I have a radio show about psychiatry, and one thing that I try to accomplish is to differentiate myself from other psychiatry practices in the area– as one purpose for the show is to market myself.  By the way, you can find podcasts of the program under the links for ‘Dr. Junig’ here.  One of the major differences in my practice is the amount of time that I spend with patients– at least compared to other psychiatrists in my local area.  From the start, I decided that I would see at most two patients per hour– including patients who are being seen for ‘med checks.’  I was confident that providing some extra time would be helpful for patients, but even I was shocked by just HOW helpful it can be!  I have no special, secret techniques, but I have had a number of patients who had been through multiple admissions and/or ECT, and just by spending a bit more time they have avoided such intensive treatments and in many cases reduced the number of medications they are taking.

I love the image of the old-fashioned psychiatry practice;  the wooden floor, the leather couch, the corner office with high ceilings and bookshelves… and appointments that provide enough time for patients to talk about their issues without needing to write them down ahead of time and strategize how to get them al out in time.  It is well known in psychiatric circles that the most important ‘content’ of a session comes up just as the patient is leaving the room– the ‘doorknob confessions’ where the patient says ‘by the way, I killed my husband last night’.  Many times at the end of the day I will think about what patients told me today during the last bit of their appointments;  the things I remember are always important enough that it is hard to imagine not having time for them.

It was gratifying to read an article in the NYT the other day about the importance of having TIME for patients– about doctor practices that have learned to come up with a different way of doing things.  People who are interested can find the article here.  If anyone is looking for a practice that provides a good 20-30 minutes, give me a call and we can meet in my telepsychiatry practice.

Fond du Lac Telepsychiatry

Unfortunately, in today’s economy one of the first factors used to choose a physician is whether or not the person is ‘in network’.  While there are times when such a determination should guide one’s search, I would suggest that for several reasons, your choice of psychiatrists should take place without limiting your search to the small group of in-network doctors.  I will explain my reasoning in a moment, but first I would like to describe the nature of my practice.

When you are seen in my practice, I will submit your claim to your insurer for you and do all that I can to maximize payment of your claim by your insurer.  I will then bill you for any remaining amount not paid by the insurer.  There are a couple cases where your portion of the bill will be very small.  First, I participate in a nation-wide group of otherwise independent physicians called ‘Multiplan’.  The Multiplan network is used by many insurers to provide additional choices for their member patients.  How do you know if your insurer uses Multiplan?  Look at your insurance card for a small ‘M’, or for the word ‘Multiplan’.  The network is also called ‘Health Eos’, and sometimes that term is written on the card.  If your card says ‘Multiplan’, you are likely covered for at least 90% of all charges– meaning that your out-of-pocket payments are minimal in my practice!

There are a few other insurers that I have partnered with over the past few months.  Specifically, I now have a relationship with Network health and United Healthcare that allows me to see their patients for minimal out-of-pocket costs.  If you are not certain whether I am ‘in network’, please call my office and ask!

I have always said, though, that I will only join the networks that place no or minimal restrictions on my ability to practice good psychiatry.  I have NO interest in being listed in a provider list if in return I am expected to practice a certain way.  Many health ’systems’ are members of every single network, but they offer a type of psychiatry that I find to be downright silly–  where patients have 7 minutes of time with the psychiatrist to discuss how they are feeling, to discuss any medication side effects, and to somehow feel ‘supported.’ I am committed to seeing every patient for 20-30 minutes– at a minimum.  And so the insurers that offer ‘low-ball’ contracts that the big systems make up for on volume are not panels that I want to join.  I will, though, do all that I can to maximize payment on your claim.

There are dangers to limiting your options to ‘in network’ psychiatrists. In a town like Fond du Lac, all of the participating psychiatrists for most of the insurers belong to the same medical group. At first blush your book contains six or eight psychiatrists… but then you find that they all practice within 50 feet of each other, and are all subject to the same policies and practice patterns. Some choice! As an independent psychiatrist I answer to nobody except you, the patient. I teach at the Medical College of Wisconsin in Milwaukee in part because I love teaching, but also so that I remain in contact with the people who are at the front line of psychiatric research and development.

There are many factors that determine the amount of coverage under your insurance policy besides whether the doctor is ‘in network’. Many plans have insurance plans with deductibles; a person with a $1000 deductible may not cover the deductible in any one year, and so whether or not the psychiatrist is ‘in network’ is a moot point. After my first visit with a new patient I encourage a discussion of the options available, the person’s interest in type of treatment (medication, therapy, or both) and the desired frequency of follow-up after balancing cost and care issues. There is no value in a prescription for a great medication if you do not have the money or coverage to take it!

One final issue that relates to the choice of psychiatrist is that more than in other areas of medicine, you will want a ‘good match’ with your psychiatrist. In order for treatment to have the best opportunity for success, you will want to feel at ease discussing ALL aspects of your life and lifestyle with your psychiatrist.

I work hard to provide the best psychiatric services possible. I want patients to have the time to remember all of the things that were on their minds since the last visit. As I often say, I don’t want you to see a psychiatrist; I want you to have a psychiatrist.

A word of warning:  this post is more of an observation than a ‘lesson’;  a question rather than an answer.  I don’t want someone to waste their time reading and expecting a piece of life-changing advice… only to find more things to wonder about! I also need to be brief because I need to get to the office, although perhaps briefness is something appreciated by those who stumble across this site!

I just finished an appointment with a young lady who is facing a number of challenges.  She is 22 and single, and she lives with her preschool-aged daughter in half of a duplex.  In the past month she had quite a run of bad luck.  Her slumlord hasn’t come through with the repairs he promised to make; she has an oven that doesn’t work, doors with broken deadbolts (in one of the more crime-ridden neighborhoods), and a number of other annoyances.  Her attempts to pressure him to fix things culminated in a complaint to a government agency… and now he is taking her to court to evict her, despite assurances in the law that eviction cannot occur after such complaints.

But I’m just getting started!  When the heat comes on,  the unit is flooded with the smell of urine from the unit below, where a disabled crazy man lives with too many cats.  Her child’s doc said that the fecal material from the cats caused the infection that hospitalized her daughter for several days;  the patient’s workplace is too small to honor family leave, so she was fired after insisting that she spend nights with her daughter in the hospital.  Meanwhile the guy downstairs had assumed he had a close friend when she took the upper unit, but at some point she tired of waiting through his several-per-day visits, and asked him to provide some ’space’.  This angered the mentally disabled man (frankly it is not that safe for a young woman to have this 30-y-o person alone in the house, as obsessions can develop and turn dangerous).  He retaliated by stealing her mail, and eventually convincing the post office that she had moved– causing her to miss deadlines and not get unemployment.

I can imagine dealing with one of these things;  as a 40-something man (for a few more months anyway) I would find the situation frustrating.  It would have been very difficult to deal with these things on my own when I was in my early 20’s!  And to be faced with all of these situations– I cannot imagine what I would do.  I often find that in such cases the problems are self-induced, but with this person that is not the case;  she has done the things that people are supposed to do– but still things have not worked out.  Sick kid, lost job (a crappy job at that), bad neighbor, bad landlord, hospitals, non-functioning appliances, government agencies, court summons for eviction…  and did I mention that all of this is happening two years into recovery from a bad narcotic addiction?  She continues to do well on that front– somehow.

Despite these challenges she has stayed away from narcotics, kept appointments to get her daughter back to good health, found another full-time job, straightened out the Post mistakes, and prepared for court by getting a bunch of supportive papers together.  Pretty impressive for a 22-y-o recovering drug addict!

But now my question…  Why isn’t this woman depressed?  She is not, by the way, taking antidepressants– although she probably should be, just for prophylactic purposes (I am kidding– sort of, anyway)!  Why is it that one person who is twice her age and has half her problems will become stressed and depressed, and she continues to go from day to day, one after the other, without falling apart?  The answer is not ‘Faith’, at least not in any way that I can see;  I have seen patients of strong Faith with severe depressions, and this woman does not have any significant connection to a ‘higher power’.

I know I started by saying that I didn’t have an answer, but one has occurred to me over the past few minutes ( I also said I would be brief!) — an answer that will surely anger many people and that I therefore should keep to myself…  but I won’t.  The reason she hasn’t become depressed is because she can’t.  She simply does not have the time– not with a small child to care for.  I will pause for a moment to let the anger build in people before defending myself in the next paragraph.

No, I am not saying that depression or any other mental illness is a matter of ‘choice’– not conscious choice anyway.  Not in a way that people have any control over.  But I do wonder if there IS a choice component at some unconscious level— I am a big believer in the unconscious, and have watched for years in cases of addiction where the unconscious ‘addict inside’ leads a person around by the nose, destroying more and more of the person’s life.  I have to wonder if in some cases there is an unconscious awareness that ‘this is not the time for a depression’, and in other cases a similar and opposite awareness.

Such a concept would fit with a few observations about society;  the perception that in the ‘old days’ people didn’t get depressed as much– they worked extremely hard on farms and in factories or in kitchens, back when just making a meal would take an entire day to gather, prepare, and cook– not counting all of the other work ‘at home’ before the era of washing machines and dishwashers.  Perhaps in some cases the mind can abort depression by turning to a ‘reserve’ of sorts, recognizing that a depression at THIS particular time could prove fatal for the individual… and for other family members.

I like how in psychiatry we can approach things from ‘psychodynamics’ or rather from a perspective of the mind as ‘chemical reactions’, all mental illness being ‘brain diseases’.  I could do the same with this discussion;  perhaps there is something analagous to the endorphin system for pain, where in horrible injuries the brain is flooded with mind-numbing chemicals that induce analgesia and even euphoria–  perhaps when the psychological stressors become very severe, a similar process occurs that protects us from depression, and that those who DO fall apart in such circumstances are suffering from the dysfunction of such a system.

Even if I am onto something, I don’t know what conclusions should be drawn;  I don’t think it makes sense to recommend that people have lives filled with so much turmoil in order to protect themselves from depression!  But perhaps there is one idea that does follow my logic.  Perhaps we are on the wrong track when we spend all of our resources and energy in the pursuit of a life of ease–  because maybe, just maybe, when we get to that life of ease things won’t be quite as ‘happy’ as we imagine.

I’d love to  hear your responses and thoughts on the issue.

Addendum:  Shortly after writing this post I turned on the TV and watched as the body of David Kellermann, CFO of Freddie Mac was taken from his beautiful home in Fairfax, Virginia.  His tragic death can be interpreted in many ways; I am tempted to try to guess what might have happened but it feels inappropriate to say anything, except to acknowledge the grief of his wife and daughter.  I hope that they can find some peace– after the hoard of reporters are gone, the horrible calls for suicides of CEOs by US Senators subside, and our politicians find better ways to maintain popularity than to stir up class warfare.  Believe it or not, everybody hurts.

JJ

I run the expert forums in addiction and in mental health at MedHelp.org;  tonight I answered a question that has come up from patients of my practice and so I decided to share my answer here as well.

First, the question: I previously sent this directly to your email. I apologize for that. I had forgotten that you are on this forum and its more appropriate to address here. Although its not specifically related to addiction, i do believe that many people suffering with addiction have co morbid  psych issues so perhaps it will be of general interest.  I was hoping that you would be so kind to comment on an article that I read written by a group or neurologists.   I know that your primary interests are in general psychiatry and addiction but I recall that you have a strong background in neurochemistry.

I have been on a program to try to eliminate chronic headaches. The program consists of various supplements (DHEA, 7-Keto, 5-HTP, pregnenolone, phosphatidylserine, saw palmetto,melatonin, testosterone gel and progesterone gel) along with some vitamins and fish oils.  The doses were based on blood levels of my hormones so it wasnt shooting blindly.

The article that I am inquiring about stated that taking 5-HTP without taking tyrosine, dopa, and cysteine will lead to eventual depletion of dopamine and norepinephrine.  The article seems to make some sense to me with my limited medical knowledge——but could be a load of ****.  Have you heard anything along those lines.

Thanks so much . I hope you will be able to comment when you get the opportunity.

My answer:

There was a time in my life when I would go to bed each night with all of those metabolic pathways in my head…  now I have to look things up!  I would be interested in seeing the article– if you want to send it to my e-mail address go ahead, and I will give you my thoughts.  I actually already have an opinion that isn’t real favorable– but admittedly I haven’t seen it, so I am basing my opinion on things that might not be entirely fair.

It is easy for a person with a medical degree to ’scam’ patients;  medicine enjoys a certain amount of trust from the general population;  trust in the doctors, and trust in the bodies that regulate them.  Yet there have always been doctors who ‘take advantage’…  they are easily recognizable by the medical community though, and so that tends to keep it to a minimum.  But when the desire for money overcomes the fear of embarrassment, the abuse occurs.

In general it is seen by medical professionals as a conflict of interest to sell things that the same person prescribes.  The Federal Government has very strict rules against that type of thing for any medicare patient;  doctors cannot own labs or pharmacies, for example, that do tests or sell meds that the doctors ordered.

The ‘anti-Suboxone’ crowd often says things like ‘doctors are getting rich off Suboxone’, but it just isn’t the case;  if there was a great profit in treating patients with Suboxone there wouldn’t be such a shortage of physicians prescribing it.  But if I could SELL Suboxone, I could probably do very well– but I would feel uncomfortable about the clarity of my decisions.  I get paid if I prescribe Suboxone, if I recommend residential treatment, or if I prescribe naltrexone– or if I see the person for psychotherapy and don’t recommend anything else.  And while there is this impression that Suboxone is ‘chaining’ people to their doctor, in reality that isn’t the case;  it is their illness, opiate dependence, that requires medical attention.  I spent 14 years seeing the same addictionologist because of the relapsing nature of addiction– not because of Suboxone.  Yes, a tangent… but something that comes up frequently and that deserved to be addressed.

A very large study was published two months ago– I wish I could remember the reference– that showed no benefit from vitamins except in unusual and rare circumstances.  The products that you mentioned benefit from a ‘loophole’ in regulations that allow some products to be sold as ‘nutrients’ rather than as ‘medications’;  nutrients avoid having to go to the FDA and show effectiveness in treating a condition.  Some other products present themselves as ‘homeopathic’, a fancy word for ‘equal to placebo’, as a homeopathic product is a substance in such minute quantities that it cannot be harmful (or helpful– unless you accept that some healing ‘essence’ of the original substance is left behind in the otherwise-empty capsules).  I will never change the mind of those who believe in nutraceuticals though, so I generally don’t try.  I’ll just say that in MY opinion, humans have survived for centuries without adding saw palmetto to the diet.  And while foods are much more processed these days, we probably have access to much greater variety than many other healthy cultures throughout history.  How many green leafy vegetables did the eskimo population eat over the last several hundred years?

Most hormones exist in a huge range in the body;  look at the ‘normal’ levels for testosterone in middle-aged men and you will see numbers that vary over a range of 100-fold.  Why is 5 normal for one person, and 500 normal for another person? We have no idea!  And we are NOWHERE near the place where we ‘know’ the effects of adding some of this and some of that.  Yes, I could come up with a great story–  one that would sound very intelligent– but it would be BS.  And there are no docs out there that have some ’secret knowledge’;  again, medicine doesn’t work that way.  When you see an infomercial with some guy with a foreign accent who talks about his ‘research’, I wish the fake-host would ask him, how did you collect the 5000 people necessary to show an effect, randomize them into separate groups, and follow them for ten years while controlling for all of their confounding behavior— and keep it a secret?

I think the comments you described refer to the fact that in the brain, there are a number of neurotransmitters that produced from a common pathway;  one transmitter converted to the next, etc.  Each step in the metabolism has a ‘balance’ between the precursor side and the product side;  if there is a large amount of the terminal product around, it feeds back and reduces production of the entire line of chemicals.  So adding 5HT (which is serotonin) feeds back and reduces the production of catecholamine transmitters like dopamine and norepi.  You can overcome this effect by adding more of the precursors– like tyrosine and dopa.

The problem with all of this, though, is that there is a huge difference between swallowing a substance and getting it into neurons.  It has to cross the wall of the gut, survive passage through the portal vein and liver, cross the blood-brain barrier, and avoid being broken down by the many enzymes in the blood and on ‘neuroglia’ that metabolize the substance.  I don’t know for sure, but I strongly doubt that you can change the level of 5HT in the brain by taking it orally– or even intravenously.  Yes, we can get dopa into the brain when the person takes enough of it orally, but dopa is used because the desired substance– dopamine– does NOT get into the brain.  So to finally wrap up…. I would say that I am skeptical about the whole affair, and I think most other docs would be as well.  I recommend being wary about anyone who claims to have some sort of ’special knowledge’– I would suspect that what they REALLY have is a ’special’ marketing campaign.

Jeffrey T Junig MD PhD
Fond du Lac Psychiatry

I have a weekly radio show about psychiatry– you are welcome to check it out either through the links on the home page of my psychiatry practice, or at KFIZ, the radio station that hosts the show.  Yesterday a caller asked about her son, who lives at home but is about to turn 18, and who to her dismay wants to get a large tattoo on his back to commemorate his birthday.  Complicating the matter is the fact that she and her husband are divorced, and (can you see what is coming?) her ex thinks the tattoo idea is just fine.

Don't judge me for how I look! (?)

This discussion can go in many directions;  one thing we discussed on the show is that even at the ripe age of 18 it is a good thing for a ‘child’s’ parents to avoid being split over an issue that involves the child.  Ideally, the parents would discuss the issue in private and come to terms, if not agreement, over how things will be handled–  rather than have one parent put down the other parent for being too lax or too strict, with the son in the middle choosing sides.  As tempting as that sounds to the parent siding with the young man, such a situation will inevitably cause problems down the line when the son uses the ’split’ to justify all kinds of behaviors.

But that isn’t what I am writing about. I’m writing in response to a comment that came up during our discussion; the mother said that her son accused her of ‘judging people based on appearances’, and she felt that she was appropriately chastised for being that way. But was she?

We all go through life with a certain image of ourselves— with a sense of ‘who we are’. Those self-perceptions come out particularly when we are nervous—say during job interviews or during first dates, as in: ‘I’m a very giving person’ or ‘I’m such a ditz!’ Are these perceptions accurate? I don’t have any hard data, but my guess would be… No. From my experiences working with people, the perceptions have little to do with reality. Well, that isn’t quite right—they have something to do with reality, but they are not an accurate reflection of reality. For example, a person may refer to himself as ‘an idiot’, and even consider himself an idiot, because of the ‘reality’ that he doesn’t like the pressure of high expectations, from either himself or from others.

If self-perceptions and declarations are not a good indicator of ‘who someone is’, what IS a good indicator? In fact, is the question even worth asking? Can a complicated personality be reduced to a few-sentence description? I think that a person CAN be described, but only with great caution. There are many things that throw off one person’s assessment of another; for example projection involves the process of seeing in other people the traits that we don’t want to recognize in ourselves. Or for another example, studies have shown that contrary to public opinion, the behavior of children, even children with ADHD, does not change after sugar consumption. What does change, though, is a mother’s perception of her child’s behavior; mothers who believe their child consumed sugar are more likely to judge the child’s behavior as unruly. When evaluating others, we always peer through a lens made dirty by our own idiosyncrasies.

So getting back to the woman accused by her son of being ‘judgmental’ for thinking certain things about people with tattoos… she must REALLY be off, right? She is making assumptions without even talking to the other person! But wait– in my opinion, she is probably seeing things the MOST accurately out of all of the examples that I have described. How can that be?!

What is she evaluating when she makes an assumption about a person based on a tattoo? Contrary to the mothers watching in horror as their children dismantle a university waiting room, the woman is evaluating the other person’s actions in a much more objective way. In fact, there is little room for observer bias in such an example; the answer to the question in her observation is either true or false, tattoo or no-tattoo. So unlike those other mothers she has risk of making a mistake in what she sees. But similar to those practicing self-assessment, she does risk making mistakes in what she thinks. But by being a person separate from the person being assessed, she is miles ahead when it comes to accurate thinking!

What do we ‘generally’ know about a person with tattoos? I suppose the answer depends to some extent on the nature of the tattoo—large or small, hidden or obvious, happy or dark, colored or ‘blue-dye’, etc. There is a guy in my home town who drives a motorcycle, without a helmet, and who has a spider-web tattoo on his face, wrapping around the sides and top of his bald head. What does his tattoo say, compared to the 40-y-o woman with a small rose on her ankle? Or compared to the 70-y- o man with an anchor on his bicep? I could easily go wrong by assuming too much—that the spider-web guy is a mean jerk, or that the rose-ankle woman is looking for a man. I think that it would be a mistake to try to use the content of the tattoo, as we don’t know the attitude of the person when he/she got the tattoo—was it a joke? Was it sarcastic? Was the person drunk? Plus if we dealt with content we would start getting into our own unconscious thoughts about roses and spiders.

But we CAN tell something from the simple fact that the person has a tattoo, the size of the tattoo, and the location of the tattoo– with the understanding that we are talking about generalities, and that the data we collect is only one piece of data that must be consistent with the other data before it is taken as true. This is not rocket science… what can we suspect about a person who has a tattoo on his face and head—something that is virtually impossible to miss? We can assume that this is a person who wants to attract attention. This is a person who perhaps wants to be identified by something—he doesn’t feel that just being ‘joe’ is enough; he wants to be (joe), THE GUY WITH THE TATTOO ON HIS FACE. Why would that be? Just guessing, but I would not be surprised if there was a history of abuse; perhaps a family of origin with a domineering mother or father, so that he became very insignificant—almost invisible. But he isn’t invisible anymore—not with that big tattoo… or is he? That big tattoo does two things for him—he is no longer invisible, but is still protected and in hiding, as it isn’t really him people are noticing— it is the artwork on his face. This fits him because as much as he wants an identity, wants to be noticed, he doesn’t have a sense, deep down, that he is worth noticing or that he HAS an identity.

Isn’t this fun?

How about the woman with the rose on her ankle? What do we know about her? It would help to know when she got the tattoo; if she got it at the age of 35 I would wonder the reason—finding herself after a divorce? Or a busy career woman who took a step back from all of the ‘responsibility’ to take a second look at life? Or if she got it at the age of 18 I would suspect that she wanted to rebel a bit, but JUST a bit… no pierced nose or pierced lips, just something that is rarely seen, and that is only seen by people close to her. I would think she is a bit more introverted, perhaps even shy.

I suggested to the woman—the one with the son who wants a tattoo—that she ask him why he wants to get the tattoo. Does he want to ‘stand out’? Is he making a statement of some sort? It really is not true, if the person says ‘no reason’… it is something that hurts a bit, costs considerable sums of money, takes some time… so there is SOME motivation. I suggested that she try to determine his motivation and then see if there is any way to accomplish the same thing in a way that is not ‘permanent’. Young people are often not able to verbalize or even realize what is motivating them… but that doesn’t mean that the motivation doesn’t exist.

As I mentioned at the start of this post, my thoughts on tattoos began in response to the idea that it was somehow improper to judge a person based on appearance, specifically based on the person having a tattoo. I have probably voiced a similar protest at some point during my youth; at least it sounds like something I would have said. But I now realize that particularly given the problems with other means of sizing up a person, the best way to assess or learn about a person is to look at the person’s behavior. In my practice, a person may talk for hours about how considerate he is; if I have to cancel because of a sick child and the person calls me an SOB, I see the behavior as a more accurate indicator of ‘what the person is like’. Likewise when a patient tells me that he ‘doesn’t know who he is anymore’, or when someone says that she ‘wants to be a good person’, I suggest that the best way to judge who you are is to take a look at what you do.

The idea fits well with another thing that I often talk about; acting ‘as if’. For example, if a person doesn’t ‘feel like’ doing the right thing, or isn’t the ‘type of person’ who would do the right thing, I suggest that he ‘act as if’ he IS that type of person, or as if he DOES feel like doing the right thing. In a short time, after acting like the person he isn’t, he will find that the person he isn’t is exactly who he has become.

As I have mentioned, I wrote a column for Psychiatric Times during my residency in psychiatry.  My intent was to write about the feelings encountered by a resident training to become a psychiatrist.  Training in any field of medicine includes new experiences, many of which are not encountered by non-physicians, or which are experienced to a much lesser extent.   In the next article I wondered about the effects that those experiences had on my personality.  To take an extreme example, all doctors start their training with three or four months in the cadaver lab;  our group of four students dissected the body of a woman who appeared to be in her 20’s at the time of her death from melanoma.  I recognized at the time that I was changing in some way as I learned to focus on the brachial plexus, a network of nerves that extends from the neck to the armpit, rather than on the dead woman who owned the brachial plexus.  Later in my training I knew that I was changing when I learned to put on a stoic face, as I told a 40-y-o man that he had cancer.  I learned a totally new concept– that I needed to present a persona that provided the right measure of security, compassion, and confidence, so that the man could perhaps experience some measure of comfort and support from me as he heard the horrible news.  A critic would say ‘just be yourself’!  But there are many ways for a person to ‘be himself’.  I wasn’t learning to be ‘fake’;  I was learning that being a doctor carried certain responsibilities beyond simply cutting out tissue or writing prescriptions.  People study their doctor’s face when they are told bad news;  they want to know how bad it is, and whether there is cause for optimism… or whether there is nothing but despair.

I’m getting off track a bit.  The point of the story I am about to post is that those learning experiences, and my ongoing experiences in medicine, do something to my personality.  Clearly there are some doctors who have developed big egos, anger, or bitterness from a life of doctoring.  In the story I wonder whether the bulk of my experiences have had a positive or a negative influence on who I have become today.  The story:

Stepping lightly over boxes of medical experience

A multi-vehicle trauma! This is what it is all about, I thought, as I followed my senior resident to the stairs. While my age placed my training against a St. Elsewhere’s backdrop, my excitement was more consistent with the modern, high-energy ER soundtrack. The emergency room itself inspired excitement, and as a third year medical student I had not yet developed the healthy fear that affected more senior, and more answerable, members of our surgical team. As we approached the cubicle I noted that the patient was small, maybe two years old. Red froth bubbled from his mouth as the emergency room staff frantically removed his cervical collar. I heard the word ‘tracheotomy’, and someone said “hold him down!” as his arms reached into the air. I grabbed his hand and held tight, grateful that I had found a mission that I could handle.

To my surprise, the hand gripped back. And suddenly… time stopped. Small fingers wrapped around my finger, and at once I was sitting with a small boy, stillness around us. I looked beyond the red froth, to see his clear, blue eyes gazing forward. No longer aware of the work to be done, I began to understand a tragic story. Through pieces of conversation I realized that the boy’s mother and father lay dead on gurneys in cubicles behind me, victims of a drunken driver. In a flash I could see all of what our experience on earth offered: life and death, hope and despair, beauty and horror.

After 15 years, I still feel heaviness in my heart as I remember that night. I have not attempted to describe the scene before, but I have sometimes felt the moment’s essence, as a secret part of what has since become ‘me’.

I have many secrets. I remember the 5-year-old girl who I met in the oncology clinic, with newly diagnosed leukemia. I silently winced in pain at the smile on her small face, an innocent unaware of the needle-sticks ahead of her. She sat with her mother, whose expression betrayed the knowledge that her daughter would be forced from the world where she belonged; a child’s world of security and happiness. I remember the seven-year-old child who died of sepsis in our recovery room after hours of attempted resuscitation, and I remember the horror that filled the room as we accepted the futility of our efforts. And I wonder, how have these secret images affected me? Am I a better doctor, or parent, or friend, or do I now carry a seriousness that has driven some of my personality inside, and beyond reach? Will I be a better psychiatrist? Am I more tuned in to pain, or has my exposure given me a resigned, grim acceptance of suffering?

For much of my life, my approach to learning was that all learning was good learning. My goal was to face life’s experiences as a sponge, seeing as much as I could see, and experiencing as much of life as possible. My assumption was that humans had the capacity to keep the wheat and discard the chaff; to assimilate the positive and to disregard the negative aspects of experience. The end result would be a ‘complete’ personality, free of bias, unfettered by misconception, and nourished by the ultimate sustenance of personality, information.

At some point my early opinions about learning became tempered with caution. I began to see that in regards to learning, experience, and personality, at least in my own case, I am what I eat. As much as I wanted to believe that I was capable of learning only the desirable aspects of experience, I saw that my personality was affected in ways that I hadn’t predicted. I remember briefly facing these questions as a college student, when I wondered, in 1970’s fashion, if there was in fact any evidence that people were ‘smarter’ after formal education. I thought more about the topic during a period of my life when I actively meditated, as I became aware of the constant parade of thoughts that drifted through my consciousness, despite my best efforts to limit them. This view of personality as an unorganized collection of experience is more Eastern, more consistent with what I have read of the developing ego, and more consistent with my experience as a parent of teenagers. Some things, once learned, cannot be unlearned. Some bad experiences are unconsciously assimilated and eventually inhibit function, much like adware on a Windows 98 computer. Memories accumulate like boxes of artifacts in a darkened basement. In my own case, half-opened boxes litter the floor, and some emit frightening noises.

As I work toward becoming a psychiatrist, I would like to develop an understanding of the biases that shape my attitudes; biases that have the potential to interfere with neutral observation and reflection. It is easy to identify the obvious examples of personal experience that interfere with the neutrality that I desire. For example, I can easily recognize the barriers that stand in the way of my feeling compassion for the playground bully. And the death of one of my best college friends during the attacks of September 11 undoubtedly affects my opinions of America’s role in the world. But while in psychiatry we learn to identify personal and historical events that have shaped our attitudes, I wonder if work and training experiences are incorporated in potentially prejudicial ways as well, perhaps beyond question because of their endorsement by common medical experience. I would like to identify the ways that my experiences in medicine and psychiatry change my view of the world, in order to have foresight into bias that will develop in the future. Of course, unique character traits result from experience in all professions; as I sit in the auditorium prior to my daughter’s band concert, the principal, oblivious to the ages of the assembled parents, reminds us to remain quiet and respectful during the concert. But with admitted narcissism, I see the experiences faced by physicians as particularly memorable.

The experiences faced in psychiatry training, while less overtly dramatic than the world of CPR and tracheotomies, force one to incorporate a different type of emotional experience. In my short training, I have been moved by the isolation of schizophrenia, by the emptiness and despair of depression, and by the ravages of families wrought by addictions. It is often difficult to come to terms with reactions to psychiatric experience because of the lack of formal resolution. Psychiatric diseases for the most part are not cured, and yet are not fatal by themselves; so there is no exclamation point to treatment successes and failures, and less opportunity to place experience on the opposite side of the line that protects our present world view from the tragedies of the past. There is also a learned frustration that develops as we accept that the will of our patients does not always coincide with our desire to help. And again I wonder, what have I begun to ‘understand’ about mental illness? Can I make a difference? What is the meaning of life in the face of such suffering?

At these moments, I try to find gratitude for the opportunity to seek psychodynamic understanding. The beautiful, horrible experiences of life weave tapestries, unique to each of us and to each of our patients, with fibers visible only to those willing to see them. And in the tapestries lie the questions, and the answers to the questions, and the answers to all of the questions to come. To study the fabric of these tapestries is to study the essence, and the meaning, of life itself. It may be asking too much to weave our own tapestries by design, but one can be aware of the admonition of Aldous Huxley, that experience teaches only the teachable.

And once again, we are back to the original question. Is all learning beneficial, and are all experiences enriching? Is it true that what does not kill us makes us stronger? Perhaps the answer is moot, since no matter our preferences, experience finds us. Maybe I can make an occasional decision as to what to remember, or face life’s challenges and disappointments with the respect required to ease cynicism. Perhaps I can embrace the feelings and the meanings of life events, rather than attempt to diminish their awareness. Perhaps all I can ask for is to find experiences with my eyes open, and to place my boxes in a well-lit room, where I won’t trip over them.

Continuing on the relationship between mind and brain, there was a study recently reported in the journal Psychological Science and described by the New York Times that concluded that people with ‘neurotic tendencies’ are more stressed out by uncertain feedback than they are by unambiguous negative feedback. To illustrate the point, let’s say you are having your in-laws over for Thanksgiving dinner and you really want them to like you. And let’s say, for the sake of the discussion, that they don’t like you—they don’t like your clothes, your personality, or your cooking. Would you rather have your mother-in-law tell you straight-out that she doesn’t like you, or would you rather have no idea whether she likes you or not?

According to this study, the answer depends in part on whether or not you are ‘neurotic’. People with ‘neurotic tendencies’ in the study preferred certain bad news over uncertainty, at least as measured in the study. This is where we come to the ‘mind-brain’ connection; in the study, the levels of misery of the subjects were determined by the activity in a certain part of the brain, called the anterior cingulate cortex. This brain region is part of something called the ‘limbic system’, a primitive collection of brain structures that give rise to emotion.

I found it interesting that instead of just asking the subjects about their level of inner turmoil, the investigators attached electrodes and measured electrical activity in the limbic systems of the study subjects. I haven’t read the original study—I don’t get the journal—but sometimes studies can get a bit too ‘techy’ and miss the point of what they started out investigating. For example, from reading the review of the study, the primary end point appears to be the level of distress of the subjects. I could imagine a researcher stating that the electrical activity is more ‘objective’ than a survey, but what if a person scores high on the electrical activity, but claims to have little actual distress? I could see the researcher believing the ‘objective data’ over the ‘subjective’ descriptions of the subject, but if the end point is ‘distress’, I think the subjective response is the most relevant. But this isn’t what I wanted to write about… so I will move on.

When I read about the study my first thought was: what is ‘neurotic’, anyway? The study talks about measuring five personality traits, including ‘neuroticism’. This led me to Wikipedia, where neuroticism is defined as ‘an enduring tendency to experience negative emotional states’. Woody Allen is the classic ‘neurotic’, of course; not the ‘married to my stepdaughter’ Woody Allen, but rather the Annie Hall or Hannah and Her Sisters Woody Allen. If you haven’t seen those two movies, you should—they are classics, and you will never again wonder what a ‘neurotic’ is after you has have seen them. I have written about ‘Borderline personality’; the ‘border’ is between neurotic and psychotic, and patients with borderline personality disorder or borderline traits will sometimes cross that line, transiently, during times of severe stress.

The Prototypical Neurotic

I continued to read about neuroticism at Wikipedia and other sites on the web. Gotta love the internet—it reminds me of going to ‘Fleet Farm’ in Fond du Lac, a store that carries clothing, hunting supplies, hardware, plumbing supplies, farm and auto supplies… I will go there to buy a screwdriver and come home with cordless drills, laser levelers, epoxy caulk, and my favorite— minimally expansive foam sealant! With the internet I will start out looking for a single definition, and end up reading page after page of barely-related information.

I came across another interesting finding about neuroticism: it has a geographical distribution! There is a higher incidence of ‘neurotics’ among the east coast population than among the population of the western states like Wyoming, Colorado, and Montana. That doesn’t surprise me at all, but perhaps it should. Why would there be a difference? Is it genetic drift? Some conditions, for example schizophrenia, tend to concentrate in cities; there are more support services available, and it is probably easier to be ‘homeless’ in a big city than in rural parts of the country… so over time the genes for schizophrenia tend to be more prevalent in people who live in cities. But why would ‘neurotics’ favor the east coast?

But then, who am I kidding? Personalities and personality traits run in families—they are carried to some extent in our genes—and so the neurotics of today were more likely to have neurotic parents yesterday. And neurotics are not the type of people to jump on a horse and start riding into Indian country! I can imagine the conversation on the trail, bouncing along on the seat of a Conestoga wagon: ‘gee guys, this is HORRIBLE… it’s so HOT! Is anyone else hot here? I don’t want to be difficult, but gee—what if they don’t LIKE us out here!’ So yes, genetic drift likely played a role, where people who were highly neurotic opted to stay behind and read the postcards rather than risk going to battle against ‘savages’.

No place for neurotics!

There is also the ‘survival of the fittest’ influence on population; people with certain personality traits were less likely to survive and have offspring with similar personality traits. I picture a gunfight with a highly-neurotic gunslinger: DRAW! says the challenger, and the neurotic says ‘You’re kidding, right? I think you must have me confused with someone else! I KNEW this would happen if I came out west!’…

The good news, of course, is that there is a place for pretty much everyone.  A neurotic Woody Allen-type guy would be annoying on a cattle ranch;  the prevailing attitude would be ’shut up and just do it!’  At the same time, the no-nonsense hard-working rancher, completely at ease in a pitch-dark desert, would likely be put down as a ’simpleton’ in the boardroom– naked Broadway cowboys aside!

There is nothing to say that people should stay where they ‘belong’.  In fact, many people seem to enjoy being in exactly the place where they DON’T belong– the cowboy in the city, or the sensitive worrier on the oil platform. Some people are most comfortable when they are blending in;  others thrive on standing out.  The important thing, though, is for a person to know where he/she stands.  There were times when I worked at the prison when I felt like an alien; the prison where I worked as a psychiatrist was filled with union yes-men and mid-level government administrators, mostly determined to keep their mistakes secret from the ACLU and Justice Department lawyers who were suing them… (no bitterness here!).

From those experiences I learned that when I think I am going crazy, the first thing to do is take stock of my environment and decide whether or not I ‘belong’.  Doing so would have saved me a great deal of heartache during my prison work.  Another way to state my point is to say that it is not worthwhile to strive to fit in, when you don’t respect the people you are surrounded by.

Peace,

JJ

I always take note of studies that draw connections between mental activity– aspects of consciousness—and the physical matter of the brain. I became interested in these connections a long time ago as an undergrad at Carroll College, when I wondered why eating dried-out mushrooms made the plant on the coffee table in my room in the fraternity house turn into a head that talked to me. I’m not trying to glorify drug use, but this was back in the 1970’s when everything was a bit different than it is now. I didn’t enjoy most of those experiences; the mushrooms in particular brought only frightening, painful experiences despite trying three times to find something pleasant about the psychosis that they induced. Supposedly the mushrooms contained psilocybin, but looking back I suspect that the material actually consisted of some benign organic matter laced with LSD, given the stimulant-activity that the material contained and the long duration of action.

The first time I tried them I went to a movie called ‘Heavy Metal’, an animated feature-length film that by my addled memory contained obscene images of violent sexuality. I sat in my seat and became more and more certain that humans had crossed some boundary into the world of Satan, where cartoons that were supposed to be filled with innocent images for children had been taken over by the forces of evil. I ran from the theater after about ten minutes, and waited in the car for my friend Kent to do the same. Interestingly he had the same thoughts and ran from the theater about five minutes after I did!

The second try was at Alpine Valley, an outdoor rock concert arena where on this particular occasion I went to see the Grateful Dead. I remember feeling as if I was being sucked toward the stage, which was down the hill from our seats, and I struggled against the crowd to climb to the back of the arena and exit—over a fence and into a cornfield. I made my way to the car and somehow got home that night; several friends were not as lucky. One ‘frat brother’ stumbled in at about 9 or 10 the next morning (we lived about 40 miles from the arena). Both of his eyes were swollen nearly shut, and he didn’t have any shoes; he told us that he had climbed the back fence as well and gotten lost in the cornfield, eventually coming across Interstate 43. He tried to hitch-hike back to the house, and got picked up… but instead of bringing him home, the two men who offered the ride drove him to a remote area and beat the heck out of him, stole his wallet, and also took his shoes—for reasons that were not explained to him. We still were missing one person, and later in the day we received a call from the East Troy Police Department, asking for someone to drive down and pick him up. At the end of the conversation the man on the phone added, ‘bring some clothes with you—he’s naked’. Our ‘brother’ apparently found the same cornfield but decided to be ‘one with nature’, before finding the same Interstate and trying to ‘hitch’ home. Apparently the police have concerns about a stark-naked college-aged man walking along the highway with his thumb extended!

The third try was the worst for me, and enough to convince me that there was no future in such ‘studies’. I did have some very interesting perceptual experiences, though—I already mentioned that the plant on my coffee table became a head that talked to me; I was the ‘social chairman’ of our fraternity and so I was supposed to police the party that night to keep out underaged students. In the ‘chapter room’, the large room with kegs lined up and garbage pails filled with Kool-Aid and grain alcohol, I saw a ‘circus strong-man’ wandering through the crowd of students. You know the guy I’m talking about– he had a shaved head, a big mustache, big biceps, and he was wearing a one-piece set of tights that had red and white horizontal stripes, that extended to his knees and hung from straps at the shoulders. I would catch the circus-guy staring at me, and then he would disappear—something that was a bit disconcerting. I became more and more worried about him—why would a circus strongman come to our party, particularly wearing his tights? And how did he keep disappearing? Moreover, nobody else was concerned about the circus man. I kept trying to drum up help to find him and kick him out of the party, but nobody would listen to me. After awhile it became clear that he knew I was trying to get rid of him, and he started to look more threatening toward me—and so I left the party. I remember walking down the middle of the street, and the old houses that lined each side were ‘friendly’, and comforting. They were alive, and I could feel their breath as they exhaled out their front doors, their warm breath blowing against me as I walked past them.

I was about 21 years old at this point, and this was the tail end of my experiences with psychotropics. I don’t feel guilty about the experiences, but I do feel lucky. I am grateful to have survived those experiences, and I hope that my own children can avoid taking the stupid risks that I took back then.

Several years later, during my neurology rotation in medical school, I listened as my attending talked about evoked responses and the ‘P-300’ wave that he thought may correlate with intelligence. To explain, impulses in neurons travel through electrical charges that propagate down the nerve fiber; if I hit your foot with a hammer, the pain signal will travel up nerves all the way to your brain, and theoretically we could detect the electrical impulse as it hits the brain. Theoretically, because the impulse is just one out of thousands of impulses, and so the impulse we would listen for would be drowned out by all the others. With ‘evoked potential testing’, electrical activity at the brain is measured while a number of identical stimuli are applied; over time, the non-measured electrical activity adds together and ‘averages itself out’, while the activity from the repeated identical stimuli adds together and becomes more evident.

My attending neurologist was discussing something called BAER, or ‘brainstem auditory evoked response’. The person being studied would wear headphones and hear a tone, over and over, and the electrical activity in the brainstem would be measured during and after each tone. After 100 tones, the background activity averages out and becomes flat, and a series of waves becomes evident on the screen where the electrical activity is displayed. Stick with me—my point is almost here! The first two waves, P-1 and P-2, were caused by the electrical impulse from the tone, passing through the nerves, and going through two major ‘switchboards’ in the brain that filter auditory material on the way to conscious recognition of the auditory material. Now, if instead of just passively listening I was told to evaluate the tone—and to decide if the tone is higher-pitched or lower-pitched, for example—a third wave appeared, the ‘P-3’ or ‘P-300’ wave (I think it came at about 300 msec). The fascinating thing at least in my opinion was that the third wave represented mental activity. It didn’t come from the tone; it came from the decision about the tone—the mental activity alone. People with high IQs supposedly had a shorter latency to the P-3 wave—or something like that.

These were a couple of the early experiences that got me interested in the mind/brain relationship. Almost every day I see another study that points out relationships between brain structure or function and mental activity or personality characteristics. I will try to point them out here as I come across them; consider this post to serve as a general introduction to the topic. I find it fascinating that the subjective ‘I’—the sense of ‘me-ness’ that we all have—is a product of neurons and other tissue. At the same time I have a hard time believing that neurons and tissue explain EVERYTHING. I can accept the notion of memories stored in synaptic connections, or sounds compared with other sounds through neural impulses in the association cortices; but I have a hard time believing—and don’t want to believe—that my hopes for the future, my longing for connection with a higher power, or my love for my family can be reduced to tissue and neurons. I would find it most comforting, and most logical, if THOSE things persist long after the tissue is gone.

People come to a psychiatrist because they want to change.  At least that is what they think they want.  They get up the nerve to make an appointment, walk through the door– not a small thing!  In fact, considering that psychiatrists are supposed to be the doctors who deal with depression, anxiety, and ‘frailties’ of the mind, it is interesting how much dread they invoke in people!  I think the reason isn’t necessarily because psychiatrists have horrible personalities… at least I hope that isn’t the reason… but rather I think people fear going to psychiatrists for at least two other reasons.  The first is that people think that psychiatrists will ’see through them’– that we have some special ability to read minds, or determine what a person is REALLY thinking… the second and more important reason is that people tend to push their problems out of their awareness, and when they go to the psychiatrist they have to think about things that they would rather not think about.

There are other reasons, of course–  psychiatrists ‘ain’t what they used to be’, at least in my humble opinion.  They spend way too little time with people, selling their souls to the big systems that have them work on productivity, seeing too many patients for too little time.  And there is nothing worse than getting all worked up to go tell a person your problems, only to have the person totally ignore everything you are saying, or push you out the door before you even got started.  I wish people would just avoid those psychiatrists, because they are giving psychiatrists a bad name and ruining the specialty.

But that isn’t why I am writing… I am writing about change.  People come in saying they want to change… and then they fight that change from that point going forward.  I’m not complaining, because that is just how people are.  But it is something for people to be aware of, so that they understand why they keep making the same New Year’s Resolution year after year!

Because of resistance to change I usually aim fairly low in my expectations of the steps people will take… I don’t for example tell people who are depressed to ‘just start exercising’, and get mad when it doesn’t happen.  On the other hand there are times when it is possible to induce change, and I try to opportunistic– and grab those opportunities if they arise.  Such was the case with the patient I am about to talk about.  As usual, names and details have been changed a bit for privacy.

The patient, ‘Jane’, had been miserable for a long time.  Her husband doesn’t communicate beyond a grunt or two here and there;  Jane has given up a great deal of ‘power’ over the years, in part because she has a recurring substance problem that has been mild so far, but that gives her enough shame to buy into her husband’s comments that ’she has no right to complain’… about anything.  This is a tough situation for a person to be in, and a frustrating case for a psychiatrist.  The person in such a position is miserable, but not miserable enough to really do anything about it.  I can suggest things, of course– ways to foster communication, tips on relaxation, parenting suggestions… but for the most part people don’t take ‘advice’ to heart.  Now and then I will find an area where the person has a ‘blind spot’– were the person is seeing something in a distorted way, and if I can get the person to see it differently I might increase insight into a problem… this is trickier than it sounds, because I can’t just point it out to the person, as then it will be rejected.  But if I can make it come out in a way where the patient ‘discovers’ it, then it might stick.

Off track again… I should try to write in the morning, as late at night I tend to get a bit tangential.

Opportunism…  if the person gets desperate enough, THAT is when there is the possibility of change.  That is where I was today with Jane, after she wrote me this message:

Hi Dr. Junig,

I left a message at your office last week; but I was unable to get back to you —to get in as soon as possible.

Things feel like they are getting worse than ever…Financially and emotionally with Tom. It’s not only him. It is me. I just want to leave. For the last month the thought of leaving, just driving away to escape my life is a thought that I can’t get out of my mind.

I hate our unorganized mess and life and finances- and when I look around I start to feel like I am going to lose it. I just keep saying, this is not how my life was supposed to be…

Bill collectors are calling all the time. Our furnace isn’t working and Tom doesn’t seem to care. We are all living in the basement of my mom’s house now– pretty sad. I have no energy to do anything at all; except barely get by with the daily activities which are overwhelming. I have gained the 25 lbs over the past three months, strange because I never feel like eating anything.

My girls are the only thing that keeps me going every day. But they can tell there is something really wrong with me.

I used up the valium 2/day, took twice as much cause it didn’t do anything for me at the lower dose. I hardly ever feel relaxed or not un-nerved.

Please call!

My Reply: Again, this is one of those rare times when one swings for the fence.  A person with a ’small’ substance problem is not going to accept buying into a 12-step program;  people with addictions come in and say ‘doc, I’m so miserable from these drugs… I can’t stand it anymore… I’m broke, my wife left, I have no food in the house– I’ll do anything!  ANYTHING!!  Please, help me’.  I’ll ask them to check out one AA meeting during the next week– one hour, costing one dollar.  The person says ‘Oh no, doc, I can’t.  I have too much to do–  in fact, I’m not really all that bad.  Just forget I said anything!”  People hate AA– unless they know anything about it and have actually opened their mind to it– then they recognize just how effective it is, and they understand that it is NOT about finding sympathy, or whining about problems.  It is about courage, and follow-through, and responsibility, and ‘carrying one’s load’.  And it is life-changing.

OK… my response, finally:

Hi Jane,

I hear you loud and clear. I don’t have an easy answer– I don’t think there is one, because you would have found it by now if there was. But there should be reason for hope; if we look at your life there are reasons to be happy, at least moments of happiness– I don’t want to sound like I am making less of things because I don’t feel that way– I realize that things are really hard right now and you are totally miserable. But you have food and you have shelter– not great being in grandma’s house, but at least you have shelter…

I think about my own despair in 2001 when my addiction came to a head– lost my job and career, marriage sucked, kids didn’t know me, no hobbies, feeling totally stressed out and physically miserable. In my case there was addiction to focus on, which was lucky for me, because the 12 step program really does have the ingredients for some level of happiness— even when everything else is going wrong.

In your case, Jane, there are little things that will improve the situation for you, but I think it will take drastic measures to make a real change in your level of happiness. Anything short of that will be a temporary fix– at best—and you would end up back where you are now. Do you see my point? You need something that is ‘life-changing’– nothing else will make all those things better!

I hate to sound like a salesman, but a 12 step program is the only thing that is going to really help. The good news is that if you are truly desperate– desperate enough to open your mind– a 12-step program will potentially fix ALL of those problems. I know it seems like a stretch, but it really could. And it wouldn’t cost anything except a buck per meeting.

Will you consider that option? I would make recommendations on which meetings to go to– and the goal would be to get off the lorazepam. We have to do something about those anyway– they will only destroy you at the rate things are going. You can’t control them; don’t feel bad, because I wouldn’t be able to control them either. We have to get you off them because there is just no other option– you take them, run out, get sick…. they are not helping, and they are probably making things much worse.

Will you check out a 12-step program?

JJ

After a shot at the fences, people sometimes strike out. Time will tell…  we will take a big step forward… or I may never hear from this patient of two years again.

I’m tired… so… sorry, but this will have to be continued.  I don’t know the ending yet anyway!

I used to write a column for Psychiatric Times, describing my experiences as a psychiatry resident.  I have decided to post a few of those articles on my blog.  Some are on the long side, and others are shorter;  some took more effort to write than others.  I tried to focus on my feelings as I learned to work with patients as a psychiatrist.

The writing opportunity fell together in a nice way;  I was on my way to a meeting in Boston and Dr. Laura Roberts happened to be presenting at the meeting;  I tend to be intimidated easily and I was making nervous conversation with her, telling her about the unusual experiences I have had over the years (I used to be an anesthesiologist, for example).  I told her I would like to write about them, and she told me about a column at Psych Times that needed an author.  I called the editor the next day, submitted some material, and she liked it… and to my delight I had the column!

This first effort was in response to a very depressed patient.  Looking back, the person most likely had a condition called ‘Borderline Personality Disorder’, something that is commonly misdiagnosed as ‘bipolar’. Patients who are ‘borderline’ have horrible depression that is very ‘reactive’– meaning they will be doing fine until something happens that they interpret as rejection, and suddenly they feel suicidal.  The condition probably comes from a lack of sufficient bonding and security at an early age, and doesn’t respond well to medication.  It does improve to some extent with insight;  as a person learns to identify the triggers for their mood swings he/she can reduce their intensity a bit.  The story is about my encounters with such a patient;  I didn’t recognize the borderline component at the time, but was more preoccupied with the sense that ‘I couldn’t help her as much as I wanted to’.  Now I understand borderline, and I also understand myself much better;  when I get the feeling that ‘I wish I could do more’ I recognize it as a sign… a sign that I might be missing Borderline Personality Disorder.  Read on:

Reining in Compassionate Counter-transference

As I sat down to Thanksgiving dinner, I kept thinking of the look of despair in her eyes. I was haunted by the last thing she had said to me the day before: that I could walk away and forget for the holiday, but that she couldn’t. That, she reasoned, was why, in fairness, I should allow her to kill herself.

I had discussed and experienced counter-transference during my short period as a psychiatry resident, particularly in relation to borderline patients. I was learning to be aware of my emotional reactions to patients; I was beginning to understand that my feelings could serve as indicators of deeper meaning that my conscious mind was unable to grasp. But before now I had been trying to make sense of occasional feelings of aloofness, anger, or frustration. I had not yet felt such gut-wrenching, moral obligation to rescue a patient.

She was by far the most severely depressed patient that I had met since beginning my residency. Her pain had been unrelenting for over two years, despite treatment with multiple classes of agents and augmentation strategies. And her suicidality lived within her like a demon, waiting for the slightest opportunity to overcome the last remnants of her will to live. Since becoming involved in her care, I found myself facing many questions, grist for the mill during residency experiential group. Does a person ever have the right to choose to die? And what motivates my actions to keep her alive? At what point are my actions self serving, like those of a cancer surgeon who cannot accept defeat? My patient, a critical care nurse, answered all of my hopeful statements with more existential questions, all based in intelligent, plaintive nihilism.

But it was her eyes that mattered most. She had gazed directly into mine, her face tearful and contorted in pain. “Can’t you see,” she whispered, “that I’m too tired… that I just have… to… stop?” I stood with my arms at my sides, feeling a wall of professional boundaries threatening to form, and at a loss for which side to stand on. Were she an animal, I would not have been able to walk away without doing something, including providing death’s final relief. I felt limited by my role as a physician, for the one natural impulse, to embrace her and comfort her, was obviously off the table. And so even though I drove home from the hospital that night safe in the knowledge that I had done all I could as a physician, I wondered if I had failed as a human being.

I did not sleep well that night. My wife of 18 years knew instinctively where my mind was. She reminded me that I can’t carry the weight of work with me all of the time. “How are you going to manage for the rest of your life?” she asked. I understood her point, but I also recognized that with this case, for now, forgetting seemed wrong in some way. I decided that the issue of letting go of work would have to wait until future experiential group meetings. My concerns that night were deeper, and centered on the nature of my feelings. I thought about my automatic reaction to her pain, and my impulse to embrace and provide comfort. I worried that my thoughts were unique, and I was embarrassed and ashamed for them. Yet at the same time, I was haunted by the feeling that I had not done enough- that I had used the bounds of professionalism to avoid the messy work of truly helping a suffering person.

As I sat at Thanksgiving dinner, I thought of the despair in her eyes. As the warm glow of family connection entered my consciousness, I realized that her despair was seductive. In the business of life, we are often far from the deep connection with others that perhaps most people secretly long for. In her desperation, her plea for salvation was raw, unfiltered, and essentially human. I realized that the desire to respond was natural, but dangerous in its primitiveness. I suddenly had empathy for practitioners who made the mistake of giving out there personal phone number, and who found themselves overwhelmed by boundary issues. I realized that I had much to learn. And I acknowledged my respect for the field of psychiatry, in that I would be facing challenges unlike any other field of medicine.

Returning to the inpatient unit on Friday, I felt more confident about the position I had taken in regard to the wall of professionalism. I had learned something about the desire to remove the wall, and at the same time I recognized its importance. I also recognized, with gratitude, the privilege of being trusted with the despair of another. The experience of human connection provides the greatest rewards in all of medicine.

I decided to present my feelings to my attending as we staffed her case. I searched for the words to describe my feelings, predicting that I would be seen as immature, or unprofessional, for my reactions. “The way she stares with her eyes- so desperate…” I said. “I feel like…. I wonder if….”

“You should give her a hug,” he said. “I know what you mean. Let’s talk about why you feel that way, and what that tells us about our patient.”

And while I had only just begun the long journey toward understanding and effectively using counter-transference, I understood that my feelings were not shameful or superfluous. I was intrigued at the prospect of understanding how my own humanity contributed to, and potentially threatened, my therapeutic relationship with a patient. And I had new respect for one of the challenges ahead of me.

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