Paranoia

"Paranoia strikes deep.
into your life it will creep..."
~ Stephen Stills

Of all we could say about paranoia, one thing is pretty clear: it's a symptom of something gone wrong. When we're coping well with life, we aren't generally suspicious or mistrusting without reasonable cause. Even under stress, when we are compensating, as we say in "shrink lingo," we're able to distinguish between real and imagined threats. True, we may not be able to cover every single solitary possibility imaginable -- no one's perfect -- but we do our best. And most days, in most situations, that's good enough.

In extraordinary situations, however, things can change rapidly. With good coping skills and a healthy ego, we're okay, maybe even better than okay. With poor skills or a weak ego, it's not so good. It may even get scary once in a while. Especially to those of us who are on the outside looking in. 

I'm referring specifically to the rash of paranoid ideations that have found their way into video and print in response to the terrorist attack in Paris. Don't let those Syrian refugees into America, they say, you can't tell the good guys from the bad guys. Well, maybe not, but haven't bad guys been able to enter the United States for a long time? What self-respecting, evil, scheming bad guy is so stupid that he'd masquerade as a refugee and expose himself to serious scrutiny, when he could simply walk through customs with a legal passport on any other day?

That's the problem with paranoia, especially the socially-acceptable kind. It checks its brains at the door and starts shouting about the sky falling when the issue is actually much closer to the ground. It becomes irrational even when couching its rhetoric in rational terms. It is true, America has endured terrorist attack before and it only makes sense to be prepared. Once burned, twice cautious. To become obsessed with the possibility to the point we abandon our leadership role on the world stage isn't caution. It's more like crazy.

These are times for brave, sensible people. People like the Parisian father who explained to his young son that memorial flowers and candles were there to protect them from bad people with guns. He's too young to grasp the concept that flowers and candles represent the collective will of good, solid, brave people who refuse to give in to terror. Someday he will, though. When he does I hope he also understands that paranoia is a warning, not a watchman to be heeded.


Creative Commons image by Katlew via Flickr.com.

The White Coat Brigade

Although I wasn't running late, it still felt that way. It was my second day of residency and a meeting with the psychiatry training director had me intent on arriving early. At my hospital, residents have access to a parking garage, unlike lowly medical students. Having been one of them for so long, the garage looks to me like the Taj Mahal. Anyway, after driving round a couple of minutes and coming up empty-handed, I spied an empty space marked, "Physician Parking Only." Wouldn't you know it? I thought, may as well have Dirty Harry guarding it. I started to drive past when the lights came on. 

"Wait a minute, that means me."

If there was a single thing typifying the impact of residency thus far, this incident depicts it. Over and over something happens -- entering the resident's lounge for the first time, hearing my name called with the title "doctor" appended to it, having other residents smile in greeting -- something happens to remind me I'm not in Kansas anymore. Medical school really is finished, I really did graduate, and I really am here, at long last.

It's kind of funny, when you think of it, the way reality creeps up and sinks in. I don't know if it affects other people like this, but I can't help thinking about how everything feels. Maybe that's why I'm in psychiatry: just being here isn't enough; I have to take it in and digest it. And unlike some third year rotations I was glad to bid farewell to, I want these first six months of inpatient psychiatry to poke along at pace that would make a snail impatient.

It's weird, though.  I feel like a buck private who's been given a battlefield commission. Only a few years ago I was an enlisted man, now I'm at the opposite end of the food chain -- or chain of command, as the case may be. Sort of. As a first year resident, I'm little more than a medical student with a title. But the people I work with didn't know me back then or in my life before that, on the front lines of mental health care. They only know me as I am now, a member of the White Coat Brigade. It's up to me to let my behavior spell out what I learned while serving on their side of the coin. 

Nothing is automatic, but it's all as pleasurable as it is satisfying. Especially sitting down with patients for therapy knowing it's partly what I'm getting paid for. I'm here to learn everything I can, but I'm also here to work and at this point, psychotherapy is something I can do quite legitimately. It's one of the tools I've had rattling around in my backpack the past few years, waiting for its time to come.

(Creative Commons image by Kids_Safari2 via Flickr)

Like Walking on Water

 
Walking on water is easy; it's when the waves turn into giants that things get sticky. ~ Beggar

I don't usually quote myself but since there was no one else to blame for my opening line, I figured I'd best come clean. Walking on water, metaphorically speaking, isn't hard, as long as the water's quiet and glassy smooth like the surface of a Colorado mountain lake on a summer evening. The storms that come from out of nowhere in late afternoon, however, before the evening calm, those are what separate the men from the boys.

That image has been running through my mind almost daily, the past few weeks. Walking on water, trying to "keep the faith" when all around the waves are lapping and a glance at my feet tells me I'm going under. Walking on water is precisely what seeking a residency position has felt like, walking on water without a life-jacket.

On March 9, 2010, I wrote a blog post entitled, "Medical School Through the Back Door," describing my experiences as a psychotherapy intern in the company of a group of  psychiatric residents. Back then, I was a street urchin off the pages of A Christmas Carol or Oliver Twist, my face pressed against a restaurant window, gazing hungrily while patrons dined sumptuously. The memory of that internship kept me going through medical school. I knew residency was out there, or at least I believed it was, it was just a matter of reaching it. That was in 2010.

2011 was different, or it looked to be, when I began clinical rotations. The basic sciences were behind me and board exams and I had battled it out, sword on shield, sometimes tooth and nail. Starting rotations in mid-cycle meant I wouldn't have a predictable schedule, resulting in graduation being pushed back a year. 2012 brought an unexpected gap between rotations and once again, I watched graduation skip away with the alacrity of a child playing hopscotch.

In 2013 I received my degree at long last and applied for residency. The Match came and went, leaving me without  "a date for the prom." I'm not sure there's much worse news for a fourth year medical student or recent graduate than, "We're sorry, you did not match with a program." As with any loss, your first reaction is shock and disbelief, followed by anger and frustration, and then despair sets in and you start wondering how you'll ever pay student loans. Hopefully, acceptance comes along soon, enabling you to regroup and get busy chasing available positions and contemplating Plan B or C.

The truth is, I was up and down. One day I felt optimistic, based on nothing more substantial than a phone call with a polite departmental secretary, and the next felt certain I was totally screwed. All the years I'd spent loving and learning psychiatry were circling the drain and there wasn't a single thing I could do to stop them. My Plan B involved a family medicine residency for a year and then reapplying for psychiatry. It had been done before, successfully, by others, why not me? If that failed, I'd go to Plan C: finish family medicine and see psychiatric patients. It was a good strategy, it was workable, but it really did feel lousy. It was like giving up and that's what hurt most of all.

Still, I had to face reality, painful or not, and so I began contacting family medicine programs about openings. Then a call came from the Midwest. I tried to sound casual and friendly, but I could scarcely contain myself as the voice on the other end said, "I'd like to offer you a position in our psychiatric residency program." Talk about the cavalry riding to the rescue. I even think I heard bugles blowing. Until that point, my "best day" was a Saturday morning in January, 2005, when I learned I'd been accepted to medical school. Now it had a contender.

I'm not sure what it's like to "walk on water" that's calm and placid. I'd like to find out. The past few years, though, it seems there's always been a storm brewing, either because of my own frailty or stupidity or because that's what storms do. I'm not complaining; it's better to have to negotiate a storm than sit on the bank, watching others make their way to the other side. That I've managed to come this far is a testimony to good people who stepped onto the water alongside me when the sky was at its darkest. Thanks in no small measure to them, when someone finally opened the door to a psychiatric residency, I was standing on dry land, free to walk through.


(Creative Commons image of Trout Lake, near Telluride, Colorado by Mountain Belle via Flickr)

The Death of a President

 
In psychiatry, a great deal depends on timing, including the correct diagnosis. For instance, while you may have experienced or witnessed a traumatic event or may have had prolonged exposure to highly stressful, traumatic, or abusive conditions, you can't be diagnosed with PTSD unless your symptoms have persisted longer than six months. Under six months, we call it acute stress disorder. PTSD symptoms can persist a long time.

Looking back, I definitely think 9/11 resulted in the semblance of a nation-wide case of PTSD from which we've done a fairly good job of recovering. We're more alert to danger but less likely to shut down the entire country over an isolated, local threat. We're no longer quite so eager to send in the troops at the sound of gunfire on the far side of the world. Life has begun to approximate "normal," though we're more aware of our vulnerability and the memory of tragedy is still there and always will be. Even the extreme political right seems more intent on defeating the president's health initiative than tackling terrorism. I don't think we've done as well with November 22, 1963.

I've often thought the free love, abundant drugs, and Tune-In, Turn-On, and Drop-Out mentality of the 60s was more an expression of anger -- acting out -- than typical adolescent rebellion. For the first time in our history, almost an entire generation gave the establishment the middle finger. Its hero was dead, LBJ had taken office, the Warren Commission was established, there was a national day of mourning, and now, it was time to move on. But this generation wasn't ready yet, and we would all have to wait for Kubler-Ross (On Death and Dying, 1969) to inform us the funeral was only the beginning.

Watching the 50th anniversary of the Kennedy assassination programming the past few days, I've been struck by how often someone uttered the phrase, "People don't want to think Kennedy could have been struck down by a single individual, acting alone. The magnitude of his personality as president seems to demand much more."  I'm not certain this is accurate. I don't believe his personal magnetism or his role as the nation's leader are nearly as important as the magnitude of his loss. Ongoing conspiracy theories and the tendency of 2/3 of Americans to doubt the findings of the Warren Report symbolize the depth of grief many still feel, as well as an abiding need for it to be recognized. Mistrust of government may have burst into full flower with Watergate, but it is rooted in the mismanagement of national grief over the death of a president.  

This is likely an unfair generalization, but there is still some truth in the statement that Lyndon Johnson's generation was more accustomed to putting tragedy behind them than paying close attention to what it means and mourning its significance. Anyone who's watched the HBO presentations of Band of Brothers (2001) or The Pacific (2010), or talked at length with veterans from the Great Generation knows how exceedingly reticent they are about digging up old wounds. The idea that the country as a whole needed time and leadership in the matter of grieving was unheard of in 1963. In a very real sense, we needed a president who understood and embraced his role as nation's chaplain as well as it's chief executive. Unfortunately, this was not one of JBJ's strengths, in contrast with our current president who has been known to take hours comforting the victims of gun violence.

I was also struck by the numbers of interviewees who commented on how America had changed, subsequent to the assassination. They lamented a loss of optimism, hopefulness, and the belief anything was possible. Whether those feelings are shared by all is debatable. There were and still are, sectors of the population that make no secret of their hatred of Kennedy and the causes he and his brothers championed. Nevertheless, his loss was felt by far more and the feelings associated with it have lasted far longer than anyone might have imagined. 
 
Grief isn't resolved, if it's ever truly resolved, by assigning blame, getting even, and nursing the satisfaction gained from a moment of passion. We learn to deal with our losses, to live with them, making them part of ourselves, by refusing to play down their impact and brush them away like crumbs from the table. Grief has to be honored and mourning respected if we're ever to regain the optimism, hope, and sense of the possible that seems forever out of reach when we feel bereft. If there are lessons worth learning from the past 50 years, this is one to take to heart. 


(Creative Commons image of eternal flame at grave of John F. Kennedy by Tim Evanson via Flickr)

Healthcare Without Politics: The Future is Now

Is it even possible anymore, healthcare without politics? 
I don't know, but I hope so. I'd hate to think the only place it could exist was Disney World. I hope we can reach the point midst all the  maneuvering and jockeying for power and influence where our concern for those who need healthcare exceeds its value as political capital. Sadly, we're not there yet.

Back in the day when, for the average person, Blue Cross/Blue Shield was pretty much the only health insurance game in town, coverage protected in case of catastrophe, i.e. hospitalization. I've described in other posts my own experience of kidney stones necessitating two major surgeries. My family paid out of pocket for outpatient doctor visits and prescriptions, grateful our Blue Cross policy meant the cost of my hospital stay wouldn't hit us with the force of a tsunami carrying the threat of bankruptcy in its wake.

At the time I was recovering from kidney stones and for a few years thereafter, doctors were reimbursed by insurance for services rendered. It was called a fee-for-service system. More services meant greater reimbursement. Eventually, managed care firms came into existence and in the effort to control the costs of operation, they established criteria that must be met, justifying tests and procedures, before  insurance claims would be paid and doctors reimbursed. Soon it became necessary for providers and/or policy holders to obtain authorizations for treatment before managed care considered itself obligated to pay. If you think about it from a business perspective, this makes sense. A company can only pay out so much before it is unable to pay at all.

The road to hell is lined with good intentions, as the saying goes, and while management of healthcare costs was doubtless a factor in the evolution of managed care, we have to remember, healthcare insurance is still a business and the first priority of any business is to make a profit. To accomplish this goal, a business has to increase revenues and/or reduce expenses. Determining which procedures or medications were clinically indicated, ostensibly based on empirical evidence, was one way of setting limits on expenses. Refusing to cover pre-existing conditions was another. Over time, decisions of medical necessity were taken over by managed care and stories of treatment denial, some of them truly horrible, started surfacing. You've heard them on the nightly news as have I.

Despite public outcry, doctors' frustration with a growing insurance beuracracy, and the efforts of congressional leaders like the late Senator Ted Kennedy, insurance reform lagged. Ours is a free-market economy, it was argued, competition lies at the heart of the American Way. Socialized medicine in Canada and Europe, opponents declared, provided poorer quality care and ours was the best in the world. The reality, however, failed to live up to the evidence even as the arguments proliferated.

Families on the verge of collapse because of alcoholism or drug abuse may resort to performing an intervention, confronting the substance abuser who is unwilling or unable to get treatment themselves. Not dissimilarly, someone had to intervene if healthcare insurance was going to obtain the "treatment" it had long needed. Relying on competition to even the field failed to yield more affordable coverage and the number of uninsured Americans continued to grow. Either free-market theory was wrong or the industry discovered how to prosper in spite of it. Although many believed there were good reasons for reforming the system, there was insufficient motivation for the system to reform itself.

Enter the Affordable Care and Patient Protection Act, the function of which is to enable one to obtain affordable healthcare insurance and provide protection against potential abuses by the insurance industry. Under its umbrella, patients can no longer be denied coverage because of preexisting conditions. The determination of medical necessity has been placed back into the hands of those who are committed to serve the needs of patients. Doctors now have the right to review private insurance company files that identified physicians with high utilization patient populations and directed new referrals to those whose patients were regarded as healthier and therefore cheaper to insure. 

It's not a perfect solution but imperfection doesn't automatically render it a bad one. If anything, we're discovering it's a work in progress and we'll need to adjust and adapt it as we go. I don't think it represents a step toward socialism anymore than the Selective Service represented a step toward a police state. Most of us are too smart to believe that line, even if politicians aren't smart enough to find a better one. 

The Affordable Care Act is an attempt to reform a system sorely in need of reform, not only for the sake of patients and policy holders, but for its own sake as well. As with any intervention, the insurance industry finds change painful and naturally responds with anger, disbelief, and a desire to bargain, hoping to retain something of the status quo. Over time, acceptance will ensue and the industry will find itself better off for the changes that have been made. In the meantime, we're past the point of no return; pretending the good old days were the best days is a fantasy and Fantasy Land is for cartoons. We live in Tomorrow Land and the future is now. 


(Creative Commons image of Walt Disney Politics by sbwoodside via Flickr)

Why is Spirituality Important to Medicine?

 
That's a good question. Why is it? Well, to try and formulate what I hope will be an equally good answer, we should begin by defining our terms, though I'll tell you right off, precise definitions are elusive. "Spirituality" can suggest devotion to a particular religious tradition, but often as not, it refers to something that has little or nothing to do with organized religion. It may signify a feeling of relatedness to something and/or someone greater than ourselves or express the way a person conceives of their life unfolding. It may describe a personal sense of meaning and purpose or the conviction there is no purpose, that life is a series of random events possessing no more significance or predictability than the numbers drawn in the lottery. "Spirituality" literally can mean almost anything; it all depends on how we use the word.

Sigmund Freud called religion and by extension, spirituality, a "universal obsessive neurosis," inferring it was associated with psychological ill-health. His most famous student, C.G. Jung, disagreed and considered spirituality essential to a patient's well-being. Individuation -- the process of achieving fully conscious self-realization -- could be nurtured by a spiritual orientation as well as psychotherapy. But instead of relying on the doctor and patient relationship, spirituality activates archetypal images residing in the unconscious that enable us to feel grounded and genuinely connected with the deepest aspects of ourselves, a process some call "soul work." Unlike Freud, it wasn't the practice of spirituality that troubled Jung; it was its neglect that created problems requiring psychiatric help.
 
Jung gave considerable attention to Christian images and theology in the development of Depth Psychology, but he also drew on other forms of spiritual expression, including Hinduism, Islam, and the study of alchemy. In the I Ching, for instance, Jung discovered a useful instrument for revealing his own unconscious motivations. He regarded the symbols that recur throughout the I Ching, religion and mysticism as comprehensible images of a mature and fully integrated self.

If we think of spirituality, therefore, as the expression of a powerful desire or need that, when adequately addressed, leads to a feeling of wholeness, we can begin to let go the notion that spirituality must be opposed to science and reason. True, spirituality is irrational in the sense that it's an intuitive process, but irrational doesn't equate with anti-rational. It simply means spirituality "knows" in a way that sidesteps reason or logic. We call this relying on "flashes of insight."

You could say, intuition operates like saltatory conduction in the brain and spinal cord. Some nerves, particularly the longest ones, are wound about with a substance called myelin, making them look like a string of hotdogs placed end to end. An electrical signal travels along a nerve by leaping between the spaces between one "bun" and the next until it reaches its target. This type of signaling is much faster than the stepwise transmission employed by nerves that don't require "rapid transit" for communication. Similar cognitive leaps characterize intuition, though we may have to retrace our steps in order to explain to others how we "arrived at the station," so to speak.

Quaker philosopher Elton Trueblood described post-WW II America as "the cut flower generation," and identified its critical existential problem as disconnection from its psycho-spiritual roots. Cut flowers look very nice in a vase, but they don't survive very long that way. Spirituality can be understood as an intuitive effort to find one's place in the universe, to put down roots and establish a sense of belonging.  

Although most people probably think about seeing a doctor or psychiatrist when they feel ill or they've got a problem, medicine is moving toward a model that promotes health and wellness. You take your car to the mechanic for regular maintenance, why wait until you're sick to see your physician about health maintenance? If your doctor is an osteopathic physician or psychiatrist, attending to the mind-body-spirit triad lies at the heart of their medical philosophy. "Spirit," like "spirituality," can mean many things, but as physicians, recognizing and cooperating with its presence means we wish to promote wholeness, a type of wellness that touches a patient through and through, that improves their quality of life and the lives of those around them. 

(Creative Commons image by NA dir via Flickr)

Osteopathic Psychiatry, the Forest, and the Trees

You remember the 1998 film, The Horse Whisperer, don't you? Robert Redford riding the range of Montana. Kristin Scott Thomas the intense New York magazine editor. Her daughter, Scarlett Johansson, reeling in the aftermath of an accident involving her, her horse, and an 18 wheeler. Music by Thomas Newman, recalling redemption at Shawshank Prison, sets the tone (no one scores redemption like Newman).

Kristen Scott wants Redford to fix her daughter's horse. It's pretty simple, she says, do whatever it is you do, take my money, and I'll be on my way. I'm busy, my life is full, I don't have time for distractions. He's an animal, not a person, fix him, like my car. You live on a ranch, you fix things, fix this.

But Redford can't and neither can anyone else. Not with a snap of the fingers, anyway. Some things take time, he replies, and your horse is one of them. You should also know, I don't treat symptoms in isolation. Your daughter will be involved and very likely, so will you, before all is said and done. The forest is as important as the tree.

Osteopathic Psychiatry is like that, or it ought to be. 

When I published Osteopathic Psychiatry: Time to Smell the Roses, I had no idea it would become as popular as it has, suggesting other people are as interested in the subject as I am. Curiously, that particular post was inspired by a problem I had researching osteopathic psychiatry. Apart from chapters in the seminal osteopathic textbooks and scattered journal articles, there wasn't much out there. Google "psychiatry" and you'll be busy reading til the next millennium. But a body of literature, devoted specifically to the theory and practice of osteopathic psychiatry, eluded me. I was reminded how unexplored territories are labeled on old maps. No roads or rivers, just the phrase, "Beware, there be dragons here."

Sometimes I wonder if this "empty book shelf syndrome" stems from uncertainty about whether there is such a thing as a peculiarly "osteopathic" psychiatry? What if psychiatry is nothing more than a purely allopathic endeavor that osteopathic physicians practice in imitation of their M.D. colleagues? If that were truly the case, we could stop right here. End of discussion. 

On the other hand, what if the diagnosis and treatment of mental distress and disease, its biophysical underpinnings, and behavioral expression, is a sub-field of medicine, independent of theoretical orientation or professional degree? I believe this is precisely how we should think about psychiatry, much as we do with the other forms of practice that make up the fabric of medicine as a whole. 

Now we're in the position to ask, is there any justification for an osteopathic approach to psychiatry? Are there identifying marks rendering it unique? Suggesting clinical activity is "osteopathic by association," i.e. osteopathic by virtue of being practiced by a DO, doesn't work as well as it sounds. That's too much like saying a wedding ceremony is Baptist (or Jewish or anything else) because a Baptist minister performed it. You can take my word for it, I've performed enough weddings to know, the minister's denominational affiliation means very little. The character of the rite itself must reflect the tradition the minister represents. 

Taking a clue from DOs who practice physical medicine, one of at least two key elements in the "rites" of osteopathic psychiatry should be the insistence upon a person-centered framework for diagnosis and treatment. In my experience, MD physicians almost universally describe DOs as whole-person oriented in contrast to their own problem-based focus. Put simply, and perhaps too simply, MDs are trained to evaluate the tree; DOs to evaluate the tree and the forest as a single entity. Superior is not how I'd describe the difference; complimentary is far more accurate. Our medical house is big enough for each of us to have our own room and share the common spaces without feeling cramped.

A second key element, which could actually turn out to be the defining feature of osteopathic psychiatry, is the way it attends to the mind-body interface. We're physicians, not psychologists. We learn how to perform physical examinations, treat physical illness, and use Osteopathic Manipulative Medicine (OMM) in patient care. Whether we do these in the clinical setting or not, the training and experience are still there. At the core of osteopathic medical training is the explicit understanding there is no artificial distinction -- no disunity -- between mind and body. If the triad of mind-brain-behavior represents the tree, the body, at bare minimum, represents the forest. Mind-body integration lies at the heart of everything we do. How this will work out in terms of philosophy and psychiatric practice guidelines is the direction I think we're moving.
 
The way we're accustomed to thinking about medical practice is changing rapidly. Integrative care, involving psychiatrists who function as consultants within primary care settings, may become increasingly common. A new generation of osteopathic psychiatrists has begun applying OMM to alleviate the somatic dysfunction accompanying, compounding, or in some cases, even leading to symptoms associated with psychiatric illness. DO and MD psychiatrists alike may find themselves monitoring medical conditions their instructors customarily referred to the Internist. Our generation of psychiatrists -- particularly osteopathic psychiatrists -- may eventually be known as the one that took the stethoscope out of the desk drawer and placed it back round our necks, where it belongs.

(Creative commons image by takomabibelot via Flikr)

You Only Live Once

To be completely honest, I've rocked back and forth between remiss and downright absent-without-leave more often than not these past three weeks. And for that I sincerely apologize. The intellectual drain of rotations is as severe as the physical strain and it's getting so that weekends are my only time to contemplate writing. I do fantasize about it at other times, but usually when something cute, wonderful, or memorable has occurred, by the time I'm home, my mind is lucky if it can say, "Huh?"

Now, this condition is not uncommon. Most of my friends are tap dancing around their mid to late 20s and when one of them comes home, so slow and heavy are the footfalls up the stairs, you'd think they were summiting Everest. Rotations are tough and residency is tougher. I've got pals here from my entering class in psychiatry, surgery, and internal medicine and they're the pudding's proof. Tired R All of Us.

But there's more than that and I'm thoroughly enjoying the dormitory environment here in the "osteopathic ghetto," as I've christened it, since the apartments in our converted house are occupied by my classmates. Barely a knock before opening the door to shout is about as polite as we get.

About week ago, a few of us spent Friday evening playing Guitar Hero, a serious challenge, I discovered, for those of us who really know what to do with a six string. The game is about counting but we want to get down with the rhythm and be "big rock stars and live in hilltop houses, drivin' fifteen cars," even if the audience is only electronic and fame and fortune as fleeting as a flip of the switch.

Oh yeah, that's right, you read it here first, Beggar plays Guitar Hero and will again -- first chance he gets. I may have a hard time getting my brain to think in the evenings, but chasing that neon rainbow? Hey, you only live once.


(Creative Commons image by Kermitz72 via Flickr; I Wanne Be a Rock Star, words and music by Nickleback)

Osteopathic Psychiatry: It's Time to Smell the Roses

In August of this past year, the House of Delegates of the American Osteopathic Association passed a resolution supporting the use of osteopathic manipulative medicine (OMM) for the treatment of psychiatric and neurological patients. In some circles, this might be viewed as a controversial decision and for non-medical readers, I need to explain why.

To begin with, we're not really talking about neurological patients since OMM has long been used in their treatment. With psychiatric patients, however, it's another matter. You see, psychiatry has traditionally been the one medical discipline in which practitioners, apart from a polite handshake, generally tried to  refrain from touching patients as a matter of principle. Psychiatric relationships are already complicated due to their subject matter, why risk complicating them further by introducing physical contact into the mix?

Not all psychiatric writers agree, however. Irvin Yalom, MD, for example, argues physical contact shouldn't be rigorously avoided; rather, when touch has been appropriate, the next step is to talk about its meaning for the patient (The Gift of Therapy, 2003). There is a wise saying, Everything is grist for the therapy mill, which means everything that takes place between doctor and patient should be discussed as a natural part of the patient's psychotherapy. But OMM involves more than placing a comforting hand on the shoulder of a grieving patient, which is why the decision to employ it has the potential to generate controversy. From my perspective, the issue has as much to do with history as with theory.

The practice of psychiatry as it's usually conceived can be traced to the work of individuals who were adherents, so to speak, of The Indiana Jones School of Psychiatry, i.e. they made it up as they went along. That's legitimate, by the way, when you're quite literally going where no one else has gone before. You sort of have to find your own way because there isn't anyone who's done what you're about to and can advise you to take up a hobby instead, or better yet, just get a dog.

In those days, psychotherapy was the psychiatrist's primary, if not only, tool -- it would be years before lithium became the first psychiatric medication on the scene. I studied under a psychiatrist who completed her training prior the advent of psychiatric medications and I asked her what that was like. She said being thrust into a ward filled to the brim with actively psychotic patients with nothing to use but psychotherapy was a hopeless endeavor, but as they had nothing else, what else could they do? 

According to the pioneers in the field (Jung, Freud, and others), the cure to neurosis was found in the resolution of the transference (the idea that a therapist unconsciously reminds a patient of another key figure in their lives, a parent for example, and by working through their feelings toward the therapist, they are actually working through painful feelings toward the parent; past and present meet in the transference). I can't say that psychiatrists and patients didn't ever touch because there are records to the contrary; it just wasn't a formal element in the process because it was feared touch might interfere with resolving the transference. The relationship between patient and doctor, therefore, was primarily cerebral and words were relied upon to render it incarnate in flesh and blood.
 
For the most part, the osteopathic community has focused its interests on the application of OMM to promote wellness and treat physical illness, especially in the context of primary care medicine. There are references to its use with psychiatric patients in the literature, but these are few and far between. Many, if not most, osteopathic (D.O.) psychiatrists have been trained in the traditional hands-off model and hence, experience a natural reticence about using touch to any great extent as a treatment modality.

Now, here's the problem. If osteopathic medicine represents a similar but also different approach to medical practice, it only makes sense that osteopathic psychiatry should represent a similar but also different approach to the treatment of psychiatric illness. As long as our methods are identical, however, it's kind of hard to see how anyone can point out a distinction between us and our MD colleagues. If you want to claim your degree confers a measure of "something else," it's only fair to ask what that might be.

In response, many have been inclined to say, we're interested in the whole person. But here's where I run headlong into my own experience. I've trained side by side with M.D. psychiatric residents and witnessed how much they care about their patients. They may not use the mind-body-spirit terminology that is the heart and soul of osteopathic medicine, but they care and that's what matters above all. What I'm getting at is, whatever differences exist between us, they have to be real, measurable, and not based solely on a well-worded principle, as critical as it may be to osteopathic identity (see Mission Impossible, 2/5/2014).

I realize I may be treading on thin ice and not all my osteopathic colleagues are going to be comfortable with the prospect of introducing therapeutic touch into the psychiatric mix. But times change. Physicians can undergo sub-specialty training in alternative medicine. The diagnosis and treatment of psychosomatic illness has its own subdivision within the American Psychiatric Association. The landscape of psychiatry is becoming far richer and far more complex than our forefathers and mothers could ever have imagined when they invented the talking cure. I think the House of Delegates is telling us it's time we woke up and smelled the roses.

(A follow-up essay may be found here)


(Public Domain image via Wikipedia)
 

Narcissism: Unmasking the Victim

 
When talking about narcissism and relationships, one question that almost always comes up is, what kind of person would choose to become involved with a narcissist? This is a sensitive subject; no one wants to come off as critical or blaming, yet it's a question that needs to be broached, if for no other reason than the fact that former significant others ask it of themselves. What was I thinking, how could I have been so naive, so blind. 

To begin with, those who've been in these so-called "relationships" were looking for, and honestly thought they'd found, someone who was genuinely caring. It's terribly difficult to admit to yourself -- much less anyone else -- that the woman or man of your dreams is really a nightmare. It's also true that partners usually aren't dragged, kicking and screaming, into hooking up with a narcissist. There is the aspect of being an accomplice that must be addressed. That said, I don't believe someone who gets involved with one of these individuals necessarily does so with conscious intention. Unconscious motivation can be a powerful underlying factor in one's choice of romantic partners. 

Narcissists are smooth. In the early stages of a relationship, it's nearly impossible to conceive they could be fraudulent. They're too considerate, attentive, supportive, and affectionate. They appear utterly smitten, unable to get enough of us. It was love at first sight and they make the most of every opportunity to remind us of it. 

The narcissist's regularly repeated declarations of affection, however, are what is called "love-bombing." It's one of many techniques employed by narcissists to weaken and break down a potential partner's defenses, rendering them emotionally receptive. Before we know it, they're talking about moving in, sharing an apartment, getting married and having children. Our family loves them, our friends love them; we're living a veritable fairy tale. Until Sleeping Beauty starts to awaken, that is.

Interpersonal psychology suggests partners of narcissists are inclined to have dependent or masochistic personality traits. Either because they prefer relationships to being single or because they possesses an unusually high tolerance for emotional pain, they don't tend to make waves when they're unhappy. Instead, usually out of a sense of loyalty, they excuse their partner's behavior, even when others find it troubling. As long as a partner is relatively comfortable mirroring the narcissist's imagined superiority or insistence they've been ignored, overlooked, and misunderstood, things go fairly well. But there is nearly always some sort of verbal or emotional abuse that goes along with preserving the relationship. Safety and security come at a high price.
 
Partners are convenient targets for the arrogant narcissist's (what we usually think of when we hear the term "narcissist") verbal or physical abuse when they feel embarrassed, slighted, or has failed to receive the respect and admiration to which they feel entitled. Covert narcissists, in contrast, rely on complicated, carefully planned and executed strategies of manipulation to control others. Under severe stress, they resort to passive-aggression as their normally sweet, harmless demeanor disappears and the pent-up rage we rarely see begins surfacing. As a result, they can be as unpredictable and unsafe as their arrogant counterparts. When partners have finally been drained of their usefulness, they're often surprised to discover the narcissist has already chosen their replacement and has them waiting in reserve. 

While not always true, partners of narcissists have generally been trained well. One or both parents possess narcissistic traits and thus, unconsciously identifying similar individuals for intimate relationships is second nature. Recreating the atmosphere in which a person grew up feels familiar. I've heard it said, "I can find a narcissistic predator in a room filled with good women with my eyes closed. It's like my radar is tuned their frequency." Masochism, in the interpersonal sense, doesn't refer to the enjoyment of suffering or pain; it simply means we've learned from parents that abuse is to be endured as part of the relationship landscape. 

None of this is meant to hint that partners are somehow psychologically flawed. On the contrary, they possess considerable psychological strength, as demonstrated by their ability to survive a great deal that is truly unnecessary. Unmasking the qualities that render a person vulnerable to "narcissistic possession" is critical to recapturing one's feelings of self-worth and reinforcing the ability to protect oneself, emotionally, in the future. Failure to do so only increases the likelihood that having been hurt by a narcissist once, we may be hurt again, and that's something truly worth avoiding.

(Creative Commons image by Riccardo Cuppini via Flickr)