Some months

It’s been a while.

Academic medicine makes life a divided attention task. To say nothing of having these small people at home who want such luxuries as regular bathing and food.

In the last few weeks I’ve been doing all the stuff I’m supposed to be doing – data for a study just came in that I’m slogging through, a paper I gave up for dead may see the light of day, and various people who have been sorely deceived into thinking I know something asked me to give a few talks which I’ve been piecing together. All that has kept me away from you lovely folk.

I think I also took a bit of a knock a couple of months back. The way things work at my institution I am on service, meaning running an inpatient team, for one month rotations. We had a rough month.

It’s an addiction treatment service and because of the high volume it can be flukey. Some months you get a run of people who are sick as the devil, sometimes you get some who are sweet and grateful, sometimes you get people who are just mad at the world. Once a mood is set in the group, it can be infectious. A few patients who are experienced and wise in the ways of recovery can pull the whole group back from the various crevasses of self-pity, other-blaming, and shame that can poison the air. Then again, sometimes a few charismatic troublemakers can derail the whole train.

That month we had a remarkable run of people bailing out early, with no rhyme nor reason I could see. The fundamental principle I run the unit by is that people who don’t get into treatment don’t do well; so right from the jump I’m talking to everybody about what they’re going to do when they get out. Our whole team works every minute to set up that next step and help people make it to there.

Yet, you will sometimes have the one who thanks you profusely and talks about what a wonderful job you did; then tells the cab driver after discharge she was forced to go to treatment and asks to be dropped off at some corner. Or the young one who starts out on day one talking about how she can’t keep living this way, and walks out two days later saying she can’t imagine ever going a day without getting high.

I know such things happen. I know there will be bad months.

At the same time, I think you always have to ask yourself if there is something more you can do. That is the question that helps you find ways to make the system better, to help more people, to work smarter.

The other edge of that sword is that the answer is always yes. You could have said this instead of that. You could have seen the problem a day earlier. Maybe it would have worked, maybe not.

Maybe it would have.

Sometimes I need a little time to recharge from all the maybe it would haves.

So, I’m recharging.

I’ll come back. I always do.

Keep going, friends, and so will I.

…and back again.

The CDC guidelines on opioid prescribing just landed like a ton of bricks. The media blitz has begun.

They’re pretty straightforward. In the context of the most godawful opioid epidemic in living memory, you could probably guess the content without seeing them. Let’s try a game, shall we? Pick the item not included in the recommendations. The answer is at the end, NO PEEKING!


 

  1. Opioids are the work of Satan on earth.
  2. People who take opioids are likely to BECOME ADDICTED AND DIE.
  3. Nobody should ever take opioids for acute pain for more than 3 days or they could BECOME ADDICTED AND DIE.
  4. OPIOIDS = DEATH
  5. Ibuprofen is nice.

 

The answer is number 3; the guidelines actually recommend no more than 7 days of opioid therapy for acute pain.

OK. I’m exaggerating some.

My feelings about this, I admit, are a little paradoxical. I spend half my days withdrawing people from heroin and trying to get them into long-term treatment, and the other half dealing with folks whose pain treatment has gone completely to hell. I do all this in one of the most drug-ravaged cities in the country. If I found out what proportion of the inpatients I have seen over the years died in this overdose epidemic I probably wouldn’t get out of bed for a week. I have been up close and personal with the failures and horrors of opioids for my entire professional life.

To be clear, my discontent is not exactly with the guidelines and certainly not with their intent. Opioids were handed out as monotherapy way too often, with way too little evidence of long term benefit, and with remarkably little appreciation of long-term risks.

Here’s my problem: I don’t think the steady drumbeat about the dangers of opioids is as much a change of course as it is part of the same cycle that produced the epidemic in the first place. If that’s true, then I suspect we’re just setting ourselves up for the next one, a generation or so down the line.

Here’s my take on the history of these epidemics. On the upswing, generational forgetting sets in and the horrors of the last epidemic fade, and maybe some new thing happens. Perhaps there’s a newest-latest-greatest drug that’s “different.” Less stigmatized, believed to be less habit forming, or what have you. Perhaps a higher potency, cheaper version comes out. It could be any of those; but some combination of destigmatization, increased availability, a more behaviorally powerful drug, and perception of low risk gets a lot of people exposed.

At the crest, the drug spreads up the social ladder – suddenly it is not just the endemic population of impoverished, stigmatized “criminals” who are using it; it’s Aunt Effie who’s hooked on her pain pills. Alarm bells start ringing.

On the downswing, the stigma reasserts itself, new legal and regulatory controls are put in, and the drug’s perceived safety goes out the window. Any benefits are judged to be trivial relative to the risk and, in hindsight, any who believed otherwise are considered naive fools. The drug settles back into the endemic, stigmatized population and bides its time.

Thus we find ourselves at the crest of the opioid epidemic, and just starting to notice that we’re in the midst of a benzodiazepine epidemic, while happily skipping along as marijuana slides from illegal to pseudo-medical to accepted recreational. As to the latter, I don’t think it’s a coincidence how many people have been showing up in ED’s rip-roaring psychotic off the various synthetic cannabinoids that you can buy in a 7-11 these days.

Here’s what doesn’t happen: We never figure out what the actual risks and benefits of these @#&#^ things are. While in one generation we decide cannabis is the destroyer of youth and weigh down research; in the next that very lack of information allows anecdotes to fuel its return as a “treatment” for everything from glaucoma to nausea to mood disorders.

So now we’ve gone from “there is no top dose of opioids” to “over 50mg of morphine is the danger zone” in the last ten years or so, with barely a shred of evidence in support of either. Pop back over to those CDC Guidelines, and you’ll notice the evidence base for these recommendations is barely better than expert opinion. That being exactly the grade of “evidence” that led to the prior approach to pain that got us into this mess.

So the pendulum swings back. Again.

Where is the sweet spot between deadly ignorance and what have we done? What is the rational approach to the use of opioids?

We still don’t know. 

As physicians we are advised to take functional outcomes into account, when opioids have but moderate effects on chronic pain intensity and even less on function. We are advised to screen for risk of addiction when that entity is poorly defined for prescribed opioids,  and the instruments that purport to screen for it are poorly validated and barely break a sensitivity of 50%. It also doesn’t address the public health consequences of putting opioids in more medicine cabinets.

So are we any closer to preventing the next epidemic, once we work our way through the shattered lives, and death, and the secondary heroin epidemic, and the tertiary spikes in HIV and hepatitis and crime and all that misery? Are we finally going to learn something?

Oh, I hope so. I just don’t see it happening. In my more optimistic moments, I think there are opportunities to learn. There are testable hypotheses here. Here are mine:

  1. Long-term (years) chronic opioid monotherapy for chronic pain probably doesn’t work all that well, though it might do something.
  2. The endless pseudoaddiction vs. addiction debate will only be settled by (mostly) ignoring it and agreeing on identifiable, countable aberrant behaviors as bad outcomes.
  3. The risks of chronic opioid therapy depend intimately on how risk-averse prescribers are. When prescribers think it’s high risk, only the most carefully selected patients are exposed and adverse outcomes are minimal. That implies that in the opioids are evil era prevalence of bad outcomes will be low, which then primes the pump for the generational forgetting that can drive the next opioid epidemic, just like the success of vaccines opens space for the anti-vaccine movement.
  4. Attempting to treat chronic pain with a comorbid severe psychiatric condition without making treatment of the psychiatric condition co-primary (or, maybe even primary) is a losing game. So we have to fix the ridiculous divisions in our payment system.
  5. Standard addiction treatment systems are poor at managing people with opioid use problems and chronic pain. That has to be fixed or screening for addiction in this context becomes a circular mess. It’s a sick, sad thing when someone has to wind up switching over to street heroin to finally get into treatment for addiction, but that’s what I’m seeing aplenty these days.

In all fairness and in a moment of seriousness, I applaud what the CDC is trying to do. What I really, really want is for us to stop the cycle of stupidly lyonizing these drugs, causing untold harm, then demonizing them in a panic. The problem isn’t whether they should be demonized or lyonized.

The problem is the stupid (and the panic).

In the absence of any new, real data; I’m afraid we’ll win the battle only to set the stage for the next one. I may still be alive, and maybe even still practicing, to see it.

Here’s hoping I’m wrong. What I’m seeing right now is a bloody disaster, and it would break my heart to see it again.

If only something could be simple.

There was a recent article in the New York Times reporting on the findings of this paper comparing two treatment strategies for ADHD.

I sent the article around on social media, partly because I thought it was an interesting bit of work. The greater part of my spreading the article around, though, was curiosity about the reactions. Occupational hazard. Or requirement.

This is a complicated study. When complicated studies are reported in the media, I find a couple of things happen. First, there’s just a little distortion of emphasis in the reporting that fits the prevailing popular narrative about the condition. I’ve talked about examples of this before. (Here, and here, to start.)

Then there is the public reaction, which tends to be similar to the media distortion, but without the media’s attempt at balance. If there are camps on an issue, one (or both) sees exactly what they already believed.

So in this article the reactions I typically saw were along the lines of:

  1. “Of course these nonpharmacological treatments work better. They’re natural and this ADHD thing is mostly medicalizing normal kid stuff anyway.”
  2. “These medicines are dangerous, and we just shouldn’t use them on kids.”

The former was most interesting to me. Because, right there in the article, it says that’s not what the study found. It’s almost the opposite of what the study found. Here’s the whole paragraph:

After two months, the yearlong study took an innovative turn. If a child had not improved, he or she was randomly assigned one of two courses: a more intense version of the same treatment, or an added supplement, like adding a daily dose of medication to the behavior modification. About two-thirds of the children who began with the behavior therapy needed a booster, and about 45 percent of those who started on medication did.

Got it? After two months, kids did better on the (relatively low dose) medication than they did with the behavior therapy, and more in the behavior therapy group needed either more intensive treatment or a switch of modality.

In other words, if the question is which treatment gets more kids better at two months, the answer seems to be the medicine (though that’s not exactly how the study was designed).

Which is not to say that non-pharamcological treatments don’t work. If anything, I’d say cognitive interventions for adults are pretty promising these days, if you can find them. In kids, it might be a little more iffy – some things look like they let you get away with less medication but aren’t necessarily better, full stop.

Happily, this isn’t a which-treatment-is-better study. We don’t have enough of those, so if it were I’d be happy. But it’s better. It’s a which strategy is better study, which is far more useful. Yet strangely, can go badly wrong.

There are several fundamental questions I constantly face. So often, I’ve strongly considered throwing that choice in as a Law of Psychiatry. Usually, I can only do two of these, and sometimes just one:

  1. Use the treatment with the best chance of success.
  2. Use the treatment with the least bad effects.
  3. Use the treatment the patient is most likely to get.

Case in point, the recent study of SSRIs for major depressive disorder. Overall, using higher doses gets the best chance of remission. However, using higher doses also gives higher adverse events. From the population perspective, going high seems to produce the most wellness. On the other hand, if you have a patient who has recurrent depressions, lives in the real world, and may need stay on this stuff for years; maybe tolerability ought to be a consideration.

Such is the paradox of this study. The behavioral treatment worked at getting kids to follow rules, but so did the medication. I expect the behavioral intervention probably didn’t work as well on the other aspects of ADHD – executive dysfunction and attention impairment. I could be wrong. Behavioral systems change behavior, so that’s what was supposed to happen.

Now here’s the rub: if you start off with behavioral therapy, and it failed to produce adequate improvement (as it did more often than not), the kids for whom behavior therapy failed did better than the kids for whom medicines failed.  

Why didn’t you get the same effect if they started with meds? Why on earth is A then B the magic sauce, instead of A + B? Most particularly, when A doesn’t work as well as B the first time around. The strategy here is, starting with the least effective option and then adding in the more effective gives better results than starting with the more effective.

As is often the case for these strategic studies, the results are absolutely not commonsense and sometimes downright counter-intuitive.

The authors had a suspicion which I share. Those parents who started with low dose medication and were randomized to the behavior therapy afterward didn’t work as hard at it. Could be they weren’t as highly motivated to do something else in the face of (presumably) the partial improvement from the medication, or maybe they just didn’t want the trouble.

OK, enough of the armchair social critique, Dr. Bloggs. The study says teach the behavioral management techniques to improve problematic behaviors, then add medication for residual symptoms, and you wind up with someone who’s better off in the long run. So let’s just do that.

That’s probably exactly what we should do. I would also bet it will barely happen in the real world.

First off, behavioral interventions aren’t easy. Not every teacher, nor every parent, is going to participate fully; and that assumes you have the people available to teach the treatment and that insurance will pay for it (what with it “failing” more often than it succeeds even in the domain in which it is most adapted).

Second, speaking of insurance, is the deep love in the insurance industry for “fail first” criteria. What would happen, say, if an insurance company required the family to “fail first” at a trial of behavior therapy (8 weeks, plus a whole lot of work) before allowing medication; or vice-versa?

 

Then there is this: Families who are doing behavior therapy explicitly instead of medicines are not following this protocol. They are picking the less effective initial treatment without the plan to engage in the strategy that renders that less effective initial treatment the better starting choice.

So what this study says is not behavior therapy works better than medicines. What this study says is that starting with behavior therapy and using medication later at a low dose produces better results, and maybe for some kids you can get adequate behavioral improvement and you may not need the meds. I’d really like to see their grade books before I made that judgment, but it’s entirely possible.

It doesn’t serve the pharmaceutical industry since it means a lower chance of being on medicines, and at lower doses. It might serve the insurers if fail-first criteria are used, but that won’t serve the kids or their families. It certainly does not fit the “medicine doesn’t work/are dangerous” narrative of those who are anti-medication. It also isn’t going to manufacture the behaviorally-informed therapists and the teachers who are willing and able to implement such strategies.

So mainly it informs good practice, but beyond that doesn’t really serve anybody’s agenda.

Is it going to change the world?

I’ll be over here, holding my breath.

 

 

Those days.

The 26th Law of Psychiatry (The Law of Therapeutic Charity): Give yourself credit for being the one in the room.

I had one of those days.

I haven’t written about it much so far, but I spend a lot of my time helping people with a nasty genetic condition. It’s called sickle cell disease (SCD).

SCD is very high on the list of things you do not want to have. It’s caused by a defect in hemoglobin, but the main problem it causes is pain. Early on, it’s episodes of bonecrushing pain called crises. Later, for reasons nobody really gets, the pain tends to turn chronic. Chronic pain is not an easy thing to treat.

Most of my patients were told they wouldn’t live to adulthood, though now they have a 50/50 chance of making it past their mid-40s. With longer life comes more cumulative complications. Strokes, joint and bone damage, all sorts of organ injuries, blood clots, and on and on. Not everybody gets all that, of course. The disease is amazingly protean considering how uniform the cause is. That said, it’s a bad disease. Where there is brain injury and chronic pain, there is depression. Of course, it’s depression that’s harder to treat.

I have really, really good days. Walking three inches off the ground good days. Days when I see the first smile of the patient who’s been miserable for months. Days when, after uncountable complicated, ambiguous decisions; I push my head up over the waves and realize my patient has been out of the hospital for a solid year when he used to be in every month. Days when somebody who was utterly gorked on pain meds and in godawful pain finally comes out of the haze and gives me that stunned, “I think my pain’s actually better,” speech. Days when I’m pretty sure somebody’s way better off because of me.

Most days aren’t like that. Usually I don’t know if what I’m doing is working.

Part of that is just plain ol’ statistics. Clinical trials can tell you that if you do the thing for a large group of people, more of them will get better than if you don’t do the thing. They can’t tell you if the particular patient you’re doing the thing for will get better, or if he would have gotten better with time, with or without you. (If you just started singing a U2 song, shame on you. This is a serious post, you Philistine.)

Clinical trials also don’t enroll my patients. You can find a randomized trial with bajillions of people with major depressive disorder (north of 5% of the population). You aren’t going to find a single one with people with SCD (around 0.03% of the population), two strokes, bone infarction, bad kidneys, iron overload from multiple transfusions, chronic pain, and depression. There may be a dozen of those people in a given state, and they’re probably going to be in my waiting room.

I know that what I do works. I seldom know if what I’m doing is working. Such is doctoring.

With uncomfortable regularity, I find myself in a room with someone and we’re three tricks deep into my bag, digging around for numbers four and five. Thus it was on the day in question.

He’s been one of my flock for years now. Since then, he’s developed various painful complications, and his insurance is crap, so he can’t get some interventions that might help. He’s lived about three decades longer than he ever expected to live. He’s also got a grinding chronic depression, and partly due to all the dirt SCD does to your insides, our options for medications are limited and we’re already pretty deep into that bag of tricks. Some things are better – his mood has lifted some, he’s not holed up in his room all the time, he’s spending more time with his kids, and he’s more active than he used to be. Still, better ain’t great; and we both know it.

He and I share a certain sense of humor. We get on, he and I.

To wit:

“How’s it going?”

“Well, I haven’t thrown myself out a window yet.”

“That’s good. It would certainly reflect badly on me if you did.”

“I would hate to inconvenience you.”

Like I said, we get on. Aside from all the bad jokes, we’ve also had some serious conversations about suicide, and we’ll have another one at the end of this session. He’s been straight with me about what he’s thinking. He’s decided to stay alive, come what may. I’ve told him I’m never going to give up on him. That’s the understanding. He’s an honorable guy, with a lot of integrity under his rough edges. Or perhaps in his rough edges. I have decided to believe in him. He has decided to show up. So, on we go.

This particular day, he was dealing with an ongoing problem with his family. Underneath that problem is that he depends on them, and he’s not the sort who likes depending on anybody else. We talked it through, came up with some concrete things to try to improve his interactions. As he walked out, he said, “All right. I’ll give it a try.”

Then, “Thanks.”

There are times people thank you, and there are times people thank you. This was the latter. My chest ached. I watched him struggle out of the chair and limp out to make the next appointment. Everything I haven’t been able to do for him hit me, hard.

I had to give myself that talk. The one I give supervisees who are stuck between the simultaneous realities that you can always find another way to help, and that you never quite know if anything’s going to work until it does.

You are the one in the room with him. 

It might be that there are dozens of other docs out there who know stuff I don’t know, and who would have made a bigger difference. They’re not here. I still am, and I’m hoping if nothing else, that makes some difference all by itself.

So, on we go.

Hmmmmm……

I am puzzled and bothered. I know why I’m puzzled, I’m not entirely sure why I’m bothered.

On the Book of Face a few days ago I saw a post from a mental health advocacy organization. To be perfectly honest, I don’t pay much attention to them, but they stroll through my feed regularly. Overall what I’ve seen from them is positive. No snake-oil remedies advocated, serious issues in the health care system pointed out.

Then comes this: A link to this site called Healthline.com. The teaser pic is a clonazepam tablet, the headline is “Benzodiazepines,” and underneath is:

Discover why a class of drugs used to help curb insomnia and anxiety has become an important component of an effective bipolar treatment regimen.

“Important component?” says I. “…for bipolar disorder?” says I, somewhat redundantly.

I click through the looking glass, and at the top of that page I find this:

Content created by Healthline and sponsored by our partners. For more details click here.

“Sponsored?” says I. Dutifully, I click here.

This content is created by the Healthline editorial team and is funded by a third party sponsor. The content is objective, medically accurate, and adheres to Healthline’s editorial standards and policies. The content is not directed, edited, approved, or otherwise influenced by the advertisers represented on this page, with exception of the potential recommendation of the broad topic area.

Curiouser and curiouser. I didn’t say that out loud, since I realized I’m talking loudly to myself yet again, and it gets weird.

So the content is paid for by some unnamed third party sponsor. It is not influenced by the advertisers represented on this page. Now if you were a compulsive freak, a corrosive skeptic, and had a certain well-developed cynicism regarding the mixed motives of our colleagues in the pharmaceutical industry, you might start thinking in funny little Venn diagrams. Like, for example:

Venn Diagram

This might lead you to note that at no time was there a disclaimer that the third party sponsor was also an advertiser represented on the page who therefore not influenced the content.

Someone could, however, recommend a broad topic area. Such as, “reasons the sky is black. ” Pretty broad. No real advocacy for any one reason the sky is black.

At this point, I smell weasel.

A touch paranoid, you say? Well, I am talking to myself a lot, asking questions of inanimate computer screens, and having olfactory hallucinations involving small vicious mammals. So overall, we must acknowledge the signs aren’t good.

Benzodiazepines are an interesting class of drugs. They do work, in that they quickly relieve anxiety. They also do put you to sleep.

There are “buts.”

  1. Behavioral therapies for sleep work at least as well, and are no doubt safer.
  2. They are not first – line treatments for anxiety disorders.
  3. Recently evidence of all kinds of problems has been piling up. Most alarming are  increased risk of dementia and death with longer-term use.
  4. They are addictive, and bipolar disorder is a major-league risk factor for addiction.

So maybe in the short run, they have a role in some aspects of the condition. “Important component of an effective bipolar treatment regimen?” Harrumph.

The article itself says lots of things about how benzodiazepines have problems. It also does say that short term treatment is recommended.

It then goes on to list a whole lot of symptoms of manic depressive illness and say benzodiazepines are useful for them, without any particular evidence cited for those claims.

It is medically reviewed, we are reassured. The doc’s name is right there at the top.

When I took a moment to look into this worthy, I find he is a family practitioner. Also, he is an executive at Healthline. A couple more clicks, and I’m wondering if he’s practiced Medicine any time in the last decade, since he seems to be so busy being a tech executive.

Never mind. He’s wearing a white coat in his thumbnail. Must be legit.

I’ve seen this hustle before. Shill docs giving “educational talks” to other docs, with their meal and his salary paid by the company that makes the drug everybody is getting educated about. Commercials offering “health education materials” to patients, who then get a load of advertising for the newest, latest, and greatest (and most expensive) drug for that condition (not to mention now being on a junk mail direct marketing list patient registry).

So, this is nothing new.

Here’s where my puzzlement comes in.

Who is doing this?

If this were the newest, bestest, and most expensive drug, or one that’s on patent, that would make sense.  It would be the company behind the drug.

This is an entire class of drugs which, though widely prescribed (often inappropriately), are all generic. One would think that there’s not that much money left to be made, and the population prevalence of manic-depressive illness is probably less than the number of people on benzodiazepines. Off the top of my head, a few times more.

I don’t get this play.

Though in terms of marketing, it does make some sense. The advertisers get around all the regulations for direct-to-consumer advertising by putting three layers of “educational intent” between them and the actual content. Perhaps, generic though they be, the various sources of bad news about benzodiazepines have the manufacturers looking for some new, particularly loyal market?

There’s that smell again.

Maybe I need a doctor.

I hear there’s a family practice doc in the Bay Area who’s good with this kind of thing.

 

 

The advantage of being the stupidest one in the room.

CODE ALERT: U.S. Preventive Services Task Force says women should be “screened for depression” during and after pregnancy. Their answer, of course, is to “find the right medication.” And how many on the “Task Force” are on big pharma’s payroll? Follow the money on this one. Hormonal changes during and after pregnancy are NORMAL. Mood changes are NORMAL. Meditation helps. Prayer helps. Nutritional support helps. Love helps.

Recently on social media I came across this gem.

I’m not going to specifically cite the author here – she’s all over social media so you should be able to find it easily if you’re interested. I prefer to avoid signal-boosting such Froot Loopery any more than necessary to make a point.

As far as I’m concerned, the recommendation is long overdue. I have to say I’m disappointed they didn’t specifically recommend paternal screening as well. I don’t think there’s anyone in the medical profession who really takes ownership of care for fathers in the way our obstetricians look after mothers. All that’s aside from what I want to say here, though.

There is a lot to say about the current crop of science denying “purity cults.” These folk act as if there was no such thing as disease in the Neolithic, when everything was all organic and non-GMO and we didn’t have any of those terrible, terrible medicines and vaccines that are steady killing folks. I’m not going to say most of that stuff.

Here’s what I’m going to say: Science is going to win, over and over, because science is intentionally and stubbornly stupid.

Let me illustrate by contrast. Take a look at this slightly enhanced version of that quote:

CODE ALERT: U.S. Preventive Services Task Force says women should be “screened for depression” during and after pregnancy. Their only answer, of course, is to “find the right medication.” And how many on the “Task Force” are on big pharma’s payroll? Follow the money on this one. All hormonal changes during and after pregnancy are NORMAL. All Mood changes are NORMAL. Meditation always helps. Prayer always helps. Nutritional support always helps. Love always helps.

Yeah, she never really came out and said meditation always helps. She damn sure doesn’t use sometimes much, either. You see, she knows.

Back when I was applying to college, in between chucking authentic artisanal spears at the antibiotic-free, free-range cave bears wandering about at the time, I was introduced to my good friend Joe Bloggs.

Joe Bloggs, according to my SAT prep books, was a guy of approximately average intellect. Joe got easy questions right, middlin’ questions about half the time, and was usually wrong on the hard stuff. To his credit, Joe B. knows his own strengths.

Joe B.’s cognitive capacity was the key to a very meta test-taking strategy. First you looked at a question to figure out how hard it was. Then you asked yourself, “What would Joe Bloggs do?” On an easy question, no need to overthink; just write down the answer. On a hard one,  the most immediately appealing answer is probably wrong.

One thing Joe Bloggs had nailed down was this: always and never statements are usually false. Very few things are so simple as to be universally true – for heaven’s sake, even a second doesn’t always last a second. Among the universe of possibilities, always and never can only be true in exactly one circumstance, whereas sometimes can be true under several.

So, our not-too-bright-but-not-too-dumb friend Joe Bloggs might look at such statements and think, “Is there never such a thing as an abnormal mood change? Is there nothing that prayer, meditation, and food can’t help?”

What our boy Joe Bloggs lacks in straight-up horsepower, he makes up for in wisdom. To paraphrase another deeply wise man, Joe knows what he doesn’t know.

Some would make science out to be a monolithic entity that spouts unquestionable truths from on high, and only a small dedicated group can see through it. In fact, the way of science is rigorous, corrosive, unrelenting doubt.

Real, no-kidding scientific conclusions tend to look like this: Under these circumstances, when you do X, Y happens more often; however, it doesn’t always happen and we haven’t looked at some circumstances. So, to the best of our knowledge, X probably contributes to Y.

Science starts out from a position of ignorance about anything, thinks up several possible explanations, and then immediately starts obsessively tearing each one of them apart. Science is pretty much one giant Woody Allen monologue.

Knowing is a lot easier. It’s a lot more pleasant to be smart, to know better than other people.

Except when you’re smart, when you know; you stop looking. For example, you might not look at the actual guidelines since you just know that those @#$%ers are in the drug company’s pocket. If you did, you might find something like this:

They found evidence that cognitive behavioral therapy and other talk therapy are effective treatments and have little risk of harm for the woman or baby. The Task Force found that antidepressants can cause serious harm for a fetus, but the risk of this happening is small. Clinicians and pregnant or postpartum women are encouraged to work together to identify the best approach for treating depression that will meet the woman’s individual needs.

What? Clinicians acknowledging that scientific evidence shows there are both risks and benefits to medications? Pointing out non-pharmacologic treatment options? Encouraging rational discussion and individualized decision-making? It’s even more sinister than we thought! It’s not Big Pharma, it’s BIG PSYCHOTHERAPY!

No, that can’t be it. Must be reverse psychology. They’re trying to misdirect those sheeple into thinking they’re not up to what they’re up to. We could look for actual evidence of their conflicts of interest. Why bother, though? We’re the smart ones. We are the enlightened. We know.

Me, I’ve had most pretense at knowledge beaten out of me. I’ve got some evidence to go by in what I do. Despite the fact that so much has been discovered, I’m still deep in the weeds a lot of the time. There are plenty of medicines that improve the chance somebody will get better, they all have side effects, and they will fail lots of people. The same can be said for all other therapies.

Most of what I’ve got now is some hard-won humility, persistence, and a sharp sense of what I don’t know.

I would rather tell somebody, “I don’t really know what to do, but I can think of some things we can try. Let’s think about which one is worth a shot” than blow smoke. Of course, I got no books to sell.

I’m Joe Bloggs, MD.

Still, I think I’m smarter than some.

Teetering.

“I’m kind of scared of it, yaknow’msayin? Like, I’m gonna lose my edge.”

He’s talking about stopping heroin. He’s a lifelong dealer, so that has to change, too. There’s a crude but clear slogan in the Fellowships around here: “A monkey can’t sell bananas.”

“Doing what I do, you know, you make enemies. For all I know, I relax, I forget to look behind me one day, and something from 15 years ago comes up. That’s it for me.”

He’s still wearing a hospital gown but it’s backward, showing his chest. He sprawls with the affected don’t-give-a-damn manner common to the street guys, but there’s a restlessness.

He should go to a residential program after he leaves but he doesn’t talk about it. It’s his first time getting help, and he doesn’t know anything about recovery. Instead, he talks the three cardinal just haftas. Just hafta be strong, just hafta remember how bad it was, just hafta get a job and keep busy. 

Me, I translate strong to mean walk blindly into temptation and expect not to give in. Memory fades too, scary fast.

The other things he talks about are his girlfriend, and moving to the county. Getting a house to themselves, after getting a warehouse job.

Half the time he talks about these things he’s not looking at me. Then he sounds like  he’s making up a story and listening if it sounds right, or maybe trying to convince himself.

He reminds me of this soldier who left Afghanistan and landed in a bottle. The two of them look nothing alike, but the soldier talked about marrying his girlfriend and getting a job in the same way; like it was some place he had only read about. I remember thinking, “So that’s what the thousand yard stare looks like.”

The man in front of me has taken some bullets, too. There are still some left in him. I reckon he’s dealt a few as well, but I don’t inquire after that. Best to wait until he’s willing to tell the truth, rather than having him lie and then have to stick to it.

One minute he talks about how the drug life kept him sharp, and strong. He’s afraid if he’s not hustling, if he drops his guard, something – seen or unseen – is going to get him. It’s a belief rooted in a kind of backward Darwinism. If you’re still alive, you must be the fittest. So what kept you alive must be working.

The next minute he talks about how the drug kept him numb, and mean. How he’s chasing a high that barely even happens any longer.

“I lie to my family. I hurt people, you know. I break laws all over, and then the law takes my freedom. I’m tired of all that.”

He’s never held a real job for longer than a month. I’d lay solid money he’s never written a check or had a bank account. Never had to swallow his temper when a boss talks down to him.

Early on, the dealers have a similar problem to the prostitutes – access to large amounts of cash fast. They have records, records that include things like “with intent to” or “with a firearm,” so bad jobs are hard to get and good ones might as well be on the moon. Unlike the prostitutes they make victims and nobody thinks they are victims. They get locked up for long times for doing very, very bad things.  Drugs make the money, then drugs take the money. The meat grinder keeps turning and young men’s corpses pile up.

He’s right about old times coming back. You can quit the life but it may not quit you. Somebody he burned might be waiting outside his mother’s or sister’s or girlfriend’s house one day.

With all that: Here he is, though. I’ve met a lot of men in his line of work. Some take pride in what they’ve become, slyly bragging about what they think they’ve gotten away with; or just doing their best to impress me with their brutality and callousness before talking about how they’re tired of it.

This fellow, he’s not in that spot. There’s real remorse there, mixed in with a fear. Fear, I think, of peace. Having it but not belonging in it, or finding out it’s just a story he’s been sold. Having heard his history, I can’t say I would trust it, either.

A question everybody faces, but magnified twenty fold for him: What do you pick, what you know or what you want? Hope or fear?

I like the ambivalent ones. The ones who want to stop but are afraid of everything that could go wrong, who still remember the good things about the drug life.

They are the ones for whom a thumb on the scale could tip it. They’re the ones you can help.

I say, “Sounds like there was a lot you liked about that life.”

He looks at me, just a little surprised. I’m supposed to be lecturing him. I won’t.

Yeah,” he says. “I know it’s crazy, but there was.”

“So when it comes down to it, how are you going to keep yourself from doing what you want?”

“I’m not even thinking about that now.”

“You will, and you are.”

He doesn’t say anything. That’s good.

“You’re going to have to deal with a lot of things you have never dealt with. That’s going to be rough.”

“Yeah.”

“You think you’re going to do that by yourself?”

He looks at me, the tiredness and sadness looking out of place in that sprawl.

“No.”

It’s on.

 

…and thanks for all the fish.

I’m heading out for a little while.

With the new year coming, I just wanted to spend a few pixels letting you all know I appreciate your attention to my ramblings and pontifications.

For those who’ve taken the time to express an interest, drop a comment or a like, or throw some dense solid object at the screen, thanks.

(And for the latter group, I hope that brickbat didn’t do too much damage to your electronics.)
Thanks, happy new year, and good luck. See you when I get back.

The Way of the White Handkerchief.

My Dad’s Law of Psychiatry: The most important tool in your shop is a white handkerchief.

When I was an intern, I was pretty good at procedures. Which means I could stick needles in people and hit the right unseen person part (good) and not the wrong one (occasionally disastrous).

When you are a medical intern, this matters. The ability to get access to a large central vein or an artery can save someone from being  far up Excrement Creek with no means of propulsion.

This might be an odd point of pride for a psychiatrist, but I think the way I sank those central lines is much the same way I approach psychiatry.

You will occasionally hear people talk about how medicine is an art, not a science. This is utter crap. Medicine is neither an art nor a science, and frankly I think doctors just love to portray it as either because we sound far more highfalutin than what we are.

Medicine is  a craft.

We are trades(wo)men.

Science is concerned with developing knowledge through a rigorous system of doubt and observation. Medicine, in the sense of doing medicine, is not about making knowledge. It’s about using that knowledge to get a result.

Art is about getting a result too, but it’s an aesthetic one. Medicine is not about aesthetics.

A carpenter can make an absolutely beautiful joint. If it doesn’t hold, it’s still a failure. The fundamental aesthetic of the crafts(wo)man is in how simply, elegantly, and cleverly he can make something that works.

My father is a mechanic by trade, though he’s the sort of Southern post-Depression farm boy who knows how to do a little of everything. Most of the house where I grew up, he put together. He can fix damn near anything that rolls and a significant number of things that float.

He taught me his Law of Psychiatry, which really is a fundamental law of all trades, when he showed me how to rebuild a carburetor.

My Dad worked mostly on small engines, like lawn mowers. The fuel and air mixture is controlled by a device called a carburetor. Most of these look like a miniature Borg cube on the outside and the nest of an aluminum-eating termite on the interior. They use a set of diaphragms, springs, and valves to meter the flow of fuel into the air stream entering the engine.

On small engines, some of these bits are minuscule. One bit of grit, a drop of water, or a hardened seal that allows a little leakage can turn it into a paperweight. Which is why they often have to be cleaned and rebuilt.

When my father taught me how to do that, he pulled out the white handkerchief he carries everywhere and laid it on a bare area of the bench.

“This,” he announced, in that weighty I’m teaching you something so listen up kid tone, “is the most important tool you have.”

Into the center he placed the carburetor. As he disassembled it, he placed each part at progressively smaller distances from the carburetor body, until upon that white handkerchief sat a realized version of the schematic from a parts book, with the carburetor exploded yet the place of each piece in the whole obvious.

Because you saw how they came apart, you saw how they came together. The notch in the needle valve obviously fit that tab in the float, and the spring pressed in the opposite direction. So there, on that white handkerchief, three little chunks of metal turned into a poised equilibrium between buoyance, tension, and resistance.

After that, Dad replaced each of the old parts on the white handkerchief with the new ones, and put the whole thing together again with an almost musical rhythm.

In my memory, this is the place where the value of method crystallized. The pragmatics of the method are obvious – it keeps you from losing stuff and helps you remember what you did.

There’s more to it, though. Method, you see, is a means to understanding. Because we’re talking about craftsmanship here we are talking about understanding that works; the kind of knowledge that really is power. It’s the way you break something hopelessly complicated into pieces that can be managed, which lets you encompass all that hopeless complexity and do something useful in spite of it.

I remember in residency a meeting with a group of psychoanalysts who were to teach us psychotherapeutic technique. One of them, when discussing a particularly algorithmic form of psychotherapy, disparagingly compared it to “paint by numbers” while implying psychoanalysis was more akin to “van Gogh.”

See, the thing is: I’m not @#$%ing van Gogh. If I did paint-by-numbers, at least I’d come out with something recognizeable. If I tried being van Gogh, I’d have something only my relatives would hang on a wall, and that would be in the basement.

People aren’t canvases and the goal when you’re dealing with someone who’s suffering is not to use her to demonstrate your artistic psychotherapeutic genius to your artistic therapeutic genius pals. It’s to do something that works in a way that it keeps working. It is this emphasis on the literary over method that is my major gripe with analysis, and I think its ultimate downfall.

The methodical way leaves you with a working carburetor, repaired quickly, efficiently, and with a bare minimum of cursing. (In fairness, those little springs are %^~@#ers. They can fly like bullets and render themselves invisible instantly.) It ain’t Starry Night, but it will cut grass.

(I challenge anyone to produce a metaphor more mixed than that one.)

When I was an intern and opened the central line kit the first time, I instantly recognized the most important tool in the box. It was the spare sterile towel that wrapped the kit. It was blue paper, but I knew it for what it was. The White Handkerchief.

Upon that blue towel, I extracted every bit of that kit, lined up at increasing distance from my hand in order of need. Looking at that setup was like Satori, coming home, and a pulled pork sandwich all rolled into one.

That’s the aesthetic of the thing. The beauty of the system, that clean white surface like an inhaled breath waiting.

Yeah. I am a compulsive freak.

The White Handkerchief, of course, isn’t necessarily a thing. Sometimes it is that most wondrous and useful of medical tools, the 3×5 card. Sometimes it is the three seconds at the end of the interview when you take a breath, close your eyes, and all those pathways you’ve burned into your head over the last two decades spit out what they’ve been semiconsciously processing while you’ve been listening, lined up left to right: behaviors, reinforcers, alternate behaviors, new contingencies. Syndrome, course, response to prior treatment, next option.

Most of the time, though, it’s the few minutes before I sit down with a new patient. In my head I have a square of white cotton unfolding over a banged-up metal bench, between two thick hands on which small cuts and grease are so constant they are part of the flesh.

Then, I’m ready.

Thanks, Dad.

 

Redemption through irritation management

Dr. K’s Law: Use your irritation to help the patient.

When last we left our heroine and her interlocutor, Arpie had just provided a story that strained the principles of probability, thermodynamics, biochemistry, and behavioral science. She risked tearing a hole in the space time continuum to convince Dr. C. she was not using marijuana.

A question was raised toward the end, there; a question about the character of this Dr. C. person and his backing Arpie into a corner about her (admittedly, glaringly obvious) lie. Is he, perhaps, enjoying this a little too much? This cat-and-mouse, I’ve-got-you-my-pretty game he’s playing?

What if you knew that every minute poor Ms. Arpie is squirming, Dr. C is chewing nails, too?

Dr. K’s Law is named after one of my many mentors, a brilliant and all around loveable curmudgeon. The good Dr. K was known for:

  1. A scent reminiscent of burning cured leaves wafting from his non-smoking office. Strange, that.
  2. A picture from a certain era involving long hair and a Harley.
  3. A vocabulary that would make a $10 impolite-word-for-sex-worker blush.
  4. Being approximately 95th percentile in eff you.

I love that SOB, for the record.

In addition to the above, Dr. K was known for taking on some patients that most other docs would not touch with a very long and highly insulated pole. The severely personality disordered, the manipulative, the deceptive, the intolerably histrionic. He took absolutely no crap off them. He liked them. He thought they were fun. He got them better.

Now, how could one of the most no-s@#t people you could ever meet manage that feat? Because he is an absolute master of managing countertransference, you see.

A little technique here: “countertransference” is a historical word that harks back to psychoanalysis. Without getting too bogged down in (completely crazy and unsubstantiated) theory, “transference” is the patient’s reaction to the therapist, which is expected to echo relationships with important prior figures. In psychoanalysis, a lot of the technique involves the therapist “interpreting” the transference, pointing out how the therapy mirrors life, thereby helping the patient achieve insight so the patient can stop repeating these patterns.

Countertransference is the therapist’s complementary reaction to the patient. 

General therapeutic principle: Countertransference sucks.

Here is an example of the development and operation of countertransference:

Patient: Hello, Doctor. Thank you so much for your help last week.

Doctor: So you took my advice and had that conversation with Jenny?

Patient: After I thought about it, I decided I was making a mountain out of a molehill.

Doctor: So you didn’t discuss your sense that she’s been undercutting you?

Patient: No.

Doctor: I see. Well, how have you been doing?

Patient: OK. It’s just whenever I talk about my work, Jenny tells me to stop complaining. I feel like every aspect of my life is just miserable.

Doctor: Quietly contemplates risks and benefits of executing WWE style backhand slap upside patient’s head.

The doctor did not, in fact, execute a WWE style backhand slap upside the patient’s head. He did not consider it. Even for a moment. This is entirely fiction.

If he had done such a thing, that would be countertransference in a nutshell. One of the things that makes psychiatrists (and all other psychotherapists) different is that when we’re doing psychiatrism, we have to be looking three different directions.

The first is the everyday talking-to-someone level. Then there’s the inward eye, watching constantly what you’re feeling and thinking, looking for something fishy. Am I angry? Sad? Pitying? Is it more than it should be? That’s the countertransference. Last is the version of yourself that stands six feet to the left and watches. What is it about this interaction that is triggering that feeling? That’s the process, the secret dirty trick of all psychotherapists. After that last part, it is time to employ the Second Law.

In the best case scenario, the next few minutes go like this:

Doctor: When you first came to see me I asked what the trouble was, and you didn’t know, except that you had some sense that you were “stuck.” Since you couldn’t see any particular problem to address, I started offering you specific advice. Each week, I offer more advice, and you say you will try it, but so far not much has changed. To be frank, I’m  getting pretty frustrated. Yet still, despite the fact it clearly doesn’t work, I find myself telling you what to do.

I remember you said that Jenny constantly nagged you to do things, and she didn’t understand how hard it was for you. You said you kept trying to do what she wanted, but eventually just gave up and ‘shut down.’

When I look at what’s happening in therapy and what happened with her, I wonder if there may be some common pattern?

Patient, as heavenly shaft of light shines down upon him: O sage and clear-eyed doctor, now I see! I seldom directly deal with the obstacles in my life. When someone offers advice after I complain about my lack of progress, I resent her for making me feel guilty. Eventually she takes me for a passive-aggressive kvetch and explodes, thereafter executing a WWE style backhand slap upside my head. Eureka! My eyes are open! No doubt I will have difficulty overcoming my passive coping style, but at least I can communicate to people that I only need them to listen when I have a difficult time; and perhaps I can commit to using that listening time to come up with plans rather than simply complaining and resenting my partner for making suggestions I find frightening. Thank you, O healer of my soul!

That never happens, but oh it felt good to pretend for the few minutes it took me to write that. Actually, I’m going to pause and savor that for a couple more seconds. Pardon me while I glow.

To be completely fair, that does happen. What I just presented is the  “inspired by true events,” Lifetime network,  “Courageous story of a woman who escaped her baby-eating Satanist husband” version of the process. The way the real thing works is a lot more slowly.

Back to Arpie and Dr. C.

A thing you might not know, on account of your not paying attention when I didn’t tell you, is that this little encounter is the middle of a longer story. The beginning was some weeks ago, when Arpie brought someone into her house who was actively using drugs against the advice of everyone she knew, including her counselor and the good Dr. C. Not only is Arpie lying, she is lying to the people who care about her who are exactly the ones who told her not to get into this situation in the first place.

After heaven knows how many cycles of this, Arpie’s friends and family are long fed up with her. Let’s be frank here, Dr. C. is pretty fed up, too. So is her counselor, an otherwise superhumanly patient soul who’s been on the front lines watching this slow rolling train wreck for weeks and powerless to do anything about it. 

Dr. C. could just call her on this crap, and tell her straight out that she’s lying and he’s not going to reward such behavior by cutting her any slack. Satisfying, in its way. The psychotherapeutic equivalent of the WWE upside-the-head slap option. Except, you see, confrontation doesn’t work so well. Particularly for somebody who’s angry.

Why? Could be for a thousand reasons. The lie, like other strategies for dealing with a problem, has a function. Just ripping that crutch right out from under someone probably just leaves him flat on his tuchus , equally scared and frustrated but with no idea what to do about it. Which tends to mean he gets really mad at whoever dumped him on his tuchus and maybe just bails right out of treatment. At which point the Fundamental Law of Prognosis takes full effect.

(Attentive readers will note I just avoided unprofessional language such as a@@. I’m getting better!)

Alternately, Dr. C could just nod, smile sympathetically, and let nature take its course. Let her keep lying until she slams head first into reality. That will teach her.

Except it won’t. The goal is to stop the relapse in progress; not to let it take its course until she’s a bloody wreck and out of treatment to boot.

So calling her out doesn’t work, and doing nothing doesn’t work. Now what?

Dr. C. spent some time building this cognitive dissonance up. Is it because he’s an antagonistic #$@# and he’s miffed with her? Let’s be honest: YES. Countertransference is certainly a factor here. 

In his defense: It is, however, consciously managed countertransference.

Perhaps someone who has certain . . . difficult .  .  . personality traits and some hard earned (through the equivalent of a number of WWE-style-yadda-yadda from reality and the occasional friend, mentor, or wife) self-awareness may apply those characteristics to the present situation in some way that is beneficial to his patient.

For one thing, he is one stubborn @#%#@, and he doesn’t like letting one of his flock go without a fight. For another, he likes the underdogs. Perhaps he has some sympathy for those with certain ahem personality characteristics.

So maybe, just maybe, he used that rough streak and his own irritation to set up an endgame. Cognitive dissonance is the motivational equivalent of stored energy. It wants to discharge itself. While Arpie’s doing her level best to dodge the consequences of her behavior; this Dr. C. keeps just forcing her over and over to become more and more uncomfortable with how inconsistent what she’s doing is with the better self she’s been building. Even more diabolical, he hasn’t given her the least excuse to blame him for it.

Now, what can that endgame be?

Maybe saying something like:

Arpie, I have no crystal ball and I can’t read anybody’s mind. There are two possibilities, though. One is that you’ve been positive for marijuana for weeks on several pretty specific laboratory tests, and you’re not using. If that’s the case, then I am terribly sorry for what is about to happen to you. You’re going to lose this program.

The other is that you’re doing something that’s causing this. It wouldn’t be unusual if somebody was reluctant to talk about that. But that’s actually the better option. Because if that’s true, then you can do something different.

If this program matters to you, and there is anything at all you can do that will lead your tests to be negative, you should do that. We all care about you, and you’ve done really well here, and we would hate to lose you.

Every word is absolutely true, absolutely authentic, and passive-aggressive as all get-out. The lie is called without being called. There is nothing to manufacture anger from and blame the injustice of it all for what she’s doing. She’s stuck, faced only with a bunch of people who care for her and her own behavior, and that wrong feeling in her gut.

Arpie looked a little trapped and sputtered half-heartedly for a while. Then she looked lost, like all the fight was out of her. She walked out looking resigned.

What happened after that?

She pulled it out of the fire. Well, the one Arpie mostly is pulled it out.

It took a while for the testing to show up negative – weed takes a long time to wash out. Could be that she got an extra week or two once some doctor or other heard that she threw that guy out of the house. Could be.

The day came, though, when she tested negative and got back into that better life.

Hopefully, she never has to deal with that Dr. C guy again.

He can be . . . difficult.

He does mean well, though. Every once in a while, he probably even helps somebody out. Not every time. Let’s hope, for his sake and his flock’s, that it is enough.

Maybe there is enough redemption to go around.

Let’s hope.