Psychotherapy Notes — The Humble Elitist

Six months into psychotherapy he asked to tell me a secret. “But of course,” I said. He told me that he is a humble elitist. That’s an odd juxtaposition of ideas because they seem contradictory. He told me that no, there is nothing odd about it, and it is so much of his inner turmoil.

 He is an extremely bright, creative and sensitive 40-year-old. He knows that he is blessed with artistic insights and skills that propel him above and beyond the average artist. But his upbringing was so emotionally disparaging and mercilessly critical that he hid his fears out of worry that being open would position him for more criticism. The criticism was not from peers but from family, and he couldn’t step out of the rut that the family emotional ties had over him. So he became shy. People thought he was humble. In fact he was scared.

 He was scared not only of the criticisms that he had come to expect so much from his family but also that others would exclude him from groups because he was so uniquely talented. He said that he didn’t know how to reveal his talent and be a common man at the same time. Of course this was the focus of much psychotherapy. And of course this involved him trying to figure out who was and where were his real peers..

 Whenever he was asked to do something, clearly his talents became evident. But he was usually kept them quiet insofar as how he spoke about them. He didn’t market himself – instead he kept waiting to be found. Advertising himself was too risky.  So therein sits his apparent humility. But in his heart and in his head he was an non-cocky elitist because he knew how superior he was. He just didn’t want to be called superior for fear it would evoke denunciations of elitism, which were old manifestation of his family’s criticisms. So he lived in a world of humility on the outside and inside, and he lived in a world of elitism on the inside.  Those worlds were not good neighbors. He loved to use his special skills to help people, but would be happy to do it without the overt recognition. Yet in that recognition he would feel better about himself and that would improve his vocational and social life. The notion of elitism was his family’s choice of words, and he carried it in large part from habit and not choice.

 His pain is that of the humble elitist. This is a rather good concept.

Psychotherapy Notes — Those who see the forests, and those who see the trees

I watched a commercial in which an older teenage boy painted adjacent buildings with flowers. When his sickly bedridden sister woke up, he pulled open the curtains and she saw a note, surrounded by flowers, painted on the neighbors walls. The graffiti said “be brave.”  Then the words “sometimes it takes more than medications” rolled across the screen.

How touching and how true.

Most people who saw this responded with accolades of how impressive it was, how it touched the need for connections between people, that it relieved us of our overconfidence in medications to heal, and of the importance of touching. But one person commented that we should not be endorsing antisocial behaviors. The graffiti artist, he said, violated the property rights of those who owned the wall that he used as a canvas. I must say that initially I was really taken back by this. I felt the larger message was missed. But a friend told me that, technically, that the commentator was correct. And much to my initial resistance, I conceded. Of course I’d be happy to donate any amount of wall space if it made a child smile. But that’s me.

My lesson: we need those who see the trees, and we need those who see the forests. I saw the forest and not the trees. He saw the trees and not the forest. I wonder if he would see the same forest if different trees had been used.  An interesting set of thoughts.  A lesson to take into therapy too…

Society’s Tonic – Dr. John Snow, toxic water and the 1854 cholera epidemic

The issues with water pollution are far from new. One of the more famous cases is in 1854 when Dr John Snow plotted the cases of cholera in London. He concluded that the water pump on Broad Street was the source.   He disabled the pump by removing the handle, and the epidemic ended. He is considered the founder of epidemiology and his germ theory of disease is accepted.

The contamination at Camp Lejuene is chemical and not biological, but the effects are indeed biological. Water vectors are still real safety issues.

 The Physicians for Social Responsiblity presents the Broad Street Award to those whose work reflects the spirit of John Snow.  PSR has a rich website worthy of our time.

More to follow about the  Camp Lejuene concerns…..

Society’s Tonic – Camp Lejeune Marine Base and Toxic Water

A May 29, 2009 report from a Tampa newspaper notes that Marines for years drank, bathed and cooked with polluted water. The polluting chemicals were dumped by a dry cleaner and the Marine Corps itself.  The report claims the contamination was discovered in 1980 yet 4 years passted before the wells were closed.  The contamination was been called the largest mass exposure to a single bad water supply in the nation’s history. There are surely many medical sequalae to the exposure.

 As such, anyone living or working at Camp Lejuene  (1987 or before) –   the Marine Corps is planning a health study, or call 877-261-9782.

A private web site has additional information.

Concern is raised for those near the base who may have also been exposed via seepage to larger groundwater systems.  The beauty of a blog is how can evolve.  I’ll ask if and how others may also be victims of  the exposure, and then post the information.

Society’s Tonic — Regardless of origin, climate changes are here.

A UN Report published in  TIMESONLINE,   May 29, 2009, notes that 300,000 people a year die as a result of global climate change.  Some  suggest the data is not rigorous enough to rank as ’scientific.’

Perhaps —  the science may not be rigorous enough. But the point is that something bad is happening. Too many similar reports exist from too many genuine and non-alarmist scientists. So we need to prepare for the changes.  If it is from our activities, then we must immediately further reduce our inputs. If it is natural phenomena distinct from human involvement, it still affects us, so we must also adjust and change our geopolitical and social systems. In either case, we need to reduce our pollution/carbon footprints if for nothing else than out of respect for our ecosystem and all living creatures.

The psychoscial effects of these changes are further detailed at The Doctor’s Ear.

Psychotherapy Notes — The Hangover Metaphor

We were talking on  left over effects that events have on people.

 My colleague would frequently inquire how long it took someone to accept a lost, release an anger, reveal in a victory, undo an emotional event, and the like. Included ih this questioning was also the element of how the person displayed these reactions — some would announce to the world over and over about their successes, losses, or injustices they believe befell them. This information gave much insight into how one handles, exploits, or presents these spill over’s.  So initially we felt that should be called spill-over’s, but a student gave us a better label — he called them emotional hangovers.  He said the nature of  the hangover was a window into the person’s ego structure. 

It makes sense. I have a patient who was attacked at gun point. The actual danger is long past, but the hangover remains. He found this label simple but precise enough to help him explain the impact  of that  assault took.. We call his combination of fears, nightmares, anxiety, etc., as his hangover.  Child abuse or other traumas produce their own and often stubborn hangovers.

It’s a good clarifying  metaphor.

Society’s Tonic – Years of child abuse in Irish religious residental care organizations

A disturbing report from Ireland now exists on years of child abuse by religious organizations. Known as the The Commission to Inquire About Child Abuse , it was released May 20, 2009.   The five volume report has a good executive summaryThe Commission to Inquire into Child Abuse was established in 2000 with functions including the investigation of abuse of children in institutions in the State. It was dependent on people giving evidence which they did in large numbers.”

The report looks at 216 institions run by the Catholic Church from 1930 though 1990, and which were supposedly inspected by the Department of Education.

The summary has one astonishing story after another.  Such modern day mistreatment of children is so chilling that it catapults the report into a huge warning bell about our worlds. Irish media is covering this; some refer to this as their holocaust

It is so amazing,  so selfish,  so heartless.  What mind-set lets people act that way?  What end comes from abuse? And how could supervising agencies not know about, and stop, the abuse?  It is more unsettling because it’s not an individual psychopathy — it’s a huge group pathology, which flavors it ever the more nefarious. 

Visiting the website will also reveal concerns that these children might have improperly been used in vaccine clinical trials.

This is one article about the Catholic Church’s response.

We need to make noise that such abuse is unacceptable anywhere in the world. Thank goodness the Irish did this work. Unfortunately it took too long to start.  Today is the US Memorial Day when we thank those who died to defend us. We need a day to memorialize those who suffered from our inactions in preventing harm at home – those who we did not defend.

Psychotherapy Notes – The showroom vs. workshop

A pleasant 32 year woman struggled with identity issues. She was exceptionally bright, and far more earthy than her social climbing and narcissistic  mother.  She felt as if her intellectual accomplishments were displayed, like a personal and prized possession, in front of  her mother’s friends.   “It was beyond being a proud parent. My mother displayed the bounty of others’efforts as if they were her’s. My mother made sure people knew I would never be what I am had it not been but for her sacrifice.  She never shared the halo.”

Her mother let every one know it was “my daughter’s work”, yet the daughter was kept  ‘off stage’.  The patient found a good laugh, some solid wisdom and  insight,  and good relief when she stumbled on the notion that her mother preferred the showroom without exposing the real workshop, and the patient preferred a workshop that didn’t need that showroom. She re-named the showroom as her mother’s ego living room.

A good set of concepts…..

Society’s Tonics – Mental Health Court in Palm Beach; 2008 Fl Jail/Prison Statistics

I learned this week that a Palm Beach County Mental Health Court is about to start. This is excellent. Attached are just two of many documents designed for Mental Health Court Judges. If you need a little time away from the 3 day weekend, they are worth reading so we have a bit more insight into what happens in these courts. If courts order out-patient treatment and not incarceration, then pops up is the old question of where  to go and who pays for it. The numbers can be daunting. 

Essentials of Mental Heath Court  and Mental Health Court Outcome Data

From: www.dc.state.fl.us/pub/jails/2008/12/index.html

An average of 60,760 inmates were in Florida’s county detention facilities during December 2008. Interestingly, 77.6%, of inmates had felony offenses, while 17.3% were detained for mis­de­mea­nor crimes. Most juveniles (95.8%) were charged with felonies.

Here are Fl details for 2008 — 60,760 in county jails, 98,192 in state prisons, 158,079 under community control. Total Fl population under some court control => 316,971   Florida’s incarceration rate up 5% in last year, up 19% in last 5 yrs. I’ve no data on how many on community control need, have been ordered to, or are getting mental health, substance abuse, anger management, etc., care.

In Feb 2008 the NY Times reported that 1% of the total US population is in jail or prison.  By my calculations, Florida has 1.6% of the population incarcerated or under community control.

Gift Cards for Returning Unused Medications

April 2009 — Florida, Flager County –  A system has been set up whereby $10 gift cards were given to those who return outdated  medications. This is great effort to reduce the mis-use of unused drugs.  Key is that the news article addressed both the human and environmental impact of improperly disposed medications.

It thus far was a one time offer, but the concept needs expanding. It also needs to include the return for disposal for any medication which is no longer used.

Click here to read the full story.

SMARXT DISPOSAL  is a public-private partnership between the U.S. Fish and Wildlife Service, the American Pharmacists Association, and the Pharmaceutical Research and Manufacturers of America.  Prescribers need to take more involvement in medication management on the side away from prescribing them. Un-used meds are too often used in OD’s, medical use errors, PHARM parties, etc. This site should be given to all patients. Veterinary medications are also included in this project.

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Society’s Tonic – A Bill to Reduce Mercury Pollution

A Congressional bill  proposes additional protection against mercury pollution. This is particularly key in childbearing women and young children.  But mercury also effects other living plants and animals.   

Here are the bill’s high points.

 (1) mercury and mercury compounds are highly toxic to humans, ecosystems, and wildlife;

 (2) as many as 10 percent of women in the United States of childbearing age have mercury in their bloodstreams at a level that could pose risks to their unborn babies, and hundreds of thousands of children born annually in the United States are at risk of neurological problems relating to mercury exposure in utero;

(3) the most significant source of mercury exposure to people in the United States is ingestion of mercury-contaminated fish who swim in contaiminated water.

These issues of contamination and toxins are too critical to over-look.  I tell people to read about them, then write elected officials, educate young women, and reduce the exposure as much as possible.

For more information:  The American Pregnancy Association and  the FDA .

More on Disposing Medications into the Water Supply

In 2007, the NY Times ran an excellent piece on this issue. This is a hard problem to measure but it makes sense that the dangers here are just waking up. The term ‘emerging contaminants’ has been born. This article is a good review, and forces us to give serious consideration to the study and proper assessment of the  real degree of danger. The common sense part of thinking says there must be a down-side to these uncontrolled disposal practices. We cannot afford to repeat the situation of  how long it took for the community to believe, for example, that higher carbon dioxide and freon levels really do harm the environment.  Though we are over taxing nature’s ability to handle CO2, it remains a natural substance, and left alone, nature can work with it if we limit the work-load.  But most medications are not known to nature, and so nature doesn’t know how to metabolize and render them inactive.  What will be the real effect of daily disposals of medications into our ecosystem? The concern that other people may use a thrown-away medication is too limited a view. We have to think of all living things down stream from the disposal.

The NY Department Of Environmental Conservation posted some key information and many good links as well.

Society’s Tonic — Disposed electronics can also be medical waste

This is a follow up to the post about un-used medications. Thanks for a reader for referring how a  US propsed law will deal with this issue.

 Disposed electronics must also be considered  medical waste because of what the waste does to the ecosystem.

Un-used medications are not intended for re-use, but electronic devices can be re-cycled. Sadly many are just thrown away without concern for how they too pollute the biosphere.  “Throwing away” is probably more a factor of laziness than lack of concern. But systems do exist for electronics – check Telecommunication Industry Association and many electronic stores.  Rechargeable batteries contain toxic metals but many drop off points exist.  Ask  computer and cell phone vendors if they have recycle programs. Many copy/printer toners come with recycle return envelops.

Electronic devices contain many toxic metals, such as mercury, lead,  arsenic, cadmium, and other materials. These leech into the groundwater. The  biological ill-effects are equal to those of medications.

Disposing Un-used Medications — What to do?

A silent but growing problem exists as people throw away un-used meds, usually done down the toilet. True, the meds are diluted out in the large reservoirs of water in which they go. But the medications are not inactivated, and over the years thrown away medications by tens of thousands of people cause the accumulation of molecules that ought not to be in our water.  I drink the water from those upstream from me, and those down steam drink what I throw away.  Water purification systems do not always remove all the medications. Fish and vegetation are not supposed to live in the medications. The pill  we swallow may seen tiny in comparison to the huge lakes around us, but that tiny amount of medication can be toxic to those who don’t need it.

A patient of mine threw away a bottle of un-used antidepressants. She said “well, I hope it makes the fish happier…”

So what to do? It would be best to incinerate un-used meds. Some counties have facilities. Many pharmacies will not take back meds to dispose them for customers.  Medical institutions use biological hazard bags to hold the medical waste (this falls into that category) until they are often burned or properly segregated.  But the average person doesn’t have access to these options, and hospitals by and large do not offer medical waste services to the public. .  That’s why the toilet is used so much.

Some facilities dissolve or soak unused pills into bleach or any strong household detergent — that makes them unfit for human use (good for controlled substances) but it doesn’t necessarily render them biologically inactive.  The chemistry’s of the different medications may not all be destroyed by bleach or detergents. Some people crush and mix them with cat litter. I asked a pharmacist if merely burning them at home would work — he said most likely not since the heat might not be hot enough to inactivate or destroy the molecules or deal with metals that might be part of the medication.  Then the ashes became a dump of molecules that could leech out.

So there are two issues — stopping inappropriate after disposal use, such as with narcotics, and stopping pollution which requires molecular inactivation.  We can all do the bleach routine, but the true inactivation requires larger programs. Fortunately medical societies have been addressing this, but it has not become part of the general MD’s practice to tell patients how to discard their old meds — this should become a normal practice. 

I would, however, take a step to bring this problem into more light by everyone asking country commissioners and elected officials what is being done to provide the service to the average patient who has a bag of un-used medications. Though I too dislike more taxes, perhaps a small tax, under the umbrella of environmental protection, could be initiated to pay for commuity incinerators or to buy these services though local hospitals.

Psychotherapy Notes — Round Hole, Square Peg

A depressed 30 year old kept saying that nothing worked in her life. “My life is always trying to push the square peg through the round hole — I don’t know why it won’t work”.  My comeback was that it might indeed work if she made the peg smaller. That caught her off guard, which subsequently lead to a deep and insightful chuckle, which then, in turn, lead to a hearty talk of how we must at times  let go of old baggage, gripes, expectations, vendettas, and occasionally re-adjust dreams,  if we want to move ahead in life.  That lead to her homework, so to speak, of considering what she has to let go as she moves ahead.  She said “I guess I can’t bring it all with me…” So true.

Society’s Tonics — The Problem of Malingering Safety

The book  Malingery  ties notions of lying and feigning to everyday life.  An example of  “‘malingered safety”  appeared in the  Michael Hawthorne April 25, 2009  Chicago Tribune piece.  He writes: “Illinois officials are taking steps to insure people aren’t  drinking contaminated water, including proposing criminal penalties for misleading the public about the source of water flowing from their taps.”  A lawsuit now accuses village officials of reckless disregard for the safety and welfare of residents.

This is an a perfect example of malingering safety.  It is also important to follow this story regarding other issues of drinking water safety.

Malingery  is available in print and Kindle form on Amazon.

Society’s Tonic – Ranking the State’s Mental Health Efforts

Every year the National Alliance for the Mentally Ill grades the states according to overall efforts, programs, etc., regarding mental health services. This year Florida came in 48th in the US.  Needless to say, this is not good, and the social spin offs are considerable insofar as the amount of suffering, the lost of production, and the related costs of inadequate treatment, such as legal involvements and emergency room visits when troublesome, untreated mental health problems evolve into crises.

Go the NAMI STATE GRADES  for more information. The link will open data paths for all states, not just Florida. The site is also a rich source of background details about the grading project, as well general information about mental health.

The  US  Substance Abuse and Mental Health Services Administration also issued a report on the unmet mental health needs: only 45% of  24 million needing mental health services got it, and the group 18-25 years have the highest rate of distress (18%) but were the least likely to get the help.  Mental health problems impact 11% of the population over age 18, but less than half get help. The agency used a measure known as the severe psychological distress (SPD) score.

Announcing: Malingery – Stealing the Truth

We are pleased to announce the publication of  Strauss’s  Malingery – Stealing the Truth. This is a collection of ideas and observations about malingering, lying, shame, problems in psychologically detecting the truth, and related critical questions. It re-thinks and re-considers the nature and styles of malingering.

Malingering is common in everyday life.  It is found more than just in the courts or psychiatric systems.  People lie in the service of a goal  – and often do so without hesitation or guilt.  They comfortably “steal the truth” to get their way. The mental health professional must look past the mere fact of malingering to the cause and style of the lie or falsification.

For example, the book discusses such situations as when different people offer opposite opinions about the same person.  The root of this challenge, examined in detail,  may lie more in the examiner’s own set of skills and biases than in the objective data.  Needless to say, this complicates legal and clinical processes.

When expert’s disagree, judges or juries have to decide. Though well intended, the groups make a clinical decision that clinical experts cannot.  A method to avoid this problem is offered.

The book also proposes an expanded and new means to define and label the types and styles of malingering, as well taking a look at current thoughts about the potential biological basis and techniques of detecting a fabrication.

Malingery is available through  AmazonAbebooks, and Alibris.  It is also available as a Kindle ebook.   We look forward to comments….

Psychotherapy Notes – Lessons from a successful suicide

I so want to tell you all about him. He died last week.  By suicide.  In his early thirties. His pains were mental and physical, though the later were never adequately controlled.  His knowledge exceeded most of his doctors, and he often spoke of educating them about his unexplained pain. His psyche was strong but he told me his body would wear him out. 

When we shared the news of his death amongst us, one woman cried “no, don’t tell me that!  Oh what torture he must have had….” He kept most of the torture to himself. He smiled when he asked about others; he once told me that he did so because he knew that others most likely also had unpublicized angst.  His smile comforted many, and he relished the joy of seeing people react when someone sincerely asked about how they were doing.

It took a week of feeling and thinking before I wrote this. His death saddens me so much, but perhaps my time on earth, and the landscapes of sufferings I have seen, makes me respect his choice. Sometimes suicides are running away from difficult but fixable problems. Sometimes they are immature statements of a protest at others. Most of the time the suicidal trigger is temporary when a perspective is lost. Sometimes though, just sometimes, the pain level of life is so sharp that only agony fills a person’s day. We parade hope before them, based on blindness and an honest, often unvoiced knowledge that no real correction yet exists for these folks. We send out these orations hoping to find in them a fiber strong enough that they can wait for some intervention to evolve.  I hate this situation, and I’ve pleaded with chronically depressed people for whom we have no solution.  Could I live in their despair?  I claim I could, but how much of my philosophical thinking would be different wearing different shoes.

A teacher once said that we would not be doing real psychiatry if there not suicides in our practices.  I’ve protested that attitude, and still fight to disprove the comment, but a inner voice said that it is correct. We cannot fix it all, but we have to try,  and try, and try, and try.

What failed? Was it fate, was it us, was it him?  Had I known him for only a short time my inclination would be it was because we did not have enough time to find the fix. But because I knew him for so long, the fault was that his fate was to have been born at a time when the fix did not exist.

His death is painful,  but he left us with a memory of his smile, his jokes, and with the humbling sense that we are but humans with skills still imperfect.

Society’s Tonic – Why Can’t We Stop Cocaine?

This week I interviewed two people who had heavy cocaine addictions.  Both are now charged with first degree murder.

The details of the cases are not as important as is the denominator of cocaine. With each of them I imaged toxic cocaine molecules ripping thr0ugh their brains, scaring and destroying the user’s and the victim’s lives. The real killer is the cocaine – the user’s act emerged from a brain poisoned and short circuited by unnatural chemicals.  ‘Cocaine’ itself should be on trial. The bad guy is the cocaine and we need to get rid of it. The users are pawns.  Cocaine erases the elements of socialization. It brought these users to such primitive and selfish self-rationalizations that their own, drug driven needs, superseded any and all sense of human concern, self-discipline and empathy. Interesting,  without access to cocaine, much of their better sense, responsibility and humanity returned. Yet just the memory of cocaine can put cocaine back into control.

People report they’ve used cocaine without falling into legal problems — but the risk is so high that it is foolish to take the chance. We cannot predict who might be lucky enough to not get into trouble.   I wish I could broadcast these interviews with these inmates to all who think cocaine dabbling is safe.

So what is the draw to cocaine? We know it is an artificially induced chemical rush unlike others. But why do people go for such the artificial?  What lies in our psyches that needs to be  intoxicated?  What lack of contentment or safety resides in user’s lives that they dive into waters with well known sharp rocks and sharks just beneath the surface?

I’d love a discussion on that. We have theories, but they are clearly inadequate to stop the epidemic. Why do some fall victim and others do not? Maybe some of it rests in the nature of the non-intoxicated lives.  All our psychiatric skills are limited, at best, in stopping the initiation and relapses into cocaine. Vaccines and other treatments are in development, but maybe parenting and social skills are more important than psychiatric ones? Will the new medications just offset treatment needing psychological problems — this is an on-going significant debate. The AA model is central in many ways. Maybe the treatment failure rate is because cocaine is particularly nefarious.  And of course addictions are not universal, having many individual flavors, histories and presentations.

We speak of reducing the problem of using treatment to produce less market demand which would put the sellers out of business. That approach has failed for countless years. The relapse rate is staggering.

The key is never to have the inclination start it.

So,  because it is so dangerous, why can’t we simply get rid of it? Maybe it just reflects widespread core inhumanity. All who benefit from the cocaine trade know it is a very dangerous product. Yet they indifferently traffic in it because it makes money.  Money, therefore, retains its title as  more important than life itself…and that, when we are honest, is a rather upsetting and widespread truth as well.

( Allowed details of how cocaine became entangled in these inmate’s lives to follow after the cases conclude. )