So I’m looking for a pair of shoes at the Nordstrom Rack to go with a particular dress (<girly>there was a darling pair of flats: black patent leather, round toe box, small black ribbon bow adorning the toes—so cute and—for shame!—just too large for my feet…</girly>). While I’m winding through the aisles, scanning the barrage of shoes strewn across the shelves, I see a woman in the adjacent aisle. She’s wearing a large white hat.
It’s obviously not a fashionable white hat.
We both wander into the same aisle. She continues to examine the shoes. I examine her hat.
It’s shaped like a top hat and composed of a soft, felt-like material. The cylinder arising from her head is a white birthday cake sitting on top of a white tray (the brim of the hat). The cake is “frosted” with flowers of various colors, which are linked by white ribbons. The front of the hat/cake reads “Happy Birthday!” in red letters.
I smile to myself. It’s cute in a totally ostentatious way.
She looks up and sees me looking at her hat.
“That’s a great hat,” I comment. Realizing that she must be wearing this specific hat for a reason, I add, “And happy birthday.”
“Thanks!” she replies, smiling. She turns to resume her search for shoes, but suddenly turns back.
“Hey,” she says, “do you want to sign my birthday card?”
I’m caught off guard.
“Sure,” I reply, still not entirely sure what is happening.
She pulls out a card—pastel colors on the front; I don’t even read the text in the card, I’m so distracted with whatever this is that is unfolding—and hands me a pen.
Black ink. Gel ink. Probably 0.7mm.
I push aside some shoes on a nearby rack and place the card on the cool, steel surface. Only one other person, with loopy penmanship (the kind that kindergarten teachers have), has signed the card:
Happy birthday!
Barbara
I start writing:
Happy birthday!
Great hat.
Maria
I return the card and pen to her. She smiles at me again.
“Thanks!” she says. I automatically return her social smile, though I’m actually now examining her face. I notice her light hair and fair skin. She’s probably got a little bit of lipstick on her lips. Freckles. Small teeth. I don’t register the color of her eyes.
I’m still distracted.
She walks away. Many questions run through my mind….
And only now, as I type this, do I realize that I never asked her for her name.
9 Mar 2008 | 3 comments.
One Month’s Worth.
Originally posted in July 2006. Inflation has increased in the interim, so I suspect that some of the comparison prices are now invalid.
The amount of money required to obtain one month’s worth of the antidepressant fluoxetine (trade name: Prozac) can buy:
- one Snicker’s candy bar (from a downtown Seattle vending machine)
- two first-class postage stamps
- Fifty-four minutes of street parking in downtown Seattle during business hours
- ($0.03 for one 20-milligram tab = $0.90 for one month)
The amount of money required to obtain one month’s worth of the antidepressant bupropion (sustained release) (trade name: Wellbutrin), which can also be used to facilitate smoking cessation (trade name: Zyban) can buy:
- 21 pounds of Washington-grown Red Delicious apples
- 30 songs from iTunes
- A seven-week daily subscription to The New York Times
- ($1.16 for one 150-milligram tab = $34.80 for one month)
The amount of money required to obtain one month’ worth of the antidepressant paroxetine (trade name: Paxil) can buy:
- About eight gallons of unleaded gasoline (at one of the cheaper stations in Seattle)
- A little over two pounds of Starbucks House Blend coffee (whole bean or ground)
- 243 Verizon mobile phone text messages
- ($0.81 for one 20-mg tab = $24.30 for one month)
The amount of money required to obtain one month’s worth of the antipsychotic olanzapine (trade name: Zyprexa) can buy:
- Three yearly subscriptions to The New Yorker
- Over 50 McDonald’s Big Mac burgers
- 32 gallons (two kegs) of Budweiser beer
- ($5.69 for one 10-mg tab = $170.70 for one month)
(Note: Medication prices listed here are approximations only and are likely cheaper than that at other hospitals due to the population this particular facility primarily serves.)
And frequently the people who could benefit the most from these medications are the ones who cannot afford to pay even a tiny fraction of the price.
When will it stop being about profit?
8 Mar 2008 | 7 comments.
Control.
For the past few months, I’ve been turning the idea over and over in my head, as if the idea was a chicken on a rotisserie in one of those greasy glass enclosures.
I perused Google Maps. I stared blankly at a monthly calendar of June. I made, deleted, and remade “could feasibly move”, “could consider moving”, and “don’t move/sell in Seattle” packing lists.
I pondered the distribution of my friends in the country and if I could see some of them—all of them?—during the migration.
I conferred with friends: “I’m thinking of driving across the country when I relocate to New York City. I’ve never done it before. I don’t know what the month of June will look like—except that it will be busy—and I’m worried that I won’t have enough time.”
And by “enough time”, I meant “the time to leisurely drive across the continent and enjoy the journey”.
There was no consensus:
- It’ll be awesome! It’ll be so nice to see friends that you haven’t seen in a while.
- Doing it in five days is gonna suck. You can do it, but you’ll be spending sixty hours in a car with little time to go sightseeing.
- If you’ve never done it before, it’s an experience. Not necessarily a superb one, but it will definitely be an experience.
I considered my own mental welfare: Would I calmly tolerate a five-day drive across the country, knowing that I would have, at most, two days to settle in New York City before starting a new job?
Yeah, but what about the ego biscuits that come along with knowing that I drove across the United States?
Yeah, but won’t there be other opportunities to drive across the country under more relaxed circumstances?
Yeah, but why not seize the moment?
yeah but yeah but yeah but yeah but
He asked the pointed question and the answer immediately crystallized in my mind. I smiled in recognition.
“Mentally wrestling between flying or driving to New York City provides me with the illusion of choice,” I said. “I can feel like I have some control… because, right now, when I think about New York, I feel like I have no control at all. I don’t know where I’ll be living, I have little idea what work will be like, I don’t know who I’m going to meet. When I think about the year from July forward, all I see right now is a black box. I have no idea what my life will look like.”
My friends—the vast majority of whom will remain in Seattle—smiled back at me. We all knew that, at that moment, my ambivalence had evaporated. My decision was obvious.
Now I just need to actually commit and buy my plane tickets.
6 Mar 2008 | 5 comments.
Briefly…
>> Christopher Payne. This man is an architect and photographer. His series of photographs of abandoned asylums (mental hospitals) are evocative. They are all captivating, though I was particularly touched by the second photograph under “Artifacts” (which is under “Asylums”, which is under “Gallery”).
>> Responding to the Erotic Transference. A whole bunch of psychoanalysts will be attending this symposium in New York City next week. The conference will apparently feature writers from the TV show “In Treatment” (the website says it is an Israeli show, so I’m guessing it’s not the HBO show with Gabriel Byrne, though I have seen neither….) The tagline of the conference: “Must all patients fall in love with their analysts?”
I just signed up to take part I of the psychiatry board exams. The whole thing seems like such a financial scam.
4 Mar 2008 | 6 comments.
How Do Psychiatrists Learn Psychotherapy?
Slowly.
Unlike our psychology colleagues, psychiatry residents, as a result of our general medical training, are first thrown into situations with patients before learning little (if any) theoretical underpinnings of psychotherapy. We learn how to interview and interact with patients from a medical perspective. Most (if not all) training programs assign junior residents to inpatient psychiatric wards, where psychotherapies frequently fall into the shadow of biological interventions (i.e. medications). Furthermore, the brief lengths of stay for hospitalizations do not necessarily facilitate the rapport that ideally characterizes a psychotherapeutic relationship.
You probably won’t share your wishes, hopes, dreams, and fears with someone you just met… and whom you may never see again after seven days… especially if your interactions with them are limited to ten or fifteen minutes a day. If that.
Most training programs schedule an outpatient clinic for residents in their second year of training. Usually, residents will have learned some essential basics to psychotherapy before seeing their first “long-term” psychotherapy patient.
And, let me tell you, residents are usually pretty freaked out before that first session—arguably more so than the patient. Most of us are not accustomed to sitting in the room for fifty minutes with a patient. Fifty minutes is a long time. Especially when one is absolutely convinced that s/he has absolutely no idea what s/he is doing. (”What if I don’t talk enough? What if I talk too much? What if I say the wrong thing? What if I do something terrible and the patient never comes back? What if I end up really screwing up the patient?” etc. You can see who the resident is really concerned about.)
Thus, part of our psychotherapy training is literally learning how to sit in a room with someone and be present with that individual for fifty minutes. Most residents settle down within the first month of weekly appointments. The focus eventually shifts more towards the patient.
Most residencies provide mandatory instruction on two types of psychotherapy: Psychodynamic psychotherapy and cognitive-behavioral psychotherapy (CBT). This is generally our first exposure to psychotherapy theory. (Our psychology colleagues follow a more logical course: They learn theory first, then see patients.) Residents can arbitrarily transform a given patient into a “psychodynamic patient” or “CBT patient”. (Indeed, we do not learn how to treat individuals; we learn how to apply theories to individuals….)
Residents have psychotherapy “supervisors”. Ideally, one supervisor (an attending psychologist or a psychiatrist) works with a resident for one psychotherapy patient. The time spent with the supervisor is termed “supervision”. For each hour of psychotherapy, there is one hour of supervision. Each supervisor is (hopefully) well-versed in a specific type of psychotherapy and provides supervision for that specific modality. This helps the resident gain mastery over that given psychotherapy.
In supervision, the supervisor and resident discuss the psychotherapy session. Many supervisors request that the resident videotape sessions (with patient consent, of course) so that the supervisor and resident can review them. Otherwise, residents can audiotape sessions, take notes during sessions, or scribble notes afterwards. (Allow me to take this moment to thank all of those patients who have ever agreed to videotaping of psychotherapy sessions—as usual, patients are the best teachers. Your generosity allows residents to monitor our progress, thus decreasing the likelihood that we’ll consistently behave like complete jack@$$es in the future. Thank you.) The supervisor may offer feedback about the content (what was actually discussed) and process (how it was discussed) of the session, as well as suggestions for improvement. There may also be discussions about the internal experiences (emotions, thoughts, hunches, etc.) of the resident and how they may (or may not) be relevant to the therapy. The supervisor may use events in the session to highlight the applicability of the psychotherapy theory and teach further details about its utility in that given (or similar) situations.
Thus, assuming that the resident is heeding the suggestions of the supervisor in this apprentice model, the quality of the supervisor will absolutely affect the therapy the patient has with the resident. Although the supervisor is not physically in the room with the resident and patient, it kindasortamaybe is like the patient is actually in therapy with the supervisor. And some supervisors are, frankly, pretty awesome.
Most residencies offer education in several types of psychotherapy, such that the curious resident (because, remember, not all psychiatrists are interested in psychotherapy…) can learn and attain basic competency (if not greater proficiency) in several modalities. This allows for greater flexibility in interacting with patients in a therapeutic fashion, which facilitates appropriate treatment of the patient, rather than treatment of the therapy. (My personal bias is obviously showing—please indulge me and allow me to opine that every single encounter with a patient can be therapeutic, even those interactions that aren’t considered “therapy”.)
It takes a long time to learn how to “do” therapy skillfully. (Please note that “do” is not the right verb.) I don’t think there are any studies to support the following assertion, though people have remarked upon this in an anecdotal way: Internal medicine docs who are just a few years out of residency are probably on top of their game; they know all about the latest updates in medical care and all that information is still fresh in their minds. Psychiatrists who practice psychotherapy are not on top of their game upon finishing residency; they’ve only laid the foundation for their clinical careers. And, it seems that most psychiatrists agree that a sense of confidence and mastery in therapy doesn’t solidify until eight to ten years after completion of residency.
2 Mar 2008 | 2 comments.