interview. They always joke about mind, tell me my notes are illegible, ask me to read back what I wrote. My response would be, Why do you think they're illegible? No one is supposed to read them but me. The writing would be difficult to discern, even for me, reinforcing the myth (maybe) about doctors and penmanship.

But that was back then, in the day, pre-electronic everything.

Shredding charts every seven years, over time, became quite the chore, and being more ecologically green, the whole thought of paper, paper, everywhere, just felt wrong. So, for a few years now, the typing began, and it is more elegant, and easier on the eyes, having the luxury of seeing words on paper and not having to wonder, What does that say?

Oh, but how to keep them safe from hacking.

Here's my system, feel free to try it. Each patient has a flash drive, their very own, that lives in the paper chart with a full name and account number, housed in a locked file drawer. Each visit, the record is typed, signed with my initials, encrypted with a password, and saved on two master flashdrives that are inserted into a USB hub that can hold several flash drives. Then, every month or so, the patient's own flash drive is inserted into that and the notes are copied to it.

This may seem tedious, but it avoids wear and tear on the flashdrives. They aren't inserted in and out so often that they lose their integrity.

Word 365 allows password encryption by going to "Review" on the menu and following instructions. Using a Mac, with "Pages," it is even easier. Go to File, set a password.

Once that note is complete, saved to the master flash drives, it is never changed, so the date never changes.

No names on any notes, no birthdays, nothing but a variation of the patient's true account number that I take off my billing program, also password encrypted on a old PC that is disconnected from the web.

Like paper charts, the master drives are locked in a file cabinet, still attached to the hub that I attach to my laptop the next time I return to the office to take notes. I turn off the Internet on my laptop while the hub with the masters is attached. Macs are supposed to be more secure, but still.

Nothing's saved on my computer. After the visit is copied to the flash drive, it is deleted.
But it is also saved on a cloud, later in the day, with visit information added to one long file, also password protected. That's done at the end of each day, when the Internet is turned on, briefly. Not that my service provider isn't safe, but it makes me uncomfortable working with patient charts.
Once the visit has been uploaded to the cloud to become a part of the patient's chart, when I need to review it, there's no waiting, no wear and tear on a flash drive. These won't last forever if they're swiped in and out regularly.

So when I need to refer to what was said last week, that's where I go, the cloud, where the entire chart is there for me to access, typed, not handwritten.

Lots and lots of passwords, but they are easy to remember because of an algorithm I made up with patient initials and two of the numbers in the account.

Here's a sample patient visit.

Pt Code and Date of Visit
Current Primary DX:
Process recording
Current Symptoms:
Plan for the week:
Long term Goals:   same  ___  new____
New Goals:
So let's say the patient's name is Jennifer McGooglestein Romiretsky. One could conceivably code her as JMR289703 if 289703. The 289703 would be the account number provided by the billing program. Or you could cut it back to JMR03-1. The 03 is the end of her account number, and the -1 means she's the first JMR03.  You might, for example, also be seeing John Miguel Robertsonsteinenvasser, who has the chart number 297403. He would be JMR03-2.

See how easy this is? And you thought therapists mostly think about despair, panic and suicide. Not so.

Now let's make up the rest of the visit note. Anything in parentheses wouldn't be in the note)
Visit Specs: Pt Code, Date of Visit, and Procedure Code : JMR03-1   6-30-16   90837
Current Primary DX:  F33.1  (Major affective disorder, depression, severe)
Process recording: OMG! I hate my life! Yesterday I slept too late, walked into the elevator with my boss. He said, "You look like ___. Why do you even bother coming to work?" And truthfully, I couldn't make it through the day, not sure how I did, and on the train home I fell asleep, realized I'd left my phone at work. I don't even know if I can stay awake for this visit.
(etc. only write what feels important)
Current Symptoms: fatigue, hopelessness, hypersomnia, 
Plan for the week: See Dr. Promtigyoplicweiner for medication re-evaluation, use imagination exercises discussed last week
Long term Goals:   same  _x__  new____
New Goals: none
           TD   (your initials)

How easy is all of that? Feel free to ask questions.

therapydoc