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Friday, May 31, 2013

How To Make a Terrorist

Tamerlan and Dzkohar Tsarnaev, the Boston Bombers
It seems that when someone plans or executes a multiple murder, I have mentioned schizophrenia. Some say I see it in my sleep, but there is reason to the madness.
James J. Lee Discovery Channel


James J. Lee didn't like the Discovery Channel's programming. He thought Planet Green should encourage mandatory sterilization of the human race. His website is replete with paranoid ideation.
He didn't kill anyone, but was prepared, carried weapons. James J. Lee went down when police raided the building where he held his hostages.

James Egan Holmes, the Joker who pumped 33 bullets into twelve people in a Colorado movie theater, had been treated for mental illness. Unable to communicate verbally, he drew the doctors pictures of what went on in his head. He didn't just go postal.
James Egan Holmes-Batman Joker


Cho Seung-Hoi, a student at Virginia Tech, murdered 32 and wounded 17 others before killing himself. With a diagnosis of either Schizoid Personality Disorder, prodromal to Schizophrenia, or both, he likely had the angst of a psychotic.

What are we to think about the Boston Bombers, Tamerlan Tsarnaev and his brother, Dzhokhar?  Is there something sick about them? Is being pro-terror a sickness?

Most think that the older brother influenced the younger, that Dzhokhar looked up to Tamerlan, did what many younger brothers do, tagged along. Families are powerful.

Tamerlan, taken down by the police, has been implicated in other murders, back in 2011.  A drug deal gone bad, three dead. Tamerlan's alter-profile, a religious Muslim who used or sold drugs, doesn't sync. The religious tend to be aesthetics, not drug users. They have conscience. This is clearly a complicated person. He had friends, too, people who were with him at the time of the murders, partners in crime.

Ibragim Todashev, who died during the interview with authorities, not only confessed to his direct role in slashing the throats of three people in Waltham, Massachusetts, but also fingered Tsarnaev.

Seems the victims were Jewish, at least one, Brendan Mess, who boxed with Tamerlan. The gloves came off, apparently, over something more than drugs and money. Perhaps hatred.

Investigators of the crime reported at the time that the heads of the three victims were pulled back and their throats slit ear to ear with great force. Marijuana was spread over the bodies in a "symbolic gesture," and several thousand dollars in cash was found at the scene.

When parents talk about their kids smoking pot, stealing, acting out, they want to believe that other kids have brainwashed theirs. It would be nice if youthful criminal behavior was a stage, a coming of age thing, having to prove independence. A way to be cool, garner the respect of their peers.

But acting out, scoffing laws, sociopathy, isn't a stage. Family dysfunction and genetics conspire to interact with social influences, shape personality. Tamerlan's mother, for example,  surely a social influence, doesn't respect the law. She's been arrested for stealing expensive designer dresses from high end retail stores. She allegedly ripped off the sensors, stole the dresses, then attempted to return them, cash out.

Tamerlan's uncle, Ruslan Tsarni  speaks of his nephew finding a new friend at Cambridge, a convert to Islam. Misha, from Armenia, a neighboring region of North Caucasus, lured Tamerlan away from the family. He told him that boxing, the youth's passion, isn't the way to God. This friendship, according to Mr. Tsarni, changed the Boston Bomber.

The US government is calling Tamerlan and Dzokhar self-radicalized terrorists, but they apparently had help radicalizing. Others are complicit.

No evidence of Schizophrenia. The 2011 murders point to Antisocial Personality Disorder, however. The features? A callous disregard for exacting pain and suffering, no guilt or remorse. Begins in childhood. No auditory hallucinations. We call it a personality disorder because there is something seriously wrong with hurting others. It is antisocial. The current research buzz is to have compassion for those who have the disorder-- abnormalities in their brains.There is a movement for leniency in the courts.

Except that 
Antisocial Personality Disorder is usually picked up in early childhood. These are the kids who throw cats in the river, who trip little old ladies, who cut up insects. 

The lite version, when a child or an adult knows enough not to get caught, when the behavior is sneaky, the crimes less overt, when cheating matures to rising up the corporate ladder at the expense of the reputations of colleagues, we think-- almost a sociopath

It could be that Tamerlan was an almost turned definite. We're sure to find out over time.  

One more story of disaffected youth. William Plotnikov's son Vitaly, shot down by police in Russia last week. Plotnikov had turned on his son, called authorities. He was concerned that Vitaly left his Canadian home to join an Islamic terrorist cell  He did not want his boy responsible for flying arms and legs, mayhem, destruction. Russian authorities found the young man in the woods with known and wanted gang members. Weapons  abound, Kalashnikovs everywhere, ammunition, improvised explosive devices. They took no prisoners. 

Ironically, Vitaly Plotnikov is thought to have known Tamerlan Tsarnaev. 

Vitaly, like Tamerlan, turned to radical Islam as a young adult, bored. His father says he always looked for excitement. Strangely enough, he had boxed, too.

So what is the recipe here, what does it take to become a terrorist, or a jihadist? We're aware that self-proclaimed jihadists believe in personal agency, their own justice. Are terrorists modern day Robin Hoods? Is the creed to rob from the rich, give to the poor? They identify as idealists, for sure, which might be cute, were the goods not human lives.

This is so complicated, it begs a new DSM diagnosis. We'll call it Terrorist Disorder, just to be clear: 


Terrorist Disorder

I. To make a diagnosis, must meet eight of the eleven criterion below.
A. Age 16-29
B. Tends to split beliefs, events, people, into good/bad, black or white, idealization or devaluation.
Splitting between one extreme or another is considered the defense of an immature personality-- reduces stress. In adults It is associated with Borderline Personality Disorder. Splitting is normal in early childhood.
C. Perceives those who do not agree with extreme beliefs as weak, ineffectual, cowardly and inferior. Minimization mirrors the rationalizations of persons affected with Antisocial Personality Disorder. It is not limited to Antisocial Personality Disorder, however.
D.  Describes spiritual attachment to God, having a mission inspired by God to better all of humanity. May feel appointed by a Superior Being to perform mass destruction of human life (in the absence of Schizophrenia).
E. Takes on self-denial, aestheticism associated with mystics, chooses a subsistence lifestyle believing the afterlife will be more rewarding.
F.  Embraces a creed, belief system, or manifesto that is either religious or political that the majority of citizens in peaceful nations would deem dangerous and antisocial. 
G.  Either volunteers for or is recruited by a group or an individual that recognizes psychological vulnerability, a need for approval, and/or inclusion in a group.
H.  Before associating with a jihad group, was disaffected, depressed, and underprivileged, suffered financially. The depressed mood and emotional detachment are relieved upon identification with the creed, sense of community, and purpose. 
I.  Manifests features of a manic episode: inflated self-esteem, grandiosity, a decreased need for sleep, flight of ideas, and goal-directed activity.
J. Identifies with a group that serves as an alternative family, brothers and sisters who advocate criminal acts, destruction and violence, mass homicide and suicide.
K. Cuts off entirely from former family and friends who do not advocate violence.
 II. The patient is not suffering from a Schizophrenia and does not meet the criterion for Antisocial Personality Disorder, but may suffer Bi-polar Disorder or other Axis I and Axis II disorders.

What did I forget? 

Oh, why not see it all in action. 
Michael Lavigne's The Wanting


Read Michael Lavigne's new novel, The Wanting, an engaging, fanciful (in its way) treatment of the development of a Palestinian suicide bomber in Israel. 

Amir, one of the many Jerusalem Bombers that we are all too complacent about today, a fictional anti-hero, wears an expensive suit, carries an expensive brief case. He blows himself up, takes others along.  

Wanting is the essence of a terrorist. Wanting. Dissatisfied. Told in three voices, Lavigne is master of first person. We hear from: (a) a survivor of the bombing, a middle-aged Russian architect, a man who doesn't even identify with religion; (b) his adolescent daughter who changes in its wake, becomes vulnerable to "religious educators" with a political agenda; and (c) Amir, the regretful terrorist, the haunting third voice.

Mr. Lavigne researched the book for three or four years. He granted permission to the following excerpts.  The terrorist, narrates. 


(1) In the days leading to my shahadah, I was immersed in prayer. I bathed my feet and hands in the waters of el-Kas, the well of al-Aqsa, which they told us rises up from the rivers of Eden, and I entered the great mosque and stayed there for hours on end, meditating. Then I would take the bus back to Jabal, to Walid's place, where we would talk and study late into the night. Only then would I sleep a few hours, lying between Walid and Fayez on the hard floor. In the morning we would wash, pray, and prepare a little hummus and tea. He always had dates and figs, sliced apples, and sweets of various kinds, and at night there was usually maqluba. We were never hungry, even though we fasted on Tuesdays and Thursdays.

(2) The slave may rebel from his master, the son from his father. Your father does not have the power to stop you, for your power comes from Allah, praise be to the All Merciful.

(3) And Yusuf al-Faruk trained me day and night and I, like a falcon on the path of All-Knowing Allah, swooped up his leavings. These were my happiest days. These were my days of light. "For the call!" I repeated after him. "For the Muslim Brotherhood!"

He writes poetry. But what have we here?  Religious asceticism, a call to a mission, the cut-off from family, the mentor. Religion, many of us are aware, feels good. We are called, follow a creed because we believe it is right, and that others are probably wrong, not as right. Some of us believe that nonbelievers will ultimately learn the error of their ways. One day. Rarely do believers take matters into their own hands.

When it is a matter of personal agency, when the methods are violent, when even parents and friends are disavowed, cut off, when human lives are dispensable, clearly something is wrong, something is sick about the creed. It is a cult, not a religion.

Deprogramming is the answer, if there is an answer at all. 

therapydoc 






Sunday, May 12, 2013

On Mother's Day

It is like a Memorial Day, but in reverse. Rather than look down, we look up.

Many are not happy with what they see, is the problem, making a celebratory day more of a day of reflection.  It's not so easy, showing gratitude to mom, sometimes.

Much of a therapist's ordinary week is about the mothers that are difficult to see, to understand. There are the ones who are selfish (narcissistic), who think every day is supposed to be Mother's Day, and that every day their children should be gazing back at them with love, appreciation, and attention.

We speak in therapy of those mothers who are confused, too, who feel too strongly, whose emotions spill over on us, far too often, for whom life is black and white, or mostly black, and their children are supposed to change that, at least understand them. Their children are to think of them, consider them, respond to them right, as if there is a right way, right for everyone. It is very hard to understand these moms and their needs when our own need for a mother that cares goes wanting.

And we speak in therapy about alcoholic and drug addicted moms, too, many of whom have left us in the care of others, often an older sibling or to foster care; moms who are passed out somewhere, not necessarily in their own beds.

And we speak of mothers who are far away, who we left to live their lives without us, without sons and daughters because these special mothers (and fathers) launched us properly. We took off, married, found work, or merely . . .left, because it seemed the right thing to do at the time.  Far away. Dinner with Mom by Skype on her birthday, on Mother's Day. Sure.

And then, there are those of us who have lost children. For moms with this issue, what can anyone say?

Such an easy, happy holiday, let me tell you, to discuss in the week before the dawn, in the weeks before the holiday that many people actually dread. And we're not even talking about the brunches, which for many are insufferable. What are the odds that a brunch or a dinner is sufferable? Fifty percent or less? Yes, probably, depends how much champagne is poured, and that could make it worse, not better!

Nothing left to do, so why not celebrate Mommy Bloggers?  Because these kids, women, grandmoms, are getting it together, have found an outlet, a way to find sales and coupons, and share. They love their children and often their parents to the degree that they tell their tales to all of us.

Some are bringing up children they adopted, or have taken on foster children. Some are single and broke, or single and working, but have figured it out, how to manage a family, yes, and do it without the help of a significant other.

Let's celebrate everyone, who is a mom or who is not, because honestly, not everyone has a mother, many have lost one, and not everyone is blessed with children. A short list of bloggers who talk about their lives as mothers or almost mothers isn't a bad place to start.

I did a little cruising, searched for happy blogs and here's what I found in my first hour or two. If you think your blog should be on the list, email me or comment and we'll link over. Granted, it isn't as if I read very far, or got to know these bloggers, but I would like to get to know them, like I would like to get to know all of you.

Here we go.

What about What Not to Say, on Then I Laughed. Terrific.
:
Okay, on adoption,  It’s expensive, adopting, many future parents solicit to defray their costs, but then, boy, can they write!
And about that long road to success, Mom At Last 

Life for mothers is a mixed bag, but when your spouse is arrested, when life changes forever, you have to write about that, too. Life Turned Upside Down

How about single moms? Mom Solo, for one. And Single Parent Adventure.

For a peak at women who think out of the house, yes, do it on the road, try Mommy Adventures.

First time mother? Well, First Time Mom and Dad, obviously.

Lots of babies at once. Quadruplets always thrill me.

Need more of a' tude? Or a banner with heels and those dopey balls kids love to fall into? Cloudy with a Chance of Wine.  Or better,
http://hotmessmom.com writes about menopause

Then there are honest moms. Refreshing, since most of us lie every ten minutes, according to a Ted lecture I watched. Or some statistic close to that. 

And mom’s who have an occasional special kid, women who know how to love. Dysfunctional Dose

Crafts and recipes? The Photographer's Wife, Mommy Katie
Baby products? No end to these, but lets end it.  Or just products: These Four No More

Kvetchers, but not really: Just a Little Nutty
Taking care of number one, One Classy Motha. on body waxing.  

What we would expect, When Crazy Meets Exhaution
 One thing we have to respect about the entrepreneurial mommy bloggers who review, sell, direct the female blogger traffic-- they are the life of the blogosphere. For an incredible list of mommy bloggers, forget about mine, go to Bloggy Moms

There is such a thing as influential social media mommy-ing. They usually are giving away something.

There are the creative moms that make us feel totally incompetent, like Mom Candy.
And RealHousemoms.

Or those who inspire us to take out our cameras. Mom Photographer, for example.

And Mommy reviewers, who get to wear cool shoes in exchange for a few words on the blog, and post nice pics, like SunnyDayTodayMama.  And shameless product promos, who doesn't like a good ad, as in, I Gotta Try That.


We have to include Childless Mothers Connect, although I would disagree that all women have the heart to be a mother. Not every mom has it in her, is the sad truth. But the bloggers at this website have their hearts is in the right place, and we salute you.

And why not read The Mom's Day Eve, and grocery shopping:
For women who wanted children but never had them, age forces some level of acceptance upon them. Grief and regret transition to “it is what it is.” Seriously, it’s worrisome if you’re 64 and still crying at the sight of a very pregnant woman.
Yes, dear, but some do. The Happy Mother's Day marketing everywhere, begins in early April. It gets obnoxious even for those of us with children.

Crazy thing, I couldn't find a homeless mom's blog. But there are blogs for victims of domestic violence, whose partners beat them or who are hurt and have no place to go. Joyful Heart Foundation is one.  Women Thrive is another.  Violence Unsilenced is another. Warning, this mom is really angry. It isn't a happy blog.


Hardly much of a list, considering that there are thousands of bloggers, but it is Sunday and this mother will still go to work, talk to other mothers who aren't terribly comfortable today.

So many kinds of moms, including older moms like mine who bemoan the losses of their lives, that they did so many things and just can't do a damn thing anymore. Still an inspiration. Every single day.

Happy Mother's Day Mom, and to all of you, no matter how this Hallmark holiday hits you.  It really will be over soon.

therapydoc








Tuesday, May 07, 2013

Teaching Them Things

(1)  Strike Two!
Spring League

Monday, April 29, 2013

Practice Snaps

Oh, I will ramble a bit. Take it in pieces or go get a sandwich.

DBT Made Simple Worksheet
(1) The Perfect Patient Mix

Everyone knows who the worst patients are. But one man’s silver is another man’s gold. Meaning my  nemesis isn't yours, my ideal patient, not your ideal patient.

By best and worst we mean type of personality, type of disorder, type of patient who jolts us out of our hum drum, our oh bla di, those who grab our attention whether we like it or not.

What makes for the best or the worst? Too many things. But if my father had borderline personality disorder, then it might mean that I’m pretty comfortable with people who have it. Or, it might mean that someone with that disorder makes me extremely uncomfortable. Therapists all have interface of some sort or another. We have our triggers.

Before we're let loose on the therapy-seeking public (a clinical population, as opposed to our friends and fellow students, unless they, too, are in therapy), those of us trained to be therapists usually have identified our comfort and discomfort zones. But these zones are squirrely, they can change, especially as we absorb new knowledge and want to try out new skills.Meaning, the zones change.

At a great continuing education workshop, for example, we might have learned volumes about dom-subdom relationships. We might want to work with this population, understanding that their issues are varied like all of ours. Feeling confident, we advertise as an expert and begin to get referrals. Things are going well.

Then one day a dom tells a what happened to me on the way to therapy story that changes things. Perhaps he stopped for gas. While waiting for a teenager to finish at the pump, he fantasized about taking out a tire iron and killing the teen for being so slow. The patient is a Vet, has killed before.

"Would you really do that? Beat a kid with a tire iron?"  We have to ask.
"Yes, if the moon is high."

Still comfortable with the dom-subdom patient mix? Nothing to do with interface, either, or an average dom. This one probably came for his four-year old's toilet training issues. It happens all the time that things aren't the way they seem. A presenting problem may not be the problem. One homicidal patient and you question what you're doing, are much less comfortable around people who are comfortable delivering pain.

You might be wondering, how to respond to Yes, if the moon is high.
Best to keep the conversation going, not judge, follow through. Ask: "How do you feel about being a man who would do that, beat someone up because he's making someone wait?"

(2) Absorption

Some therapists watch their patient mix, so as not to absorb too much emotion.  Emotion gets all over us.

A mentor of mine told me that if I found myself getting too depressed because my patient mix tipped toward depression, then I had to put a limit on how many depressed people I treated.

That makes sense. But if 90% of the human race suffers a major depression at some point in a lifetime, then it is likely that a good chunk of new referrals are in the throes, first call. And let's not forget that angry people are usually frustrated, but sad is the true emotion deep down. And our anxiety sufferers cry, the anxiety can be so debilitating. It is exhausting, so much sadness, so many tears. We may as well stop working if we're going to limit depression.

On the other hand, there's depression, and there's depression. Not everyone rates an Axis I.

(3) Punting

No matter what we might hope for, no matter how we try to watch our personal discomfort barometer, we can’t merely reject someone who comes for help, not in good conscience, once he is there in the room. We might say, as the patient tells his story, that we have a colleague who would be a better fit. If we have that colleague.

Using our best self-relaxation, anxiety reduction skills, listening for the patient's real needs, we find that we can handle it, whatever it is, all of the time. It is true, what they tell you when you graduate, that having a master's makes you a thousand times more capable at this job than the average ear. The trick is to sit tight and trust yourself.

We dig in and treat, do the job. But it ain't easy.

Perspective: A consultant, a psychiatrist and I work as a team. We have a running gag. We’re not supposed to send one another sick patients. What we mean is no really sick people. We joke that we’re too old for it, too burnt out to treat those with demands that run too high. Or so we say.  Of course this is a joke. The only reason it is funny is that grain of truth we both know is there.

Finding the network isn't easy, but there are new docs graduating every day, ready and willing to take on what could be our worst when we aren't up to taking it on. Maybe we can even find an entire team of  DBT specialists. 

(4) DBT

Oh, but what is DBT?  It is not the pesticide that the Americans used in Viet Nam in the sixties and seventies.
Sheri Van Dijk's DBT Made Simple
Dialectical Behavioral Therapy is a therapeutic model for the self-injurious population, the brain child of prodigious research psychologist, Marsha Linehan. Dr. Linehan has authored seminal books and manuals and has thousands of protegees, therapists who follow her religiously. She understood, well before anyone else could put it into words, why the cognitive behavioral strategies that work with most everyone else, don’t always work with those who have the most severe pathology-- the suicidal, borderline population.

Cognitive Behavioral Therapy (CBT), an older school, is about behavioral change, first and foremost, whereas Dialectical Behavioral Therapy (DBT) is about accepting reality first. Yet another acceptance therapy, Acceptance Commitment Therapy (ACT) is close to both ideologically. The therapist works with the patient to develop a new narrative, very much in sync with the patient's world view. DBT might incorporate the narrative, but offers much more than a better story.

The basics include a range of emotional management/distress tolerance skills and group therapy. Individual therapists have support or they would go sleepless otherwise, and oh, a 24-hour hotline.

The founder, Dr. Linehan recognized that the very sick are often an abused and neglected population. They experienced life at its worst. For them, countering negative thoughts can be waste of time. Life's evidence is to the contrary, damning. They have witnessed trauma to the degree that they believe themselves culpable, deserving. As you sow, so shall you reap. The sentence is issued, judgment must be served. The abused adult bought into her guilt years ago, like the foster child in  The Language of Flowers, a novel, about a child punted from one group home to another. (That one should be required reading for graduate students. A nurse recommended it to me.) They are full of anger and confusion.

The behavioral therapeutic schools have shifted the blame away from parents in the past forty years, but when we talk about causality, the environmental approach to mental illness wasn't so far off the mark. Parents have the power to construct realities, to make the world heavy or light. Some literally choose to make it heavy, don't know any other way. So while blaming, judging isn't fair,  saying they had no hand in the outcome isn't true, either. We can make the connection without judging.

Remember that Holocaust movie, Life is Beautiful? There, in the horror of a concentration camp, a father, by force of his positive personality, makes avoiding Nazi barbarism a game with his young son. The game is to spare the boy's optimism, to hide the truth of his experience. The two laugh throughout the movie. Most abusive contexts aren't this way, aren't fun or funny, and parents don't have this parenting skill, the skill of finding humor, creativity and laughter. Their children can't merely wish away negative thoughts, not even with the best rationalizations to counter them, not with our best hypnotic suggestions.

Therapists, then, need to accept the patient where she is, not a terribly novel idea, and introduce the irreverence, the humor in what is real, only possible if we stop fighting it, accept that some lives are more difficult than others. We old Jews, when we speak of some things that are anything but clean, we refer to them as holy, rather than profane, switch up the words. In this way, I refer to the difficult life as a beautiful life. Abused people get it right away.

(5) Beyond Acceptance

Linehan knew what she was talking about. She experienced the worst of depression, made serious suicide attempts. I read somewhere that she had an epiphany moment, one in which she decided that it was okay that she wanted to die, but she had to love herself, it was her job. No one else had that obligation in reality. If she loved herself then she wouldn't kill herself, killing isn't loving. She had to move on and teach others how to do it, too. Accept the raunchy feelings, then have a good life. Why the hell not.

So how do we do that, exactly, accept the raunchy feelings, then have a good life?

Lucky for us, Sheri Van Dijk simplified Marsha Linehan’s work, cleared the smoke of Dialectical Behavioral Therapy with DBT Made Simple.

This manual is fresh, refreshes, and if you buy it (not cheap at $27.96 on Amazon) the patient handouts between the covers are free to use. No more dividing your college rule paper into columns and scribbling homework assignments. They are all here. And the good doctor, Ms. Van Dijk, gives us permission to copy and use them at will. Who does that? Sheri, I love you.

Among the pages of patient information are ways to act differently, and pages of columns with dozens of words to describe every emotion. Who doesn't need more words?  It feels so good to describe our angst, our happiness. So yes, it is recommended reading. Required.
The Language of Flowers, a novel


To be fair, I don't like that shade of green on the DBT book cover (above). Compare it to the cover to the right for The Language of Flowers.

There, the review is balanced.

Ms. Van Dijk reinforces acceptance and teaches self-validation to reverse the self-castigation game. She teaches emotional reactivity reduction and distress tolerance skills, even mindfulness. Support for the therapists is a part of the plan. Therapy for therapists. Like having a suite mate who reads it in your eyes and takes five minutes to let you debrief.

Yes, that is why some of you wait a bit in the waiting room. Not complaining, just saying.

(6) What if there isn't a DBT therapist anywhere to be found?

My suggestion, assuming there is no DBT therapist at a local mental health center near you, is to take the time to learn the skills we've been talking about, reducing painful emotion, increasing the positive. (These are cognitive behavioral therapies, by the way.) Watch the basics of mindfulness (see video links below). Work with a psychiatrist, a therapist, and a primary care physician. Have a suicide contract in place, and the option of insisting upon a hospitalization. If the patient is in an Outpatient Day Program, stay in touch with staff. They need your input.

One on one, no team around, the job is to help people accept and love themselves. You’re fine exactly as you are, not that we all couldn't be better people. You are entitled to your anger. You are entitled to your sadness. Why wouldn’t you be angry? Why wouldn’t you be sad? Why wouldn’t you want me to feel your pain, manipulate your therapy so that I do, so that I know what it's like?

You see, misery loves company. If you don't want the  patient to turn on you, because some do, increase her demands, to try to make you miserable, then the heart of your work must be to join her, make that joining obvious, discuss the ugliest of her truths. Much more powerful than—Let’s try this!

(7) And If You are the Patient? How Do You Help Yourself?

You help yourself by being honest in therapy, for sure, and by having compassion, patience with a sometimes deficient therapeutic system, patience with loved ones, patience with yourself, if you are your only loved one. Then add patience to that patience, compassion on top of compassion. (I'll review Jonah the Woodcutter one day. In that book by Joshua Rubin, Jonah tells the shoemaker that if we have compassion, we don't need patience.)

Read the Ten Reasons Not to Kill Yourself, while you're at it, and buy Sheri Van Dijk's book, or Marsha Linehan's about how you really have a wise self. Begin to use it, that wise self. Start working your own program.

They say Linehan suffered schizophrenia, BPD, and depression. She has at least five videos on Youtube. Watch her teach.  Try her  breathing techniques, watching the breath as opposed to controlling it. Many of us teach diaphramatic breathing  for stress management, much harder, no need. Click on the mindfulness videos at  DBTselfhelp.com fall asleep to them.

Don't do anything to harm yourself. You only have one ultimate mother, one father, and that mother, father, is you.

(8) Politics

We can only hope that with changes in health care, money will be earmarked for the vulnerable, will move Marsha Linehan's epiphanies right along, train more teams of DBT therapists for the trenches, make mental health something we can buy at the local intermediate care center. It is a war, I tell you, that war against self-hate.

Next time I post, it will be on something light, maybe the Dove Real Beauty videos, or maybe whether or not having a mother who shoplifts expensive dresses from Lord and Taylor is likely to have a terrorist for a son.

Maybe why I just want to shake Don Draper and say, "Don, you are like your father, a terrible father, because, like him, you are an alcoholic. Kids are a real inconvenience to you."

therapydoc

Sunday, April 07, 2013

Ten Reasons Not to Kill Yourself

Suzie Gonzalez

I read the news today, oh, boy, 
About a lucky man who made the grade, \
And though the news was rather sad
Well I just had to laugh
I saw the photograph
He blew his mind out in a car, 
He didn't notice that the lights had changed
A crowd of people stood and stared
They'd seen his face before
Nobody was really sure if he was from the House of Lords

Beatles, A Day in the Life

For some reason, I always heard those lyrics as describing a suicide.
Not a pet cemetery


About the picture to your right. They try to make them look like parks, but these are really dreary places to visit. 


Matthew Warren, son of Pastor Rick Warren of the Saddleback Church in California, dead. Matthew's famous father spoke at President Obama's first inauguration. He wrote a letter to his congregants to tell them that Matthew had taken his own life, had lost his battle against depression. It was a self-inflicted gunshot that killed the 27-year old.  


Huff Post quotes the father  “No words can express the anguished grief we feel right now,” Warren wrote. “He had a brilliant intellect and a gift for sensing who was most in pain or most uncomfortable in a room. He’d then make a bee-line to that person to engage and encourage them."
“In spite of America’s best doctors, meds, counselors, and prayers for healing, the torture of mental illness never subsided."
We would say that Matthew had bad disease. What we lost, a picture of Matthew Warren.
THE STORY
I need to remind the reader at this point that the caveat at the top declaring much of what you read here as fiction is there for stories like these. 
A few years back I’m sitting across from an extraordinarily handsome young man in his early thirties. He has an excellent vocabulary and an eastern seaboard accent. He narrates about the mental illness in his family—schizophrenia, the schizo-affective disorders, bi-polar disease. He's been on his roller coaster of disorder and chronic drug and alcohol abuse, with multiple physical problems (as if these can be separate), too, all his life. 
He is talking and I am thinking, Oh My.
There is a feeling the therapist gets and I have it, a worried feeling that her patient will not make it, will kill himself, and it will be on her watch, and she will be held responsible for not getting him to the hospital in time, and even if she isn’t responsible, she will feel she could have intervened somehow.

He tells me that he knows he will kill himself one day, as sure as the sky is blue.

I tell him: Not on my watch.

He laughs and thanks me for that. He needs a great deal of direction in general.

Time passes, my friend leaves the city. We speak about continuing our work on the phone but I am reluctant. I want someone to lay eyes on him, as I like to put it, to feel him.  When we're with the patient we can get that feeling, some of us, that things aren't right, that the psychotic part of the depressive continuum is ascendant. The patient has checked out, wants no help, intends to finally carry through a plan that is always on his radar. He won’t tell any of us this. No, we won’t hear about it from his lips. In fact, when we try to get near to it we hear a resonant objection and a defense of his mental health. “I’m fine! Go back to your nap.” This I do hear, for he knows full well that a good nap does a body good.

He leaves, has a new team in another state, miles and miles away, people to keep him alive. Somehow. 
Six months later I get a call from his wife that he has finished the job. I am startled, surprised, upset, and very, very sad.  This was a pleasant man, a likable person. Surely he could have done something wonderful with his time on this planet, even if was some kind of volunteer work. But he is out of his pain, finally, is what everyone will say.

His wife, on the other hand, is furious at him. Selfish bastard! How dare he do this?  Why in the world would he do this to her? She would have stayed with him, headaches and all, no matter how difficult, no matter the drama! He was in total sobriety and on the right meds, in stable condition, as stable as he had ever been. He should have loved her more than to leave her like he did.

She hates him for this. She will never love anyone as much, or hate anyone so much, all in the same moment. We hold hands over the phone as she cries.

There are others he has left in his wake, parents, siblings, therapists, doctors, people kicking themselves, wishing they could have done more. Even I am thinking, Should I have called him once in awhile? No, he wasn’t my patient. But could I not have just checked in? Is that such a crazy thought?

Oh, it is water under the bridge. Sometimes there is nothing we can do. People leave clues, they tell us as much, that this is the plan, this is as it should be. We can call the police and the patient will charm her way out of an admission. Shlep a man squawking to the hospital, and if he is admitted, he is eventually released, and when he is, if he can get his hands on a gun, he’ll shoot himself. Or use a rope. A woman will ingest all of those meds she’s been hoarding for just the right moment. 

Sometimes we just have to face it. People are hell bent on suicide, either need a release from their pain or want to take others down with them as they go, make sure they are missed. We may not be able to stop it but we can try. 

We can say, "Not on my watch." 
And they can say, "Why not?"
And we have to find reasons why.

Maybe there is something we can do about it to slow it down, for this wave of youth killing themselves does seem to be an epidemic. We need to call it what it is, let’s talk, self-inflicted murder, no different from homicide except that the one pulling the trigger is the most obvious victim. 

To call attention to the problem we should support suicide awareness, visit AFSP's website. We can join in on their walk, donate. AFSP, the American Federation of Suicide Prevention, could use money to promote their anti-suicide campaign. We should make it our anti-suicide campaign. 


Taking a walk to draw attention to a cause is a nice idea. Good people do this. 

There's something else we must do. We have to counter the forces of death on the Internet. I feel it is a Star Wars mission we're talking about. We are the Jedi. 

If you aren't aware of this, you should know that there are websites that feed vulnerable, depressed kids step by step instructions on how to kill themselves. Here, where we are at this moment, people give advice on how to die. Go ahead. Open a new browser and Google: How can I kill myself? You'll fall off your chair there's so much advice out there. Sites share specs on lethal doses of poisons with anyone who asks for information. I imagine they teach rope knots, too.

This upsets me, that the Internet has become the Wild West, a dangerous place, because I like to shop here. There is nothing quite as amazing as Amazon, or useful as a university database, or Hulu. This is a wonderful place, cyberspace. A few rotten apples. Right? No. The tip of the iceberg.

They have to be shut down.

 Suzy Gonzalez was a child. 

Hear her story.





Suzanne's case has an unusual twist. She frequented an Internet newsgroup called called ASH, short for Alt.Suicide.Holiday.  Members of this news group trade advice on how to commit suicide, using code words like 'transitioning' and 'exiting' and 'catching the bus.' Suzanne found this group nine weeks before she died, posting nearly one hundred messages detailing her plans.


Her parents are grieving, her friends and teachers are, too. And it is clear that Suzy had much to offer. People who are very much still alive who say they've been there and respected her wishes to end her pain, persuaded her to hide away in a Florida hotel room and take cyanide.

They told her exactly how to do it so she would make no mistake. Hers was a copycat suicide. They coached her, told her over recipes to die.

Recipes for suicide.

So yes, THIS has to stop. These websites are taking free speech too far. Throw the perpetrators in jail. Pass stiffer laws. I plan to email my congressman. He writes me to say Mazal Tov! whenever something nice happens in my family. Time he did something more.

Is it possible that bloggers like me, bloggers like you, or just readers with Google circles or Facebook pages, Tweeters, any one of us, might participate or better, start a chain, post the reasons that suicide is a very bad option, all things considered?  I'm not technologically savvy enough to know how to do that, but some of you are.

 Feel free to cut and paste. 

         Why suicide is a bad idea. 
(1) There's an agent for everyone. We have new and better medications. Be patient. There's one coming out at a pharmacy near you soon.

(2) Brain research and the fields of psychology and neurobiology are exploding. There may be a cure for depression, a laser, a surgery, who knows? Think about it. One day, zap. You're better. Things are likely to get sunnier if you wait it out. Study up on these things. Learning anything makes you feel life is worth living, too.

(3) You are not bad, not evil, not the source of all that is wrong in your life, your world, the universe. The world will not be a better place without you, no matter what the relentless, unceasing voices in your head are telling you. This is as wrong as 2 plus 2 equals 1 to think that you MUST do this, totally irrational, the thinking of a sick mind, a mind on psychosis  It's not about you, frankly.

(4) People love you, so you can't do it. You don't have this right, no matter what anyone tells you. People love you and if you believe in God, that Higher Power does, too. She has declared all forms of murder out of bounds, even yours. We don't mess with God, but it's not just God. The people who love you will really, really hurt if you kill yourself. It is one thing to feel pain, quite another to give it to others. Wait because you  probably do have love inside, although it is surely fogged over by disease. But you loved and you will continue to love at least someone, or something, and others love you. Love is ephemeral, holy, and all that is good.. Why lose that?

(5) Tough it out because you are already in the process of change, you can't not change. Our cells change over every day. Our moods can, too. We have so many ways in therapy to accomplish this thing we call affective change. Pay attention. 

(6) Change your therapist if therapy isn't working. This should be obvious, but it isn't. A new set of eyes on you is refreshing. Therapists all get a little boring after awhile.

(7) You haven't even tried aging yet. It's not so bad. Age a little, give life a chance. See what is in your future. It will be better, you'll see. And how can you not want to know the future? Seriously.

(8) There are things that only you can do, no one else can do them, and these things have to be done.

(9) There are things that only you are. Nobody else will be the uncle that you will be, or the aunt, or the mother, the father, the daughter, the son. These are unique jobs, very, very important ones.

(10) We need you. We need a new poster child every year, at least one every year, someone who comes out to the world and tells young people: Wait! It really is a permanent solution to a temporary problem. They weren't kidding! I waited and look at me! My picture is on a bus!

We can't judge people like my friend who moved away and did what he said he would do, as sure as the sky is blue, although his wife always will, or the Matthews, the Suzy Gonzalez's. They really didn't know they had a future.They were convinced, in fact, to the contrary, that life would not get better. But  Suzy scooted around her neighborhood in a plaid skirt and green tennis shoes. And Matthew helped others as soon as he sensed their discomfort. A girl like that, a boy like that, knew how to make others happy. We can't afford to lose kids who suffer from depression. They get happiness on a level that no one else ever will. 

So why then? Why do they do it? Sure there's pain. But I propose that they lost that tiny sliver of affect that kept them alive, the one we think of as love, that very positive emotion. We need it to stay alive, need to love something, someone, and we're not talking romantic love, here, rather a sense of connectedness. Friendship will do. For some, a hobby.

On Suzy's website the people who loved her wrote:

Suzy Gonzales was a bright girl who needed to be reminded of the good things
in life, not encouraged to end it. At the time of her death, Suzy was the 14th confirmed
suicide associated with this particular site, they claim 24 "successes" today.

I'm so sorry for her family, and for Matthew's, and for all of you who have lost someone to suicide.

therapydoc

Thursday, March 21, 2013

Anger and Abandonment

It has been blustery in Chicago, the reputation as the Windy City well deserved. So blustery that at the end of March, when the weather is supposed to be mild (March comes in like a lion, out like a lamb, every second grader knows this) that we tell frail little people like mother, "Don't go out for lunch. You'll be grabbing onto your walker as the wind carries the both of you away." She goes to lunch anyway.

FD tells the story. He's in a parking lot at Home Depot, returning the cart. A bundled-up middle-aged man with a white beard is holding on tightly to a cart. If we don't hold them tightly, carts will take charge, fly off and hit parked cars. Chicagoans know this.

The man begins to curse as his hat flies off his head and hits the ground. FD, retrieving it, is rightly impressed by the long string of expletives, ef__, es___, d__, ef'in___b, b___, ef___, ef'n___, es-ef___, spewing from the man's mouth. Listening to this, he doesn't say it, but is thinking, Save your expletives for when you break a leg, or lose a house, maybe. Why waste them here?

A few years ago, two men with romantic accents came to see me in one week for anger management. It sometimes happens that two or even three new patients with similar problems come to therapy in the same week. It is as if there is something in the air or the stars are aligned in some special way. This affords the therapist the opportunity to experiment, to do her own little research study, assign homework and see what works and why, and see what doesn't and why not, because there is something of a control, having that second patient with comparable symptoms, comparable objectives.

It gets better. Both tell their narratives fluently, and both are from that continent hailing the new pope, South America. Both are reflecting upon a childhood living with extended family, not their moms or dads. Their parents left southern climes to establish themselves in this country, the United States, a land of opportunity, and called the sons to join them years later.

Years. Later. A long time to miss a parent. Without means, long distance phone service was prohibitive back then, and letter writing, well, there wasn't money for computers and email, and who had time for it anyway?

The child left behind, defenseless, odd-man out among the cousins, abused by drunk uncles and bullied at school, learned to be a very tough human being, so tough that peers eventually realized that to mess with him meant a fist fight that he relished. To beat another human being with his fists felt fantastic. This is where the phrases  sees red, has a hair-pin trigger, and Intermittent Explosive Disorder can meet as one.

Left behind.

Therapists hear about domestic violence, but usually not from the perpetrator, but the victim. The spouse or child tells the story. Here the patient is both victim and perpetrator. As an angry man, however, he doesn't hit his children or his partner, and has learned, as an adult, not to beat other adults, either, unless the circumstances clearly warrant physical violence. To him, they occasionally do, certainly if he hasn't stopped drinking yet.

We don't need advanced degrees to see where it comes from, the anger, and why the expletives become something that will need work, and surely the physical pounding, the rage, the immediate need to redistribute justice and turn things around, has to be channeled productively. One of the interventions I love, one that started with those two-in-a-week, works as follows.

The patient is told that he has to deliberately lose every argument. Every disagreement, every difference of opinion, my bad. He is to tell his partner, dispassionately, "Fine, I'm driving poorly?  I'll work on it." That kind of thing.

"Two weeks, you're an idiot for two weeks. She's the smart one. It's okay. You're really not an idiot. In your heart, in your head, you know that. You do know that, right?!" The therapist asks this in all sincerity. "Keep that in mind at all times. Nobody left because of you. Nothing to prove. Nobody thinks less of you if you are wrong. Your partner will value you more for being human."

It helps to have a partner or spouse in the therapy to reinforce the intervention, someone to look into his eyes, to tell him, "You're the smartest guy I've ever known. I love you. Love me."

And if he can't, there is that possibility, she might leave. Been there, done that.

therapydoc





Tuesday, March 12, 2013

Gaining Perspective

A dreary place at 7:00 a.m. Lincoln Towing
There's this ridiculous situation where I live.

The condo association offers guests parking in the Circle Drive close to the front door of the building. But not to residents, who presumably have their coveted spot in the garage.

That's not so bad. But if you do dare to park in the Circle Drive in the evening, if for some reason you take this risk, maybe you think you'll be right back, or maybe someone calls you and you get involved in a conversation, or you put a soup on and have to watch it and forget about the car--

if the car is still there between 2-6 a. m., a tow truck will certainly hook it up and tow it away in those wee hours.

There are signs in the driveway that communicate this; it isn't exactly rocket science. People have to move their cars from the Circle Drive.

Why? The rule is so old nobody remembers why anymore. It doesn't matter, but last night I forgot to move my car and this morning, thinking he would find it in our usual spot in the garage, FD returned to the condo, confused.

I'm pouring the coffee he has made.

"Car isn't in the usual spot," he informs me, unemotionally. "I'm walking to shul (the synagogue). See if you can track it down. Stay in touch." And he's gone.

My immediate response is an expletive, only one expletive, just so you should know, one that is preceded by a loud

OH! as in,  OH, ___!

It's the kind of thing that doesn't come out of my mouth very often, so when it does, I know I'm upset. This happened once before, this rendezvous bit with Lincoln Towing. It had been pouring that night, deafening lightening and thunder, and being terrified, I hid under the covers and fell asleep. Never did move the car. Surely innocent to a jury of my peers.

But no. To get it out of the auto pound a crummy $198.00 is required. And they don't have change.

I dig out the cash, throw on a coat, and trudge downstairs to wait for the bus. At the stop I text my kids to see if anyone is around to pick up their father. Everyone is willing, but FD is fine. He'll wait to see how things play out. His early meeting at the hospital is optional.

Chicago CTA bus
My bus comes right away and the driver is garrulousness, in a fabulous mood (this is the end of his shift, we'll see). No, he can't change a twenty, and no, this bus will not get me anywhere near 4882 Clark Street. I'll need to transfer at Lawrence. He lets me on for free and offers an "emergency" transfer.

I am tickled. It isn't as if I don't pay lots of taxes for this sort of bail out, but still. Perhaps when your car is towed it is considered an emergency to the CTA. If so, What a wonnerful city, as the late Mayor Richard J. Daley would have said. And it is, truly.

The bus is getting more and more crowded, but I have a good seat. About a half-mile before my stop I see that my driver is getting up to leave, has pulled over to the curb at the light. He's switching with another driver at Foster. I sprint to the front to thank him again and ask if I can take his picture.

I have this blog, I say, it's a therapy blog, Everyone Needs Therapy, and if he wouldn't mind, I could post his picture, tell the world what a great city this is, how a kindness like his, just being really nice at 6:30 in the morning, changes everything for the low-lifes in the world like myself, those who leave their cars overnight in the Circle Drive.

He laughs, "This isn't going up on YouTube right?  I don't want that!"

"Oh, I won't even put up the picture," I tell him, "It didn't come out very well. Don't worry."

He seems disappointed.

Now. The new driver has heard this conversation. "Yes," he nods, "Therapy. People do need therapy.  I swear, the people who ride the bus, man, do they need therapy some of them." He is whispering so that if what he's saying is inappropriate, maybe I won't hear. This man has a true conscience, it is refreshing.

"Uh, huh," I agree, "tell me about it."

He proceeds to tell me quite a bit about himself, how his Mom raised him right, and how she and his father paid attention to him and watched who he hung out with, and made sure he did well in school, and parents today don't do that, and so many of them are on drugs, what is a child to do? Mom made sure he knew that there was a God, too, and he is forever grateful for that, too.

"The most important thing," he tells me, "is kindness.  If you're nice to people they'll be nice to other people. It's a pay it forward thing, like in that movie, Pay it Forward. That's absolutely the most important thing we can do is just be nice. That's all," he says. "That's all."

And I'm thinking, that $198.00 I'm going to spend is a drop in the bucket compared to what people spend on drugs, those who spend money on cocaine, maybe heroin, and probably isn't that much to some who spend their money on lottery tickets or beer and marijuana, either.

And if I only do this, fail at moving my car, lose that gamble, say, every six months, that gamble on  parking in the Circle Drive, the one for guests only, not even a gamble if it is there between 2-6 a.m., a surety, then maybe that isn't so bad either.

Could be worth it to hang out with these guys turning the corners on the CTA in the very early morning rush hour.


therapydoc

PS: The late folk song writer/performer Steve Goodman did a wonderful spoof on a car towing company in Chicago, The Lincoln Park Pirates.  Totally worth a listen. Back then I think it was only $135 to redeem your automobile, but how would I know?

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