Boredom

We have been in this pandemic for months that feel like years. Have you reread all the books from your childhood and college years? Have you put together every jigsaw puzzle from the storage closet under the stairs? Have you binge-watched every Netflix series that caught your fancy? If you have, then you have probably hit that emotional, physical and temporal wall that is boredom. I don’t have anything to do. I just want to go to sleep. Maybe I can find a snack in the kitchen. I should be cleaning or cooking or…
I think we’ve all felt it, experienced it, and dreaded it, but boredom is not something that is to be feared or even endured. I read a January 4, 2019 Time article by Jamie Ducharme recently called Being Bored Can Be Good For You-If You Do It Right. Here’s How. It made some good points and made me think more about how we can embrace boredom and even use it as a jumping off point for creativity and productivity if we just open ourselves up a bit.
Why is boredom, and the act of being bored every once in a while, so important? According to the Time article, boredom “is a search for neural stimulation that isn’t satisfied”. I believe that we sometimes panic when we have nothing to occupy our minds or stimulate us or provide novelty, but being bored pushes our own brains to create the novelty and stimulation from nothing. It forces us to be creative. I love to write, and some of my best ideas to explore have to come to me in such unlikely places as the hot shower on a cold morning, on a steamy trail walk by the river, or when sitting drowsily in the early summer sun in my front porch rocking chair. These down times can be a resting period, a respite from the daily grind that we sometimes do not realize we need. They can happen spontaneously. That being said, can one plan to be bored?
Absolutely. Now, I should say here, as did the author of the Time article, that one should not confuse boredom with relaxation. Acts that require concentration like yoga, meditation, or even putting together a puzzle, do not lead to boredom, even if they are relaxing. Boredom requires that one let the mind wander. No stimulation is necessary. Another crucial aspect of allowing yourself time to be bored is that you must unplug. Having a phone in your hand keeps you from ever reaching true boredom, while it paradoxically fails to truly entertain most of the time. What do I mean by this? Endless scrolling keeps our brains from working out their boredom and coming up with novel stimulation and creative thoughts. At the same time, the quality of entertainment we get from such unstructured time is nowhere near the quality of entertainment that we might get from diving into a good book with characters we truly care about and invest in.
Sandi Mann, a senior psychology lecturer at the University of Central Lancashire in the UK, says that we can become addicted to the tiny dopamine hits we get every time we pick up our devices. “Our tolerance for boredom just changes completely, and we need more and more to stop being bored.”
Planning for times that you will be bored may lead to increased creativity, new ideas to explore, and thoughtful reflection about the things that are important to you but that get pushed back by technology and busy schedules. Being bored may help you become more resilient. You may even find that this new creativity and idea generation gets you outside your own head and thinking about doing something that might benefit others. Read, doodle, listen to familiar music, doze in the sun, anything that will free your brain to be quiet, attentive and open to new things. You may be amazed at what you come up with.

Can You Hear Me Now?

“I feel like a little girl at Christmas!” my almost eighty-five year old mother said, from an appropriate social distance, after she received her new iPad earlier this month.
My middle daughter, ever the organizer and planner, asked if her grandmother knew how to FaceTime or otherwise communicate by video in this new world of COVID-19 and social distancing. Her great-granddaughter is growing up in Colorado and she, like the rest of us, has not been able to see the little one, or any of her other great grandkids, for some time now. Something needed to be done to remedy that. My daughter had the marvelous idea that we should get her Grandma an iPad and teach her how to use it. I agreed and ordered one right away.
The look on her face when I saw my mother talking to me by video on the tablet was simply priceless. She quickly learned how to use this wonderful little piece of tech, and connected swiftly with her grandchildren and great grandchildren in Denver and Chattanooga. Something so simple lead to almost immediate joy. A silver lining in this dark gray Coronavirus cloud for sure.
We have found that we can all stay connected pretty easily to friends and family in this time of social connection crisis, but what about connections between patients and providers? What do you do when you have physical symptoms and have been told to stay away from doctors’ offices and emergency rooms? What happens when your depression deepens, your anxiety flares and the voices that were under pretty good control start to scream at you again? What happens when your resolve to stay sober is dashed by the fact that AA meetings are not meeting at all? How do you connect when mental health centers, doctors’ offices and clinics are not seeing people physically due to the worry about coronavirus transmission?
We have found that there are several very good apps and services that help us to do just that. Most of us in the local mental health center world are now working from home the majority of the time but we still have full schedules of people to assess, check for medications, and to do counseling sessions with. I thought I would share some generalities and specifics of this new world with you. It might help as you pursue your own mental health treatment, and you might find that it also goes for other medical care that you might receive as we navigate this new normal.
We communicate with you by phone call or by video calls of several kinds. This is a wonderful addition to our therapeutic arsenal, but it does come with some caveats. First and foremost, you must understand that while these ways of communicating with your doctor or therapist are quite private and secure, they may not be considered 100% HIPAA compliant. As you might remember, one of the primary jobs of the Health Insurance Portability and Accountability Act of 1996 is to safeguard your private personal and healthcare related information. Speaking with me in my office with the door closed and no one else around is about as safe as we can make things. Talking to me on our iPhones via FaceTime not so much, though it is a wonderfully vivid way to see and talk with each other in real time. You see the tradeoff there.
What are some of the other options for communicating in this new way that are being used by the local mental health community? Doxy.me is a video or audio telemedicine platform that is free to use, though it does have a paid tier with a little more functionality. I can send you a link that allows you to be in my “waiting room” until I call you for the session, which can be video or audio only. This service works well but the quality seems to be a little spotty at times, with freezes and restarts and other issues. If you have a Google or Android phone and have Google Duo, I have found that both the audio and video quality with that app are quite good. Google Voice is my go to for regular phone calls, as the connection is usually quite good and the quality of the call is quite nice as well. I have already mentioned FaceTime above, and some folks specifically asked to be contacted via that platform since they have an iPhone and trust it to be secure.
When we see you using these apps and services, we make sure that we tell you why we are doing this, that it is not the same as being seen in the office and that you give us permission to speak with you using these platforms. Most everyone I have seen over the last two or three weeks has been completely fine with these new ways of having a mental health visit. Some of the upsides? Patients do not have to waste time, gas money or effort getting to the clinic from their homes, paramount during this time of social distancing. When I call and you answer, we can get right to the point, cutting out much of the time walking to and from the waiting room, gathering paperwork for labs, etc (I can do most all of that electronically, as well as electronically prescribing most of your medication right from my laptop keyboard as well) and actually finishing many of these sessions in less time than at the center in person.
Lastly, may I leave you with some tips to help make this a smooth process on both ends of the phone screen? Understand that video or phone appointments are still appointments. They are set at specific times, and we expect to “see” you at those times. These are not casual or social calls. That means that you should be set up and ready to receive the call at the time specified, so that everyone may be seen on time for that day. I have called some patients this week, only to have a parent roust them from bed to speak with me, or having to wait for them to complete a task in the kitchen or bathroom before they can come to the phone. Consider your surroundings, as I do. I have had virtual tours of many backyards and decks, and met several cats and dogs on screen this week, which is certainly fun but may make it harder for us to really hear each other well enough to get our business together completed. Find a quiet, private spot for us to talk, just as we would if we were in the mental health center. One more thing. Remember to dress like you are going to talk to your doctor or counselor. I have been quite surprised and frankly startled a couple of times these last few weeks by what folks will wear while FaceTiming on the phone.
We are very unlucky in that we are all living through the first world pandemic in the last one hundred years. We are also quite fortunate to have at our disposal some of the most useful, easy to master technological tools for communication in our history. I am so glad that we still get to carry our work forward, maintaining our mental health even as we strive to stay physically healthy in these challenging times. Stay safe and thanks as always for reading.

F5s

F5
Incredible tornado.
261-318 mph.
Strong frame houses lifted off foundations and carried considerable distances to disintegrate; automobile sized missiles fly through the air in excess of 100 meters; trees debarked; steel reinforced concrete structures badly damaged.

tornadoproject.com

 

We had a strong storm front come through the southeastern United States last week. Of course, this was not the first time this happened, and it will certainly not be the last. It was fascinating to watch it march inexorably across the country, showing up on my weather app as a ragged green diagonal slash from Gulf to heartland to northeast, moving slowly and relentlessly across the landscape. In the center of the ragged slash was a well defined hard bright yellow-orange-red line of destruction. Pretty on the screen, destructive on the ground. Destroyer of worlds.

Texts began to trickle in from my daughter, who lives in Spartanburg, of an apparent tornado that touched down not five miles from her house and destroyed a shopping center. A coworker who sees patients at the mental health center by telehealth connection also reported frightening noises that drove her to her basement to hunker down until all warnings were lifted later in the day. Both reported the loud, surreal wail of tornado warning sirens, something that I have never heard in real life, but that I am sure must be quite distressing in the midst of gray skies, howling winds,  pouring rain and lightning flashes. Not an F-5, but terrifying nonetheless.

When I hear about such stressful situations and see evidence of the destruction they bring,  I think of my friends, family, acquaintances and patients have who struggled with cancer, financial stress, persecution for various reasons, and other stresses that lead to anxiety, fear and emotional upheaval. My aunt who succumbed to ovarian cancer when I was a boy. My mother, who is a breast cancer survivor. My friend, who tragically committed suicide. My patients, who tell me stories of unbelievable trauma, neglect, abuse and hopelessness. Like an F-5 monster tornado, these life circumstances can drop on any of us unexpectedly from the sky. Pretty colored X-rays and scans reveal the destructive power of the cancer underneath. Sirens go off. The mind screams take cover, take cover! The body sometimes is only grazed, shrapnel cutting but not killing. Other times, the impact is devastating. Nothing looks as it did before the storm. The landscape is flattened and only rubble is left. We return to a place, time or set of circumstances that we expect to be familiar, only to realize that all of our old landmarks are gone, destroyed. We do not know whether to drop to our knees and cry, run headlong into the pile of rubble, or turn and walk away.

Is there anything good about F-5s, cancer, abuse, trauma, and destruction?  What an odd question, I hear you asking me.

These scourges, while leaving city blocks, body parts, and psyches in absolute ruin, are often coldly surgical in their devastation. That is, a few hundred yards away, or a few inches outside the margins, or in some other part of the emotional us, the sun is shining, the tissue is healthy, the coping is reasonably good and life goes on. Friends rush to help. Prayers go up. Communities, wonderful , supportive, dynamic communities form. Support is not only offered but insisted upon. Rebuilding begins immediately in the aftermath of the siren’s wail, the surgeon’s knife, and the abuser’s fist.

When the horror and the shock and the denial and the anger and the tears and all of it subsides, victims become empowered survivors.

Strong!

The chorus goes up.

We will rebuild.

Life will go on.

We’re still here.

A Milieu of Unfriendliness?

As we had our all agency meeting at work the other day, involving mental health employees from all three of our sites and from all types of job descriptions, I was struck by something that come up as we discussed issues of cultural diversity. We had had a good presentation on diversity and how it was germane to the people that we serve everyday. Then, a few folks made observations that made me understand immediately that they felt misunderstood, unappreciated, and unacknowledged in the positive ways that they obviously felt were important.

How could that be, I thought? I started working for the local mental health center in Aiken part time in 1991 and came on full time in 1993 for the specific reasons that I loved the patients, the clinical environment, and most of all the people that I worked with. I have stayed at the center for almost twenty nine years for those same reasons. Now, I know that we are not perfect, but I do get the sense that the folks I see and work with every day are basically good people, caring people and people who care about my wellbeing as well as their own. For the most part, we cooperate, we commiserate, we collaborate and we celebrate, all important parts of being on a team that pulls in the same direction for positive changes and outcomes. I was a bit saddened to hear that some of my coworkers do not seem to feel respected, genuinely valued or appropriately acknowledged.

How did we get from 1991 to 2020 and this angst? I have a few ideas about what might have changed.

We work in a culture of fear-driven productivity at the expense of much else. Being a part of the management team as medical director, I understand this from a purely operational viewpoint, in that we must do a certain amount of business, bill a certain amount, collect a certain amount of money and constantly push for provision of appropriate services to keep our doors open. Otherwise, we would not be much good or be able to provide services to anyone at all. I get that. But it does seem to me that a lot of our staff feel pressured by the numbers, the spreadsheets and the bottom line, regardless of the emotional toll that this pressure takes on them daily. In this twenty first century world, we have perfected the art of cranking out widgets, but we have sometimes lost our drive to connect in meaningful ways with each other in the bargain.

As a corollary to that, the time that we spend with each other, WITH each other, is minimal.  I have noted, as have others, that sometimes we can pass each other in the hallways and not even acknowledge the other with a smile or a kind word of greeting. Now, there are some of us who are excellent at that kind of connection, bright rays of sunshine in an otherwise clinical gray haze, but I’m afraid many of  us, myself included, can easily fall short at times. We need to connect emotionally and model that behavior that we often try to teach our patients about.

I began to think, we have lots of folks working here, lots of people like me and not like me, with different values and priorities and hopes and dreams and ways to act and dress and walk and talk and interact with others. We preach acknowledging these differences, even elevating and celebrating them in our patients, but are we failing to do the same with those who work in the offices next to us? Based on what I heard at our meeting, I’m afraid that might be the case.

Are we fostering a workplace culture of exclusion? A milieu of unfriendliness?

There is enough stress in the world right now to go around, and then some. There are social, cultural, political and class stresses that make us wonder how we will ever get through some days. In spite of those stresses, we do get through each day.

We need to be consciously  aware at home, at work, at play, wherever we are, that there are those who feel marginalized, unappreciated, unloved, unseen and disconnected.

We must start somewhere.

Smile. Acknowledge. Say hello. Check in. Look up. Make eye contact. Tear down the wall that surrounds the milieu of unfriendliness and build your own bridge to a culture of appreciation and hope.

It starts with me, and with you.

 

Demograffiti

Way back in the day, when I was going to medical school and my beloved Mac computer was but a gleam in its creator’s eye, we were taught to think about and to present medical cases in a very circumscribed and conventional way. After reviewing all of the pertinent medical records (which were all written down on paper and required transport from nursing station to workroom on small but sturdy wheeled carts, of course), we proceeded to the patient’s room (if hospitalized) or to the clinic exam room if outpatient and proceeded to take a history. Yes, my friends, we actually sat down, SAT DOWN, I tell you, and spent minutes if not an hour or two with the sick person at hand and actually talked to them, a la William Osler, giving them ample opportunity to tell us what was wrong with them, and then to gregariously yet sanctimoniously let them in on the secret, as if we had actually figured it out ourselves. (Most of the time, it is quite true, patients have a pretty good idea what is wrong with them and will tell us of we will only take the time to listen) Yes, the whole review and history taking process could be as long…as that last sentence was.

Now, after that was done, we of course did the requisite physical examination, which might include judicious use of a reflex hammer to the knee and a sticky wheel to test for sensation and a tongue blade applied at just the right angle to view whatever was lurking down the gullet. We came. We looked. We saw. We diagnosed.

Then we reported. To the chart. To our attending. To the nurses. To our less bright counterparts who were slow on the uptake and couldn’t tell the difference between a whiteout from pneumonia on chest X-ray and Aspen, Colorado in a February snowstorm. Our discourse almost always began as follows.

“This forty-two-year-old alcoholic white male presented to the emergency room with acute chest
pain of two hours duration accompanied by nausea, diaphoresis and pain radiating down his left arm.”

“This sixteen-year-old sexually active white female presents with new onset abdominal and pelvic pain and a moderate fever, with elevated white count and a left shift.”

“This fifty-year-old obese black female presents with abdominal pain, anorexia, listlessness and depression over the past three weeks.”

“This eighty-five-year-old male, a former aerospace engineer, presents with irritability, forgetfulness, wandering behavior, and inability to find words or name routine everyday objects.”

Now it is funny to me that in this day and age, when Google knows our whereabouts and Amazon can deliver things to us in two hours before we even knew we needed to order them, some folks take great exception to the routine practice of calling attention to one’s age, sex, race, color, creed, sexual proclivities or activity, body habitus, or other defining personal parameters and characteristics. Somehow, this is seen as invasion of a person’s privacy or is knowing too much about a person’s private information.

Really.

Well, when I was taught medicine, it was very important for me to know your sex, your age, whether or not you were HAVING sex, your weight, your alcohol and drug use habits (including the use of needles), your eating habits, your stress level, what kind of job you did, how much time off you took, your complete family history, and so forth. I needed to know those things, because in order to differentiate heartburn from heart attack, ectopic pregnancy from eructation, psychosis from neurosis and flatulence from petulance, I needed all the information I could gather, and then some. I might even have to speak with your spouse (with your permission, of course) or (God forbid) your mother to find out the things that you conveniently left out and did not want me to know.

Yes, today we who work in the healthcare industry are in the business of safeguarding privacy, and I am all for that. HIPAA (a 1996 Federal law called the Health Insurance Portability and Accountability Act that restricts access to your private health information) is king. However, I am not the enemy. Your other doctors are not the enemy. Your physician assistants, nurse practitioners, counselors, psychologists, nurses, phlebotomists, and lab techs are not the enemy. We are not Facebook. We are not Google. We are not Alexa. Okay, I think you get the point. We need to know these things because we know that dementia rarely strikes eight-year-old girls and sarcoidosis might be a little more common in a middle aged African American woman. An overweight man with chest pain who tries to keep his case of beer a day habit from me when I admit him to the hospital for depression will make treatment of his ensuing alcohol withdrawal that much more difficult as we work him up for his third heart attack.

In order to give you the excellent care that you deserve, we need to know everything that pertains to your health, including habits, mental health issues, and pattern of substance use. Please help us. Because you know, some of your demographics are written all over your history and physical and are easy for me to see. Other bits of vital information are hidden in your head. Unless you let them out, that is where they shall stay.

I’m a psychiatrist, but I’m not a mind reader.

CBD

One question I get asked a lot lately is this.

“Is it okay for me to use CBD oil?”

I thought it would be a good idea to address this general question in Mind Matters this week.

First of all, CBD oil and associated preparations are types of alternative medications, medicines that might not be mainstream or readily prescribed by doctors , but are nevertheless used by many people on their own. Alcohol and marijuana are two substances that are often used as “medicines” by those that think they function better with them than without them. Many people self-treat medical as well as psychological symptoms with nonstandard therapies.

Some of these agents, like CBD oil, do not currently have FDA approval for treatment of specific psychiatric illnesses. If you choose to use them, either alone or in combination with standard therapies, you must understand that there are several things to consider. First, they may have unexpected side effects. Secondly, they may interact with other foods or drugs that you already use. And lastly, they may or may not be legal for general public use. I will address some of these issues in the rest of this column.

According to WebMD, cannabidiol is found in the cannabis sativa or marijuana plant. There are eighty similar chemicals in these plants. THC is the major active ingredient, but cannabidiol makes up forty per cent of overall cannabis extracts. Cannabidiol may have antipsychotic properties, but we are not sure why. It might also actively block some of the effects of THC. There is really insufficient evidence for use of cannabidiol in bipolar disorder, dystonia, epilepsy, Parkinson’s Disease, schizophrenia, or social anxiety. Side effects due to cannabidiol use might include dry mouth, decreased blood pressure, light headedness and drowsiness. There is no good data on the use of cannabidiol in pregnancy or breast feeding, nor for many specific drug-drug interactions.

Some of these concerns were addressed in a recent interview on Medscape where Columbia University Chief Resident Angela Coombs, MD, interviewed Diana Martinez, MD, Professor of Psychiatry at Columbia and an addiction expert. Dr. Martinez stated that there is really very little known about how CBD affects humans and why. It may have some legitimate medicinal effects, but the jury is still out on some of these. She stated that if you buy CBD at stores, the advertised doses may not be realistic or true. Some websites of companies that manufacture CBD and have their products tested by legitimate outside companies will more likely list the actual amount of CBD available in their products. It might be very important to know about the presence or absence of contaminants as well. Some states like Colorado may do a better job at this point in testing products for factual labelling and overall safety.

CBD may be effective in treating seizures in some children with specific illnesses such as Dravet Syndrome or Lennox Gastaut Syndrome, obviously a very small group of people. If they do not respond to more traditional medication therapies, high doses of CBD in the neighborhood of 1000 mg might be effective.

The positive symptoms of schizophrenia (such as hallucinations) may be reduced with the use of CBD, but this is in the presence of traditional antipsychotics, not in place of them.

There is not much research to address the use of CBD oil in the treatment of anxiety or social anxiety. Dosing is largely unknown. 300-600 mg seems to be helpful for anxiety.

Dr. Martinez also addressed the drug-drug interactions that might occur when CBD is added to other, more traditional therapies. When the enzyme systems in the liver are affected by substances such as CBD, metabolism of other drugs might be sped up or slowed down, affecting the amount of those medications available in the bloodstream. This might lead to compromised treatment with seizure medications or antipsychotics. She also was not able to clearly answer the question about the legality of CBD at this time. Because of various bills, the DEA, the FDA and other regulators, there is not one specific answer as to the legality of buying, possessing and using these agents. Will it be regulated anytime soon? She was also not able to directly answer that question.

So, if you are thinking about using alternative therapies like cannabidiol, what are some of the things that you might need to consider?

1) It the substance an additive, food, plant, chemical, alcohol preparation or other kind of substance?

2) Is it approved by the US Food and Drug Administration?

3) Is it regulated by the FDA, DEA or other agencies?

4) Is it checked for safety by an independent lab or company for purity, quality, concentration, adulterants, etc?

5) Is it expensive or affordable?

6) Is it legal in your state or nationwide?

7) Does it interact with food, alcohol or other drugs? Are any of these interactions life threatening?

There is no hard and fast advice on the use of CBD oil yet, and much more research is needed.

Gait, Gait, Do Tell Me

Two sisters (religious order, not biological relation, as far as I know) live in one of the condos across from us. They are very nice, older ladies, warm and pleasant, always ready with a kind word and a smile as they see others in the complex come and go. They seem, at least on casual observation, to lead very busy lives. They rise early, heading out to do whatever it is sisters do in the world nowadays. One drives a minivan, one a small nondescript sedan. All pretty ordinary, I suppose, except for one thing that always strikes me about one of them.

Sister gets up early most mornings. She almost always beats me out of the parking lot, and I’m an early riser and starter myself. When she exits her front door she heads for her minivan, parked about fifty feet away if that, with the speed of a sprinter and the determination and conviction (again, at least as I perceive it) of a person who is going to change the world. She is diminutive, casually dressed, doesn’t stand out, but she is driven to get to her vehicle and start the day. She walks determined, rapidly, not wasting a moment of her early morning time. If I am leaving at the same time and she sees me, she will offer a cheery hello and a wave. Then she is off.

Now, come with me to my office a little later in the morning. We walk up the clinic hallway to the waiting room up front, open the door, and call out a name. The patient is in her mid-twenties, somewhat disheveled, is chewing gum, and has earphones in her ears connected to an oversized phone. She saunters to the door from the couch on the far side of the room. She is wearing dark sunglasses, which she does not remove.

I have never met this young woman, so I welcome her, introduce myself, and thank her for coming to see me. She makes no eye contact, looks straight past me, does not acknowledge my greeting, and continues her slow roll through the door and into the hallway. We stroll, no other word for it, down the hall to my office at the far end of the building. As I begin my usual interview questions, she looks at me blankly, shades still hiding her eyes, offers one word answers, and looks quite bored. This young lady does not appear to be the least bit interested in being here, in acknowledging me, or in moving the process along toward any definable goal.

What would you say about these two women, knowing only what I have told you? Granted, we acknowledge that there is  lot more about both of them, their stories, their motivations, that we do not know. However, I am being intentionally superficial in my description of them for the purpose of this post.

What does physical gait, movement, and apparent drive tell us about each other?

Of these two women, who do you feel is most likely to have set a goal, or multiple goals, for herself for the day? Which of them is more likely looking towards accomplishing something measurable before lunchtime? Of the two, which one knows what she is trying to achieve by being in the physical place she occupies this morning?

We telegraph our demeanor, our intentions, our plans, our desires, and our energy levels  to others all the time. Without saying a word, we look motivated, driven and highly focused on whatever is coming next, or we appear tired, bored, lackadaisical and aimless.

How will you present yourself to your coworkers, your boss, your spouse, your friends and to strangers today?

Will they see you as leaning into the day, full of energy and vigor, ready to accept whatever challenge comes your way?

Or, will they see you as someone who has no plans, no energy, no spark, and no reason to move any faster?

 

 

Smallville

“No, I cannot forget where it is that I come from

I cannot forget the people who love me

Yeah, I can be myself here in this small town…”

Kenny Chesney, John Mellencamp
When I began my psychiatric training in earnest thirty three years ago, after a challenging rotating internship, the indoctrination that began was regimented, sanctioned, scripted and complete. I knew from a very young age, training-wise, that my job was to ask a few very open ended questions, listen, formulate my thoughts about my patient and his reason for coming to see me, and then to discuss this with my supervisors in order to come up with a treatment plan. A plan that sometimes was, oddly enough, kept a secret from the very person it was supposed to help. The name of the game in those days was to figure the patient out before he did it himself, and then to guide him with judicious rigor and well-timed and brilliant interpretations toward increased insight and mental health. Yes, I was trained in a predominantly psychoanalytic program that was only beginning to bring in the psychopharmacologists, who would later dominate the agenda. 

I was taught to be the proverbial blank screen. I was to show little emotion, offer little to no spontaneous conversation or banter, and to never divulge anything of note or merit about myself except under the direst of circumstances. I embraced the psychiatrist persona that was the norm for that time. This therapeutic stance was just that, but it was not real or fun to me to practice that way. I will never forget how shocked, and yes, maybe a little hurt, I was when one of my long term psychotherapy patients (a lady who had a panic disorder that would be quickly and fairly easily treated today) blurted out, ” I might as well be talking to that doorknob over there as to be talking to you. You never say anything!” When I took this to my supervisor, a prominent psychiatrist who had literally written the book on these kinds of interactions, he praised me for maintaining my therapeutic distance and stance through this obvious transference-based outburst by my patient. He gave me pointers on how to proceed from there, mapping out a strategy for the next several months. I dutifully went back to work. The patient came to see me one more time and never came back. She was not getting what she needed to get better, and she quit. 

Today, I am working in a small South Carolina town. One of my duties this morning was to go over to the probate court at the courthouse building, five minutes away from my office by car, and testify about an evaluation I did a week ago. On arriving at the probate court office, I encountered the judge sitting at her secretary’s desk, taking  phone call. 

“Aren’t you in the wrong place?” I teased her. “Your office is in there.” 

“I know! One of my staff had a death in the family and the other one had already planned a vacation, so I’m doing it all today.” 

Soon afterward, we entered the hearing room, which is just that, a room with one long wooden conference table, a dozen mismatched chairs, a wall full of musty bound county record ledgers, and us. The judge was joined by me, a clinician, the patient, her appointed attorney, and an unsmiling bailiff. 

The format, unlike the proceedings one county up in another courthouse, was informal. Information was shared, the usual legal wrangling was dispensed with, and we all made it clear to the patient and each other that we cared about her, wanted her to get treatment and supported her in doing this. Even in her pre-psychotic state she seemed to grasp the feeling in the room, the common sense of purpose, and the unification of all involved. We even joked and laughed together a few times, which felt wonderfully good and real to me. I realized, mid-hearing, that I was doing something in this sunny small town courthouse that was going to make a real difference in someone’s life. 

I will always be grateful for my training, my supervisors, my colleagues and the experiences and baseline knowledge and skill set they imparted to me. I use those skills every single day. 

However, that can never hide the fact that “I can be myself in this small town”, and it feels good when I am. I’m proud of what I can do to help people here,  and that’s exactly the way it should be. 

Stuck in My Craw

One of the things I was taught in medical school: common things are common. 

These things have been more common lately. I know I’m starting the grumpy old man phase of my blogging life, but good grief, people. Really?!?

Disrespect: 

No direct eye contact. No acknowledgement, verbal or otherwise, when greeted with a cheery good morning. Annoying behaviors designed, quite consciously, to actively annoy and derail the time in the office. Texting, typing, talking and playing games on phones in the office when active input would be appreciated! Ignoring questions outright or refusing to answer. 

Sullen mood: 

No, I’m not talking about serious depression or active psychosis. I’m talking about deliberately hostile, staring, scowling, defiant presentations designed to minimize communication. Really?

Lack of responsibility: 

“I don’t know why I had to come here.”

“I’m not sure how that gun/knife/weapon got in my gym bag, but it’s the kid’s fault that found it and turned me in that I got in trouble.”

“My teachers suck. They don’t know how to teach. They’re stupid.”

“Because I don’t like to do chores, that’s why.”

“I just don’t do the work. I don’t feel like it. No, I never turn my homework in.” 

“They can’t do this! They can’t take away my iPhone/iPad/Gameboy/PlayStation/XBox/flat screen TV just because I have four Fs and a D!”

Blaming:

It’s the teacher’s/principal’s/parents’/other kids’/government’s/doctor’s fault.

Anger for anger’s sake.

Refusal to problem solve or to see anything positive at all in a situation. 

Adversarial stance (kids and parents both!)

“Fix me!”

“We’ve tried everything and nothing works for him.”

“Nothing you can do will help.”
This was a week, friends. 

This is not entirely a mental health crisis. 

This is a crisis of investment in parenting, house rules, expectations, empowerment, upbringing, respect for elders, and establishment of normalcy in childhood. 

Enjoy your weekend. 

Next week, we all have more work to do. 

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:

SI

SI

SI

SI

SI

SI

SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.