Monday, October 31, 2011

Happy Halloween!


For today's Halloween post I thought I'd share a bit about the forensic aspects of haunted houses. I didn't think there was such a topic until I stumbled over a law review article by Daniel Warner entitled, "Caveat spiritus: a jurisprudential reflection upon the law of haunted houses and ghosts." [28 Val. U.L. Rev. 207].

For the purposes of the law, haunted houses are a kind of property problem known as a "psychologically impacted property." According to Warner, this is real estate tainted with troubled pasts: murders, felonies or suicides. The question is, when you have a house like this are you required to disclose the past to the buyer?

According to the 1983 California case Reed v King, you do. This apparently was the first case addressing the issue. A buyer tried to get out of a house deal after she found out that a woman and her four children had been murdered there ten years before. The court agreed that she had a point because the seller failed to disclose this. After this many states passed laws protecting sellers and their agents from claims over "psychologically impacted property." The problem being, of course, that things like poltergeists and other creatures can't be detected in your typical home inspection.

Then again in 1991, a man bought a house in New York and later found out the previous owner had failed to disclose the presence of a ghost, something well-known in the community. The house was even featured regularly on neighborhood ghost tours. The buyer's wife was very uncomfortable with this even though the seller reassured them after the fact that the ghost was friendly. The court ruled in the buyer's favor, stating that even though the house wasn't haunted 'in fact', the judge decided it was haunted as a matter of law. (The news story about it can be read here.)

So who ya gonna call? According to Mary Pope-Handy, licensed realtor specializing in haunted property, the first person to call is a spiritual professional who may be able to convince the "discarnate" to move on. Unless, of course, you bought the house because you knew it came with a ghost.

Whether or not they work, they're getting cheaper.

Over on Thought Broadcast, Steve Balt has a nice, disillusioned post about whether clinical psychopharmacology is a pseudoscience.    By the end of the post, I was ready to take down my shingle and go home.  I liked Steve's graphic so much (the little pill bottle guy juggling those mood stabilizers) that I stole it.


On another pharm note,  there are several popular medications that have recently gone off-patent or will soon go off-patent, allowing for more competitive pricing as generics become available.  Among them, several big-buck psychiatric medications, including Lexapro, Seroquel, Zyprexa, and Concerta. 

Saturday, October 29, 2011

What I Learned Part III

  • More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
  • People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
  • Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
  • Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
  • Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
  • Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
  • No suicide prediction tool has a predictive validity greater than 3%.
  • Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
  • In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.
Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

What I Learned Part II


Psychiatry residents on the APA listserv were surveyed about their experiences with social media. 9.7% of residents had gotten friend requests from patients. The remaining residents were asked what they would do if they got such requests. 85% of residents said they would automatically ignore them. 15% said they would discuss the request with the patient, then decline it. Less than 3% of residents received any training about proper social media use in residency. Half admitted googling their patients.

One poster presented the results of a one year study of four major media outlets: the New York Times, the LA Times, USA Today and Fox News. The outlets were culled for articles related to mental illness and violence. The stories were scored according to how many contained one of the follow true facts about mental illness and violence:
1. The majority of mentally ill are never violent.
2. People with mental illnesses are more likely to be victims of violence than perpetrators
3. People with mental illnesses are more likely to be violent against themselves than against others
4. When violent, they are more likely to victimize family than strangers.
Fewer than five percent of the articles contained any of these facts.

The state of New York has successfully used electronic monitoring and regular clinician feedback to reduce the use of polypharmacy in the state prison system.

All state prison systems were surveyed regarding their policies regarding pornography. Of 43 responding states, all banned material that represented a risk to institutional safety and security. There was high variability regarding allowed visual or verbal depictions of sexual acts. There is no published data to support any policy link between prison safety and the presence of pornography.

Crisis intervention training for police is thought to be helpful to reduce incidents of violent outcomes when responding to acutely mentally ill people, but the content of the training varies between program and lacks consistency. There also needs to be more outcome studies to learn if these programs do actually divert mentally ill people out of the criminal justice system.

The PCL-R is coming under pressure as a risk prediction tool. There was a great pro-con debate about this presented by a panel of Broadmoor Hospital psychiatrists. Although interrater reliability is 0.8, there is still significant variance in scores and this could be enough to cause inconsistency when using cutoff scores to determine readiness for release from their severe personality disorder program. It stood out as a risk prediction tool in the 1990's because it was the only one of its kind, but newer tools are being developed with better ROC-AUC scores.

Lastly, multiple personality disorder is coming back. In spite of recent books such as Sybil Exposed, Creating Hysteria and I'm Eve, which document the role the therapist played in the creation or course of the disorder, one presentation today still featured a criminal defendant thought to suffer from multiple personality disorder. This presentation would have been much more effective had there been another expert presenting the potential pitfalls of examining criminal defendants for this disorder. The psychiatrist in this presentation fell into many of those pits: he presented a videotape of the interview in which he asked probing and leading questions (admitting at one point he had to "dig" for symptoms for 20 minutes before the defendant reported any!), and occasionally referring to the defendant as a "patient" rather than as a defendant---clear evidence of bias. The redeeming feature of the presentation was an overview of case law regarding competency and insanity and MPD.

In 2006 there were 4000 civilly committed sex offenders in the US. In this panel they took maps of several large cities in New York, overlaid a map of schools and school bus stations, then overlaid a map of available housing. Finally, the last overlay was a map of legal exclusion zones---boundaries of areas that were legally "off-limits" to convicted sex offenders. This illustrated, at least in Buffalo, New York, that there was literally no place for a sex offender to legally live within city limits. Then they overlaid a map of reported home addresses of sex offenders: 90% were living in restricted areas. There is increasing evidence to suggest that sex offender registration and living restrictions may increase recidivism.

So that's the second conference day. I also enjoyed the computer committee's presentation, which was a two hour geek-fest off all things tech and forensic. It's something you just have to witness to appreciate, sorry. Lots of cloud-based software for document management and report-writing. Not relevant to most Shrink Rap readers but fun for me.

Friday, October 28, 2011

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic psychiatrists consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

  • The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
  • Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
  • According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
  • The collection and selling of serial killer memorabilia is also a venue for potential fraud.
  • President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
  • There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about psychiatrists in the media. The panel presented an interesting categorization of activities: psychiatrist as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "psychiatrist as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

Thursday, October 27, 2011

Destined to Disappoint?



Tomorrow, I'm going to pick up my new iPhone.  Mind you, I've been an iPhone owner for about 4 weeks now, and I'm returning a month-old iPhone 4 to get a 4s.  I can't wait, the phone arrived today and I've had to restrain myself from going out in the rain tonight and waiting until tomorrow.


I'm looking forward to having Siri be my personal assistant.  For weeks now, whenever I look things up or schedule an appointment or send an email or text, I wonder: Will Siri do this?  Will it work?  Can I tell her to send text messages?  Do I need to switch back to iCal from my Google Calendar?  No big deal, right---I'll just tell her to schedule things and my calendar will be revised and moved in a matter of minutes?  Can Siri phone in prescriptions?  Can she preauthorize my life?   I'm excited as though I'm about to move in with a spouse in an arranged marriage. 


So have I built this up in my imagination? Is it too good to be true? You can bet that if Siri texts, Roy and Clink will be the first to know my new iPhone has arrived.  I'm finally going to be the kid on the blog with the newest toy: it's never happened before!

-----------------------

On another note, I am feeling rather cool.  Our Shrink Rap book was scraped by a Hip Hop site!
 --------------------------
David would like to be credited with the title for this post.  Who knew?

Wednesday, October 26, 2011

Guest Blogger Dr. Jesse Hellman on "Acting Professionally."

 
Psychiatrists “friending” their patients or interacting with them on Facebook led to the discussion of professional boundaries on Podcast #62. I thought of expanding the discussion because the oft-advised “act professionally” is less than truly helpful: how does one know what is professional? That does not elucidate the underlying principles. I’m talking about one aspect of this below, and am posting this to see what ideas others have. If possible, try to look below the concrete example to expose the underlying principle. 

The psychiatric relationship is a special extension of what is considered proper in all relationships in which one engages someone for professional ends. A mechanic, accountant, electrician, each has access to certain information and he is to use it only for the purpose intended. When you invite an electrician into your home he is to concentrate on the task at hand, not dwell on your art or the design of the home, and certainly not on how beautiful you are. 

A psychiatric patient opens up extremely sensitive personal information, potentially much more embarrassing and intimate than that seen by other physicians. The psychiatrist needs to behave in a way that not only takes no advantage of the information but also keeps the focus on what will help the patient. 

The more the psychiatrist holds to this dictum not only is it easier for the patient to speak openly but the psychiatrist may learn of things that the patient has revealed to no one, perhaps information that he has had trouble admitting even to himself. 

Keeping to proper boundaries is very important in psychiatry. Certain remarks which are common in ordinary social situations would be quite seductive in a psychiatric session. We do not use our patients for our own gratification. That is the basic principle and it is essential if we are to help them.

Sunday, October 23, 2011

More on How Lousy Psychiatrists are at Determining Prognosis



A few days ago I put up my post on the Clinical Psychiatry News website on Rethinking Bipolarity.  I talked about how we've expanded the diagnosis so that now it captures so many problems as to make the diagnosis imprecise and I talked about how we really can't predict prognosis.  In the same vein, the front page of the New York Times has an article about people with schizophrenia who do better if they keep busy with busy careers, even if they are very stressful.  In a High Profile Executive Job as Defense Against Mental Illness, Benedict Carey writes:

Now, a group of people with the diagnosis is showing researchers a previously hidden dimension of the story: how the disorder can be managed while people build full, successful lives. The continuing study — a joint project of the University of California, Los Angeles; the University of Southern California; and the Department of Veterans Affairs — follows a group of 20 people with the diagnosis, including two doctors, a lawyer and a chief executive, Ms. Myrick.


The study has already forced its authors to discard some of their assumptions about living with schizophrenia. “It’s just embarrassing,” said Dr. Stephen R. Marder, director of the psychosis section at U.C.L.A.’s Semel Institute for Neuroscience and Human Behavior, a psychiatrist with the V.A. Greater Los Angeles Healthcare System and one of the authors of the study. “For years, we as psychiatrists have been telling people with a diagnosis what to expect; we’ve been telling them who they are, how to change their lives — and it was bad information” for many people. 

It's a good article, but I have one gripe with it (...ah, for me to have only one gripe with an article by Mr. Carey is close to amazing).  He makes it sound like people with schizophrenia have chosen less stressful jobs because that's what doctors recommend.  I think some people with schizophrenia lose their motivation to work at any job because it's one symptom of the illness.  Like bipolar disorder,  schizophrenia and schizoaffective illness seem to play out differently in different individuals.  As a field, our crystal balls don't seem to work very well. 

Toys!!!

I think I have officially caught the Toy Disease.  It's taken a long time, but oy, I've got a bad case.  

For starters, after losing my Macbook, I bought a new one and decided I should simultaneously fix all my techno problems.  My phone had terrible reception and many of my calls.  I got a new Samsung phone, a touch screen, and it was awful.  It dropped my calls, it switched to speaker if my face touched the screen, I couldn't cradle it on my shoulder and talk to Camel while I cooked dinner...not good.  I surrendered, and after many years of happiness with my dumb phones, I gave in, risked the last vestiges of anything that might resemble sanity, and bought an iPhone.  Excited, I came home to have teenager greet me with, "Why did you get that, a new iPhone is coming out in 3 weeks."  So, I went back to the phone store (I am now the most-recognized customer), and ordered a new iPhone 4s and am eagerly anticipating the arrival of the new phone.  I can't wait to meet Siri and have her negotiate all my problems. 

Okay, and a while back, I asked Shrink Rap readers to help me decide between a Nook and a Kindle.  I decided on a Kindle, but never got one.  And then I read about the new Kindle Fire.  Oy.  I've pre-ordered one.  

Now I'm thinking I "need" Apple TV.  What is wrong with me?



Finally, I have some questions for our readers:

  • Dropbox or iCloud?
  • Apple TV: yes? no?
  • How's it going with Siri?  What's the coolest thing you've asked it (?her) to do?

Saturday, October 22, 2011

This is how i Feel today!






There's an article in the New York Times called If You're Happy and You Know it, Must I Know Too?  I thought it would be a story about moods, but it's a story about writing and emoticons by serious people.  One person said they hated them and un-friends anyone who uses emoticons or LOL or OMG.  Fortunately this person is not my friend, so I don't have to worry about this, but I did think that life is too short to expend a lot of energy on such thing.  And the article talked about how emoticons were initially used by teens and "frothy adults."  What's a frothy adult?  I thought beers were frothy.  So I looked it up and I learned that frothy means "light and entertaining but of little substance."  LOL!  


So Shrink Rap will be adding a new feature.  We will be adding a feature to our sidebar where every day all three Shrink Rappers and the Duck will be posting an emoticon to describe our moods.  I'm guessing we'll have to remind Roy sometimes, but he may be able to find an app that lets him post his mood from his iPhone, and then he may decide to change it hourly.  This will enable readers to better decipher our posts within the context of our mood states.  Hope you enjoy this new feature.  And please do end your comments with a smiley face or other emoticon.

Wednesday, October 19, 2011

Ups and Downs--The Bipolar Diagnosis



I want to thank all of the people who commented on my post What is Bipolar Disorder.  Your comments were tremendously helpful.  The descriptions of what it feels like to have this illness were incredible-- vivid, heartfelt, almost a mix of poetry and misery-- the stories were told in a way that I don't often hear in clinical settings.  So, thank you.  And if you're someone who doesn't read the comment section of blogs, I would urge you to make an exception for this post.  The comments speak to what an intelligent, educated, and articulate readership we are lucky enough to have join us here, and the commenters make the experience of difficult mood states come alive in a way it is so hard to do with words.  A little bickering (it wouldn't be Shrink Rap without that!), but I want to point out that the issues that inspired the bickering are exactly the concerns we address in figuring out the usefulness of the expanded bipolar diagnosis.


That said,  I wrote my article for Clinical Psychiatry News, called Rethinking Bipolarity.  If you click the link at the end, it will cycle you back to the What is Bipolar post.  Let me know how I did?

And thank you, again.  Thank you also to Dr. Dean MacKinnon, of the Johns Hopkins Mood Disorders Center and author of Trouble in Mind for previewing the article for me.

Sunday, October 16, 2011

What is Bipolar Disorder?


I'd like to ask your help for a moment.  I'm going to write a blog post for this week's Clinical Psychiatry News on Bipolar Disorder.  I'd like to know how you see the term used, or the symptoms that are hallmarks of the illness for you.  If you respond as my favorite commenter, "Anonymous," could I ask that you define yourself...psychiatrist, psychologist, pediatrician, patient with bipolar disorder, friend of someone diagnosed with bipolar disorder....


Also, please just off the top of your head, I can read DSM or Google myself, and I'm more interested in your ideas about what exactly the disorder is.


I may not use your responses (I sort of know what I want to say) but no matter what, I'm curious.  
Thank you so much...

Friday, October 14, 2011

Podcast #62: Sooner Rather than Later


We talk about the following topics:

  • Roy asks listeners to suggest a topic for our next book (Dinah and Clink suppressed all urges to scream).


  • Professionalism and social media for physicians.  Roy refers to a post he wrote and Mark Ryan's discussion of the challenges of determining what is professional in social media. We ramble a lot and Dinah talks to much.  Here is the AMA policy on Social Media.  Should psychiatrists put their poetry and their political beliefs up on the internet? We don't talk about Google+ now, but we do talk about not talking about Google+ now.


  • Clink and Dinah argue about whether we (the Shrink Rappers) know a lot about social media.


  • We discussed how Dinah isn't sure she believes that psychiatric patients die an average of 25 years before people without mental disorders.  Roy referred us to this article on life expectancy in chronic mental illness.  Is earlier mortality due to antipsychotic use?  Is it due to lack of coordination of medical care?  ClinkShrink tells us that people with personality disorders die more of all causes and we talk about who the studies address.


  • We finally discussed Google plus-- is it going to add to medical social media or is a party that no one is going to?  Roy likes it better than Facebook & Twitter and he invites you to join his Shrink Rap readers' circle.  ClinkShrink predicts that social media will die and Roy disagrees.  He talks about the PatientsLikeMe website and an article on How Google+ Could Transform Healthcare.  

  • We digress to topics of electronic medical records and what to do if patients don't want to know their diagnoses or do want to see their medical records.  I do believe we could talk about this subject for all eternity.  We came close.


No clue why ClinkShrink titled this "Sooner Rather than Later."


This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com





Thank you for listening.
Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Monday, October 10, 2011

Guest Blogger Dr. Jesse Hellman: What are the Limits of Psychiatry?



Recently a colleague and I were talking about a question that had been posted on our psychiatric society's Listserv. The question had to do with the age at which a parent would tell their child he had been adopted, and who the birth parents were. This question is quite complex, depending on a multitude of factors. Child psychiatrists responded, as did adult psychiatrists. Is this a question, though, for Psychiatry? One might argue that the question has nothing to do with mental illness. But does our field define itself only as addressing mental illness?

A few days ago in the NY Times there was an OP-ED piece in which the author touted brain studies as showing that we do not just "like our iPhones" but "love our iPhones." When I read it I was surprised, as the idea of whether one might "love" an iPhone (or, for me, my camera or sports car) never occurred to me: Of course I do. What was surprising was the apparent sense of discovery by the author of a phenomenon that Freud had clearly described well over eighty years ago. He invented the word "cathected" to describe that we can "cathect" or imbue any particular thing, or even idea, with erotic energy and so love it with the intensity we have for living things. He explained that that cathected energy can be withdrawn from these things as well as from people, and the formerly loved object discarded instantly.

So psychiatry, to me, includes psychology in its broadest sense as well as the complexities of human interaction. In my own practice the most difficult and important issues are not usually the questions of medication but those that have to deal with all the issues that  beset the patient that are then brought up in their sessions: getting promoted at work, the problems of a marriage, the competitive strivings within a family or its workday substitutes, the losses one faces inevitably in life, and so on. Almost infinite variety.

So how do others address this question? Just what is Psychiatry?

October 10th: World Mental Health Day




U N I T E D   N A T I O N S                    N A T I O N S   U N I E S


THE SECRETARY-GENERAL
--
MESSAGE ON WORLD MENTAL HEALTH DAY
10 October 2011

There is no health without mental health.  Mental disorders are major contributors to illness and premature death, and are responsible for 13 percent of the global disease burden.  With the global economic downturn – and associated austerity measures – the risks for mental ill-health are rising around the globe.

Poverty, unemployment, conflict and war all adversely affect mental health.  In addition, the chronic, disabling nature of mental disorders often places a debilitating financial burden on individuals and households.  Furthermore, individuals with mental health problems – and their families – endure stigma, discrimination and victimization, depriving them of their political and civil rights and constraining their ability to participate in the public life of their societies.

Resources allocated for mental health by governments and civil society are habitually too little, both in human and financial terms.  Recent data from the World Health Organisation clearly show that the proportion of health budgets devoted to mental health is inadequate.  Most low- and middle-income countries spend less than 2 per cent, and many countries have less than one mental health specialist per one million people.

The theme of this World Mental Health Day is “Investing in mental health”.  We cannot expect improvement in global mental health statistics unless we increase financial and other support for promoting mental health and providing adequate services to those who need them.  Deaths, disability and distress caused by mental disorders need to find their rightful place in the public health agenda.

Mental illnesses can be treated effectively.  We have the knowledge.  Feasible, affordable and cost-effective measures for preventing and treating mental disorders exist, and are being implemented, for example through WHO's Mental Health Gap Action Programme (mhGAP).  However, if we are to move decisively from evidence to action, we need strong leadership, enhanced partnerships and the commitment of new resources.  Let us pledge today to invest in mental health.  The returns will be substantial.

Saturday, October 08, 2011

Send a Message to Congress: Don't Cut Access to Healthcare for Medicare Patients




Medicare has been using a flawed formula to annually revise Medicare fees to all providers. The formula results in a larger and larger cut each year, which often gets temporarily "fixed" at the last minute. Due to the current dysfunctional Congress, the expectation is that it won't get fixed this time around, and so this year's cut -- 30%! -- will stay in place, resulting in many doctors, nurses, psychologists, social workers, and other providers to drop Medicare.

What we need is for them to repeal this flawed "Sustainable Growth Rate" (SGR) formula, and replace it with something that makes sense.

Please CLICK HERE to take a few minutes to let your elected representatives know what you think about this.

Thank you.

Friday, October 07, 2011

Cheeseburgers for Yom Kippur...

Yom Kippur, the day of atonement,  is a solemn Jewish holiday.  It occurs at the beginning of the new year, and marks the end of a period of reflection.  While it the usual tradition to fast, Danielle Gelfand has a moving editorial in the New York Times where she talks about a tradition she has of eating cheeseburgers on the beach with her mother as they remember her father who died many years ago of suicide.    The author writes:

For the last 18 years, my mother and I have spent Yom Kippur, the holiest day of the Jewish calendar, at Tod’s Point beach in Old Greenwich, Conn., near where I grew up and where my mother still lives. I’m a TV producer living in Brooklyn now, but I still go back every year. My mom reads my father’s old prayer book while I order lunch for us from the greasy concession stand that stays open into the fall, double hamburgers with grilled onions and French fries.

To those who fast during the holiday, our version of a High Holy Happy Meal might seem sacrilegious, but we didn’t always spend it this way. We used to go to temple like everyone else. But when I was 17, my father, who had just turned 59 and had suffered from depression for many years, shot himself in the head. The police found his body two days later, on the eve of Yom Kippur. 

Do read the whole article at  Years of Atonement. 
 

Shrink Rap Around the Web


In case you're having any trouble finding us:


Over on Shrink Rap News, ClinkShrink is talking about the unpredictability of patient violence.  It is not at all clear to me why the patients she described were in a YouTube video.


Over on Shrink Rap Today, Roy is talking about his favorite palindrome.  Madam I'm Xanax?


Over on the Johns Hopkins Department of Psychiatry and Behavioral Sciences website,  I'm pleased to report that Shrink Rap: Three Psychiatrists Explain Their Work is the featured faculty book!  : ~ )


And finally, over on MovieDoc's blog,  he has a post up about the Shrink Rap movie.  Sadly, the movie has absolutely nothing to do with us, but I do like the name and Roy watched it and attended a Twitter event held by MovieDoc. 

Thursday, October 06, 2011

He's Gone






At 8:30 last night I got the news. It came from somebody who knew me quite well and knew my hardcore loyalty to Apple, enough to call me a "Steve Jobs Apple toady bootlicker." A good friend, yes. He told me: Steve Jobs was dead.

Wow. I remember when John Lennon was killed and I'll remember getting this news.

Steve Jobs has been part of my professional and personal lives for 25 years. I got my first Mac in 1986, during my second year of medical school. It was a huge decision, and even with a student discount a tremendously expensive thing to do. It was a decision I've never regretted. I still have that machine.

The day I went to pick up my new machine they held a special event at the university hockey stadium. The whole place was filled with aisles of Macs stacked six feet high. People were lined up around the block to pick up their new machines. The only time I've seen anything like that was at the opening of the first Apple store in 2001. I was standing in line at Tyson's Corner, fortunately not at the end which curled around the second floor and down the stairs. The waiting time to get in was rumored to be three hours, and there was security in place to make sure the store stayed below the fire marshal's limit of people in the store.

The Apple years without Steve Jobs were grim. A series of five CEO's successively drove the company into the ground. The quality of the machines dropped, there were recalls for broken parts, bad monitors, stuff that never would have happened under Steve. (OK, the Apple Newton eventually became the prototype for the Palm Pilot---using an operating system designed by former Apple engineers---but it never quite got it right.)

Then he came back. Just in time, like Superman coming back just as the bomb is about to explode, to save the world. We got that weird-looking first-ever all-in-one pyramidal iMac. We got OS X, one of the most stable operating systems I've ever used. We got iPods and iPhones and iTunes (without which our My Three Shrinks podcast would never have happened). We got the iPad. We got the software. It just happened.

So here we are. We three Shrink Rappers all use Apple products. We edit podcasts with Garage Band, have iPhones, use MacBooks. Our iPhone edition of Grand Rounds was one of most popular posts (complete with clickable iPhone buttons). Technology for non-geeks.

There's not much else to say. If there is, the Twittersphere has it covered---it's been nothing but mourning for hours after the news broke.

He's gone.

Goodbye.

And thanks.

Wednesday, October 05, 2011

The Special Needs Child


Oh, we're not kiddy shrinks, so this post is not really about children.  But I like the term, it implies that the person needs something more, that they have special-- presumably increased-- needs.  It says nothing about potential.  I use the term often, and sometimes with a bit of humor, to remind people that the playing field is not always level.  There are people who start any give race with a handicap-- a learning disability, dyslexia, major health problems, mental illnesses, horrible childhoods, addictions, -- and these set them on a slightly different course.  


Some people overcome tremendous adversity.  They function 'as if' they had no special needs.  They have stories that would let you understand if they didn't do very well in life, stories that would explain burying their heads in the sand, or crawling under a large rock.  Sometimes these special needs people are so driven to excel that they don't just hang in the race, they lead the pack, as if they had no problems as all.  They measure themselves against those without special needs and everyone forgets that they are racing with a bit of extra baggage and often very remarkable stories.  They are among the most resilient of people, and their stories are often inspirational.


Why is this a problem, or even a Shrink Rap post?  I suppose because the issues come up all the time, and they get to be problems when the special needs child gets so good at running the race "as if" they are not hindered by the weight of their problems that they come to expect nothing short of excellence. They run without the memory of their handicap and are particularly unforgiving of their lapses.  So what if one needs to rest, or if one doesn't finish the race first, or doesn't finish at all?  But even worse, their loved ones often come to expect so much that they may become critical if special needs child lags a bit here or there.


Sometimes it seems it's fine to simply say, "I have a special burden and I can't keep up right now."  


This is for Carrie who shared her remarkable narrative with me and for all the other people I know who expect so much of themselves in inspirational ways. 
And tonight, this is for Steve Jobs who gave the world so much until the very end of the fight.  

Monday, October 03, 2011

Frontier Psychiatrist


Please, someone explain this to me.