Monday, November 30, 2009

The Trouble with Door Knobs

Door Knob

I haven't told Beggar this, but I could have gotten him a turkey really easy. There's lots of them in the yard, especially on rainy days. I know this because I sit in the window every morning while he writes and spy on them. I've got their movements down pat and if you think 007 can be stealthy, wait until you see a cat on a mission. That's stealthy.

There's only one problem: I can't get outside. I know the door knob has to be the key to opening the door because that's what Beg grabs onto when he goes out. I can reach it when I stand on my hind paws and I've been practicing turning it, but I still can't quite get it to work. It catches and won't budge. I'll bet it's locked -- rats! That's the trouble with door knobs.

This is very frustrating because I can do other things, like pick up a piece of food with one paw. You'd think a stupid door knob would be easy-treasy after that. Of course, now that Thanksgiving's come and gone, the fact that I could have saved him a trip into town is a moot point. Still, there's the principle involved.

I used to live on the street and get hand outs from tourists -- that's where I learned to be self-sufficient. Then one day I got caught and taken to a pet shelter. It wasn't so bad -- they gave me regular food and a blanket. And that's how I came to meet Beg.

The shelter took a bunch of us to Petsmart on a field trip and it must have gotten late, because we stayed overnight in the adoption agency. The next day I saw this big guy (Beggar) standing at the window of my "room." At first I thought it was rude for him to stare -- I was taking a bath for crying out loud -- and then I realized he was my guy, the one I was supposed to be with all along, so I pawed the glass to let him know. Now I have a dog and a home with turkeys outside in the yard. Mm, did I say turkeys? Isn't Christmas coming?

Let's see, I know how to work the door, all I need to do now is figure out how to pick the lock.


(Image by Omakakii via Flickr)

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Sunday, November 29, 2009

Out of Thin Air


"I'd just ridden over the ridge, the one that flanks the creek, when a bear ambled out of his cave. Brownie spooked left, I flew right, and landed almost at the bear's feet. I guess he wasn't expecting that kind of welcome, because he sure took off. I tried to get up and that's when I realized I'd probably broke my leg -- my head hurt, too."

They were sitting in the bunkhouse after a long day, the four of them, one getting coffee and two others listening raptly while my father harangued them with his tale of chasing cows in the high country. "Well, how did you get back down the mountain?" asked Mr. Coffee in mid-pour.

"Oh, I held on to one rein somehow. Brownie dang near drug me twenty feet or so before he stopped. Then he stood there, blowing and breathing hard, looking at me as if to say, 'What are you doing on the ground?' So, I pulled him close, grabbed a stirrup and hauled myself into the saddle. Hurt like hell, I'll tell you."

"And you rode back to the ranch like that? What did doc say?"

"Aw, he put on a cast and told me to stay away from bears. I thought it was pretty good advice."

"Yeah, and I'll bet you're supposed to 'take it easy' for a while, too, and that means more work for us. Are you sure it was a bear and you didn't just fall of your horse?" asked Mr. Coffee with a sly grin.

"I'm sure, and it's only for a few days, then I get a walking cast. You'll live until then," replied my father.

Now, the truth is, this particular exchange never took place, at least not in the real world. But others like it must have because, after my father passed away, I discovered one of his friends had penciled names above each of the characters in the print you see. My father is the storyteller.

I had no idea his friends viewed him in this way, and the discovery was a revelation I've come to cherish. Dad wasn't a writer in the same sense his son has apparently become. He was a minister as well as a saddlemaker and I have his sermons, but his imagination expressed itself verbally.

He used to complain -- tongue in cheek -- about so many of his cronies hanging around the shop while he was trying to work. I realize now there was something going on I had completely missed back then. They were his circle and he drew them in with stories he created on the spot, right out of thin air.

You can live with someone all your life and think you know them well, yet when their friends begin to speak, you realize there's so very much more. It's as though you barely know -- or knew -- them at all.


(Partial scan of a print of unknown title by Chuck DeHaan, copyright 1969, Potts-Longhorn Leather Company)

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Saturday, November 28, 2009

The Girl with the Auburn Hair

Love Note 2Image by Linds :) via Flickr
For years it never really crossed his mind. Life had moved on and so had he. First, junior high, then high school, and college after that. Only when he tried and failed at love did the memory surface and then with the peculiar sadness that accompanies the losses of childhood. Her note had read, "I like you, do you like me?" There were spaces where he might check yes or no and despite feeling he was making a big mistake, checked "no." He'd had a crush on another girl since first grade and even though it was one-way, he still cared and didn't want to lie.
It was the first time a girl had even so much as hinted that she liked him. Interestingly, just days before, she'd tackled him and rubbed his face in the dirt while playing a game of "girls against boys." He, in turn, once free, had slugged her. The ways of the heart are inscrutable. Maybe she liked him for standing up for himself. He never found out because, of course, he had checked "no," and then school was over and life moved on.

In his second year of college, one warm spring Saturday evening, he was invited to a student gathering
-- more than a party, less than a convention. A vocal ensemble performed, someone spoke, and there was time for socializing. During the music portion, he thought he recognized one of the singers. It had been a long time but she looked like a grown up version of someone he'd known, once upon a time.

Curiosity overcoming his natural shyness, he approached her afterward and asked i
f she had been the girl who surreptitiously passed him that third grade note. She admitted it was and said she'd recognized him as well. Far prettier than he remembered, she was tall and slender, with auburn hair that fell just short of the collar of her blouse. Their conversation was brief and he was left feeling he had been right, checking "no" was a mistake, but how could he have known? Back to the Future was still in Spielberg's imagination and there was no Doc Brown to remind him the past is not set, so he said something nondescript like, "It's been great seeing you," and turned to leave.

Getting into his car, however, what is clear to you and me, finally hit him like a ton of bricks. As he had never quite forgotten her, neither had she forgotten him. This is crazy, he thought, reaching into the glove box and taking a piece of paper, he quickly scribbled, "Is it too late?" with a blank for "yes" and one for "no."

Back inside, he walked over to where she stood, chatting with friends, and silently slipped the note into her hand. She looked down and read, smiled at the memory, then at him. "Do you have a pen?" she asked. He pulled one from his pocket and watched while she firmly checked "no" and added the words, "We're going for pizza. Would you like to come?" with the familiar blanks.

And this time, he checked, "Yes."



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Friday, November 27, 2009

At Your Own Pace

Flatirons by Moonlight

You couldn't pay me to go mall-crawling today. For one thing, I'm not all that fond of crowds and for another, Christmas shopping requires a lot of planning, as far as I'm concerned. I need to wander without feeling an obligation to commit myself and allow the ambiance of Christmas music, lights, children, and hopefully, snow, to bathe me in the spirit of the Season. For the most part, this process requires time which is why Black Friday doesn't work for me.

If you're task-oriented and thrive on efficiency like the Head Elf Bernard from The Santa Clause, this might be your day. I'm all for that when it comes to my grocery list or packing for a trip, but whenever possible, I want Christmas to last, which explains why you're likely to see my tree still decorated in mid-January. One year, when I was about 12, we took the tree down, placed it in my room in a bucket of water and sand, and by golly, the thing budded by the end of February. We couldn't plant it, of course, but we loved having it around.

Besides, even though the radio stations have begun their annual marathons of Christmas music, it's still Thanksgiving weekend. There are left-overs to munch and more pies to bake, combined with the gentle sense that life is good. It's a great preparation for all the wonderful things that have been waiting throughout the year to make an appearance. If we were in Boulder, this afternoon we'd gather downtown at sunset for the annual lighting of the Christmas star on the side of Flagstaff Mountain. It's a community affair with children's choirs, hot chocolate, and together, we all count down to the magic moment they throw the switch.

It's too easy to become wrapped up (no pun intended) in all the details, expense, and stress, reducing the Holidays to a month-long pressure cooker. When we decide to take them at our own pace, doing what feels comfortable day by day, we have a chance to look around and see why our children love this time of year. It allows us to be a little freer, happier, more loving, and more at peace. Not a store in town stocks these kinds of things; instead, they come from within. And thankfully, they aren't that hard to find -- all it takes is a little time.


Note to reader: If you'd like to see the Boulder Star, visit the following website and click on Boulder web cams. The image with the widest view is from the University of Colorado and you should see the star in the lower right corner after about 5:00 PM Mountain Standard Time: www.dickgilbert.com/coloradocams.htm


(Image of Boulder Flatirons in Moonlight by Molas via Flickr)

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Thursday, November 26, 2009

Thanksgiving on the Ranch

Thanksgiving dinner, when I was growing up, must have reminded my grandmother of the ranch. Two sons, a daugher-in-law along with her sister and brother, herself and me, crowding into a dining room built for half that number. It had to have seemed like those days when she and her mother-in-law cooked for four children, a husband, and two ranch hands, as well as anyone else who happened by looking for a meal.

They were seriously out in the country, the closest evidence of civilization being the one-room schoolhouse a mile away. Reminiscent of films like The Cowboys, my father and his siblings truly rode horseback (or walked) to class every day. There was no church, no gas station, and certainly nothing resembling a grocery store for forty miles. Forget Butterball, holiday dinner depended on the skill of one of the boys with a rifle and the population of wild turkeys on Black Mountain, a flattened peak on the slopes of which my father herded sheep as a teenager.

They grew potatoes, onions, green beans, and pumpkin in the garden, and like me this morning, my grandmother baked her own bread -- hers was for stuffing and mine, just dinner rolls. The house probably smelled much like yours may this very instant, except for the fact that their dinner was cooking on a wood-burning oven and water in the sink was pump-drawn.

As you can tell from the photo (I wish I had a larger one -- maybe later), this is sage brush country, although pine and Aspen grow higher up the mountain near the site of the fabled family homestead. Just after the turn of the century, my Montana grandmother and her Oklahoma husband built a log cabin in the trees near the headwaters of a creek called Fortification, making a life for themselves based on her faith and his hard work.

I've walked through the remnants of that cabin as a youth, and carved my initials on the same aging Aspen trunk as my father when he was my age. In my imagination, I've sat down to Thanksgiving dinner in the dining room of a clapboard ranch house with three feet of snow on the ground outside. Better yet, I've awakened to the sounds and smells of my grandmother making stuffing. She'd tell me she didn't miss the wood-burning stove but I know she missed the ranch and all that it meant to my family, even as I miss her today.

May your Thanksgiving be a happy one, shared with family, friends, and fond memories.


(Photo courtesy of Webshots)
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Wednesday, November 25, 2009

Holiday Fever

Wood-burning fireplace with burning log.Image via Wikipedia
I finally succumbed yesterday at about 9.30 in the morning and it came about like this. I'd gotten up fairly early because I needed to drive down to New Hampshire for a follow-up eye appointment -- my contact lenses are fitting and working really well, thanks for asking. Before that, however, I had to go into Portland to pick up a turkey at Whole Foods.

When I first got out of the car I noticed a little chill around the back of my neck but didn't pay it a lot of attention because I was in a hurry. Once inside, standing in line with three other early risers at the meat counter, that chilly feeling was more pronounced and I found myself cheerily wishing everyone Happy Thanksgiving.

At the check out counter, things were getting even worse. My energy level rising, I felt as though the clerks were old friends. The very moment I got to my car and opened the trunk, I realized the obvious: I'd come down with a full-blown case of Holiday Fever.

Usually this happens to me around Halloween but sometimes later, depending on the circumstances. First year in medical school I didn't have time to get "sick" until the last couple of days before Christmas. I knew something wasn't right but we were all so inundated with what seemed like forty million exams the holidays were like a blip on the radar screen easily dismissed as a flock of seagulls. This year there's been the book, studying for boards, and trying not to worry about rotations, but I guess my resistance is low, because I've got it now.

What are the signs and symptoms of Holiday Fever? First, you want to smile nearly all the time. And then you start telling everyone you meet, Happy Thanksgiving, Merry Christmas, and Happy Hanukkah. Scanning the radio stations in the car you realize you're looking for holiday music. When you see little kids, your eyes fill as images of wonder and merriment fill your head. If you're like me, you think about baking and begin watching for the first snow fall.

Not everyone is susceptible and for some, pain dampens the slightest flicker of joy. When you've been down that road you want to help those who can't seem to miss the turn. That's one of the best things about this time of year. It can make us more generous, more caring, more aware of how very tenuous blessing can be and how fortunate we are when we experience it.


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Monday, November 23, 2009

Revisiting Oedipus

Parthenon from west
It sounds like something off the evening news. Two men get into a fight over the right of way at an intersection, and one ends up dead. Only in this case, the one killed is a local king and the other is offered both the throne and the former queen to be his wife. As is typical in mythic tales, a plague befalls the land, and the new king discovers he's killed his father and married his mother. In response, he blinds himself and his mother commits suicide. The ancient Greeks knew how to write tragedy.

Freud eventually used the myth of Oedipus to describe a developmental process
in which young children yearn to possess the opposite sex parent and eliminate the same sex parent. Admittedly, while not everyone agrees the Oedipus complex is always useful, it does help explain a thing or two.
I mentioned yesterday that one of the things grandfathers do is help their grandsons make the transition from boyhood to healthy manhood. Relationships with grandfathers tend to be more relaxed and exert less pressure to live up to expectations. In other words, grandsons learn how to be patient with, and accepting of, themselves and others. It happens not only in play but in those grandfatherly moments when they tell us the secret lessons they've learned throughout life. In their company we gain the kind of maturity and judgment that helps us avoid fighting over who has the right of way.

Fathers and their fathers who are generative men create optimism and a sense of what is possible. They are encouraging and nurture free and creative self-expression. In their presence we feel more, rather than less, ourselves. Sons who grow up in this atmosphere find resolving Oedipal tension a positive experience because, without even trying, generative men make us wish to be like them.

Women can tell when a man hasn't worked through his Oedipus complex. They may not describe it in those terms, but they know. He may be impatient over trivialities, lack confidence in himself despite acting self-assured, and demonstrate rigid intolerance of what he perceives as the c
haracter flaws in others while ignoring them in himself. The issue isn't a matter of identification with mother as opposed to father; it's the insistence upon remaining a child and an entitled one at that.

Parents who work together to lovingly help their children move past their natural ego centrism accomplish a tremendous thing. They place among us individuals who have the capability to contribute, to make life better, and become role models in their own right. To paraphrase the Charles Schulz character, Pigpen, it kind of makes you want to treat parents with a little more respect.

(Note to the reader: while the subject of this essay is fathers, grandfathers, and sons, the author has known women who, single-handed, have raised some of the finest young men he's ever known. Stereotypes don't apply here.)

(Public domain image of the Parthenon

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Phantom Sensations

"The Favorite" - Grandfather and Gra...
I never met my maternal grandfather. He passed away when my mother was six and her memories were the biography I read. The smell of his pipe, an easy laugh, she as a child running down the street to meet him coming home from work and being carried on his shoulders. He was Irish, the first-generation son of immigrants who came to America in the late 19th century. Like many of his generation, he roamed west and eventually met my grandmother in one of the farming communities of Northern Colorado.

I have a small photo of him -- only one -- and it's in black and white, so the bright, flaming red hair my aunt used to describe doesn't come through. It was an unruly mop and like me, I suspect he was perpetually sweeping it back from his forehead to keep it out of his eyes. He was a carpenter and while my mental image has always been of a man in his late 20s, he and my grandmother had five children, the eldest of which must have been close to eighteen, when he died.

Fate couldn't have picked a worse time to strike. It was 1931 or thereabouts -- I'm not at all certain of the date -- and the Great Depression had begun. Now my German-descended grandmother had to raise a family on her own at a time when work was scarce and her children collected bits of coal from the railroad tracks nearby to burn in the kitchen stove. It's no wonder my mother was never fond of disaster films as an adult; she'd seen reality up close and fantasy was too evocative to be entertaining.

While I think of how dear my paternal grandfather was to me and how grateful I am to have had him around to help initiate me in the ways of men -- one of the essential tasks grandfathers perform for their grandsons -- I've always felt there was something missing. Like an amputated limb, where severed nerve endings produce phantom sensations, the presence of my maternal grandfather is significant for his absence. But I think I would have liked him and as I grew older, I came to see him in his children. I wish I could tell you more but maybe this is enough, and since it's about all I have, it will have to do.



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Sunday, November 22, 2009

Sunglasses and the Unconscious


I'll tell you how the unconscious works. Yesterday, I bought a pair of sunglasses. In and of itself, there's nothing remarkable about that, people do it almost every day. I've owned clip-ons and the goggle types that fit over regular glasses and they worked fine. But this was the first pair I've had since college intended to be worn by themselves -- or so I thought when I bought them.

Sunglasses have gotten expensive in the past few years. When I was in junior high school I saved the money I earned working part-time in my father's retail western store and saddle shop to buy a pair of Ray-Bans. At twenty dollars, they were a bargain by today's prices, had gold wire rims with large rounded-corner square glass lenses, and I loved them. The world somehow just looked better wearing them.

Since I'm currently living on a medical student's budget, I did some fairly serious research before pulling out my bank card, and right here is where the unconscious comes in. The ones I chose are almost identical to the pair in the photo, taken by a roommate of mine quite some time ago when I was doing doctoral work in theology. I'd completely forgotten about these and I wasn't aware of the similarity, at least consciously, until I reached over to switch on the lamp a few minutes ago and noticed the photo hanging behind it. I can assure you, I wasn't thinking of them yesterday. I can imagine Rod Serling saying, "Picture a man purchasing sunglasses..."

The Labrador is my dog, Babbo, who passed away at nearly fifteen after surviving bone cancer and the amputation of one foreleg. I could write many more than a single post about her and someday I will. For now, I'll say only that she was the most amazing and loving of companions. We went through a great deal more than cancer together and managed to keep each other sane and happy.

My behaviorist colleagues would likely explain all of this by saying I have a fondness for a particular style that persists over time. That's true, but they weren't my first choice. I gave in to the purchase because there was something about them that wouldn't let me go. In my experience this usually means something in the deep dark recesses of my cerebral cortex wants recognition and I do well to pay attention.

What this may be is not exactly clear. I've only been aware of the similarity for about 30 minutes, I guess? My inclination, however, is to think I could be in the process of reclaiming the person I was then and making him a more integral part of who I am now. Or, possibly, I'm in the position of becoming the person I wished I could have become then. I don't really know but I'll keep at it. I don't think it's ever a waste of time for us to take a closer look at things like this. You don't know what might be lurking around, waiting patiently until we've finally gotten to a place it can break through and lead us to who knows where.


(Photo copyright by the author)


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Friday, November 20, 2009

These Last Two Weeks of Summer

Two Bloggers, after Norman Rockwell

He was nine, nearly ten, and it was supposed to be the summer of his fourth grade year. Only it wasn't. His teacher, dissatisfied with his progress, recommended he spend June, July, and August being tutored. It was either that or repeat the entire grade. For his parents, the decision was simple; for him, instead of a nine-month-long anticipated parole, it meant his "sentence" had just been advanced three more.

His teacher -- the warden -- was old school and issues like penmanship were paramount. The l
aptop hadn't been invented and she was adamant. If handwriting wasn't legible, no one cared what you read or how well, you were still deficient and deficiencies would not be tolerated. Nor was his boredom during her daily noontime rehabilitation sessions or whatever it was she called reading stories aloud. He could do that for himself and preferred it at every opportunity, even if it meant sneaking a book and using the back of the student in front of him as camouflage. Until he was caught, that is, and brought back into the fold with stern warnings against taking the initiative.

So now, he thought, I'm paying for it, as he spent day after day in the "warden's" home, relearning arithmetic and wondering what that had to do with penmanship. Her husband was a quiet sort who rarely spoke. When the boy greeted him, his mouth moved but all that escaped were undertones. Perhaps he, too, had learned resistance was futile and had given in to silence, his speech as flawed as the boy's attempts to move his penciled hand across a page. Fellow inmates, they both knew too well.

It was the middle of August before he'd had enough, before anything was better than another day listening to her and wishing he could be anywhere else. With two weeks left in a summer that had dragged instead of flown, he was playing among friends and, knowing full well what he was doing, conveniently forgot the time. The sight of his father arriving to claim his errant son made his stomach turn over -- he knew what was coming. But nothing did and walking home, his father was as silent as the warden's husband, only thoughtful. "So, you're going to repeat fourth grade? It will be at a different school, you know. Different kids, a different teacher, nothing at all like this past year," he said, finally.

Feeling something he would one day describe as hope for the first time since the end of May, the boy agreed. "Well, that gives you some time," his father continued, "it may not seem like much, but you've earned these last two weeks of summer. " Nothing more was said but nothing needed to be, either. Everything that truly mattered was already understood.


("Two Bloggers -- After Normal Rockwell" Image by Mike Licht, NotionsCapital.com via Flickr)

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One Year Later

I thought today was the day but it's really Sunday. I could save this post until then, but it's like going out for some late night pie and coffee. Your taste buds are prepared for apple only to discover all the restaurant has left is cherry. If you're feeling really assertive, you go somewhere else instead of making do. I've been thinking about this post off and on for the past week, my fingers have their heart set on writing it, and I'm feeling assertive, so here we go.

It was November 22, 2008 when I sat down and composed the first entry in The Beggar's Blog. At the time, I wasn't sure anyone would want to read it, but one year later, the number of times someone has done so leaves me speechless. I can't hardly believe it.

At first, it was very much like Field of Dreams. Ray Kinsella builds a

{{en}}Here is a photo of the bleachers and the...

baseball field in response to the urging of an unnamed and previously unheard Voice, then waits all winter long waiting for something to happen. The phrase, "If you build it, he will come," has become part of our national vocabulary. But that's precisely what I was doing, writing occasionally, then daily, in the hope that someone was out there and might be interested.

For a couple of months, only close friends visited and I'll be eternally grateful for their confidence; they kept me going. Eventually, more and more began to appear out of the cornfield and instead of "Shoeless Joe" and I playing catch, we had a team. I don't know if they're drawn by a title, first line, or they're merely prowling the web and looking for something to read. Whatever the reason, I'm always glad they come here.

The idea that one writes because of an inner compulsion is quite true, yet writers need readers. You want to communicate and without someone on the other side of the page, you may as well be talking to yourself. As a child I thought about writing, along with a few hundred other things, as children should. Dreaming is the stuff of childhood and God help us if we lose that capacity. As adults we need it as much if not more. It's what brought me to medical school and the joy of my life. But as a child it was hard to imagine translating dreams into words. Now it happens every day, usually first thing in the morning though not always, in large measure thanks to you, whoever and wherever you are.


(Image of Field of Dreams filming site via Wikipedia)
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Thursday, November 19, 2009

Just a Second

Streetclock by Howard in front of American Clo...

Apparently, there's a difference in clock/watch second hands, did you know that? At least that's my understanding and when it comes to measuring time, you should exercise caution when following my lead. I did well in premed physics but that doesn't mean I always know what I'm talking about. Besides that, I've been wearing the same watch for nearly fourteen years and still have no idea who made it, so what does that tell you?

Anyhow, having said all that, it seems there are the normal second hands that tick away, one second at a time, and there are those that travel around the face in a gliding motion, measuring (according to the manufacturer) the continuous flow of time. Now, if you're a real stickler for accuracy, the gliding motion is probably the way to go because, if you think about it, the ticking motion has to lose time each second.

You're not certain about that? Well, take a look at your watch -- go ahead, I'll wait. Okay, did you notice how the second hand hesitates just briefly each time it marks the passing of a second? If we were to time that delay and multiply it by 86,400 (the number of seconds in 24 hours), we'd discover the amount of time lost just keeping track of it. It's enough to make The Lone Gunmen from The X-Files start looking for a conspiracy. I loved those guys but I could never quite make up my mind whether they were supposed to mimic The Three Musketeers or The Three Stooges.

Now, if you're a therapist, it doesn't matter how the second hand moves because you're only concerned about the minute and hour hands tracking the flow of conversation. I mean, you have to be able to say, "We have five minutes left," because that's when the really important issues often come up. If you've ever been there -- on either side of the couch -- you know exactly what I mean.

But let's say you're trying to do something like take a pulse. With a glide drive, the second hand is sailing along while you're counting beats, but the moment you're done, it keeps on going. Not sure whether it's fourteen or fifteen beats per minute, as if that makes a difference, you start over. Pretty soon you're spending more time chasing the darned second hand than taking a pulse. It's enough to drive a bean counting insurance case manager, who says you're taking too much time with your patients already, crazy. Wait a minute, that's a good thing, right?

So, here's how this all came about. I was trying to explain it to my dog the other day during one of our deeper conversations, and he surprised me. We'd covered the minute and hour hands and when I got to the second, he didn't interrupt and ask which one was the "first." Following most humorists who presume dogs think concretely (see Inside Voices 10/18/09), that might be expected. Instead, his face brightened and he said he knew why the second hand moved fastest. Fool that I am, I said, "You do? Why does it?."

And he replied, "Because, being second, it always has to try harder to keep up with the other two!" Now, why didn't I think of that?


(Image via Wikipedia)
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Wednesday, November 18, 2009

Willing to Listen

Group photo in front of Clark University Sigmu...

One of the things I'm most grateful for has been the opportunity to learn from clinicians who practiced before the advent of psychiatric medications. There haven't been many and I can call only three by name. Two were psychiatrists, one a psychologist, and as members of the Great Generation, they had the shared experience of developing clinical judgment at a time when there was little else to fall back on.

For example, one related to me how she and her colleagues during residency were called upon to do psychotherapy with psychotic patients. When I asked what that was like, she replied, "It was bedlam. But I learned first-hand what worked and what didn't. I also learned how to express myself as meaningfully as possible knowing my patient had a limited capacity for understanding. It's different now -- we wait for medications to begin to work. That's much better, but the personal element can't be forgotten."

I once had the good fortune of participating in a hour-long eight week individualized seminar with this same woman. At the time, I thought we were reading and discussing the classics of psychoanalytic literature. In retrospect, however, I've realized she had a more practical goal in mind: she was teaching me how to think. With all of the current emphasis on data gathering and analysis, one might be inclined to regard careful thinking about patients as a luxury, but in fact, it's the guiding principle in the determination of what constitutes a potentially effective treatment.

By making the time to contemplate who we're dealing with and what they really need, we provide ourselves with an opportunity to break free of restrictive and artificial constraints that limit creativity. Thinking outside the box, to borrow a well-used phrase, requires a willingness to consider alternatives that may not exist in the laboratory setting.

Perhaps what I've gained most from having some older teachers is the awareness that there's something more important than the newest and best thing. I don't mean they're distrusting of change -- quite to the contrary, they're the agents of it. I mean their insistence on the individual patient being the primary consideration in decision-making. It doesn't matter if all the evidence in the world is persuasive, if we're not intent on meeting the needs of the patient, we're not likely to make a difference. It takes real presence of mind to make those kinds of decisions. The ones who have it are the ones who've gained it the hard way and by passing it along, they've definitely made things a lot easier for me and anyone else who's willing to listen.


(Image via Wikipedia)

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Tuesday, November 17, 2009

To See What I Might See

Dreamland Express album cover

You can blame John Denver, he's the one who got me started. Well, that's not strictly true, but it sounds good to say. For years, his identity was tied to long hair and granny glasses. Then came the Dreamland Express album in the mid-80s and with it, shorter hair and yes, contact lenses.

I've worn glasses since age nineteen and while I won't tell you precisely how long that's been, let's just say my first pair had glass lenses and turtle-shell frames. I'll let you do the math. Anyhow, then came the miracle of plastic and gone were the days of pushing glasses off the end of my nose every five minutes.

Why not get contacts? Well, that's complicated. For one thing, I've always had a thing about putting anything in my eyes, and that must have frustrated the dickens out of every optometrist who tried to get drops into them. For another, contacts never came in my prescription. So, even if I could have tolerated wearing them, there weren't any I could have used in the first place.

But now we have soft contacts and that's had me thinking. Maybe I could, at long last, cease viewing the world from behind what I've come to regard as a pair of windows, and be in the world, less an observer and more a participant. I certainly felt that way whenever I left my glasses on the desk, but the problem was, I couldn't see well enough to keep from getting in trouble. Besides, my distance vision was blurry, and it's hard to be engaged when you can't see what's coming down the road.

So, today was my day. During my frequently less than regular exam, I told my doctor if he could fit me in a pair, I was determined to make them work. After about 45 minutes of sweating through learning how to insert and remove them, I drove away feeling like John must have felt in the summer of his 27th year, coming home to a place he'd never been before.

I hadn't planned on writing about this experience but it feels so good, keeping it to myself seems selfish. It's not anything transcendent, it's just been a long time in coming and I'm glad I finally got up the nerve to take the step and see what I might see.


(Dreamland Express album cover, copyright 1985, Rocky Mountain High copyright 1975, both owned by the estate of John Denver, image via Wikipedia)
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Monday, November 16, 2009

Water Out of the Tap

Mark Twain photo portrait.

"My books are like water; those of the great geniuses are wine. (Fortunately) everybody drinks water." So saith Mark Twain. It's a wonderful thing to know what you're good at and be able to do it without feeling it has to be great in order to be worthwhile. That doesn't mean we give up trying to improve and, perhaps, even achieve something resembling greatness, even on a small scale. It just means we've gotten to the place where being ourselves in the realm of accomplishment is so imminently satisfying that anything else is like freshly made gravy streaming over mashed potatoes.

You're smiling at the analogy. Well, it's like this: you're whipping potatoes together with small amounts of milk and butter (maybe a teensy bit of cream, since it's Thanksgiving) and stopping every now and then to give it a taste-test. For me, the moment when you get the mix exactly right and then, like a little kid, lick the beaters clean -- that's when mashed potatoes are the best. It's a promise of things to come when you'll dish them onto the plate and flood them with gravy. But if all you had was a spoon and the bowl, you could be happy.

We get things so easily bass-ackwards, as they say in Texas, mocking the phrase ass-backwards. Striving for success becomes the goal instead of developing skill and nurturing competency. Now, there's nothing wrong with success and I like it as much as the next guy, but when the drive for success and the recognition that usually accompanies it, becomes all-consuming, we lose the joy inherent in becoming persons with capability. Gravy by itself may be tasty, but it fulfills its purpose when poured over something else.

A few years ago, someone (probably a relative, I can't remember) asked if I couldn't find something that was less demanding than medicine, something that paid as well but required less time investment. You've got to keep in mind, they said, you're not getting any younger. Income isn't what this is about, I replied, it's the fact that I'm better at this -- I'm more me -- than I've ever been at anything else; this is my one thing, to borrow a line from City Slickers.

Some people are truly like wine and it's wonderful to know and spend time with them. Speaking only for myself, though, I'm like water out of the tap. As long as someone's thirsty, that's all that matters.


(Public domain image of Mark Twain via Wikipedia)

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Saturday, November 14, 2009

The Local on the Eights

Wind Vane Weather cock

Hurricane Ida may be on her way out to sea but the residual -- spelled r-a-i-n -- that has been falling steadily throughout the day has the stream near my house overflowing the banks tonight. Not to worry -- the water would have to rise at least another fifteen vertical feet to even lap the foundation, but as I walked down to the bridge with umbrella and flashlight to have a look, I couldn't help but think about what a storm like this must have been like before electricity, before television, before The Weather Channel.

The nearest thing we have to a weatherman is Benjamin Franklin and since he's in Philadelphia, holding his dampened finger out the window to determine wind direction isn't much help to us. Besides, the weather vane on the corner of the barn roof works just fine. The Farmer's Almanac won't be published until 1818, so we can forget that as well. Looks like it's by guess and by golly and yours is as good as mine.

The clouds have formed a long grey bank to the south for the past two days and this morning was a drizzly dawn. We're glad we got the last of this season's hay into the barn and the firewood box filled. As the day deepens into an increasingly early dark, we've watched the downpour at a rate our great, great, great grandchildren will call a half inch per hour. Holding a candle-lit lantern at the door does precious little to cut through the dim, so we head for bed -- having done all we could, we're at the mercy of the elements and in the hands of the Almighty.

It's easy to think of life back then as terribly insecure in the light of what we're able to accomplish today. But I wonder if that's how it seemed to them. Maybe the absence of predictability rendered people more inclined to take things as they came. I think it's fair to say farmers would have liked anticipating the onset of bad weather whenever they could, but the idea that they felt a sort of chronic insecurity may be projection on our part. We imagine what it would be like for us to live under those conditions and presume it reflects the feelings of the time. In reality, it depicts how dependent we've become on the tools we hope enable us to minimize risk and keep chance at bay.

It's difficult to know, really, and you'll forgive me, I hope, because I need to close now -- it's nearly time for the Local on the Eights. You know, the local forecast every eight minutes on The Weather Channel?


(Image via Wikipedia)

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A Division of Labor

An Eastern Grey Squirrel (Sciurus carolinensis...

There ought to be a philosophical statement to be made about finally getting the half dozen piles of leaves raked and hauled out of the yard. I rake, therefore I am, or Know Your Leaf. Something like that. Trouble is, I can't think of one.

Maybe spirituality would be better. Laboring together with Nature -- how's that? Except yesterday, I was the one doing all the work while Nature was busy creating the necessity for it in the first place. I didn't notice one tree pick up a rake or bag and offer to help out. Can you believe that?

Furthermore, not a single one said thanks afterward. Talk about poor upbringing. Now, I'm a human (most days) and was raised to express appreciation when someone cleaned up a mess I'd made. Please and thank you, my mother used to tell me, are words you should never forget to say. Obviously, this group of trees and I have very different roots.

The squirrels and chipmunks, on the other hand, clearly have a well-defined sense of civic pride. A month ago, Butternuts and acorns littered the yard like confetti in Times Square on New Year's Day but lately I notice their numbers have dwindled and it appears somebody besides me has been busy.

I'm fine with this as long as they don't leave their tools lying around for me to pick up when they've finished. Last year it took me forever to collect and store them in the hollow trunk of the fallen tree behind my house that serves as their storage facility. The worst part of it was this big, grizzled gray fellow who insisted on supervising. Taking orders from the dog and cat are one thing, but a squirrel? That's a bit much.


(Creative Commons image of an eastern gray squirrel via Wikipedia)
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Friday, November 13, 2009

Imitating John Elway

John Elway's Quarterback
A few weeks ago I wrote about reviewing the initial proof copies of our book and this morning I've just finished doing similarly with the final ones. The production editor will combine my corrections with hers and send them to the typesetter who revises the text and delivers it to the printer.

In my imagination, I see this process unfold like the last seconds of a tight fourth quarter. John Elway is scrambling in the backfield (as usual) and does a quick hand off to a running back who fakes left and then passes to a wide receiver. With the defense closing in, he tosses the ball to another player who makes the scoring run. The Denver fans are going crazy while Coach Shanahan has begun to wonder whether his team would prefer to be the Harlem Globetrotters.

From John's perspective, it's about getting the ball over the goal line, but once it leaves his hands, all he can do is watch, hope, and trust the other players. That's where I'm at. Everything I've been expected to do, finish up the last chapter, edit the proofs, write an index, and review the proofs again, is done. The ball's in play and there's nothing left for me to do except await the outcome.

It's kind of odd, really. For the last three years, my friend Lynn and I have pursued, courted, and complied with one publisher after another. And because of medical school, it's been a part-time activity on my part. Then Lynn and Jonathan both passed away, as you know, and I felt like John must have felt all those times when a mammoth-sized linebacker was bearing down on him and he hadn't yet gotten rid of the ball.

Thankfully, that scenario has been resolved, but I'm still a little wistful and at a bit of a loss. All the detail work has kept me in the game and though I haven't been sidelined, it's time to rely on the rest of the team to get the job done. And that's a good feeling. But one thing is definitely certain, this is the closest I'll ever get to imitating John Elway.



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Thursday, November 12, 2009

Healing Broken Hearts

The powder blast of a slab avalanche.

I had been in my first pastorate in a small mountain town in Southwest Colorado for a couple of months when a snow plow driver was caught in an avalanche. Ministers are supposed to know what to say and do at times like this, and despite the fact that I had no connection with the family other than the fact that we lived in the same town, I was called and naturally, I went.

The scene was chaotic, to put it mildly. All that we knew at the time was, his snow plow had been swept away in a massive slide and rescue workers were laboring to find any sign him or the vehicle. What makes a slide so lethal is a matter of physics. The mass of snow multiplied by its velocity equals the force with which it strikes an object. Tons of heavy, wet autumn snow moving at an estimated five hundred miles per hour had shoved his dump truck off the road and onto the side of a mountain as easily as you might wipe crumbs from a table.

I was so inexperienced at the time I had absolutely no idea what to say. Somehow I fumbled through and introduced myself, then tried to offer some word of comfort and support from my parish. What they wanted was news rather than comfort, and I had none of the former and felt woefully inadequate to provide the latter. The arrival of family was timely because, at that moment, the phone rang and the search had been turned into a recovery effort. His body wasn't found until spring.

On the way home, I wondered if I was ever going to be of use to anyone as a minister. My education had done little to prepare me for something like this. It was literally like being thrown into a lake and told to swim when you've never done anything except read about it. All the theory in the world can't help you overcome the panic long enough to remember to kick your legs.

I'm mentioning this experience because it's very similar to what medical students go through when they have a patient die for the first time. You question yourself, wonder if perhaps you shouldn't have gone to law school instead, and yet, somehow you fumble your way through. People can be quite forgiving and if you're sensitive and concerned, they'll appreciate it. You don't have to be gifted, you don't even have to be "doctorly," you just have to be genuine. Genuine really does go a long way when you're trying to help heal broken hearts.



(Public domain image via Wikipedia)
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Wednesday, November 11, 2009

The Mystery of the Missing Pants

w:Bunker Hill MonumentImage via Wikipedia

"Ah cahn't find me pahnts," he said, his Irish as thick as the scent of old whiskey on his breath. Standing there at the nursing station in shirt, undershorts, and socks, it was obvious something was missing. Patrick been brought into the substance abuse unit by the police, after having been found wandering the Bunker Hill Monument soliciting tourists. I took him back to his room and thus began what would henceforth be known as the Mystery of the Missing Pants.

"Where did you leave them?" I asked, as he crawled back into bed. He looked at me like I had two heads -- from his point of view, I probably did -- and fell asleep. They've got to be here somewhere, I thought, and began to search his belongings, then the closet, under the bed, around the window, even above the foam ceiling tiles. Nothing, not a sign. It was as though I'd walked into an episode from The Twilight Zone.

I was about to leave when Cathan, the second-generation Irish charge nurse, poked his head in the door and asked, "Any luck?" I shook my head no, he shook his in disbelief, then pointed to the window and suggested it might easily have been mistaken for a dresser drawer under the circumstances. So, out I went, and digging through the bushes (intentionally avoiding the curious glance of a hospital security guard), found only aluminum cans, paper cups, and cigarette butts. Whatever had been thrown out the window at one time or another, it didn't include the faded and worn plaid wool pants I'd seen when my patient arrived in the company of Boston's Finest.

A week later, at discharge, Patrick was decent: we'd found a pair that fit in the stock of spare clothes kept for such occasions. When we relocated from the second to the eleventh floor of the hospital we did a more thorough, albeit informal, search and still, no pants. Eventually, the tale became part of unit lore, recounted at Christmas parties and during long evening shifts when snoring echoed down the halls like the rumble of hot rod glasspack mufflers at a stop light.

Several months went by -- it was late September -- and as I was preparing to leave Boston for Colorado, I decided to take the Green Line downtown for one last walk through Boston Common. I'd just gotten off at the station when I felt someone in the crowd grab my elbow and whisper in a thick, whiskey-laden Irish accent, "Ah, Lad, tell me now, didja ever fahnd me pahnts?"


(Image of the Bunker Hill Monument via Wikipedia)

(Note to the reader: as always, names and details have been altered and/or fictionalized to protect patient anonymity -- and make for a better story!)
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Tuesday, November 10, 2009

Keep Your Eyes on Hers

Portraitfoto

The referral letter read, "borderline," and my first glimpse reinforced its assessment. Tight jeans, low-cut blouse, anatomy pushing out of every available space. Keep your eyes on hers, I reminded myself -- therapists are human, too. Once she began to speak, I realized I would have no problem because her story was compelling. She had a highly placed position with a large firm in San Diego, had a comfortable income, but she'd gotten into debt, and couldn't understand why she'd taken the job to begin with. It was everything but the dream of a lifetime. Having few close friends, she'd begun sleeping more, had no energy, and finally overdosed on some nondescript medication.

She took a leave of absence, hoping some time away would help, and attempted suicide a second time. Two serious efforts at self-harm, young, female, prone to dress in a manner some might call provocative (others merely stylish), and it was decided she must have borderline personality disorder. Unfortunately, it's an easy mistake to make -- psychiatry tends to lie a little more on the art side of the medical spectrum anyway, and particularly when your predispositions color your judgment.

But borderline seemed not quite right -- her emotions were fairly stable, her recent impulsiveness was uncharacteristic, she didn't abuse drugs or alcohol, and she didn't have the off-on, in-out history of multiple relationships you often see. She was depressed, felt her choices were less her own and more those of boss and boyfriend, and she had become desperate. As we talked, I felt increasingly embarrassed about my initial impression.

You've heard it said, I'm sure, that appearances can be deceiving. It's very tempting to become so attached to a diagnosis that you're loathe to abandon it, even when the evidence that you should is absolutely glaring. You end up trying to force someone to fit your expectations and miss the real person sitting right in front of you. In this case, she was a young woman who gradually demonstrated a tremendous capacity for self-reflection and change. By the time our work together had come to its natural conclusion, I was no longer certain which of us had learned the most. And those are not only sometimes the best kinds of therapy, they're also some of the best kinds of relationships.

Period.


(Public domain image of an unknown young woman via Wikipedia)

(Note to the reader: some details have been altered and/or fictionalized to preserve patient anonymity -- the lessons learned by the therapist, however, are quite real)

Monday, November 9, 2009

The Learning Curve

The Red Telephone

It was about 10.00 PM and I should have been thinking about getting ready for bed. Instead, I was on the phone with the psychiatric clinician in the ER, trying to convince him my patient needed hospitalization. Until earlier that afternoon, day treatment had been adequate -- going home at night, returning for therapy the next morning.
Lately, however, his depression was worsening, problems at home seemed more severe, and he had begun thinking of alternatives, as he put it.To make things worse, he had a gun at home and was reticent about having his wife lock it up for him -- not a good sign.

We talked about inpatient admission and I walked down to the ER with him to get the evaluation process started.
I spoke with the ER director, she agreed with my assessment, and at that point, technically speaking, the decision about hospitalization was out of my hands. I had a funny feeling, though, that gnawed at me all evening.

When faced with hospitalization, patients can experience what's called "flight into health," which means they suddenly feel less distressed and despite having been suicidal hours before, for example, they deny it completely. And, of course, this means they don't meet criteria for inpatient care. The problem is, once released, their "recovery" doesn't last and their behavior can become rapidly lethal.

So, I gave in to the feeling and got on the phone. Sure enough, my patient had a change of heart and the evaluator was contemplating a discharge. A few minutes into our conversation he reversed his thinking and the next morning my patient said he was glad we'd decided not to listen to him after all.

They say you shouldn't take your patients home with you -- metaphorically speaking -- and that's generally true. But if you're going to care about the people for whom you're responsible, sometimes it's going to happen. You'll wake up in the middle of the night, make a call, and go back to bed glad you did. It doesn't happen quite as often as one might think and eventually, experience (and the supportive advice of colleagues) teaches you how to set limits on yourself. Like everything else in medicine, there's a learning curve and all of us are students, no matter how much practice we've had.


(Image by Toni Blay via Flickr -- creative commons licensure)

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Sunday, November 8, 2009

The Dis-Ordered Self

Character disorders, they used to be called and sometimes still are, if you're talking to those experience-wizened women and men who received their psychiatric training in 1940s. Later on, the name became personality disorders, as we began to realize how deep the rabbit hole goes. Language changes and its appropriate to change with it. Feelin' groovy was fine in the 60s, but unless you want your peers looking at you as though they had cartoon balloons filled with question marks floating over their heads, you need to find a better way to say it in 2009.

Now, it seems, we're taking another step in the way we label the kinds of disorders that suffuse through a person like Bell's Seasoning in Thanksgiving stuffing (more about Bell's in a couple of weeks -- stay tuned), and calling them self disorders or disorders of the self. Actually, I like that term because it describes what seems to take place: a dis-ordering of the self as an integrated unit. This is more than a temporal phenomenon such as might be seen with depression or anxiety. And it extends beyond personality: we're not referring to being an introvert in an extroverted world and feeling like a stranger in a strange land. It's like a breakdown in the development of many of the essential functions that enable effective coping, appropriate emotional expression, and

Lightnings {{es|Tormenta el├ęctrica.Image via Wikipedia

reality-oriented thinking and problem-solving.

In essence, it's a disruption that influences a person from the inside
out. From the basic neurochemical level, where electrical impulses trigger chemical signals resulting in cell to cell communication, to the production of the amorphous and ambiguous thing we call mind -- true mind-body interactions -- to interpersonal relations. It's that pervasive. When you think of it in these terms, the classification of dis-ease becomes terribly artificial. Nevertheless, we do it in order to make sense of what we see and in the attempt to develop treatments that may genuinely do some good.

So, you take another look at the fragile/vulnerable individual I described yesterday, and ask how can these things be? In the absence of a well-ordered interior life that is capable of expressing itself meaningfully or establishing relationships with mutual give and take, one resorts to using their environment to compensate. My close friend and coauthor, Dr. Lynn Smith, was very fond of saying in regard to psychosomatic illness, "What the mind cannot express, the body will." If we take that a step further, we might say when the self is unable to express itself functionally, it turns to external factors and virtually insists they perform on its behalf.

And that helps explain why these conditions are so disabling. When you don't have your own intrinsic resources to draw upon to help manage stress, form reliable and consistently satisfying relationships, or cope with uncertainty, you're inhibited in some very critical ways. Navigating your way through life becomes a catch-as-catch-can proposition and you experience considerable pain en route. It's not an enviable position to be in. Ironically, dealing with such a thing means you've got to be able to recognize where you are to begin with. For many with self disorders, that prospect is so disturbing as to seem nearly impossible.



Saturday, November 7, 2009

The Fragile and the Vulnerable

He was such a sweet guy, she asked, how could I not trust him? I can't tell you the number of times this question has been posed to me and my response is usually a combination of support and gentle explanation. You weren't alone, many people trusted him. He was very, very good at hiding who he was on the inside -- especially from himself.

I've mentioned previously how I often look back over topics I've covered in an effort to avoid repeating myself. It's easy to do, particularly when you have favor

A couple of examples of rocking horses.
ite hobby horses you enjoy riding. I'm climbing onto one of them this morning because I've lately realized how one-sided my comments about it have been. Not intentionally so, but there's more to be said and I want to be fair.

In the past, I've described narcissism as though the competitive, arrogant type was pretty much typical, and in my experience, it has been. Nevertheless, I've also known individuals who seemed to feel a similar entitlement to special treatment, but for whom life is like an elaborate fantasy. It was as though they're playing chess and working both sides of the board to suit themselves. Anything that doesn't agree with what they imagine reality to be is treated as not having occurred at all.

It troubled me how they acted sincerely concerned for people but could resort to manipulation without remorse. I also noticed they were exquisitely sensitive to shame. A mistake for which you or I would admit responsibility and then move on, had the potential to trigger pent-up rage that easily turned into a grudge.

I've recently learned this pattern actually represents a more nuanced understanding of narcissism and is called the fragile/vulnerable or covert type. The underlying traits -- lack of genuine empathy, a sense of entitlement, self-absorption, etc. -- are virtually the same as those in the arrogant type, but they're expressed differently. The arrogant type is confident and self-assured while the fragile/vulnerable/covert type is prone to appear modest, unassuming, and possess a high moral code -- one which they apply ruthlessly to others but not equally to themselves. Their self-esteem is in the basement, along with a coal cellar filled with rage over being misunderstood or under-appreciated. They can use people as easily as the arrogant type, but they act nicer about it.

And this is why they're harder to identify and we can be more easily fooled. We overlook what we can't believe and make excuses for the rest. But we feel drained -- emotionally anemic -- after being around them, and when their denial crumbles under stress, you may begin to see how much of their life is organized around their particular fantasy.

If you're interested, there's a growing body of literature -- just do a search for fragile/vulnerable/covert narcissism and indulge yourself. Whether you're "in the business" or not, it can be enlightening, especially if you're familiar with someone like this. And if not, well, it never hurts to be prepared, just in case.

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