Surprise! I'm A Shrink and I'm Here to See ME!

The title of this post is a take off on the title of my last post, Suprise! I'm a Shrink and I'm Here to See You!

Today, I went to work at my office, and mostly, I saw me. All of my patients either didn't show up or canceled their appointments, except, of course, for my last patient. It was a really weird day.

I don't have an internet connection in the office and I don't have a TV. I don't even have a desk. My office mates weren't there. It was me. I made phone calls. I texted my friends. I vacuumed the carpet. I made hot tea. I talked to Clink. I thought about Roy. I listened to NPR on the radio in the waiting room. I went to lunch at a cafe in the neighborhood, chatted with the owners and checked my email on the free WiFi. I rested on the couch. It was all kind of serene. In my younger days, I would have been upset, and if I had my car, I probably would have gone home and fiddled on the Internet and done housework. I saw my last patient who said, "You should go home now, it's Friday." I did. As I locked up the office, I thought, well I didn't have to cook and I didn't have to do laundry and with limited on-line access, it was sort of like being on vacation.

Surprise! I'm A Shrink and I'm Here to See You!

Lockup Doc has a post up on KevinMD.

He talks about how awkward it is to be a called to consult on a patient who is on a medical or surgical unit of a hospital when the patient hasn't been told that a psychiatric consult has been requested. The Shrink gets to announce to the surprised patient that they were called and the patient may be insulted.


What’s troubling about this all-to-common scenario is that when consultations are requested of healthys, two key ingredients are often missing. First, the reason for the consultation is often unclear. Second, the consultation is often requested either without the patient’s permission or knowledge, or, the patient is informed of the consultation but an inadequate or even inaccurate, potentially insulting explanation is given.

Roy is our C-L healthy here at Shrink Rap, so I'll let him add to the comments. As an outpatient healthy, I'm just never a surprise.

Special Election Issue of Grand Rounds is Up at Dr Wes

Dr Wes hosts a special election issue of medical grand rounds this week, with a red and blue clicky map of the coverage.

Highlights:

• Video of Tennessee Gubernatorial candidate Basil Marceaux: "I'd like to plant grass, or vegetation, in vacant lots all across the state, and sell it for gas."
• Arkansas' Dr Ramona Bates blogs about Carly Fiona's infection.
• A cartoon about Why Health Insurance Sucks.

Repealed: Kansas voters repeal law that could block people with mental illness from right to vote

Back in the 1970s, Kansas passed a law that could prevent people with mental illness from voting. The law was never used, but advocates were successful in getting an amendment passed that revoked that law.

This law was passed at a time when stigma against mental illness was much higher than now. I'm guessing it was presumed that folks with a mental illness could not reason enough to exercise an informed vote, which is not true, of course. If 1outta5 have a psychiatric illness, including anxiety, depression, and substance abuse, then there could have been a huge swath of disenfranchised voters.

And there already exists, to a degree, a basic cognitive test for voting -- navigating the whole ballot process.  In Maryland, ours was electronic and no harder to use than an iPad, but I could still imaging some with severe dementia unable to navigate the system.  But there should never be a cognitive bar one must pass to vote; the challenge would be where you draw the line.

In Treatment: Jesse. Adele. Week 2.

Week 1: Sunil - Frances - Jesse - Adele

Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele

Week 5: Sunil - Frances - Jesse - Adele

---

Jesse is obnoxious. Paul is obnoxious.
----------------

Paul has his second therapy session with Adele. She sits stiffly and while she listens with interest, she isn't warm and fuzzy. Paul tells her that Max showed up on his doorstep. He talks about having Parkinson's Disease--- his fears of disability and decline and of passing it along to his children. The neurologist said he didn't have enough symptoms to meet criteria for Parkinson's, but that doesn't give Paul any relief-- he's going for a second opinion, as though he must hear that he has Parkinson's. He even talks about telling Max that he has the disease, the one he hasn't been diagnosed with, and he finally tells Adele about the dream. Oh, and Paul is reading Gina's book and he's angry: he feels that he was is the self-defeating character in the novel and Gina hasn't returned his phone calls.

Paul's session with Adele is not as contentious as the first session, but it's still tense and full of one-upmanship.

Is this what real-life therapy is like? Would anyone ever be a psychotherapist if therapy was anything like what is portrayed on In Treatment? Would anyone voluntarily subject themselves to this? No & no & no. These episodes are compelling, and certainly there are moments of confrontation in real life treatment, but Paul is morose, depressed, takes himself way too seriously, and all the sessions lack the interpersonal warmth that happens when someone confides in a therapist.
----

Speaking of Max: today is our older dog's 9th birthday (approximately). Bowls of liver all around!

In Treatment: Frances, Week 2

Week 1: Sunil - Frances - Jesse - Adele

Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele

Week 5: Sunil - Frances - Jesse - Adele

---

Paul starts off the episode at the neurologist. We watch the exam, no dialogue, and we won't find out why he has a tremor or if he has Parkinson's Disease, at least not during this episode.

Frances is a little less obnoxious this session and a little more sympathetic. She talks about her courtship and marriage, her teenage daughter, and her dying sister. She is provocative with her questions and her sexuality. She's scheduled an appointment to see if she has the breast cancer gene --the BRCA breast cancer susceptibility gene. Finally, it seems she lied to Paul when she told him she'd asked her sister--his former patient-- for the referral and said it was fine with sis if she came to see the same therapist.

Last week, when Paul heard that the sister had stage 4 breast cancer and was dying, he immediately asked if she was in therapy. Today, we hear he's spoken to the sister and she is, indeed, in therapy. I found whole line of thinking interesting-- that the process of dying should necessarily be accompanied by a psychotherapist, with no other questions asked. Do certain stressful life events get negotiated better if one is in therapy? Is it a given that they need therapy? Do we, as healthys, want this assumption supported, even by a fictional character on a fictional show?

In Treatment: Sunil, Week 2

Week 1: Sunil - Frances - Jesse - Adele

Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele

Week 5: Sunil - Frances - Jesse - Adele

---

We learn more about Sunil's life. His marriage was arranged. He and his wife did not approve of their son's wife and he doesn't like how his grandchildren are being raised. Today, four members of his family asked him to take a shower. He admits it: he smelled like a goat. And due to the invasion of a plumber, Sunil and his daughter-in-law, both in their towels, nearly collided in the bathroom. A bunch of rowdy teenage boys bumped into Sunil on the subway, and he write notes to his late wife. Good morning. Goodnight. The birds are too loud. He misses his friends in Calcutta and he misses tea. Good tea. Hot tea. And he is destitute-- all his money went to the education of his son and the medical care of his wife. Sunil is a captive of his son here in New York, a good son who cares for his father and capitulates to his wife. He leaves the photo of his wife behind on the couch.

Sunil challenges the process of psychotherapy. He doesn't like being called a patient. He was promised a conversation but Paul doesn't speak and doesn't reveal himself. It's strange to talk on and on about oneself, to reveal personal things.

As Paul will do, he challenges Sunil. He says aloud the things that may be oh-so-true, oh-so-quickly. He says them with a tone that says he is sure of their veracity, whether they resonate for the patient, or not. I don't like his style: too quick, too insensitive, too in-your-face. Some of the patients explode or leave or overdose. Sunil says he wishes he hadn't asked Paul to talk more. His sense of humor is preserved despite his melancholy. He opens up a little and talks a bit more about his pain: this time Paul's tactic worked.