rivka

Some true things really make you feel like a jerk when you say them.

Today I told my research assistant, who wants to be either a physician or a psychologist: "One of the hardest and most important skills for a clinician to have is the ability to go out of the room and leave the patient behind you."

It didn't feel like a very human thing to say.

The impulse that leads her to brood over what will happen to a homeless, bipolar, drug-addicted, HIV-positive research subject she met, who has obviously critical mental health needs and yet couldn't be forced to stay in the hospital for psychiatric treatment - that's a good and human impulse. That's how people should care about each other.

"I told Dr. WardAttending about it, and she told me he was typical," she said miserably.

"Yeah," I said. "That's our patient population."

And it is. There are hundreds more just like that guy. If she carries every patient around with her, it will break her. She needs to learn to do what she can, with all of her caring and skill and compassion, and then leave the patient in the room when she goes out. It's a difficult lesson to learn, and probably none of us learns it perfectly. But I know from bitter personal experience that it is much, much more difficult if you don't learn that lesson.

I still felt like a jerk for saying it, though.

I'm back at work for the second day. Yesterday I had an unusually light clinic schedule, so despite some continuing shortness of breath I decided to go in. Then I wound up having to arrange for a patient to be hospitalized, so it wasn't the lightest day after all. I need to call and find out whether he was actually admitted - I walked him over to the ER, and left the kind of note for the ER physician that should always result in admission, but the patient is kind of confused and I suppose that a lazy doc trying to avoid an admission at all costs (it's a lot of extra work) could worm out of him a promise not to kill himself before he sees his outpatient psychiatrist again, and call that justification for sending him home. So we'll see.

I just got off the phone from an hour-long conversation with my dissertation advisor. I sent him a huge number of analyses almost a month ago, and he kept putting off looking at them. I finally cornered him into agreeing to a phone appointment today to discuss them. The good news: he agrees that there really is something there in my results. The bad news: he thinks I need special analytic tools that neither of us really understands. Anyone out there an expert in logit and probit models? How about nonparametric models?

Lydia's taken on a practicum student - a graduate student at a nearby university looking for clinical training.
( Read more... )
One of the things I want to do is pass on the legions of good advice I've received in the past. Sometimes that advice is technical: "Usually you shouldn't diagnose an Axis II [personality] disorder if the patient has a primary substance abuse disorder." Sometimes it's philosophical: "People come to therapy because they have become demoralized. It's the job of the therapist to instill hope." Sometimes it's medical: "If an HIV+ patient ever mentions that their vision has recently gotten blurry or they have spots floating in front of their eyes, it's a medical emergency."

And sometimes, the advice is simply practical. Here's a sampling of the best practical advice I've received:

1. Always leave the clinic by the back door. Never walk through the waiting room unless you're willing to stick around and see someone if they ask.

2. Never mind what your graduate program taught you about appropriate therapeutic boundaries - if you work in a medical setting, touch your patients. Your graduate program didn't teach your patients about appropriate therapeutic boundaries. If you refuse to touch someone with AIDS or cancer, they'll think they know why.

3. Relaxation training is the aspirin of behavioral medicine. Hardly anyone can't be benefited by a quick relaxation training session. It makes the patient feel good fast, and it makes you look like a genius. However, like aspirin, sometimes relaxation training has catastrophic effects. Know the signs and be prepared.

4. Never write anything in the chart that you wouldn't be willing to read to the patient. If you think this is an impossible task, probably one of three things is wrong: (a) you're making clinical judgments you can't back up with evidence, (b) you've lost empathy or perspective on the case, or (c) your chart notes are too detailed.

5. Never expect a doctor or a judge to read something longer than a page. Yeah, they should - but they probably won't. Make your report more concise.

and finally, and most valuable:

6. Don't look in the bucket. If you ever visit a patient who is holding a basin, or has a bucket at the bedside, don't look in the bucket.

You don't want to know.

Not having a great day here.
( this got long. also ugly. )

In all persons there is the possibility of decency, however it may have been warped and deadened. The greatest adventure is to seek it out and establish it.
-George O'Dell

This is one of my articles of faith as a therapist. I heard this quote yesterday, at church, and seized upon it as an expression of something I have long believed. I used to say that my therapeutic skill rested on my ability to find a grain of likeability in just about anyone, and my belief in the possibility of change. But I like this way of expressing it better, because I can believe in the possibility of decency (however deadened) even in people for whom I can't find a single present thing to like.

I'm not sure that this is a particularly common article of faith. In some circles I move in, I get the feeling that the reverse is true - that there's a usually-unvoiced belief that real people, decent people who matter (because they're highly intelligent, and read for pleasure, and weren't popular in high school, and don't believe in silly things like Christianity or mainstream culture) are a small minority, while the majority of people are pretty much wastes of space. Deadwood. Sheeple.

How to explain the eagerness to believe that "most people" are everything you despise?

When you train as a psychologist, you learn a new language: one with new words and phrases (euthymic, anhedonic, ideation, oriented times three, restricted affect) and new definitions of common words and phrases (reliable, valid, normal, object). Everyone knows that - people make fun of the jargon, or complain that they can't understand their own psychological report. So that much is obvious.

What's less obvious - or was to me - when you're in training is the other new language you need to learn in order to be any good as a therapist at all. Part of it is being able to do on-the-fly translations from psych jargon to colloquial English - that's how evaluate the negative cognitions and develop a rational response becomes find your negative thoughts and argue back. But it goes further. The other part of it is learning the jargon of the world in which you practice. Not the medical world, the civillian world.

Last year on internship, I did a rotation in the Psych ER. I once interviewed a patient in front of a third-year psychiatry resident from Africa. His English when talking to other professionals was good - he'd been practicing in the US for three years - and yet after my interview he said to me: "I was impressed by your style, and the way you managed to establish rapport with the patient and gather information, but I have some questions for you. What is dealing, what is tricking, what is dope-sick?"

I cannot imagine practicing for three years in an inner city and not knowing how its residents describe their common activities. I made it my business to know. My clients in Iowa, where I trained, didn't complain about being dope-sick - that's a word I learned for Baltimore, just as I learned that the word cocaine, unmodified, always refers to crack cocaine - which is not what they call it in Baltimore anyway. (Here they call it rock or ready rock.) Just as I made it my business to learn that in Baltimore dope is not a generic term for drugs but a specific term for heroin, that speedballs don't have amphetamines in them, that an ambo takes you to the hospital, that hacking is riding in or driving an illegal cab, and that hustling doesn't necessarily involve prostitution.

My major resource for this was The Corner, a profoundly depressing book by a couple of guys who spent a year on a Baltimore drug corner getting to know people. That's where I learned about the different equipment involved in a drug injection, so that now when I ask people about needle-sharing I also ask if they share cookers or cotton or rinse water. That's where I learned how to recognize nodding. I also learned from my patients - either through following context cues or through simply saying "I don't know what that is." My point is that if you care enough to learn, the language lessons are there.

Why does it matter, if patients are willing to provide definitions and able to understand standard English? The African resident would have asked that patient if she was selling drugs, engaging in prostitution, and experiencing withdrawal symptoms, and she certainly would have understood him. But I think it would have created a distance.

I'm different enough from my patients already - I'm young, and white, and middle-class, and highly educated, and have never been a hard drug user. They can tell that I'm not part of their culture, but I still owe it to them to at least show intelligent familiarity with that culture. They can tell I haven't been there, but at least I can convey that I know where there is.

Wednesday through Friday I was at a work-related conference. The Institute is developing a new protocol for HIV treatment involving observed therapy, and the conference brought together doctors, nurses, public health people, psychologists, social workers, peer advocates, community organization leaders, and patients, to discuss how this should best be done.

On Friday, some of the patients there approached me. They're putting on a weekend retreat for HIV positive heterosexuals, and they wondered if I'd be willing to come and give a talk about dating. Huh. I'm really quite pleased to be asked - it seems like a compliment, given that they'd been talking with me for a couple of days, and it's certainly an interesting topic. But I'm also not entirely sure what I'm going to say.

Some of the things that come to mind:
- loving yourself and accepting your HIV as a (probably) necessary precondition to finding someone else to love and accept you.
- refusing to accept bad treatment from a partner just because you think no one else would have you.
- disclosure: why secrets are harmful, why early disclosure is better than late disclosure, why your reasons for thinking you don't have to tell your partner are pretty much all flimsy rationalizations.
- educating your partners about HIV and being patient about the time they need to become comfortable with the information.
- broadening your definitions of a sexual relationship and being more creative about sexual interactions, so that you can focus on lower-risk activities without decreasing your total enjoyment.
- why you still need to worry about health risks to yourself, even though you're already positive.
- pros and cons of only dating other people who are HIV positive.

I'm expecting that, even though they presented it to me as a "talk," we'll want to structure it to include a lot of group discussion. After all, they're a lot closer to being experts at this than I am. I really think this is going to be fascinating.

It's all too easy for my LJ to slide into an eternal litany of complaints and outrage and depressive maunderings. I don't know why bad moods and surliness seem so much more appropriate to share, but in recompense I offer (in no particular order) ten things that are currently brightening my life.

1. Baseball season fast approacheth. Full squads report to spring training this week. Opening Day is in forty days. Baseball is one of the things that makes me feel especially close to curiousangel, in addition to its myriad of intrinsic virtues.

2. The days are noticeably longer. More daylight usually means more energy and a more positive mood, for me. It's also meant that we've gotten to see some spectacular sunsets on the drive home.

3. I have more projects and social plans right now than I have time to do them in. This has its frustrating aspects, but it also makes me feel good: energized, liked, busy, full of good ideas.

4. Tonight is English Country Dance night. I love being able to un-self-consciously lose myself in the music and the patterns, and I love having found a form of dancing that puts so little stress on my hip.

5. I started data collection today for our study of spirituality and health in HIV patients. I've been working on this study for more than a year, beginning with helping to develop the original idea and write the grant proposal, and on through endless efforts to get the project approved. Now it's really happening. That's so exciting.

6. Seventeen days to our Key Largo vacation. curiousangel and I and my oldest sister, Debbie, have rented a waterfront cottage, and we're going to spend an entire week swimming, lounging on the beach, kayaking on the Florida Bay, learning to snorkel, eating seafood, reading, and sleeping late.

7. I have achieved great results with a notoriously difficult patient. At last year's clinic, no one would have noticed. At my new clinic, people have gone out of their way to praise both me and the patient.

8. I'm developing highly enjoyable new friendships with Sam and with therealjae.

9. I don't have to borrow curiousangel's computer to play The Sims anymore. And it runs so fast on my new 1.1GHz processor. It's a whole new experience - and much more enjoyable. Whole vistas of pleasant obsession lie before me.

10. I feel more and more as though I'm managing to get my life set up in a way that I have chosen. Most of the things that are part of my life right now are there because I consciously chose them. I don't feel nearly as buffeted by uncontrollable forces as I used to feel. I think I'm getting closer to living a conscious life.

I spent my first full day at my new clinic in P.G. County, mostly figuring out how they do things and planning how to integrate our services. In contrast to the clinic where I spent my internship, and where psychology/behavioral medicine was always scrambling for a toehold, these people are welcoming us with open arms.

We're going to be doing standard mental health care, of course. The poor psychiatric nurse who is doing all the mental health screening and all the psychotherapy right now seems more than eager to turn over new referrals to us until we build up caseloads. But the clinic also wants us to be part of the routine care of every patient. We'll screen all new patients for nonadherence risk factors and transmission risk behaviors. We'll screen people coming in for HIV tests for transmission risk behaviors. And we'll set up interventions as appropriate.

We've been saying for ages that in HIV care you need to assume, as the default, that people are going to have a hard time being adherent and a hard time modifying risky sexual and drug using behaviors. And finally we've found someone who believes us and wants to make those assumptions policy. It's wonderful.

In other news, Misha and I have decided to take a trip to Portland. Tickets aren't as cheap as they were last week, when we were first kicking this idea around, but they're still under $200. I'm excited about showing him all my favorite places, and seeing those places again myself.

Now I have to contact the Portland friends I've been sadly neglecting, to find out if they still like me enough to want to hang out with us. Yay! Portland friends!

When I first read Freud in college, I sneered at his idea that clients tended to fall in love with their therapists. Projection, I thought. Oh, the vanity of those middle-aged male psychoanalysts.

But you know, the more I develop a professional identity as a therapist, the more it makes sense to me. When I'm doing therapy, I'm so intently focused on the client that everything else fades away. Our entire interaction centers on the client's needs, the client's feelings, the client's happiness. I find ways to be accepting and caring in the face of even the most difficult interactions. My needs get met elsewhere - the client never has to worry about them. If I'm doing things right, it shouldn't even occur to the client that I might have needs. I'm (apparently) never tired, never distracted, never preoccupied with my own problems, never looking for solace and support just when the client could use those things from me. Especially if a person's never gotten that kind of focused attention and unqualified support and acceptance elsewhere... I can see where it could have an intoxicating appeal.

It's not my real personality, of course. Not to say that I'm not being genuine when I'm with clients, because I am - but it's not my ordinary self, it's a professional role. I work at it. It's exhausting. In real life, as I'm sure my partners would testify, I get tired and cranky and sarcastic and catty and impatient. I don't suffer fools gladly, yet I'm sometimes supremely foolish myself. I get whiny and needy and emotionally demanding, from time to time. The unidirectional-energy-flow relationship (I give energy to the client and don't take any energy back) is as much a myth as the perpetual motion machine; my family and friends are the equivalent of the generator hidden behind a curtain. I give to them, sure - they get my focused attention and acceptance and support and assistance, when I can give it. But it's not the fantasy version. They've got to give as good as they get.

Or, well, that's how it's got to be if it's going to work.

The hard part is that, as I get better at the professional role, it becomes harder not to try to carry those good-therapist assumptions over into my private life. Lord knows it's not my partners' fault - they all genuinely want the support and care to be mutual. But as I get better at the whole unidirectional-energy-flow thing, I find myself slipping into it automatically. Squashing my own needs and feelings down, doing the auto-erase thing to remove any sign of them from my face and posture - because one of my partners is depressed or under a lot of stress. For weeks, maybe. Maybe months.

It's not sustainable, because I just don't have perpetual energy to give. The fact that I do it myself, automatically, doesn't prevent me from eventually resenting them for it. It necessarily puts a false front between us that interferes with genuine emotional intimacy. I recognize that it's a bad idea for all these reasons.

But at the same time, I need to keep developing and practicing the skills that let me do it well, and as I practice those skills become more and more a part of me. And, you know, people like it. It makes them feel good. It protects them from burdens.

Let's hope this is an early-career thing, and that as I master therapy I'll be able to set up firmer walls between my professional roles and my private roles. Because otherwise I could see myself ending up a certified hermit, just for the sake of self-protection.

(Okay, that was probably all slightly overdramatic. But they're ideas that have been percolating through my head for some time, and this is the first time I've tried to get them onto the page.)