Traffic and Weather

I’m taking a 7th inning stretch, moseying into my colleague’s office to say hi. She’s aggravated because patients aren’t showing up.

“Do I charge them?” she asks.

“For sure! Charge ‘em!”

I’m in a take-no-prisoners mood, who knows, why, but have spent a good deal of the day working without a break. And the day started at the hospital, checking on my father. Every morning this week is at the hospital, which I don't mind, but I've been driving there, which is bad enough, and hate the parking lot, going around and around and around and around and around.

And there's no time to get home after the visit to change clothes to ride my bike to the office. There just isn’t time to waste.

So in general, I’m a little out of sorts. And some of the crank, for sure, is my father’s because he’s the helpless one lying around in a hospital bed.

I haven’t even told my colleague this, none of it, because (a) there hasn't been a lot of time to talk, and (b) I don’t want to talk about it. That’s what a blog is for anyway.

She says, “Charge them? How do I charge them? Should I call them up on the phone right now?”

“Don’t be silly! When you can talk to me? You'll get a call for another appointment and will say, ‘By the way, you know you owe me for the last visit. You didn’t show.’

And your patient will say, 'Oh, drat! I forgot!' or will spill out some excuse. Then you'll give that little speech we give." (Most professionals have a variation of this one.)

Sure, I understand, but you're supposed to at least call, we had a deal, even if you're sick, or have a funeral you have to go to, and you stole another patient’s time, because there's always someone who wants a cancellation. But no one could take your spot because it wasn't open cuz that didn't happen. That's why we charge, it's why I charge. Makes people more sensitive to other people the next time.

"You deliver the lecture," I tell her, "get paid and are no longer resentful and grumpy. The world is beautiful again."

“I’ll try it,” she says.

She might, but she probably won't charge. We social workers can be all mush.

ANOTHER STORY

So today I say to FD, “I’ve had it with driving. I’m riding my bike to the hospital and from there I’ll ride it to work. I’ll leave early so there's plenty of time.”

He’s skeptical, “Uh, that adds 11 miles to your bike ride.”

“No way,” I say. “And anyway, it’s all bike trail.”

For the most part it is bike trail by the river, meaning easy riding, and the only real danger is urban cougar, the feline species, and an occasional tricyclist. (By this we mean child on a tricycle, not someone on an antidepressant).

“You’ll see how far it is. It’s going to be tough. I can drive you, do what I have to do, then pick you up at the hospital. Then you can drop me off at work and have the car,” he continues.

“Senseless. It’s a beautiful day. Birds gotta’ sing, girl’s gotta’ fly.”

And it is fine, it truly is, for the first mile and a half. I’m very out of shape, have had no time this summer to get on my bike most days, and when I have done it, it’s been slow going. I’m not the person I was even a year ago. Enjoy your youth, my friends.

But I get to the hospital, no worse for the wear, and lock up my bike, take off my helmet and take a deep breath. I’m a half an hour late and for sure have missed the doctors. I want to talk to one of them, at least. Anyone on the team will do.

I get up to my father’s room and he’s rearranging the hoses and tubes that are sticking out of his arms so that he can sit down comfortably in his recliner. The drips are full of diuretics to get the excess water out of his body. The kidneys aren’t working, the heart’s not working, nothing’s exactly doing what it’s supposed to do. He’s braced himself for disaster and has been very philosophical.

“The food here is good, but I’m not hungry.”

“You’re sick,” I say.

“Yeah.”

“And it’s sickening, right, being sick, so how could you have an appetite? It would be weird to have an appetite, I feel.”

He laughs and shows me the paper and pencil review he’s given the nurses and the doctors so far. He has been very positive, very happy with his care-givers.

“I love it," I say. "You know, there are people who won’t give a positive review. No matter what, they will find something wrong with the people who are just trying to get through their day, trying to be helpful.”

“And those people are wrong!“ he confirms quietly. “They should write a good review anyway.” He would tip even the worst waitress. “Even if they’re terrible you tell their bosses how good they are. Then they’re not so terrible. They get better.”

Right, Dad.

We banter about nothing, and I realize that if I don’t get back on my bike I’ll be late for work and can’t let this happen. Mom will take the next shift pretty soon, anyway. I buy a bottle of water at the snack bar before leaving.

The ride to the office is LONG (about seven miles, FD is right on the money) and I have a sandwich in my backpack and I’m thinking maybe I should stop and eat or have a drink. There are plenty of park benches calling my name, but worry that if I do, and something happens, maybe a flat tire, I’ve wasted time eating and drinking. I hate being late. And I’m not hungry, anyway.

But I get to work in plenty of time and my fish (2 baby maroon clowns) are thrilled to see me. I feed them and they think they've died and gone to heaven. There are patients who have been calling all morning long on the office line, my cell phone, too, that I should call back, so I get to that. Eeeny, meeny, minee moe.

By 5:30 my back hurts and I reach for the Advil, pop open some email, too. One says in the subject line, 'I'm venting.' Why not? What's a therapist for?

There’s one more appointment to go, a 5:45. I get the call.

“Doc?”

“Yup, where are you? Caught in traffic?”

“Yes, how did you know?”

“I’m a genius.” (I don’t say this)

The city has been impossible, one of the allures of biking. Chicago has a short summer and construction begins and we end, so to speak, with the good weather. It is possible to spend the best hours of the day behind the wheel.

“Oh, a little birdie told me.”

“By the time I get to your office our time will be up,” he moans, remorsefully.

“We can talk on the phone,” I tentatively suggest.

“Okay!”

“But you’re in traffic, I just remembered, and I want you to pay attention to the road.” And I’m thinking, I can leave! I can go home!

“Can we reschedule?” he asks.

"Lemme look."

I find him a spot next week, knowing there's money lost here. I tell him, “I’m not charging you.”

“Thanks!” He’s so happy.

“Have a great night.”

Fact is, I could have charged him, and he would have gladly paid me. But he is powerless here and I am happy here and why would we punish either of us for either of those things? Hey, and he's called.

I pack it up and am out the door. It’s threatening rain, but you know, it’s that light summer rain that doesn’t bother you, the kind that sort of wakes you up, reminds you what it’s like to be a kid again, not worried about things like rain.

therapydoc

Your Letters

I've told people who email me and ask for help with personal issues that I can't do this online. There are many reasons, but the most important reason is that. . .

I'm petrified that I'll make a mistake.

We're close, there's no question, and bloggers and blog-readers are a community and a close one at that, loving even. But there's no way to do a real evaluation from a letter, even from a blog (although they're revealing, no question!)

But here's the deal.

When a person contracts for therapy we sit down in a room, eyeball to eyeball, depending upon the capacity for eye contact, and I listen for about 45 minutes or an hour, depending upon what we've agreed upon from the start. Then I listen for another 45 minutes to an hour on another day, giving both of us time to think, and then maybe yet another 45 minutes, and then another.

So it's a lot of active listening, basically, all the while watching your body, your face, your dress, and all that listening and watching shapes a comprehensive extended socio-family-medical-sexual history.

Then we probably will add other people in the flesh to the mix, other important players in the system. The first person to have made contact is considered the "identified patient" in the system, usually.

Eventually, sometimes sooner than later, I'll make several psychological assessments, perhaps with the help of another clinician or medical doctor's input, also systemic, and add a few numbers maybe to a person's medical history via this lugubrious process we call diagnosis.

It takes more than a DSM IV, not to make a big deal about it. But assessment is half the battle..

And then there are HIPPA (government privacy) laws to contend with, confidentiality and privacy are critical, so how do we address that on the blogosphere. Even if someone broke into my building, picked the double locks on my doors, somehow cracked the ones on the cold steel filing cabinets, nobody could read my handwriting. But you can all read my Ariel, or whatever font this turns into when it's published.

This is my long way of telling you that using this space, this blog, to advise people about their personal problems just can't happen. You wouldn't want it, really; it's not what you want, a half-baked consultation.

I'll support you, even try to give you chizuk* (strength) but will surely recommend that you get real therapy when you write to me. Everyone needs it, if only to deal with somebody else. We humans are impossible.

But I'm thinking it is possible to answer generic questions here. It's risky because context is missing. So much context is missing when you ask me questions by email. And if you provided it, if you wrote me pages upon pages of detail to fill in the context, would I read it? Would I listen? Would you keep on working after work?

Probably not.

I'm sorry. Don't hate me.

But lets give a few questions a whirl. We'll do it right now. See how it goes. You add the context, color the meanings in your comments, and I can spin them back. An intellectual exercise, for teaching purposes, not therapy.

We'll consider two of them here, then in the post below this, you'll have a little more to chew on. I guess I can't let go of that topic of shame. Not just yet.

But let's start with an easy one.

Recently a reader asked:

How do you handle it when you have to cancel an appointment?

I say that I'm sorry, but I have a conflict and have to reschedule. Rarely do I specify what that conflict is, unless there might be some lesson in that, some therapeutic import. An example might be My family (parents/kid) needs me. Family is important, you know, sometimes more important than anything else, even work.

If I haven't given the patient 24 hours notice, then the next visit is discounted somehow. We figure this out. And sure, we talk about it if necessary. For about three minutes.

When a patient cancels on me, I don't want to hear more than that they were sick or had to go to a funeral or someone else was sick, and when can we reschedule? Unless it's face to face, during a visit. That's your time.

That was easy. Let's kick it up. A commonly asked question:

What should I look for when I shop for a therapist?

This is tricky and the answer depends upon what you need, obviously. But if I personally were looking for a therapist I would ask:

Will you be consulting with my primary care doctor?

I want a Yes. Or if the identified patient is a child,

Will you be talking to my kid's teacher?

Or, also, and

Do you also treat other members of the family? Do you think you'll want to do any family therapy?

How do you deal with my confidentiality if you do?

Did you get some family systems training in graduate school?

There's more to look for in a therapist than that, but those are some of the issues that surely matter. They're an indication of how a therapist thinks (and you're asking me).

Other therapists might say that warmth, humor, compassion, and the capacity for a therapeutic relationship exceed all. And they may be right.

But I'd look for someone who thinks big, too, who uses my world, not just his or her brain.


therapydoc

*Chizuk, chee, hard "ch" rhymes with "me"-zook, rhymes with book; this word chizuk means strength

History and Strategy

You might find this question and answer interesting.

A reader writes in response to the shame post, The Bistro and the Date (below). First he answers those all important questions* then asks

How can I keep my boundaries tight when my family tries to sabotage what I think should be a moratorium (a.k.a. cut-off ) for the sake of my mental health?

The reader worked for years to distance himself from his verbally abusive father, a man who denies his emotionally violent parenting to this day.

If I were the reader's therapist, I would explain that it is shame that is buried under those layers of denial, that his father and he may not be all that different. The difference is subtle but important. His father's shame is so tragic, so toxic, that it is no longer conscious, he has successfully defended with that most primitive of defenses, denial, unconscious denial, the worst kind. He has to believe himself a good dad. Anything else would destroy him. He hasn't psychic permission, he hasn't given himself permission, to be imperfect.

An identified patient like our reader will sometimes try to cut off communication with people in the family who were "dysfunctional" "toxic" "violent." He may try to hang onto one limb, to save a relationships with a sibling, the seemingly healthiest member of the family.

But this last branch, his only connection, will eventually become angry and resentful, may even threaten to cut him off unless he reconnects when parents become elderly and physically unwell. Siblings needs one another when that happens, when there's family work to share.

We're addressing cut-offs here, obviously. The reason people cut-off their families is not that they don't need them or feel responsible and connected to them, but their families became sources of pain. Families do abuse and shame, betray members. Mis-steps such as these (including addicted siblings who visit and steal the silverware) make us wary. We put up boundaries.

It's the permeability of the boundary that concerns me. Boundaries need to breathe.

Parents who emotionally abuse with words, who shame their children, who fertilize a child's self-doubt, sense of inadequacy, and unworthiness have to be sealed off for a little while. The fence needs some sturdy nails. Not electricity. No, I won't block the metaphor, let's keep it going.

See, you need a fence, because children who grow up with verbal abuse believe it and when it's a steady stream of negativity will join the dissension, believe the words, find someone else who will abuse them, or do the dirty work themselves, continue the lashing, cut, try suicide. Maybe succeed.

This is why therapists will advise conflicted patients to stay away from the source, to protect themselves from further emotionally violent communications with family. Heal.

But we're all human. We will want to cling to the healthiest member of the family, perhaps the one who saw the abuse, who may have also been a victim. And ultimately cut-offs fail. The family guilt and invasiveness is stronger than the average soul can stand. Therapists often get cases like these when they're sinking, shored up by a quick but ineffective hospital stay.

Sometimes during that stay the family has been involved. A family therapist like me will keep that going if I can, at discharge, will contact family members (with the patient's permission and release of information). I work to convince the family to let me take over for awhile, to give the patient less of themselves, not more. But don't worry. We'll be in touch.

And I stay in touch.

It takes time, but if a family therapist can work with the healthiest branches, things can change, really change for the best. Branches only need be a little green to grow. People change late in life, given the chance, given the relabel, the opportunity to be a hero.

But what do we do when it's too late for that, when the cut-off is fragile and not working, and Dad is sick in the hospital and our Identified Patient hasn't the strength to deal?

Not at all uncommon. The sibling, the one care-taking Dad, wielding the chain-saw (help me or you're no longer my brother/sister), is clearly of the tougher child variety. But even the tougher children wear down when they have to care-take sick parents. They look tough. But it's just for show.

Family therapists push for direct communication. First the identified patient has to be straight with his or her sibling(s), the care-taker(s), either by writing (under a therapist's direction and editorial skill) or calling (in the therapist's presence) to communicate something along these lines:

I'm going to call Dad or write to him and tell him what's going on with me. I'm sorry you're stuck with this, but for the time being I probably won't be visiting. I'm not quite healthy enough yet, but I'm working on it. Here's what I'm going to tell our father:

And here is what the identified patient would tell his or her father, either by telephone or in a letter, not face to face, something along these lines

I'm sorry that I'm too sick to reconnect with you right now, that I'm no good to you. Some children, the ones with big issues, get a little funky when parents get sick, and that's what I am right now, laid a little low, too depressed and withdrawn to get out of my shell to help out with you, visit with you.

I know you don't believe in mental illness, but you and I are different like that. You probably see this as a weakness and an excuse. So be it. It's real enough to me to make visiting impossible right now. I just can't do it. I hope that you don't hate me for it. I imagine you do.

One day I'm sure I'll regret this decision, not seeing you, not helping you. It doesn't seem fair to do this to you, especially now. But I don't see life as fair. A parent raises his kids, gives them his all, and just when he needs them, they're gone.

I have bad memories of us, and they haunt me (this is called chipping denial, you're not accusing him of anything). I have to work through things, mostly negative thoughts about myself, nobody else. You did the best you could. You tried to parent the best you could.

I feel like a bad person, a failure, for not meeting your expectations.

I'm in therapy, working on my own set of expectations, and how I'm going to live with myself when you're gone.

Maybe I'll get it together soon. Who knows? I don't expect you to forgive me for this or to really understand me. But despite your take on mental illness, I think everyone gets depressed sometimes. Maybe even you.

And then the identified patient stops talking or signs off (he doesn't have to write "Love" that's up to him) and hopes his father begins to talk about his own feelings, his own depression, his own childhood abuse, knowing he probably won't.

But he might. They sometimes do.

This is a strategic intervention, full of lies. The identified patient is not remorseful, probably doesn't even believe his father did the best that he could. The identified patient may never regret not talking to his father, cutting him off.

With good therapy, he will live with himself just fine once his father has passed on. He probably won't care. Some celebrate. It is survival we're talking about here. And you can't always sleep with a person you perceive as the enemy. You can't always go home just because they're ringing the dinner bell.

The therapy, surely, is about changing that perception, the one that identifies the parent as the enemy. If that's possible.

To do that, you need history. You need the extent to which the parent suffered abuse during childhood. If the identified patient doesn't know the history or denies transgenerational abuse, I make finding out a therapeutic objective. It's there.

He was criticized, abused, shamed. Not loved. Abandoned. The child who cuts him off finishes the job. It's the unkindest cut.

In family therapy you want to get to a point with an abusive parent that you can admit you're not so tough. You don't know how he survived his childhood. How did he do it?

Families can toughen us up or wear us down. The resilience variable is having a healthy adult around who counters the abuse, one who puts a hand on the abused child's shoulder and says, "You're a good kid, a wonderful kid. You'll grow up. You'll get out. Talk to me any time. Tell me everything."

We can get into calling authorities about child abuse another day. In a word, Yes. Call.


therapydoc

*Those questions include:

Did (your father/mother/guardian) call (you) lazy?
Retarded?
A loser?
A fool?
Stupid?
With gusto? With sarcasm? With hate? Disgust?
Were there tirades directed at making people feel badly about themselves?

As they pack up to leave

An Expedia itinerary

A St. Francis Hospital discharge summary protocol

An In Style Magazine with Sandra Bullock on the cover

Leggos, big ones, surprisingly not all over the place

Bibs, dirty

Many ping pong balls and similarly-sized wiffle balls in corners of the living room, dining room, kitchen, and family room

At least 7 empty matzah or cake meal cans* used to play the Grand Prize Game (that's why there are so many wiffle balls). If you're too young for Bozo the Clown, you can't possibly get this.

a high chair piled high with things that don't go on a high chair, like Passover Hagaddahs and sweaters

many paper plates, some clean

cognac, barely touched

many, many aluminum foil containers of varying sizes, strewn earlier around a one-year old toddler who is now asleep in her bed

an inside-out long-sleeved forest green striped shirt, size 4

a lime-green pair of cargo pants, size 4. Empath Daught: I couldn't resist these.

A tie-dyed burnt sienna and gold body suit, sized 12 mos., from India, a present from Uncle Bean to H-squared, but it's too small. Which is totally a shame.

Jonathan Safron Foer's second novel, how could you be surprised, he is my favorite author. It boggles my mind that one person can be so young and yet so psychologically brilliant.

sherry, kosher of course, not all that good, no where near as as good as the wine my father made in our basement, also hardly dented for obvious reasons

A car seat and 2 "child" seats. They had neither in my day. How did I make it?

A Reader that begins, "Who baked the cake?"

One of those toy vacuum cleaners that seconds as a popcorn popper.

More leggos.

More books, mostly about Spider Man, no one knows why.

A very small apple on a stuffed chair, Jonathan

sippy cups, 4 of them, some with apple juice, some grape juice, all dangerous if left unattended for too many days

2 magna doodles, one with a Pixar Toy Story book attached

Hungry Hippos. I know, the noise did do me in.

2 vases of wilted flowers with that crud that builds up on the inside

water bottles with varying amounts of left-over water

machzors and a sefira counter (you don't want to know)

Several neck ties.

Oh, that's enough. My voicemail messages sound urgent. Mainly did I get the LAST messages about the cancellations? So the 11 people I had on my schedule for today (it is 1 a.m. as I write this) have shrunk to 8, and I've learned there are 2 very nervous people who do not trust that I receive voicemail if I don't return their messages, even though my voicemail clearly says, I probably won't get to returning your messages. But who can blame them for being nervous?

*cake meal is a "fake" flour that some of us use on Passover' I know no more than this.

Sure. I'm looking forward to eating chometz (bread, or anything with flour given half a chance to rise), as soon as I get an appetite (I'm so stuffed). It's been a long 8 days.

Thank G-d.

Copyright 2007, TherapyDoc