On Chronic Depression and Myth

One of the things that occurs a lot in the mentally ill, especially, thought not exclusively, in the mood disordered, is that a mood episode is treated with medication, and the cycling of moods is stopped, yet the person remains miserable, suicidal, even, and suffers a lingering handicap. In the world of psychiatry, this is the stage in which the doctor says, “There are personality factors at work,” which is code for, “This person is nuts and I have no fucking idea what to do.” The patient is then referred for long-term therapy, which rarely helps.

I know because I experienced this recently.  My acute episode ended – the heavy cardinal signs of depression and mania were gone, yet I remained miserable. The same pattern is readily apparent on many of the blogs on my sidebar (Exact Science, Coloured Mind, PWH). The thing that is last to fade, it seems, is the temptation of suicide.

The doctors never seem to understand this. “We fixed the chemical symptoms, why are you still fucked up? Why can’t you just go back to doing whatever it is that you were doing before you flipped out?”

My partner has been traveling to the Far East a lot lately, and has become interested in Buddhism. I got him a copy of Siddhartha, which I only read in high school and remember not liking that much. I thumbed through some of the coffee table books on Buddhism that he brought back, and one detail of the life of the Buddha struck me: that the hardest part of his journey was not leaving home to seek out new knowledge; it was not the reaching Nirvana, complete insight into the order of the universe, and not spreading his teachings to his disciples.

The hardest part was, after reaching Nirvana, reintegrating into the stream of life, caring about other living beings. He was presented the choice, upon seeing Nirvana, to either remain there for eternity, or to stay and spread his teaching on earth. The Brahma itself (God) had to come and convince him to continue on the path.

This struck me as the crux of the matter, as the reason I continued to be suicidal well after the depression had lifted. It is not the descent into symbolic death that is difficult, nor the ascent out of the underworld. Rather, the most painful and difficult part of the narrative journey is the return to the flow of everyday life after the threshold experience.

Myth studies and Jungian psychology are the types that most move me, interpretation through metaphor, myth, and poetry, seeing each individual as a Hero. It gives strength to people to realize that what they are facing is not mundane, not a result of skewed object relations or personality flaws, or dysfunctional families, but rather a part of what humans have faced since the dawn of time, and helps awaken them to the fact that they will have to call on their own mythic strength to prevail.

Mental illness in its life-threatening forms – suicidality, depression, mania, psychosis – is a liminal experience, one in which, unrequested, people are forced to face the boundaries of normal human experience. Symbolically, suicidal depression is a descent into the underworld, in which all of the trivia of normal life is stripped away.

During my last illness, I considered whether I would live or die, nearly each moment of each day. I made preparations for my death, and saw the world differently, knowing that I might not reside in it much longer. Trivia fell away; the world seemed quieter. Preoccupied with thoughts of high cliffs and nooses, the overwhelming unbearableness of life, other things seemed to fade.

When the episode was treated, under control even, I stayed on the edge of suicidal thoughts. They didn’t go away, even though the misery that had led to them did. And the shrinks never understand why.

But myth does. A classic stage in the monomyth is “the return threshold.” Dying is one threshold, and every hero has to face a symbolic death and descent. The hero is then saved and brought back to life with new understanding, either by his own prescience or a force from without. Though it seems like that should be a central plot moment, it is very short, albeit dramatic.

The true struggle comes after. It is not easy, once one has seen the void and been swallowed by it, to return. Everyday life seems trivial, bland, meaningless. When one has faced the pit, how is one supposed to return to preparing dinner, to cuddling in bed, to laughing? To getting up and going to work, to petting the cat, to doing the million small and seemingly meaningless things that make up life?

The road back is long and not terribly exciting. It is nothing like the symbolic death or the symbolic rebirth. It is arduous, in many ways more painful, and its outcome less certain than the simple death or rebirth. It is natural, easy even, to be faced with this journey and to wish to return to the underworld, where things appeared more certain, if darker, more essential, more stripped down to meaning-and-unmeaning. It may be a horrible place, but it least it is a final one, unlike the slow journey up the mountain to a destination – life – that one hardly remembers, that does not promise to be less frightening than the life that led one to the threshold of death in the first place.

And so we stay suicidal long after the depression has faded. We frustrate our doctors by continuing to talk about death and pain and our wish to be freed long after we have stopped waking up at 3 AM and being restless and wrestling with God.

This part of the journey is much longer and more arduous than crawling out of the grave. We, and our doctors, deceive ourselves by thinking that the gateway out of hell is the end of the struggle, the hardest part, when in fact it is the easiest and shortest part. The only way back, as the Buddha knew, is to immerse oneself in the river of life, and forget the rest, let the questions of life and death fade away, at least until they are back for good.

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Yet another Shrink’s Line of the Day

Yesterday I decide that I feel bad about quitting the shrink all abruptly and in a rage. That I didn’t want to end like that, if just out of politeness. I really wanted to call and leave a message apologizing, and wishing him a happy holiday. I said that I was going to be the bigger man here, be the one to let my ego come down off the high horse first. Because, true, he shouldn’t have gotten sucked into the whole yelling and power struggle, but I participated too. I felt bad. I decided that, for the sake of my own dignity, that no matter what he said or did, that I wasn’t going to get into another knock-down-drag-out. I was going to be mature and in control, like my first therapist taught me.

Unfortunately, he answered the phone, despite my best attempts at timing to get voicemail.

“Hi, this is Sara. I just wanted to say that I’m sorry for losing my temper, and I didn’t want to end on that note. So…I’m sorry for anything I said or did that was inappropriate – ”

At this point he cut me off and said ominously, “Well, I’m sorry too that you’ve chosen to be like this and end things this way.”

My blood pressure immediately rose and all of a sudden I was almost ready for a fight again. I mean, even if I and my personality flaws are 90% at fault, there was at least some unprofessionalism on his part.

I took a deep, deep breath, and said, “Let’s not go into this again. I really just wanted to apologize for yelling, and wish you a happy holiday.”

He could hardly control his anger and snapped back at me, “Happy Holiday!” and hung up.

* * *

I promise, soon to get to the post on recurrent/long-standing mental illness and what the Buddha has to teach us. You know, something that might be of use to someone.

But since this is my journal, I can use it to think in writing. This incident raised so many questions for me.

Am I so crazy that I am imagining the anger/stubbornness/power struggles coming from him? Is that projection or some other psychological bullshit I am doing because I’m really as fucked up as he says?

Is there a legitimate therapeutic reason ever for being obscure or concealing the therapeutic mechanism? Is it ever right to say to a patient: I don’t think we can discuss your condition, how we are going to go about treating it? Is it ever ok to refuse to discuss the kind of therapy you do? Is it ok to say, “You just have to trust me” – and not at a given moment, but as a guiding policy? Especially when the patient is going through considerable distress as a result of the treatment? I mean, if I give a patient steroids for a serious disease, and they complain of side effects, I feel obligated to explain why I think that the benefit of the drug outweighs the side effects, what it is doing to them. Is psychiatry really so different?

Is it ever ok to refuse a patient their record, especially while refusing to give a reason? (Thanks to Jay for some perspective on this one.)

Is honesty on the part of the therapist always an important part of therapy? I mean, to me, it seems like that’s exactly what I’m paying for – someone else’s honest and trained opinion. But maybe I am understanding wrong – maybe I am supposed to just let him do whatever it is he is doing?

Is there a rule that therapists should never apologize? I mean, this whole thing would have been avoided (in retrospect), if he could have just said something like, “I’m sorry you feel hurt.” I wouldn’t even expect an apology for the content of what he said or anything – just some sort of acknowledgment that I was upset. Is there a rule in therapy that it undermines authority/transference/focus on the patient to apologize? I mean, my natural instinct in a similar situation with a patient – no matter how nuts they are – is always to say something like, “I’m sorry you’re so upset.” And when I’ve lost my temper or gotten annoyed with a patient, I always apologize – but maybe out of my own sense of guilt and remorse rather than concern for them?

The reaction I got was, “Why are you upset? There’s no reason for this to be upsetting to you. Why should this (being called both narcissistic and borderline in two sentences, one after the other) be a cause for concern?” This seemed so invalidating after I had said it was worrying to me to think that that might be the problem and asked what the treatment would be, what to do about it. I think I would have been ok if he had said something like, “Yeah, it’s hard to hear.” But a total failure to understand why I was upset – and then to tell me to “not be upset” was incredibly invalidating. It’s ok to tell a patient, I think, that their feelings are colored by their past experience or knowledge, that maybe they are taking offense or being hurt excessively – that, after all, might be part of what brings them to therapy. But to flat-out say that someone has “no right/reason to be upset” seems sort of anti-therapeutic to me – I mean, isn’t part of the idea of therapy recognizing and acknowledging feelings (even if one wishes to change them)?

Is any problem always the patient’s pathology?

And most importantly: Why do I keep seeking validation and understanding in a place where I so obviously am not going to get it? Why am I seemingly endlessly attracted to going back to someone who repeatedly hurts me, hoping for a different outcome the next time? What buttons is he pushing in me, or what screwed up need do I have that I keep running right back in for another round?

* * *

I’d like anyone, but especially therapists working in various schools, to respond to any question that catches your eye.

Anyway, if anything, that phone conversation should have cemented my position. From time to time, the situation catches me and I feel kind of bad. Not abandoned or whatever – I mean, I know if I’d just give in and stroke his ego a little, I’d be welcomed back and “forgiven.” It’s not like he’s kicking me out. I am, as he said, “choosing to end this way.” I think the choice is being made rationally, for sound reasons. I mean, I have to trust my own intuition and logic – it’s the only source I have. The real question is why I’ve been ignoring the signs for so long.

But still, I think it’s ok to feel a little sad. After all, even if he never did offer me much in the way of comfort, even if I’ve gone downhill under his care and felt worse for it…it still is, as Tony White would put it, an attachment, even if not the healthiest one in the world. I did like the guy as a person, if not as a therapist. And we’ve known each other a long time. And he did try to help me. Maybe I’m just unhelpable or unreasonable. So I think it’s ok to feel kind of bad, knowing that in the long run I’ll be better off. And I think I really do need to examine why, after so long and so much of my gut and brain telling me otherwise, I kept being pulled back.

Is a big part of it hope and regression? That he promised that, as deeply flawed as I am, that there was hope of a “cure” if I’d just keep coming and talking to him? (A lot of my frustration that brought up the conflict was that this therapy seemed to be going nowhere – that it was just like chitchat…with no change in anything.)

* * *

About the comment on the last post about the colors and design of the blog being dark and depressing, well, true. But I rarely see them anyway – I just see the compose window and get the comments by email. I almost never look at the finished blog, so I forget the dark colors and photograph. I feel sort of like I do want to leave it, just because this is the place I can let the darkness out, my place to be the goth teenager I secretly always wanted to be. My other blog, the one about my real life and not my mental patient life looks nothing like this at all. Though it is a good point. I do take a lot of these kind of suggestions in real life – exposing myself to sun, to sunny people, exercising, keeping the Dali posters off my walls in favor of something warmer – definitely a good point.

Enough

I finally wrote what I thought was a reasonable letter to the shrink, since he never seemed to hear what I said…about how I can’t live in the dark about what is wrong with me or how to fix it, that I was deeply hurt and concerned about the borderline thing, etc. I hoped that we could work something out.

But today, we met. True, I knew I was in a bad mood going in. But on the other hand, he claimed I had nothing to be upset about, accused me of splitting between him and the GP (I knew from the minute they started “coordinating care” that sooner or later I would be accused of this and tried to be so careful not to say anything negative about either of them), said he couldn’t understand why I would be upset, that he was so sure I’m just trying to push away. It felt like always – I say and mean one thing, and he sees it through his filter. Refused to tell me why he thought I was borderline (and then later, when I was angry, said, “See – that’s classic borderline. You’re upset, so you’re trying to make me upset.”), what he thought my problems were, or how we planned to work on them together. (“Part of your problem is needing to just trust me.”) In short, it was the classic psychoanalytic bullshit – the shrink is always right and the patient is always crazy.

To top it off, I requested my medical records and was refused.

The whole scene was incredibly upsetting – to be so totally invalidated. But I had spelled out that I just am not interested in paternalistic care, where my problems and how they will be treated are hidden from me. That if this is the care he gives, I’m not interested…not interested in his diagnosis and not interested in buying a treatment that can’t even be explained to me. That I need collaboration, I want to change, but need the direction on how.

No good. “I can’t understand why you are so upset.”

I left, finally. It was sad, and it was scary. I’m now without a safety net and badly medicated, though I did meet a hippie clinical psychologist I sort of liked (woman).

I drove home and cried a little, felt like throwing up. It was so humiliating, invalidating. But – I also drew my lines in the sand. I can’t say I was totally calm; in fact, I was angry. But I spent months examining myself closely to see if what he said could be true, if there was justification in my anger. I decided there was, and that I needed some acknowledgment of that. I really didn’t expect not to get it at all. But I didn’t.

And that’s just not ok with me. No matter how sick I am, how bad I feel, how much I need help…I don’t need it that bad, bad enough to believe that I am so crazy that I am totally out of touch with reality.

So, through my tears on the way home, I reminded myself that I can save myself, that maybe only I can save myself, that I’ve done it before, and that I can do it again. That I’m somehow going to be ok. That I am a decent person, despite how broken I may or may not be.

I might go re-read The Color Purple. I think that is the message that I need to hear – remember Celie? Raped as a child, beaten, cast-away, unloved by anyone, half-literate…she knew somehow that she was a human being of intrinsic worth, one of God’s creations, one of the things that is included in the phrase “God love everything you love–and a mess of stuff you don’t.” That even if she was poor and ugly and a woman…the universe had created her with love. That God loved her, even if nothing and no one else did. That she existed, just as lovely as a wildflower.

I may suck at being happy. At being patient. At controlling my temper. I even may suck at loving the people I love. But I can do some things – I can comfort people and I, on a good day, can write words that mean something, that capture something real that happens to people. I can forgive. On a good day, I can be grateful, and on a great day I can pray, or at least I used to be able to. I can be part of the universe sometimes, and of the human race when I am not sick. I can overcome my fears. I can see the color purple. I can survive the dark night. I am a living, breathing part of the universe, and sometimes, that is enough.

I just need to remember that, to remind myself that during the moments when it seems like everyone is trying to tell me to the contrary.

  • * *

Note to self for next post – remember to post the thoughts about chronic depression, the idea of depression as an addiction, why some people can’t seem to give it up, and the Buddha.

Thanks for continuing to read

When a poster on a blog like this stops posting, usually one of two things has happened: either they’ve hit a significant remission and have somewhat lost interest in all things mental-health-related, or they have taken ill in a way that keeps them from writing, usually either a severe depression, hospitalization, apathy, or the black hole, in which there is nothing to say. And, I guess, sometimes they die.

Usually they come back to writing sooner or later, good for the second group, not so good for the first. As far as I know, there are no reports from anyone from the third group hasn’t returning to blogging.

I, unfortunately, belong to the second group, have had a tremendous crash-and-burn. I’m not sure why I’m writing now, and I apologize for the quality; it is written through a haze of legal psychiatric drugs that makes it difficult to stay conscious, let alone coherent or eloquent.

I just wanted to say that the other night, I went outside in a miserable state, where there was no peace to be found – not in drugs, not in music or poetry or adventure novels, not in trashy magazines, and not in sleep, which, anymore, is haunted by nightmares. I sat under the stars and smoked a cigarette. The moon was half full; soon, it will be full, and then, after that, the next time it will be full, it will be Passover.

And I thought: I really would have liked to see another Passover, that holiday I love so much, when I really do feel the holiness in the air, the meanings, the social and the mystical. The elision of time, when it is that same night as it was so long ago, in which we start out bound and by the end, hopefully, will be freed. And the merging of the physical and spiritual – the tastes of the bitter and the sweet.

I always loved Passover, the one time when my skepticism and atheism faded into a sentimental belief in magic. I would have liked to see this one. One more. One more full Nisan moon, one more race to bed before midnight. One more hope for Eliyahu to come and save us from this sorry world. To save me, on the wings of the Shechinah.

But I just know that it isn’t going to happen. That I won’t have one more Spring. I think it’s too late now. I’m too far lost, beyond a way back, beyond where I can even want one.

And finally, after all this time of numbness and dead souls, I sobbed. I could imagine something, anything, that I did want to see, would have liked to see, to be there for. Knowing that, I could sob. Not for missing the rest of my life and not for the gruesomeness of death or hopelessness or suffering, but for the simple, plain, yet cosmically significant idea that  I really would have liked to make it to Passover. One more time, I would have liked to feel that. And I most likely won’t.

Just that. I am beyond missing future adventures, past beauty, beloved books and books to come, future love, past love, present people and the spectacular world around me. I’m far beyond mourning any of that. Those things all have lost the hold they once had on me. I don’t love the things that I used to love anymore.

But I would have liked to see the Seder table, one more time, the poetry and ritual of it, the full moon, the sense of blurring of boundaries between present and past, the individual and the symbol, the present reality and the hope for a better day. I would have liked…to just be there this Passover. And oddly enough, when nothing else could, that was enough to make me cry. I was sort of surprised I still could.

I did not see this coming

The latest in my escapades – no essays or deep thoughts or medical stuff here, just my personal update.

The anxious racing episode, naturally, crashed into a depression that hit hard and fast. Or maybe not so fast, but I didn’t feel it until it was out of control.

I think I am more and more becoming a burden. I haven’t had many normal conversations with any of my friends lately, it all revolves around my condition. I feel like a burden, and though they’d never say it, we are all doctors in training and under so much pressure that we are very limited in how much we can give to each other. It’s sad, but it is how things are. I also just sort of want everyone to go away and leave me alone, so they won’t see all this, and I can return to my life after I’m better without having done too much damage.

It is very hard for me to accept help, and I just want my partner and everyone else, well, I want them to help me and care for me, but I don’t want them to see me like this.

Since the depression got worse and worse, I went to my GP, who is very sympathetic to these kinds of problems, having had a son commit suicide, so he treats people with mental illness like people, not diseases. Actually, I didn’t want to go, but the psychiatrist wouldn’t treat me further unless I did because he wanted to be sure I wasn’t physically ill. I had attributed a lot of the physical symptoms to medication side effects and the depression effects.

I went to the GP and told him to just sign off, send some basic blood tests etc, and to give the shrink a green light to continue treating me. I told him I was not alright, but I couldn’t tell him about the suicidal thoughts. He knows about the depression, not sure how much about the whole bipolar story. He said I looked bad, and asked if I had ever been this bad before – I had, twice.

He started to do a brief physical exam, like, put a stethoscope on me while I was just sitting in the chair, but once he heard my heart, he told me to get up on the table, and did a full exam. He started yelling at me (well, not “yelling at me” but he got surprised and upset) that I was in horrible physical condition – apparently malnourished and dehydrated almost to the point of shock – racing pulse, minimal blood pressure, gray, the whole textbook version.

I had been feeling dizzy and horrible, but thought it was some central effect of some drug so I didn’t really pay attention. I was surprised because I’d been working as usual. I knew I hadn’t been eating because the depression sort of took away my appetite and one of the medications or another was making me either unable to eat or throw up often. But I didn’t think it was so much. I had been trying to eat a lot of calories in whatever I did eat – adding butter and honey and always juice with lots of sugar. It’s my “depression diet” because I know that sometimes I lose a lot of weight fast when I get like this, so I try to pack as many calories as possible into what I do eat. I guess I didn’t start early enough this time.

He called the psychiatrist from the office right then and there. This felt really bad, like I was this wayward child who needed to be taken care of – all of the sudden I was the ward of these two doctors, playing ping-pong about what to “do with me.” I only heard the GP’s side of the conversation, but he said at the end, “Look, I really think we’re getting to the limits of what can be treated outpatient.” No idea if he was referring to mental or physical state.

He sort of vaguely asked me about suicide, asked if I could or would talk to the psychiatrist about that. I said, “Probably not.” But it got the idea in my mind that maybe I should say something.

I walked out of his office and I remember sitting down at a bus stop just to rest and catch my breath for a few minutes before going to the car. It was freezing. But I was so tired, two hours passed while I sat there, watching people and buses come and go, waiting for the energy to get up and leave.

I did the blood test and the H. pylori test, and then went to meet a close friend (also a doctor), and told him how scary facing hospitalization was (for either the medical or mental stuff, I wasn’t even sure which anymore). He told me, “You look terrible. I’m a friend, not your doctor, so I’m not going to tell you what to do, but maybe you should go to the fucking hospital.”

The next day, I went to the shrink and confessed the suicide stuff, even though it was hard. It seemed like the responsible thing to do. I think I was actually looking a little less depressed by then because going to his office makes me so nervous that it gives me a little energy. He basically didn’t react. Nothing. I asked what to do. Nothing. I felt ridiculous, like some drama queen. He didn’t ask any of the suicide questions that even I know to ask (Do you have a method? Plans? What do you think will happen if you do? What stops you?).

Finally I asked, “Do you think this is some sort of manipulative thing, just to get attention, or something?”

His answer was, “It would only be manipulative if you were doing it consciously.” (I guess that qualifies as a Shrink’s Line of the Day.)

Then he said he wanted to give me Zyprexa “as it recently got approval as a mood stabilizer.” He sounded like a fucking Lilly commercial. I absolutely refused. Then he got angry at me. “You just can’t work with you! You say you want help, but then you refuse the help anyone offers!”

I asked him if he would take a pill of that. He said that that wasn’t a fair question. I said I ask myself that every time I prescribe something for someone (true). At the same time, he told me to stop the antidepressant that he started a week ago – just as I had started to get over the nausea from it, way before anyone has any idea as to if it will work or not.

As usual, I left there feeling worse than when I went in. Maybe he was right, who knows? Maybe not reacting will discourage me from threatening suicide again. He’s a nice guy. He did call today to suggest maybe somehow finding some derm specialist who can solve the side effect problem of the old drug (or possibly that was the subtext for calling to make sure that he didn’t kill me after all), that he had searched around the area and there was some guy a few towns away who specializes in drug reactions in the skin.

I said I was sorry for being such a horrible patient.

The next morning I went back to the GP for the test results and because he had said he wanted to see me again the next day. To make sure I was still alive, I guess. I told him what happened. I asked him if he thought I was being unreasonable to refuse the Zyprexa. He did the screening for psychosis (of which I have never had any symptoms). Then he said that Zyprexa seemed a little excessive (“an atomic bomb drug”), but that he didn’t know why a psychiatrist would suggest that or what psychiatrists consider.

You see so many psych patients who come in with lists of maybe 5 or 7 psych meds, from all different categories, and they look horrible, like zombies, and you have to think that whatever their illness, it can’t be as bad as that, and that there is no rhyme or reason to treatment, they just keep throwing more drugs at them, one on top of the other. That poor girl I wrote about was on something like two antidepressants, and old and a new antipsychotic, a benzo, valproate, and a sleep aid. No wonder she could hardly speak.

I felt like I was slowly turning into that. I was on a lot of peripheral shit at the time. The psychiatrists, including mine, mean well, but it’s such a strange field, no one knows anything, and they just keep throwing more and more drugs on people until they are just shells. I feel bad, so he gives me a med, and I still feel bad, so he gives me another – it’s all well-intentioned, trying to relieve my misery. But I got the feeling that that was what was happening to me – I was being made sicker.

So a few days before, I had also stopped taking all kinds of benzos and sedatives and phenergan and shit that the shrink had put me on, and only left the antidepressants, so I think I had a little more affect when I walked in to the GP, looked a little better, even if I didn’t feel better. I wasn’t like the walking dead.

The clinic was very busy so I didn’t want to take up a lot of his time. But it took me a minute or two while I asked him to wait so I could get up the courage to tell him that I had been checking my life insurances, making sure everything was in order. I didn’t tell him the rest. But he took me seriously, told me to go home, go to sleep, and come back in the morning again.

I was supposed to go with my partner to his parents’ for a few days, but when he got home from work it was late, and I had showered for hours and gotten minimally dressed to leave. But I was so weak and lying in bed, thirsty, sort of hungry. I couldn’t move (as had happened most of the week, lying down with no willpower to physically move my muscles). I just couldn’t get up and pack a bag and get in the car. The wind was howling outside, and the bed was warm and soft, and I was so tired, and thought of the uncomfortable bed at his parents’, and their yapping dog and the noise there…when I finally felt sleepy and warm and safe at home. I just told him to leave me a glass of water and go without me.

The prospect of a silent weekend alone was so tempting. I slept. Woke at 3 AM again, but not as restless as usual. Just relaxed in bed and listened to the wind until I fell asleep again at dawn. I got up in the morning at 9. I wanted to go back to sleep, but I figured that since the GP had been so decent, the least I could do was show up. (Friday is a half day for him at that clinic.) So I went in there, and sat down to wait, and started to feel faint so I went and bought some juice. I didn’t want to pass out and make a scene, or worse, be sent to the emergency room of my own hospital.

I told him that I thought all the drugs had really knocked me down and out, taken away the last bit of energy I had to cope with anything, including the depression, that they were slowly working their way out of my system. I kept taking the antidepressants but stopped all the heavy shit. And suddenly I could move again.

He asked me about my plans for the weekend, and I told him honestly…that I just really wanted to be alone at home. He said I deserved some rest. I was glad he didn’t try to insist I be around someone, that my partner be home or that I go with him. I thanked him and apologized for making such a mess and scaring him, and he hugged me and told me to come back sometime next week.

Then I went across the street and bought a newspaper and some bread and light food and went home and, for once, instead of dropping it all on the floor to deal with later, put the things away. I took out the garbage and minimally cleaned the floor. I drank and ate a little bit, then went back to sleep until the afternoon. Then I moved to the sofa and watched bad 80s movies. The quiet day, no one at home but me, the big bed all to myself…the sleep, for God’s sake. It was all so sweet.

I hate to say I’m getting better because every time I say that something horrible happens, but I wish this quiet could never end. I am just going to try to enjoy the rest of the evening, watch bad sitcoms. Try to sleep off the rest of these drugs. Not to worry about all the things that got me to this point or when I will go down again. Not to fantasize about suicide. To eat long enough before taking the meds that I will gain some calories from it. To drink. To try to orally fix the electrolyte mess that came back in the bloodwork.

* * *

I’m not sure if I learned anything from all of this or what the point of writing it down was. No profound insights. I didn’t suddenly find purpose in life, and I don’t know how long I will remain ok. I have to go back to the race shortly and I am terrified and still exhausted. It’s not a big happy ending. I don’t “know that I have more of a safety net than I thought” or that “people really care about me” (they do, but I already knew that and it doesn’t really matter when I’m in that place). And it seems like I have made a real mess of my body that will need some straightening out. I guess that there are probably some readers who read for the personal stuff, the same kind of stories as they go through. So that is why I am trying to be honest here for you.

I may go back and remove or edit this. It feels very raw and exposed. But for now, this is my story.

Crying at the shrink

I did cry at the shrink’s the other day, and that was strange, because I’m usually so hard and in control. But I was so strung out by anxiety and three days of no sleep from the bupropion that it took me a few minutes to even calm down enough to talk (this kind of hysterical shit is very unlike me). In an ominous tone, from him, “You NEED a mood stabilizer.”

He wanted to send me home then and there with an injection of phenergan so that I would sleep a few hours before being on call; I declined. Not a fan of the sleep aids. Last time I took zolpidem, I was fine and awake in the morning, but almost got in a car accident, which had never happened to me before. (And while on call, I saw yet another acute dystonic reaction, so there about the phenergan.)

But at least the massive anxiety from this drug, as well as the calming of the affective storm, for once made me feel both stable enough and uninhibited enough to actually talk to the guy about something that happened in my life that was very meaningful to me, that happened a long time ago, advice that someone gave me that let me move on from grief and heal tremendously from a big wound.

Without going into a long and sort of irrelevant story, the gist of it was that an older woman knew me well, and gave me permission to grieve about something when I was a teenager, to acknowledge a severe loss and hurt. She was one of my mother’s friends, artist-spiritual type, and gave me a concrete ritual to do to give myself permission to grieve, and maybe open doors to a grief I didn’t fully realize I had, or was entitled to. I remember thinking the idea was silly at first, but I went home and tried it (starting by looking at old pictures and just thinking about the people in them), and it unleashed a tremendous flood of tears.

Let me state that the “ritual” she recommended wasn’t an exorcism or supposed to work on some bullshit supernatural plane; I think it was pretty sound psychological advice, if phrased in terms of spirituality. It allowed me to realize a loss I hadn’t acknowledged because it came at such a horrible time in my life anyway, and to free me from the past by letting me discover various feelings of anger, injustice, and ultimately, mourning. It was not “out there” by any means. It wasn’t like she told me to draw a crop circle so aliens could come heal me. It was just something to formally mark a loss, which gave me the opening to feeling it.

And sometimes even today, years later, maybe once every couple of years, I revisit those photos and what she told me, and I cry again, hard. But it is different now, in the way that grief changes. I look at the pictures, and it’s not this raw gaping wound, it’s just sort of a nostalgia, a sense of being sorry that things didn’t go the way that they would have in a perfect world. A love for times and people past, with all the imperfections.

She gave me the gift of being free from something that could have torn me down, destroyed any potential I had to be other than numb or in shock for the rest of my life. She gave me the gift of healing.

When I think about it…no, that’s not right, when I feel it, really let myself remember and feel, I can’t help but cry. And that’s what happened at the shrink. It wasn’t like I was sobbing hysterically and out of control. It’s just that the story opens in me some very bittersweet emotions – of the loss, of the gratitude of being able to let go, of the magic of healing, and of a million other things, too.

I noticed also that for the first time with the shrink, I was talking in terms of how I really think, how I used to be, because it took me back to so long ago, to a time when I was in my core state, when I was really ok. I spoke in terms of ritual and feelings and symbols, which is a reflection of how I see the world, how I grew up, in a world of artists.

I think I concluded the story by saying something like, “That’s what I think I need now…a priestess. An older woman who knows what happens to women, how they get so hard and cold, the way I’ve gotten to be. I wasn’t like this then. I was warm, and loved everyone, and was so idealistic and compassionate and forgiving. I wasn’t ice like I am now. I need someone who understands how that happens to women’s spirits, how they get lost in the woods and meet so many monsters that they start building up armor, and how to set me free again.”

I’ve said to the shrink many times, “We don’t speak the same language.” I don’t think he ever quite got what I meant. It became clear to me. I have always spoken to him in medical language, the language I’ve learned, the language of pathology and death. But that isn’t my real language. I think that I had forgotten my real language a bit, and speaking in it, of ritual, magic, symbols and signs.

After I said all this, the contempt was all over his face. Then he said, “Sure, she just gave you a magic solution.” Obviously he also wanted to say that he thought that she had probably done me psychological harm. But it wasn’t a “magical solution” and it didn’t solve anything overnight.

He thinks that at the core, there is something wrong with me that it will take expert reparenting or whatever (naturally, by my submission to his worldview and acceptance of it, by letting him be daddy). I think that at the core, I am actually healthy, and just need to be freed from a lot of things that happened to me along the way. I need to find my way again.

And that is what became so clear to me sitting in front of him. For once, I didn’t give a shit that he was so dismissive, so utterly un-understanding, because I know what is wrong now. I need my language back, my self back. I need to get rid of the chains that medicine has wrapped around my soul and return to the path. I don’t need to fix what is broken; I need to find what is whole.

Suddenly I could see a chain of events, a period of time, in which I became hard, and cold, and unrelenting, began to speak in a foreign and cruel tongue.

I saw that he didn’t get it. So I started to say something like, I just think I need to see a woman…because I just hate men too much. It was my way of letting him off the hook. It isn’t his fault he’s a man. It’s easier and kinder to say that than to say that it is his fault that he hasn’t seen me, not really, not once, in all these years. That managed to set off a huge argument over whether it is normal or not to hate men. Which was missing the point, but that’s ok. I finally see it: he’s just not going to get the point.

But I do. And that’s a start.

* * *

When I asked her what I/we could/should do, she took up her walking stick and walked expressively and purposefully across the room. Dipping a bit from side to side.

She said: Live by the Word and keep walking.

– Alice Walker

Another psych patient. Could the signs be any clearer?

Another psych patient just fell on me last night. (Not the two other cases I didn’t write about.) We had split the night up and gone to bed – two hours and twenty minutes for each of the three of us on call. Two patients came in on my watch with abdominal pain. One was seriously psychiatrically ill.

He knew none of his medicines except for valium, which also was the only one he brought with him. (I actually can understand this; in an emergency, I’d definitely pick the clonex over just about any other drug.) His pain wasn’t really probably that serious, but his anxiety levels and panic caused him to pace around screaming, “I’m dying! I’m dead!” Fist pounded into wall. “Give me something for the pain!” He had a bed, but didn’t want to stay in it. He was doing the exact thing I described here. The nurses and staff were sick of him, especially since at 3 AM, most of the ER was sleeping and he was disturbing other patients. It would have been easy for me to get annoyed too, but I couldn’t, having written what I wrote just days earlier.

Everything about the story and exam suggested nothing serious. When talking to him calmly, he calmed down considerably. Touching his abdomen, even deeply, caused no obvious discomfort as long as I kept talking to him about something else while doing it. He had taken so much valium at home that I was hesitant to give him a narcotic, even though I did believe that he was in a lot of distress. I explained that to him. I thought that the thing that most would help him would probably be to give him a little more valium, maybe even IV, but I didn’t. I didn’t know how much he took regularly; he said he had taken 40 mg at home. He didn’t seem calm at all, so I figured that was just about maintenance for him.

In the hospital’s infinite wisdom, the psychiatric hospitalization discharge summaries in the computer are blocked. I couldn’t see what he was taking other than that (thinking along the lines of drug ileus), or what much of his problem was. An old medical summary had PTSD in there, but also mentioned a psych evaluation that had included episodes of psychosis under stress, borderline IQ. Whatever. All I wanted to know was what meds he was on.

The thing is, since I was already up, and not really feeling safe about giving him serious pain relief, and the nursing staff was going apeshit, I decided that it was time to try a “non-pharmacological pain control” mechanism, the kind of shit you learn about in the touchy-feely medical lectures, but never actually have time to do, and don’t believe will work anyway. I went over to the bed, stood at the head, put him back into bed, and I actually dropped the head of the bed down to put him below eye level for me. I always tend to walk in and the first thing I do is put the head of the bed UP so people don’t feel so helpless, and because it’s weird to me to talk to someone not on eye level, but this time I wanted the opposite effect.

I decided I was going to try something I’d never done before. I was going to do like the ER docs do. He was still yelling to “do something, I’m dying.” I summoned up my most authoritative “doctor” face and posture (and believe me, that gave me a little internal laugh), and instructed him to lie very still.

I examined his abdomen again very slowly, even though I had done that just 15 minutes before. I told him that nothing had changed, that everything was fine. I kept one hand on his shoulder, firmly, as I spoke. I told him that even when I went to work at the station, he was in a bed very close by, and I was keeping one eye on him to make sure nothing would happen.

To my utter amazement, it worked.

Anxiety and pain are funny, linked phenomena. People regress when they’re scared, need someone to take charge.

Unfortunately, when the morning surgeons came on, they decided that they couldn’t communicate with him well enough to rule out a serious problem without a CT. So he got a heavy dose of radiation. I never would have ordered that, especially given the whole history of the pain.

Damn.

* * *

I guess the lesson of this is for me is that there is a time and place for me to take on the authoritarian role. To speak very certainly, not explain options, just tell the patient that something is fine or not, and what the next step is. “I am now going to send you straight to x-ray,” without explaining why.

Usually when I do a physical exam I talk through it, while I’m doing an abdomen, I say as I move my hands around, “There’s the liver area, look, it’s not tender…and now let’s see about the spleen.” I also note every normal finding as I do it, because a lot of people think the worst. For example, when the doctor listens to your heart, really most of what they check is the valves only. A heart having a heart attack most likely sounds completely normal. It’s my little personal routine, as I move the stethoscope from spot to spot,  to say in between, “Everything sounds good.” This is a fairly meaningless statement, because plenty of hearts with problems sound fine, but still, it seems to me the considerate thing to do. I’ve never had a reaction other than relief or gratitude when I say this.

I also think: after all, it is the patient’s body, not mine. Just because I am trained to know things about it, to extract details about its state of health doesn’t mean that I have the right to know something about it that the patient doesn’t.

Incidentally, I also explain why I ask a weird question when I do, one that might seem irrelevant.

I do this because I remember as a kid, or not even a kid but a college student, the physical exam being so mystifying. What the hell were they doing? What could they tell? Why were they sinking their hands into my stomach? What did they hear in my heart?

But I didn’t do that this time. Instead, I examined very slowly, with a serious face, as doctorly as I could, and then gravely pronounced him “Well.” And…it worked.

* * *

I would like to improve at dealing with angry, challenging patients. Not the ones who come in angry that they are ill, that they had something horrible happen to them, that they had to wait. Those who come in immediately hostile to doctors and to me, often to women in general, and who immediately challenge me on every point, including “Good morning.” They often have very suspicious streaks toward the world in general, or narcissistic ones that mean that no one is a good enough doctor for them, that they aren’t getting the treatment they deserve, no matter what. They also often come from a perspective or worldview that is very violent or power-struggle oriented, in which the way to get something is through a show of threat.

I suck at these patients. One reason is that they are usually men who are physically bigger than me (I’m a teeny thing, even if my presence is larger than life sometimes, ha ha), and it’s always a little scary for me to step alone into an exam room with them. I rarely know these patients beforehand, so I don’t have any gauge of violent potential or what will make them blow.

Furthermore, while I can call security to come stand there, to me that seems like it would just make everything worse. Maybe not, though. Maybe I need to reconsider.

I used to think this was just a situation to deal with, that they were whatever they were for their own reasons, and I just needed to get in and out of there as fast as possible. On some level, I’m probably angry at them for them being able to scare me. I am sure that they see that they intimidate me. Then, they end up pushing me more and more for unnecessary testing, and nothing every satisfies them. A good example would be the father of the girl with no acute problem.

But I’ve noticed that some doctors walk in and manage to defuse the situation, at least partially, very quickly. Lately, I’ve been watching very closely, trying to figure out what they are doing.

I have been dealing with them in the same way that I deal with most patients, explaining everything I am doing and thinking. I think this is where I go wrong. The doctors who manage to deal with them, sometimes even get a “thank you, doctor” from them at the end, don’t do anything like this. They usually walk in very calmly, sit very close to the patient, and are absolutely unruffled by the aggression. Now, to be fair, I’ve seen mostly men who are very gentle by nature do this. And usually they are older than I am, with those few gray hairs that make them look more authoritative, more “like doctors” than I do.

They take a history, explain nothing except what will happen next. Then, at discharge, they say confidently what it is (without admitting to the uncertainty involved in almost any diagnosis), state that the patient will be fine or needs to do x, y or z, and walk out.

I think that what happens is something like this. These patients see everything as a power struggle or hierarchy. This is a primitive kind of thinking, but it is what it is. The doctors who deal with them well, I think, do something like this: they walk in and establish their authority immediately. They use the position of doctor and the socioeconomic gap as leverage; they are not “fellow human beings” in this relationship.

Yet while they do that, they use their calm, gentle demeanor to establish themselves as benevolent authority. When a patient only understands pecking order, he also understands the concept of being in the subordinate position, and can accept that, and is quite happy when the authority is benign and caring. I suspect this is what happens because the “thank you, doctor” they get is often in a very deferential tone. They say things like, “That guy was a great doctor. He knew exactly what he was talking about.”

A position of equality, or maybe of uncertainty as to where they stand, bothers them; they need to know who is in charge. With someone like me, a kid, and a girl, on top of it, all they know how to do is to push and bully. What I see as being respectful and fair and honest is seen to them as an invitation to try to get “on top.” These are the patients who get angry when I offer them treatment options.

My problem with this is as follows: we don’t always know, even most of the time, we don’t know. We can say it is nothing serious with confidence, but God knows we have no explanation for various headaches, stomachaches, joint pain, constipation, etc.

Here is an example. An older man had hernia surgery. The family was very concerned, because a few hours following the surgery, he had one episode of loss of control of urine. After that, he had no problems and the incident did not recur. They were very concerned, which is reasonable enough – after all, there are nerves down there that are definitely in the area operated on. Had he had a stroke? Had he had a seizure?

After that one time, he had no urinary symptoms, no retention, no incontinence. Normal neuro exam. It had been general anesthesia, not anything in the spinal area.

The family kept pressing me for an answer. Now, I don’t think any doctor has any idea why this happened, except that elderly people can lose continence around a medical stress. I was certain that nothing serious had happened. I said, “I don’t know why it happened. It most likely won’t recur, and there is no evidence of any damage.”

They were pretty unhappy with me.

Then a friend of mine came through (at exactly the stage of training I was), and they asked him. He immediately said, with a ridiculous amount of confidence, “It was a reaction to the anesthetic or the muscle relaxant used during the surgery, that caused the muscle to stop working for a little bit.”

Now, what he said was certainly plausible, though it isn’t really a listed complication of anesthesia. Was there any evidence that what he said was actually what happened, other than “it could have been?” No. But the family was overjoyed with this “explanation,” and loved him, while assuming I was a shitty doctor.

Most doctors do this a lot for something minor – come up with some “explanation” that sounds vaguely physiological, something that they could believe themselves. But I always feel dishonest if I do this, if I say, “We know exactly” when we don’t. When doctors discharge someone with non-serious, yet undiagnosable complaints that will probably go away on their own, they usually throw a medical word or two at it: You have “gastritis.” You have “a slipped disc.” Do they actually know the stomach is inflamed, or is the history very suggestive of it? Is there any evidence to suggest that the disc is the cause of the pain?

I have trouble doing that. I feel dishonest. I usually say something like, “You don’t have appendicitis. You don’t have gallstones. You don’t have a perforated ulcer. You don’t have anything dangerous at this moment. Given the symptoms you have and the way they occurred, it is most probably infectious and should go away on its own.” I am always afraid to toss out one of those half-assed diagnoses, because I always think that it is possible that as the natural course of the disease plays out, a different and more clear diagnosis will come through, and I’ll be the idiot who said the wrong thing.

But it seems like people really want that. Ambiguity is, apparently, a tough pill to swallow.

* * *

As for me, I seem to be doing better, as evidenced by the fact that I’m writing about medicine and life, rather than my own personal misery. In fact, I’m not sure I want this blog to take that direction; medicine consumes enough of my life, and this was supposed to be an outlet for other things, for me. My misery blog. I wouldn’t want to gather a readership that is the “medblog” group. This is where I want to be allowed not to be a doctor.

And most misery blogs get boring or abandoned once the writers get well. I mean, I’m happy for them and all, but reading these kinds of blogs, well, we mostly do it to find someone who feels bad too. During my well periods, I usually abandon this blog.

But I’m going ahead with it, at least this time, because it is roughly a continuation of the last post and touches on some psych issues, if not mine.

And knowing me, don’t worry, more misery will be on the heels of this good spell. Just stay tuned.

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