…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.

 

…with both hands and a flashlight.

Dear my friends in the news media, repeat after me:

An infant cannot be born #$%#$% addicted to drugs.

I do not know what’s been going on lately, but I have seldom heard so much flat-out stupid, uninformed, backward reporting on the opioid epidemic as I have been hearing in the last couple of weeks. It’s been so widely distributed among different outlets that I’m not sure it’s even fair to single out any one particular corporation.

The first such noises I heard were about “fetal assault” laws. It boils down to threatening imprisonment for women who are pregnant while using illegal drugs if they don’t get treatment. The getting-into-treatment part I dig; however, interestingly enough, one often finds such States have a lot more room in jails than they do in treatment programs. Funny, that. Wouldn’t it be nice if the States had enough treatment slots to provide treatment on request and massively ramp up the drug court system, instead of all this retroactive stuff? I think so.

The media pointing out the ethical problems of this is fine with me. However, we got into a whole other realm when pregnancy outcomes started getting discussed. One was the neonatal abstinence syndrome – basically, opioid withdrawal in an infant. In some of these reports, reporters were constantly and unself-consciously referring to “infants born addicted to drugs,” including when talking about kids born to mothers who take methadone or buprenorphine.

There are several huge problems with this and I’m only going into a couple because I’ve already had too much coffee and I’m trying to maintain normotension. The first is this: Why are you not talking about cigarettes and alcohol?

To be fair, this is a problem with the media and with the legislatures. Illicit drugs are tremendously stigmatized and they do godawful amounts of damage, but let’s face it – the legal drugs probably cause the most public health harms. If your goal was seriously to impose consequences to prevent pre-natal injury to infants, you would hang a breathalyzer around every pregnant woman’s neck and lock up anyone who tested positive for nicotine while pregnant. In terms of long-term outcomes, “neonatal abstinence syndrome” is probably nothing much compared to fetal alcohol syndrome and all the stuff that smoking can do.

So that’s one. Here’s the second: the constant lumping of therapeutic drugs in with active addiction.

It happens several ways; one of them with the use of the word “clean.” As in:

She couldn’t tolerate the withdrawal, and her doctor told her that quitting cold turkey could be dangerous. So she went to a methadone program, hoping that it could serve as a bridge to getting clean.

Because, you know, nobody on methadone is really “clean.” Even if, for the last 5 years, she happens to be showing up to work at 8:00 every morning, leaving at 6:00, looking after her kids, abiding by the law, paying taxes, and generally being a productive human being. She is still “dirty.” Unlike that guy who just walked out of detox two days ago and refused to get into the treatment that would keep him from relapsing in the next two weeks. He’s “clean.” Right? Right.

I wonder how many reporters writing these stories spent the morning talking about who’s “clean” and who’s “dirty,” and then hoisted a couple at happy hour after work.

I get my knickers particularly twisted about this because this stigma kept coming up for the people in a program I worked in. They had to be careful in the Fellowships because even though some newbie might be nodding out in the back row with pupils the size of the period at the end of this sentence; if they talked about being on methadone, they were instantly “unclean.” It’s even more ridiculous out in the community, where being on either methadone or buprenorphine cuts you off from all kinds of resources. You can have treatment for your cravings and withdrawal, or you can have a roof over your head, but not both. Crazy.

The common thread to this craziness is a fundamental confusion.

Addiction is a behavioral disorder.

You cannot know how people are behaving based on what chemicals are in their blood. Go to a cancer ward and check out how much morphine and fentanyl are floating about. Now ask which of them should be locked up, or which are “dirty.”

This also is why you can’t be born addicted. No three-day-old is going to raid Daddy’s medicine cabinet or slip out to the corner to meet his boy to cop some pills.

It’s about how you act. There are situations in which taking opioid medications, like methadone and buprenorphine, helps people act better. It helps them stop using, stop getting infected with really nasty viruses, helps them turn into functional parents and citizens. As long as there is some implicit assumption that success only counts if you do it without medicines, and the highest goal for addiction treatment is to be medication free; we will be encouraging people to stop doing stuff that works. That is not the way we’re going to dig our way out of this hole.

I don’t know why these various media outlets feel they can file such reports with an obvious lack of expert guidance. Any good they do questioning the ethics and effectiveness of criminal justice based responses gets washed away when their next sentence stigmatizes some of the most effective treatments we’ve got, and further teaches potential patients that such treatments render them “unclean.” They are operating with exactly the same stigmatizing assumptions that lead these legislators to pass these laws.

Dear my friends in the media:

Find some actual addiction docs, talk to them. Take this seriously.

The truth is out there, but on your own, you’re not going to find it …