RUTH DEMING TALK FOR GRAND ROUNDS
DEPARTMENT OF PSYCHIATRY
ALBERT EINSTEIN MEDICAL CENTER
Friday, February 25, 2005, from 11:30 AM – 12:30 PM
“WHAT EVERY BIPOLAR PATIENT WANTS
HER PSYCHIATRIST TO KNOW”
WHAT MAKES A GREAT PSYCHIATRIST:
COMPETENCY AND RELATIONSHIP
Intro: Yesterday, February 25, 2005, I gave my talk to the Psychiatric Residents. Rob Lokoff of New Directions kindly drove me down. The students received Continuing Medical Education Credits for my Grand Rounds talk and I will receive a check in the mail for $250. They were a wonderful group of psychiatrists, very open-minded, and I would be happy to have any one of them for my own doctor, including their wonderful teacher, Dr. Kimberly Best, who made me feel very welcome and comfortable. One of the residents came up to Rob and me afterward, and said that he and some colleagues would like to attend a New Directions meeting. I’d mentioned that we encourage mental health professionals to come out and see what we do.
As always, I injected a little humor into my presentation. As did the psychiatrists. When I mentioned we meet at the Willow Grove Mall twice a month, one psychiatrist quipped, “…so you can all go on a manic shopping spree!”
Everyone had a great laugh! I also shared that at our last Mornings at the Mall, I did go on a shopping spree – after our power walk – and bought $267 worth of clothes at The Gap. I hate shopping and do all my shopping in one huge clump.
“I believe in planning ahead,” I joked. “So I bought a terrific pair of new pants, yesterday, but didn’t have time to get them hemmed for today. So I simply turned them under and put ‘straight pins’ in”– I held up my leg – “and if nobody told you any different, you’d just think they were tiny little spangles that came with the pants!”
Also, speaking of psychiatrists, I want to share a very funny story about a psychiatrist I met earlier this week in New York. My daughter’s boyfriend, Ethan Iverson, was giving a jazz recital at one of the rooms off Carnegie Hall. He’s what you call a “pianist’s pianist.” (Plus a wonderful person.) Anyway, at intermission, I was talking to lots of folks, and recognized a fellow, John, from when Ethan’s band, http://www.TheBadPlus.com, gave a concert at the Village Vanguard. We’d sat at the same table with about 5 members of my family and all chatted.
“Hey! I know you!” I said to John.
“Yeah!” he said smiling. “I’m practically a member of the family.” He wore tiny black-wire glasses and looked very debonair in a sports jacket, sweater-vest and tie.
We were leaning against the wall in the opulently simple Weill Hall. The ceiling was high. The room was painted a delicious creamy white. The acoustics were great. The authoritative biographer of John Coltrane was sitting behind my daughter Sarah and me. Eve Stotland, a lawyer for disadvantaged kids and fellow student of Sarah’s at Brown, whose mom is a famous psychiatrist who writes for Psychiatric Times, was there with her cute new boyfriend, Ben. Eve remembers coming out and visiting us in Willow Grove and all of us running down the great hill of the Bryn Athyn Cathedryl. Beautiful Julie, star dancer of the Mark Morris Dance Company was there with her impossibly long skinny legs and long blond hair, and Mark Morris was there, too. Talk about in-your-face-personality, brilliance and intensity! He’s a one-man show.
I was wearing my daughter’s tight-fitting pink plunging neckline blouse, which I also wore at Grand Rounds, because I wanted to look foxy, (my daughter says I should emphasize my body more when I dress – so John was happily looking down at my plunging neckline – he’s a pianist himself and plays with jazz bands – and I know he’s trying to meet a chick).
“Look, John,” I said. “You always stand with your arms folded. I have never in my life stood with my arms folded. Here, let me try it and see how it feels.”
I folded my arms. “It doesn’t feel natural,” I said.
“Yes, it’s very isolating and standoffish,” he readily admitted.
“Absolutely, John,” I said. “If I were your therapist – and I am a therapist, you know,” I said, wagging my finger at him, “What I’d advise you to do is stand like this.”
And I put my hands in my pockets, and strolled around a bit “Try it,” I urged him.
He struck up a pose with his hands in his pockets.
“Perfect!” I said. “You look very self confident, debonair and approachable. Walk around like that and you’ll get a woman in no time!”
Later on, back at Sarah and Ethan’s Brooklyn apartment, Sarah said to me, “Mom, you know – don’t you? – that John is a psychiatrist!”
“You’re kidding!” I shouted. “I didn’t know that!”
John is just one example of what’s called a “violin d’Ingres.” A person with a career plus an unstoppable passion to do his art on the side. Like our own Pamela London Barrett, “The Singing Psychiatrist.”
This piece is dedicated to all the great psychiatrists I’ve had on my journey of healing, and to all the new psychiatrists who will have a powerful impact on the lives of their patients. It’s also dedicated with love to every member of New Directions Support Group who, since 1986, has passed through our doors and sought our help, and the wonderful supportive healing network that is synonymous with New Directions. “I was a child who cried out for help and no one heard my cry.” At New Directions, we hear your cry, and are there for you when you need us.
Ruth Z. Deming, MGPGP, is founder/director of the nonprofit organization New Directions Support Group, Inc. for people with depression, manic depression, and their family members and friends. We meet for twice-monthly meetings at Abington Presbyterian Church in Abington, PA, drawing an average of 50-plus people per meeting. Ruth has a master’s degree from Hahnemann University in Group Process & Group Psychotherapy, 1992. She is also active in the poetry and writing community of suburban Philadelphia. She lives in Willow Grove. As a mental health advocate, she gives community talks on bipolar disorder to lessen stigma, as well as teaches a class on “Conquering Depression and Bipolar Disorder” at the local adult evening school. New Directions invites mental health professionals to come out to our group and sit in on a meeting to see what our lives are all about and how we successfully problem-solve to get through difficult times. We encourage our members to bond with one another and to call one another in good times and bad. We provide a list of Top Doctors and Top Therapists. With hard work, tenacity, faith and a boundless love of life, people who come to New Directions get better!
POINTS TO COVER:
. Introduction to myself
. Establishing a strong therapeutic alliance: Good communication
. During Session
. Policy & Procedures
. Current issues to be aware of
. Helpful Links
. Review of Key Points
. Poem – “Ah, Mania!” 1998
Introduction to myself: I am 59 years old and have been under the care of a psychiatrist since I was 38 and suffered my first mania and psychosis. That makes 21 years that I’ve been under the care of one wonderful psychiatrist or another. It is pointless to see a psychiatrist unless he or she is great. Who I may think is a great psychiatrist, another person may not. It’s a very individual choice. Fortunately I have the financial means to pay out of pocket to find the very best psychiatrist possible to help me in my journey of healing.
I never settle for anyone less than the best and have seen many bad psychiatrists. As a testiment to my rigor in getting better, I size up a doctor quickly. If I don’t like him or her, I never give them a second chance. My life is too important to waste on giving someone as important as a psychiatrist a second chance.
That said, the truth is: I celebrate psychiatrists. You got me better, with your wisdom, your caring and your pills.
When I was 38, I had my first mania: a euphoric, then dysphoric psychotic mania. It lasted one day. The experience was so terrible, there are no words that can describe it. I remember telling one of my four sisters (I’m the oldest of 5 girls, all of whom suffer from varying degrees of emotional distress. My brother was the youngest. He was autistic and died by suicide when he was 28.) –
I said to Sister Number Three, after my psychotic breakdown, “There is no reward you could give me – I could have the greatest love of my life, be the greatest writer on earth, have a billion dollars – but there is no way I would willingly ever go through that experience again.” The feelings were so awful, so excruciating, so massively terrible, I’ve spent my whole life trying – and succeeding – in avoiding them.
The secret is teaching yourself what (1) intrapsychic phenomena and (2) outward behaviors are taking place – these two events begin to change, as if an aura is spreading across your mind (as in epilepsy) – when psychosis is approaching – and then to immediately take action by taking an antipsychotic, and/or changing your life situation. Or, if a person doesn’t have the ability to perceive his thoughts and behaviors, he should “sign a pact” with his doctor, family member or friend, that when these pre-manic events manifest themselves, he will take action.
Twenty years ago, I was unaware of the elaborate corridor I was traveling through into the doors of mania. I proceeded unawares, a true spectacle to anyone observing me. My inane behavior and my feelings of agony (note: “agony” not “euphoria”) finally came to a halt when I was forcibly medicated with an injection of Haldol Decanoate (without Cogentin). It was a terrible drug. Just terrible. My current psychiatrist, Larry Schwartz, told me Haldol was formerly used in the Soviet Union to torture people. But even Haldol with its extrapyramidal side effects – the feeling that “you’re jumping out of your skin” – and then later, the total inaccessibility to all thoughts and all imagination – “paucity of thought” – was better than being in the terrible dysphoric psychosis I suffered. When you think about it, it’s uncanny how human beings can suffer so much.
Although this happened on February 14, 1984, I can remember nearly every detail as clear as if it were yesterday. In the interests of brevity, however, I’ll condense this truly fascinating experience that you wouldn’t wish on your worst enemy.
I was totally unaware of everything I was doing. I was an automaton. Every now and then my “observing ego” – the real me – would pop up and make a comment. One time it said, “You must be having a nervous breakdown.” I was having “insights” and was writing little epiphanies down on pieces of scratch paper. The notes, written in very dark scrawls of black ink, were scattered all over the living room.
At the time, I had a great job as assistant editor of “Art Matters,” an art publication, where I went out in the field to interview people and then would write from home. I was also a divorced single parent of two children (their father lived in Texas and I never told him about my mental illness for fear he would try to take the children away from me). My children were 8 and 6. During the night of my boistrous nervous breakdown, they slept through the whole thing. The three of us lived in a two-bedroom second story apartment in Upper Moreland, PA, Eastern Montgomery County, near Hatboro.
Each child had their own room. I slept in the living room on a couch. The night of my breakdown, I stayed up the whole night, listening to loud rock music (the rock group “Genesis”), and was euphorically dancing, singing, leaping across the furniture (the lady downstairs was banging with a broom on her ceiling), so I had to turn the music down, and was making all sorts of crazy phone calls. One was to a former boyfriend, a massively talented, now deceased metal sculptor, whom I had met in the course of my work. After calling him twice at four in the morning, he called my mother and told her I was having a nervous breakdown.
I suffered from classic “hyper-religiosity.” In my case, the religion was Greek mythology. While listening to Genesis (I was “madly in love” with Phil Collins and had a poster of him in a white T-shirt) – I listened to one particular song for hours, getting “higher and higher” – I pictured myself as the son of Apollo the sun god, who, if I remember correctly, cajoled his father into allowing him to drive the Chariot of the Sun around the Earth. As the music played, I would imagine myself whipping the horses, as did Apollo’s son, to bring daylight to the earth. Unfortunately, the deed was too much for the young man to handle.
He lost control of his father’s horses, his chariot plummeted to the earth and scalded the earth. And he was crippled in the fall.
I, too, was crippled in my fall, my crash, but got right back up again and walked away from the ruins.
That night, I would periodically lie down on my living room couch to rest. My thoughts were racing a million miles a minute (racing thoughts). I could feel every part of my body reacting to every single thought I had. This was most interesting. I would think a particular thought and then feel a particular part of my body physiologically responding to each thought. Perhaps this is how Indian “chakras” were discovered. I’m very open to all different kinds of medicine, particularly Asian/oriental. But do strongly recommend that people with depression or manic depression take medication, as do I. Though, quite frankly, a series of circumstances and mishaps and just plain luck has led me to come off every single medicine I was on except for Klonopin, which is an antiseizure medication used to quell anxiety and mania. My experiences allow me to think that some brains are capable of healing themselves, as mine apparently has.
I must throw in here, however, the fact that I am 59 – post-menopausal – and past the most difficult and challenging time of my life, when I was raising my two children by myself, and earning a living as a psychotherapist at a large now-defunct community mental health center (a great place to train!) in Newportville, PA and Bensalem, PA – which I loved – and which helped heal me.
Perhaps people like myself who have suffered nervous breakdowns are indeed capable of building back up their brains. The medical community may be skeptical. I personally know of half a dozen people whose brains have healed from manic depression or schizophrenia and are leading productive lives. One of the most important and comforting things I’ve ever read is: “The brain is capable of learning up until the moment we die.”
So, I was up all night in a state of mania, absolutely clueless that there was anything wrong with me. Next morning, I sent my kids off to school. Although I hadn’t slept, I was full of energy – and raring to go. I remember leaving my apartment at one point in my red jacket, stepping off the step, and raising my arm in victory and saying about myself “The Alpha Male!” (Reference to a great book I read about wolves.) Classical grandiosity!
Then Sister No. 3 arrived to pick me up and wisely sequester me at my mom’s house. No one knew what to do with me. Our family had never witnessed mental illness in action. There were no “closet” relatives with depression or manic depression. And, again, I was totally unaware of my bizarre behavior.
My mother’s family doctor advised her to take me to the emergency room. My mom hesitated, thinking I would calm down. She was a 62-year-old widow at the time. She is now 82. And, again, I was 38. My uncontrollable behavior continued all day. From my mom’s kitchen phone, I was making calls to all these people I knew in the art world, calling folks I’d written articles about. I phoned an art gallery owner and said to the secretary, “Marian is awaiting my call.”
It was classical grandiosity. Marian certainly was not awaiting my call. But I was moving so fast I didn’t have time to wait for an answer, so hung up the phone. I was a whirling dervish with my mind going a million miles an hour, with so many ideas. My body and mind were in constant motion, constant activity.
A week before the psychosis, I began to suffer from anxiety. This was anxiety on an exponential level. The feeling is indescribable, horrific! For two days I couldn’t swallow. Every moment of the day was concentrated on my next swallow. (I had actually experienced this phenomenon as a young child about 5 when I asked my father where the world physically ended and he said “there is no end” – and I couldn’t fall asleep thinking about this, and he would come in and sit on the side of my bed and comfort me, until I’d fall asleep).
Also, six months before my breakdown, an odd physical thing happened to me. I’m very athletic, (was, at the time, an acrobat, who could walk on her hands across the room and cartwheel across the lawn) – a girlfriend, Barbara (http://www.artistexpo.com), remembers me making an entrance into the room doing cartwheels – but after the breakdown lost my eye-hand coordination. I could no longer play tennis or competitive volleyball, nor toss things into the wastebasket from across the room. Hence the term “nervous breakdown?”
After the breakdown I suffered a whole host of terrible things. (These experiences are not uncommon. Many people, after suffering psychosis, have a similar “opening of the floodgates” where terrible conditions assault them.) Let’s stop here a stop a moment and ponder the word “terrible.” We say lightly, “I couldn’t find my car keys. It was a terrible experience.” Or, even, “My credit card was stolen. I felt terrible until I got all the details worked out.”
Yes, those experiences are terrible. But I want to let you know that they pale in comparison to the indescribable sensations of the Truly Terrible Feelings experienced by those of us who suffer from mental illness. This suffering is called Agony.
However, I have always refused to be a mentally ill person and sit quietly on the sidelines. I was determined to get better and conquered, one by one: panic attacks; anxiety attacks; social anxiety; post-traumatic stress disorder from … the breakdown, the diagnosis, and the unimaginably traumatic hospital experience: the feeling of being incarcerated, put in four-point restraints, fending off patients who were sexually aggressive, and worst of all, a sadistic male aide who sought me out wherever I went to torment me. He actually entered my room when I was alone in bed, closed the door, stood by my bed, said some sexually suggestive words, and was probably contemplating raping me but changed his mind. My own mind was de-activated and I was in a state of utter powerlessness and terror.
I wonder how many other defenseless women he preyed upon?
The list goes on of things I had to conquer: “every phobia known to man,” nearly unbearable psychosomatic pains like electric zaps through my body – from the medication? – (finally treated successfully through homeopathy), and – the worst! – an intense shameful fear – for perhaps as much as two months after my initial breakdown – that I would somehow harm my children while they slept. My then wonderful psychiatrist – my first great psychiatrist – Alex Glijansky – who I had for 5 years, reassured me this was just a powerful thought that would and did go away. I did tell Alex, in the course of our treatment, that I loved him like a brother.
Until a few years ago, I had zero self-esteem, this, in spite of my many accomplishments which you can read about in my CV. Thinking well of myself was “ego dystonic” (a term Alex explained to me) – in other words, the perceptions I had of myself were not the same as the way the outside world perceived me. I never knew I was a successful, lovable human being. This is a story in itself, predicated somewhat by the fact that my most current mood stabilizer, which I’m no longer on – Lamictal – was making me crazy, unbeknownst to my current psychiatrist or myself. Its strong antidepressant qualities – helpful, in 2001, when I experienced intense suicidal urges – were, undoubtedly, now propelling me into intolerable hyperactivity and hypomania.
Now, since April 2004, my doctor and I agreed to come off the Lamictal, and I am solely on 1 mg of Klonopin and have normal moods. I am probably unusual because I have never changed or tampered with my meds. When one has a good psychiatrist, that psychiatrist becomes an introject, someone about whom you say to yourself, “Now what would Larry think if I stopped taking my pills!” I no longer, however, have introjects, as I am capable of thinking for myself.
On the day of my nervous breakdown, Valentine’s Day, I was at my mother’s, and at around 3 in the afternoon, it was time to meet my kids at the schoolbus. My car keys had been wisely confiscated by my mom, so I slipped out of her house unawares and began the long walk down Byberry Road in Lower Moreland, PA, to where my apartment was in Upper Moreland. It was a good 90-minute walk.
I did many bizarre things along the way. There was a farm on Byberry Road, a block-long farm with corn fields. I walked through the field pocketing little dried corn cobs and rocks. I was wearing a warm reversible red jacket – the same jacket that I would later look to for reassurance at the psychiatric hospital (Montgomery County Emergency Service, then “Building 16,” on the grounds of Norristown State Hospital), – subsequently under new management – www.mces.org – where I was eventually “incarcerated.” The red jacket was kept behind shielded glass at the nurse’s station and every time I looked at it I remembered who I was. I was so out of it I barely remembered I had a name. (Read the poem below I wrote in 1998 called “Ah, Mania!”)
In the farm field, I wandered. After winding my way through rows and rows of tall dead corn stalks, there was a clearing. In the clearing lay some sort of dead animal. Probably a dog or a deer. I thought it was a coyote and squatted over the dead body, staring at its shiny eye and receiving “messages” from the dead dog’s eye. The final message was: “Don’t stay here with me and focus on dead things. Get moving.” Whenever I was manic, I used to receive messages: From songs, the TV, newspapers, pens – my name would be written on it – and once from the sun, when I was told, among other things, I was a “spiritual healer.”
Next, on my journey to the bus stop, I stopped in a small church. I’d never been inside and was so excited to go inside. Upon entering, I sang out at the top of my lungs the first lines of the last movement of Beethoven’s Ninth Symphony, Schiller’s “Ode to Joy.” Can you imagine such a spectacle!
“O Freunde, nicht diese Toerne!” (“Joy, beautiful spark of the gods, Daughter of Elysium, We enter fire imbibed.”)
Everything I did was massively symbolic.
I sang, expecting people to come running down the hall to greet me, but no one did. Thank the Lord! I only stayed a second, mind you, because I was on a mission: to meet my kids at their busstop. (I should title my autobiography: “On the Way to the Bus Stop.”)
So even though I had no cognizance, absolutely no awareness of what I was doing – a part of me remained grounded in the temporal world.
From the church, I crossed the street, Byberry Road. It was a busy street and I remember how carefully I crossed, looking to the left and to the right until the road was clear.
I got to a small spit of land, Masons Mill Park, where I used to take my kids, and was trying to figure out how I would walk through a low two-lane tunnel without getting hit by a car, it was a railroad underpass, with beautiful February icicles hanging from it, when whom should drive by but my mother, with her aged mother in the backseat. She told me to get inside her car. I refused. She came out to try and lead me into the car. I looked at her and said, “You always stand in my way. I’m going to kill you.” Then I pushed her down on the ground. She landed on her back, and I stood on top of her and gave a victory signal with my arm held high in the air.
My mind was spinning so fast I didn’t pay any attention to her. And, forgot, in fact, that I’d pushed her down. Thank God she wasn’t hurt. All I could think of was meeting my kids at the schoolbus. (Years later, I received fantastic psychoanalytically-oriented therapy from psychiatrist Beth Lindsey who helped me understand “perceived traumas” I had with my family members. I believe manic depression is genetically based and results from traumas or events experienced in utero, during infancy, childhood, and onward. Why are some of us resilient and others not? Good question.You, our future psychiatrists, will help us rise from the mat!)
From the ground, my mother hailed a passing car and asked them to call the police. People were coming out of their cars and I was standing there feeling trapped. I tried to run up a hill where the railroad tracks were, but thought the train would come and kill me, so I climbed back down. I just kind of stood there watching all the people get out of their cars.
I was in an intense state of paranoia. When people got out of their cars, I looked at each face. People either looked like “good guys” or “bad guys.”
I was totally terrified. As I stood there alone, I was filled with a feeling of emptiness and despair beyond description. The feeling of desolation and abandonment was total. It felt like a hole had been shot through my chest. The theme of Beethoven’s Ninth continued, and I clearly heard the first movement being played by the whoosh of the trees, the speeding of the cars, and the February wind. It was quite spectacular. I was in supreme awe, sort of like Job when God appears to him out of the whirlwind. Although I was quite mad, I felt specially chosen – at the time! no more!– to be the recipient of the great gift of being part of Beethoven’s great mind, being perhaps a part of God’s great mind, and a participant in the workings of the universe. That’s how I felt. For though my despair was deep, so, too, were my feelings of being intensely alive. I was experiencing life on a level of incredible terrible intensity that few people in the world are able to experience. The volume control was set earthshakingly high and needed to be turned down. A person cannot possibly live in this state of unbearable intensity.
So, shoot me up with Haldol Decoanate, as you did, your only choice back then. ‘Twere better than the feelings I had.
Soon the white car of the Upper Moreland Police Department came by. So did my sister Donna and her boyfriend Dennis. They were on their way to my mom’s house to see what all the commotion was about, about my never-before-seen behavior. “Dennis and I were driving by,” she happened to mention to me the other day in my living room – I don’t know what made her bring it up – but I was totally unaware of it, it jogged my memory – and she said she saw all these police cars and commotion going on and then she saw me!
“My God!” she said to Dennis. “That’s my sister Ruth!” So they pulled over and joined the caravan to the police station.
I got docilely in the back of the police car – I knew when I was licked! – and was taken to the Upper Moreland Police Station, where they and my mother prepared the 302 petition – or papers to have me involuntarily committed to the hospital. Though I didn’t know why, I felt vaguely embarrassed when I recognized one of the cops as the father of one of my son’s young schoolmates. (Ironically, a week after I was discharged from the hospital I went to the Upper Moreland Library to check out books – Will Durant’s History of Civilization – and there was the same Lieutenant Robinson!). I see him from time to time in our town and wonder if he remembers who I am. What do you think, Steven? One hopes my prose is as lapidary as the shining icicles outside my kitchen window! (www.bartleby.com).
Then began the drive down the Pennsylvania Turnpike to the hospital. I thought we were going to California. I asked the cop if he needed to take a ticket from the tollboth collector and was surprised when he said, Yes.
It was exciting beyond belief to ride in a police car – except for the fearsome fact that you couldn’t get out and there was a grate on the window. Only my little finger could fit through the grate – “like caged Hansel,” from another poem I wrote about being manic. Up front sat my sister’s then boyfriend who worked as a plumber and was also a deer hunter. He and the cop were talking about guns. I remember feeling very envious that Dennis got to sit up front and talk to the cop and I didn’t.
When we pulled up to the now boarded-up “Building 16,” it was night, and I was struck by the beauty of the light brown-colored building – I have always loved beautiful buildings – lit up by spotlights from outside. I thought, at first, it was a southern mansion. Donna asked me, “Ruth, do you know where we are?” The voice of reality in me chirped up and said, “A mental hospital?”
It was a beautiful crisp cold February evening. We went in and the intake worker came over to talk to me. I thought he was Frank Lloyd Wright and went up and gently stroked his cheek. My sister later told me, “Everyone was terrified of you.” I was in a state of intense energy with absolutely no inhibitions. Then I started showing off for him. After all, he was Frank Lloyd Wright and I had to impress him, right? I was the sit-up champion in high school (150), so I started doing sit-ups real fast in front of him. Then I went over to the fluorescent lights, lay down on the floor and said, “This is where I get my power. From the lights. From the sun.”
[“Bob, do you think I’m nuts?”]
I was also in a state of classic hypersexuality. The patients and hospital personnel were watching with interest as this new patient, moi, was led inside. Spotting a great-looking guy, a patient in jeans and blue shirt, short, like me, I went up to him, embraced and kissed him. The workers told me, “You’re not allowed to get physical in the hospital.” “It figures,” I thought to myself. Actually, in those days Building 16 was a hotbed of sexuality. Everybody was horny as hell and trying to make it with everybody. Some guy said something very sexual to me later on and I said, “We can never get away with it, people will see us.”
All inhibitions are removed when you’re manic. We were all like a bunch of little puppies with mother gone.
After “Frank Lloyd Wright” assessed me and pronounced me eligible to be taken away, I was led up a small flight of stairs that led into the locked ward. My sister told me that I let out a piercing scream when they forcibly led me up the steps into the hospital. I don’t remember it. All I remember was a team of people grabbing me and me trying to fight my way free and grandiosely bragging, “Look what a great fight I’m putting up! Eleven of you and one of me!” I was immensely proud of myself!
I was given a shot of Haldol Decanoate, and my mind blacked out. From that moment on, my life was never the same again. I was put in four-point restraints, and left alone in a room with my mind spinning wildly. No one should ever be left alone when they’re in restraints. When I awoke, I had visited every region of hell possibly imaginable, and cried out: “I’ll be good! I’ll behave myself! Untie me!”
A nurse came in and untied me. I had black and blue marks for weeks thereafter on my wrists and ankles. It was dark night. I remember looking out the bars on the windows at the dark night and realizing I was in fact a prisoner. I gave a little futile tug at the black bars on the window and knew I was locked inside.
I asked the nurse if I might phone my children. And was surprised she said Yes. They were sleeping over Donna’s house, who would take them to school in the morning. I called them from the payphone. They were so happy to hear from me. My 6-year-old adorable blond little boy with beautiful curls all over his head had been playing with his trucks and asked me, “Mom, are you going to die?” “Absolutely not,” I reaassured him. He quickly got off to play with his trucks again. My 6-year-old daughter was very business-like and, after she knew I was okay, wanted to get off and go back to playing with her cousins. I told my kids I loved them and would be home soon. They had no idea what their mother was going through. I raised them by myself, a single divorced parent. They’re 31 and 28 today, and thank God are both normal and wonderful people! My daughter lives in Brooklyn with her boyfriend, has just completed her first novel and teaches yoga – we have a wonderful loving, close relationship – and my son lives on the bottom floor of my split level house, has a great job and a great girlfriend. We also have a very loving relationship, but spend very little time together, as we are two extremely busy people. Thank God his girlfriend is out of town today so he can load this onto the web.
In fact, this morning, we were each having breakfast. He was eating generic Cheerios and I was eating my usual old-fashioned oatmeal, with cut-up bananas and strawberries. I’d forgotten to remove the strawberries from the plastic container, so they were starting to rot.
“So,” said Dan, who has a great sense of humor, as he looked at my shining yellow breakfast bowl. “I see you’re eating bananas for potassium and strawberries for mold.”
My hospital stay lasted three days. I’ve never been hospitalized again. I learned to catch my “early warning signs” – and then, with the parameters set by my doctor, to medicate with the various antipsychotics prescribed over the years. (Navane had been my favorite. Available generically, so it’s cheap.) I could always stop my manias/psychoses and never go over the edge again. I was psychotic, yes, but knew I was psychotic and could function in that state until the antipsychotic kicked in and the “fires” died down in my brain. During those years, I only missed half a day of work. I haven’t been psychotic in 4 years and believe it will never happen again. If it does, I’ll take extra Klonopin. My psychiatric medication is: 1 mg. of Klonopin (clonazepam) and 75 mcg levothyroxine (every other day), both before bed. This is me, not anybody else. I like taking medication only once a day! But I hate with a passion taking medication. I don’t even take vitamins, as I think it’s unnatural and that the body should get all its nourishment from…. food! Good food! Healthy food.
By the way, the moment I got out of the hospital, I finished typing up a profile of an artist I was writing for Art Matters: Eiko Fan. We can look her up on the Internet and see what she’s up to. It was while I was interviewing her, we were sitting in a diner and I was taking notes, and saw the relationship between her and her husband, that my mind began changing. Suddenly, my eyes could see things they had never seen before. Working with artists made me see I was one of them. I got fired from my job at Art Matters because I lost all the material I was working on. I can’t blame the editor. She had a deadline to make. I ended up getting the story published in the Alumni Magazine of the University of Pennsylvania and have it with all my other stories on the high shelf in my hall closet, wrapped in a shiny black plastic garbage bag. But the stories are all inside me, just like all the patients I ever saw, and like all the patients, you, our future psychiatrists, will ever see. They remain a part of us forever. They teach us so much! Perhaps we learn more from them, than they from us. Who knows? The world is a mystery. And this world, the world of brain chemistry, is perhaps the most mysterious world of all.
1 – ESTABLISHING A STRONG THERAPEUTIC ALLIANCE: GOOD COMMUNICATION IS THE KEY
The Psychiatric Session begins the moment the Patient enters your office – or the waiting room – or the building. First impressions are very important! Make sure you are prepared to see your patient. If you are running especially late, it’s nice to poke your head out into the waiting room – or have a secretary do it – and say, “I’ll be just another few minutes.” This makes the patient feel important
One of your chief purposes is to make the patient feel important. People with mental illness often, but not always, have very low self esteem. They rightfully believe they are, unfortunately, treated as second class citizens.
We are exquisitely sensitive creatures. My own psychiatrist said that bipolar patients seem to have a sixth sense – “almost like mind readers,” he said – about the state of mind of other people. I asked him for an example, and he said that when he was stifling a yawn earlier, I said to him, “I know you’re probably exhausted. I don’t mind if you yawn. After all, it’s not easy sitting in a chair all day long.” I was just trying to make him feel comfortable.
That said, body language of a psychiatrist should be welcoming, relaxed, eager, interested. Your personality is the way you communicate with us. Be yourself.
Maintain good eye contact throughout the session, even as you take notes. Make sure you’re prepared when your patient comes in. One thing that irritated me about my former family doctor, who I’d seen for many years, a very nice woman, is that she had no idea who I am or what conditions I suffer from or meds I take. So, with your psychiatric patients, just a quick going-over of your notes before you see us should do it!
Implement greeting rituals and parting rituals. Handshake, walking to door, etc.
I like doctors to call me by my first name. But you can ask what patients prefer. People always like to hear their name said. That someone knows their name. I’d imagine most patients feel the same way. Check with them. “Mrs. Deming” is too formal for me. You are our “partner in healing” – we need to remain close to you. Also, for geriatric patients – they need to be reminded that they are a person: a woman or a man – “Hello, Alice” – and not a Mr. or Mrs. So-and-So. Older adults need to reminisce about their younger years – while remaining as active as possible in the present. Remind them, as Dr. Bob Kay said in a talk at Glenside NAMI: “Your brain keeps growing until the day you die.”
Many patients keep important information hidden from their psychiatrists for fear of being judged. By establishing a strong therapeutic alliance, we will tell you everything about our mental health, including if we are engaging in bad habits (drinking alcohol, using drugs, skipping medication doses) – and also if we are feeling suicidal. Some chronically ill individuals I personally know choose to hide information from their doctors. This obviously is terribly counterproductive.
Many patients have very poor communication skills. We often come from dysfunctional families where good communication skills are lacking. And where people keep secrets. Be a role model in establishing good communication.
Patients like business cards of their doctors: a tangible reminder that you exist. Many of us lack “object constancy.” You are important to us. Many of us keep your card in our wallet. You are also a household word. When I worked at an agency as a therapist – (I quit in June 2004 because (1) The paperwork was overwhelming and (2) I worked in a “hostile work environment”) – I would sometimes phone a patient at home, and their husband or child would call out, “Ruth is on the phone,” as if I were a member of the family.
Once I wrote a validation card for one of my psychotherapy clients and told her to keep it in her wallet. She had fears that she was not a good mother to her young son. I always try to meet the families of patients I’m treating – or at least talk to them on the phone – and had seen her interact with her son and thought she was a fine, loving mother, calling him epithets such as “Hey, handsome!” The card I wrote said something like, “Ruth says you’re a fine, honest person and an excellent mother.”
Realize your paramount value to the patient.
When my psychiatrist calls me on the phone, I recognize his voice immediately and feel so happy just to hear the sound of his voice! The first psychiatrist I ever had, a rather uptight Jewish guy – he gave me my diagnosis – would call me back – he knew I lived alone with my two children – and, after I’d answer, would ask, “Is Ruth Deming there?” How dumb is that?
As I mentioned in my talk yesterday, how you deliver a diagnosis to your patient is very important. I like the one resident’s suggestion of giving the diagnosis and then having the patient go home and chat with his family about it. Also, that was great – I think Dr. Kimberly Best said, that it’s always a diagnosis-in-process, meaning, our symptoms may change.
Answering machines/voicemail: Be sure to leave a pleasant, upbeat message on the machine. Patients often call just to hear the soothing sound of your voice. One psychiatrist I know taped a soothing message on an audiocassette especially for his patient!
As a patient, I dislike leaving messages for my psychiatrist with an answering service.
If you must use one, have compassionate people man the messages. The patient goes through a third party and has to tell his often sad story to a total stranger. I remember one time I left a message with my doctor’s service saying, “Please have the doctor call me immediately. I’m getting psychotic. Do you know how to spell psychotic?”
2 – DURING SESSION
All sessions are encounters with another human being. This is why you chose psychiatry, so you could be with a person in need, in distress, and help us get better. What greater satisfaction in life can there be? As patients, we look forward immensely to being in your healing presence.
Only today, (late January) I went to a new family doctor for my hacking cough. I noted the irony of my writing this piece and meeting the new doctor. I got out of the car with high expectations. He called my name from down the hall and I got to see his face. He gave me a firm handshake (very important) – a weak handshake is taken to mean a weak person or a person afraid of other people – and engaged in intense eye contact. He asked terrific questions. And answered all mine. I mentioned to him that I suffered from bipolar disorder and he didn’t blink an eye. All patients with a mental illness wonder how their new family doctors will handle this. Not all doctors handle it well. A past family doctor of mine, very highly respected – I really liked him – saw my then rather long list of psychiatric medications and said, “What’s all this shit?”
You can be the most talented person in the world but if you’re on psychiatric medication, you may not get respect. No wonder people are afraid of self-disclosure.
There are two kinds of patients: ones who want to get well and those who don’t. Realize this. You can’t help everyone. Only those who want to get better. You will know if they want to get well by how they abide by your instructions. When a patient is on a healing path, the psychiatric appointment is the most important event in their life! How I remember with great fondness my appointments with my first great psychiatrist and the other wonderful psychiatrists I chose after him.
Yes, if you’re good, we appreciate you and look up to you. This is great. We’re dependent on you in the beginning, but you foster our independence so we don’t need you forever. Many of us, including myself, come from unhealthily enmeshed families. There’s a difference between “close families” and “enmeshed families.” Cultural attitudes are associated with this as well.
We can tell if you like us or not. Again, that’s what the whole thing is about: relationships. And, please? Unless absolutely necessary, don’t take outside phone calls while we’re in session.
As a psychotherapist, I was trained under a terrific diagnostician. It was almost like going to medical school, so please excuse me if I “play doctor” for a moment. Be sure to take a thorough history of the patient. Believe it or not, not all psychiatrists do! Ask about family history. Always remember that if a medication works well on a family member, there’s a good chance it will work on your patient. Tell them this. Always educate the patient. Gauge how much they want to know or don’t want to know. Some folks dote on information. Others don’t. I love information – except for side effect profiles. If I’m in your office, just tell me the essentials. One time after I started titrating up on Lamictal I got a rash on my back. An Internet foe, I nonetheless printed out scads of information about Stephens Johnson syndrome – terrifying! – and presented it to my family doctor. He said he was familiar with it and that my rash was Lyme disease.
This reminds me that psychiatric patients should be warned about taking certain drugs such as antihistamines, steroids or legal narcotics, such as Percosetts or codeine. They can exacerbate mood symptomatology. Some of us are exquisitely sensitive to medications. Some patients report side effects that the doctor has never heard of. Some doctors actually refuse to believe the correlation. Please realize that only the patient knows how he or she feels inside.
Also, if at all possible, steer clear of medications that cause weight gain or inhibit our sexuality. When a person has no sex drive, particularly if he or she has a significant other, they are deprived of one of the greatest experiences our body is capable of: making love and having an orgasm. These experiences are healing for the body and enable a person to feel wonderful.
Also, and this is hard to imagine, some doctors are unaware of the importance of titration, or weaning slowly off or on a drug. We’ve heard horror stories in our support group about this.
Did I mention parameters of medication? Very important to let patients know how much medication they can take PRN – anxiety meds, antipsychotic.
KNOW YOUR PATIENT.
Ask about what’s going on now in a person’s life. Find out all about the patient: Do they have a supportive marriage, how do they get along with their kids, etc. Find out who comprises their support team.
When I’d see my psychotherapy patients, male or female, I would always immediately compliment them on how nice they looked: “Wendy, your hair looks great frosted” – “Tina, I love your dolphin necklace” – “John, great striped shirt you’re wearing!” We’d always start off on a positive note.
Also, if a patient is in your office with a bandage on his finger, ask what happened that caused the injury. You will find out something new about them. If they’re late, ask why. It’s all about getting loads of information. The more you know your patient, the better success you’ll have in treating them.
Always keep an open mind. Some patients swear by vitamins or herbal supplements. If they feel it helps, join with them. Make sure they let you know what they’re taking so it doesn’t interfere with their meds.
My psychiatric mentor, Norman Lamonsoff, MD, taught me about the invisibility of the condition “head trauma.” Its existence is often overlooked in psychiatry. We have several people in our support group whose behavior is un-categorizable. When I checked about head injuries with the patients, I found out that several people had suffered severe head trauma in automobile accidents. Knowing the correct diagnosis is important so we know what can be fixed and what can’t.
As you know, some people look terrific on the outside and feel terrible on the inside.
Never make assumptions or guess how we’re feeling. Just ask us. It’s a true asset to keep up a front – a mask – and you may compliment the patient on this, even as you’re empathizing with our pain.
Again, we need to be complimented. Most of us have low self esteem and we need your praise. This can’t be overstated. Praise us and compliment us. For example, the psychiatrist of a friend of mine went to see her art show, which meant the world to my friend.
I say to my own patients, “Write down what I’m telling you about how good you are so you can look at it when you’re feeling lousy.” A “Compliment Page” was one of the most effective things that got me better. One of the greatest compliments I ever got – in recent years – was when I wrote a handout called “Taking Charge of Your Mood Disorder” and loaded it on our website. Our then professional advisor, Dr. Wade Berrettini from the University of Pennsylvania, had kindly taken time out from his busy schedule and emailed me back that the piece was “a fine work.” That made me feel wonderful and I hung it up on my bulletin board. Also, I wrote down the words my daughter told me, “Mom, I love you so much.” I was never sure I’d been a good mother or that she loved me. But I’ve integrated those thoughts into my mind now and I no longer need proof that I’m smart or lovable. Just today, two women from our group called me up to tell me how much they loved me. This is very nice. Remember, there are many types of love. [Coincidentally, when Rob and I drove home from the talk yesterday, we stopped off at a Greek restaurant where a license plate read “Agape’-1” (a Greek word for a type of “non-erotic love for mankind,” and also a sense of wonder) – terrific qualities for a psychiatrist to possess!)]
When I quit my therapy job last June – the paperwork was intolerable – I told all of my patients, “I’m here if you need me. I’m only a phone call away.” I knew that they would all transition fine to new therapists, but one man still chooses on his own to keep in touch with me, which is fine. After all, we’ve had a relationship for seven years, and I’m an important part of his support system. In fact, there was an episode on Sixty Minutes one night about the Ukraine. My former client’s people are from the Ukraine, so I called him up to tell him about the show. Your patients like to hear things like, “I was thinking about you when I saw the show.”
This brings up the question of boundaries. Establish appropriate boundaries that you are comfortable with. A relationship with a psychiatrist is very much like a marriage. When a person is sick, you are the most important person in their life.
At the end of the session, ask us, “Did we take care of everything?” Very important. Be sure everything is wrapped up at session’s end. This will prevent unnecessary phone calls that intrude upon your precious time.
Room decor is very important. It should be for both you and your patient It should be personal to the doctor letting the patient know a little about your personality. Even if you don’t have your own office, have some personal effects there, that show us who you are. Patients notice everything! And they remember everything about you! For years and years after. I remember details about every single psychiatrist I have ever had. I never had a psychotherapist. All of my therapists were psychiatrists, and feel that’s ideal, although often impossible in today’s managed care world. And, by the way, managed care, need I say, is the worst thing that ever happened to American healthcare, a totally useless, ridiculous concept. I wonder: Where were we when managed care came onto the scene. Why weren’t we paying attention to stop this monstrosity?
Some patients enjoy giving their psychiatrists gifts. Accepting these gifts makes the patient happy. I believe it is very important to accept gifts graciously! I cannot overstate this enough. If feasible, keep the gifts in your office. I’ve heard stories of psychiatrists or therapists refusing gifts and it is terribly hurtful to the patient.
If a patient decides to leave you, this is hurtful but use it as a learning experience. Find out why they wished to leave. Then use this information the next time. This is very important! Not everybody can like us.
Sometimes, we don’t want a particular person for a patient, so when selecting new patients do a thorough interview with them to make sure you want to take them on. If you choose not to have them as a patient, try not to hurt their feelings. We are so sensitive.
Should you share your own experiences with the patient? Yes, when it’s appropriate, but don’t go overboard. Be brief. One psychiatrist I saw for couples counseling talked about his relationship with his wife the whole time. When I mentioned this to him he said, “I thought it would be helpful.” I said it wasn’t, but he continued to to do so, so we went elsewhere. He did say something terrific, though, that I learned from him. He said, “The two of you are sitting there so nicely and comfortably together.”
If you don’t know something, it’s fine to say, “Gosh, I don’t know. I’ll find out the answer for you.”
3 – POLICY & PROCEDURES
It’s fine to engage in email correspondence with a patient. If you don’t have time to answer their detailed question, write them: “Got your message and will get back to you shortly.” Please don’t leave us hanging. Same thing with phone calls.
Discussion of doctor’s procedures: Fees, missed sessions, how doctor returns calls, substitute available when on vacation.
Returning of calls – prompt – discuss what constitutes an emergency and how you, the doctor, will respond. Also what to expect when you go on vacation. Patients often dread this. Tell them who is covering for you and that they’re a competent physician.
Allow patients to ask you questions about your history, where you graduated. Assure them, if need be, that although you’re young, you have been well trained and have mentors you can dialogue with. Some patients are rightfully finicky about the person who will be their healer. A friend of mine wanted a psychiatrist who was a parent.
Parameters of medication – let patient know how much PRN (or “as needed” medication) he can safely take. Very very important. Give instructions to patient – or family members – to call you immediately if mania or psychosis is suspected. Then teach the patient how to take antipsychotic as needed. Again, this is how I managed my bipolar highs. I could always spot the symptoms coming. I hated my manias because I don’t like being out of control. Many doctors erroneously assume patients like their highs. Remember, please don’t assume anything.
For bipolar patients, find out what their triggers are, so they can avoid mania (or depression). A patient can be taught to perceive “early warning symptoms” so they can avert mania or depression (which is harder, but possible). I have stories about this.
When prescribing a new medication – give a brief description – not too much – answer all patient’s questions, evoke confidence that “I think this drug will really help.”
When drug doesn’t help – you might tell the patient, if it’s true, that you have been consulting with other doctors about “our case.” Use the word “our” or “us” or “we” – this fosters appropriate “intimacy” and makes the patient feel important. If necessary, suggest patient get consultation with someone else. Again, do not take this personally, nor think you have failed. You have not.
Office staff – must be friendly. So many patients complain about nasty receptionists. This is the entry point into therapy. Check with patient about all aspects upon entering your treatment facility.
Check with patient to see if he understands directions you are giving him with medication before patient leaves office. Be crystal clear about this, so patient will not be confused. Offer suggestions on how to take their medication – pill box, etc. Many patients forget to take their meds – they intend to – but simply forget. Work with them on establishing timetaking rituals.
If at all possible, have patients take ONE DAILY DOSE of all meds, although as one of the residents said yesterday, your patient enjoys taking his medication several times a day. We are all different.
Be aware of Patient Assistant Programs for Low-Income Patients offered by the pharmaceutical companies. We have this loaded onto our website. Give out free samples to needy patients. Don’t be swayed or coerced by pressure from pharmaceutical companies. On another note, a psychiatrist friend of mine was told by her agency she was prescribing too much Klonopin because it’s a Class 4 drug. She’s a great prescriber and refused to buckle under. She knows the difference between “drug-seekers” and people who need a drug, as do all the Recommended Psychiatrists on our New Directions Support Group list.
Make yourself available to the patient. “Call me if you need me.” Patients really like this and will not take advantage of your offer. If you do a good job during the session, patients will rarely call you between sessions except when absolutely necessary.
Response in emergencies – This is the test of a doctor’s skill: Prompt, calm, reassuring. Maintain steady calm voice and total confidence. “I’m here for you.” Speak slowly to calm a person down. “I have confidence you’ll come through this distressful situation soon and I’m here to help you any time you need.”
The patient should always leave the office on an upbeat note, a note of hope and optimism. Very important. The previously mentioned former boyfriend of mine would always leave his psychoanalyst’s office feeling more depressed than when he went in. “Why are you seeing him?” I’d ask rhetorically. He was actually, sadly, a masochist, as are many people with or without mental illness. They are comfortable in their role as sufferer, or martyr, they know no other role, and are too frightened to try and succeed. This is very sad.
Encourage occasional family members to attend treatment, if patient wishes. Often you get a one-sided view of patient. Family members help flesh out the whole picture. Again, learn as much about the patient as possible. Keep notes of patient’s family members, ages, friends, interests. Know thy patient! Patients love when you remember tiny details of their life. Again, you make them feel important. When I worked at an agency, I had a special sheet of paper where I’d write down all the important people in a patient’s life, their names and ages – I did this in front of them – it made them feel important.
Partner with the patient. Psychiatry is not yet a science. Seek the patient’s input. If they ask about new drugs, be responsive. Consider using it.
Never feel defensive.
Patients who do not work and who suffer from lethargy should be encouraged to adhere to a daily schedule and do meaningful work during the day. Encourage the patients to do volunteer work and use their talents. Often, when I receive crisis calls, I have people write down on a piece of paper the things they’re going to do within the next 24 hours. Then, as they cross off each item, they feel a sense of accomplishment.
Everyone needs a reason to get up in the morning. Encourage the patient to plan for the next day, to write things down on a “To Do” list.
Patients like to hear that you, their psychiatrist, are keeping up with the latest findings. I always ask my psychiatrist what he learned at his last conference. Or from talking to a colleague. For example, I know that my doctor is a follower of psychopharmacologist Donald Kline. I just saw my doctor Feb. 21 and asked him what he learned at a conference at NIMH. He said, “Take Folic Acid. It’s good for the central nervous system.” And he wrote me out a prescription.
Patients like their doctors to be as human and transparent as possible. Not every doctor has this kind of personality, especially in the beginning when we tend to be more guarded and go by the book. Share as much of yourself as you feel comfortable doing. Some people describe seeing their psychiatrist as “having a conversation with them.” A friend of mine who saw a psychiatrist said she felt like her female psychiatrist was a rabbi.
Patients like to hear statements like, “I was thinking about you only the other day when I ……” This makes the patient feel special. Again, remember our often low self-esteem and that you are helping shape us into the best possible person we can possibly be. You are like a sculptor, except you are a sculptor of souls.
Pay attention also to the physical health of the patient. Many folks with bipolar disorder – or patients with mental illness in general – have physical complaints. And may ignore their physical health. Enthusiastically encourage good nutrition and exercise. Exercise is tremendously important to the mental and physical wellbeing of every human being. Exercise is the best “stress-buster” there is.
Discuss diet and nutrition. If the patient is up for it, suggest they join Weight Watchers or a fitness center. Being fat does not enhance self esteem, nor is it good for the body. I lost 40 poounds while on lithium by having a consultation with a dietician from Abington Memorial Hospital’s Nutrition Department. Suggest this.
Promote support groups. They are of supreme value to patients who often view themselves as alone or different. Encourage them to go on the web to find a support group that’s right for them. Be aware of the advocacy group NAMI (National Alliance for the Mentally Ill) www.NAMI.org. This is the largest and most influential advocacy organization in the world for the mentally ill, though I’m not sure how effective they really are. Can you imagine the irony of having a nation where 10% of the people suffer from mental illness and not having a superior advocacy organization? NAMI’s family member support groups however are often superb. I myself often attend Speaker Meetings in Glenside, PA. Only the other week, I went to hear iconoclastic psychiatrist Dr. Robert E. Kay, who will now be a guest speaker at New Directions. He refers to himself as “the no-nothing psychiatrist.” How’s that for honesty and humility!
Provide literature on various conditions. The best brief literature is available online from the National Institute of Mental Health. (www.nimh.nih.gov. )You can refer patients online, or you can order copies of brochures which offer “just the right amount of information.” I find info from NIMH to be superior to any other literature I’ve read.
The gift of sublimation: Many patients have artistic abilities. Find out the patient’s talents and encourage them to utilize them. Many people with manic depression are extraordinarily talented. Three of my past psychiatrists (Alex Glijansky, Beth Lindsey, and Mike Vaccaro) were instrumental in having me create art in many forms. Also, psychiatrist Laszlo Gyulai of the University of Pennsylvania told me I’m a poet. That meant a lot to me! Possibly a majority of people diagnosed with manic depression write poetry. Encourage them to write poetry. There’s something healing about writing poetry. It’s a way of finding oneself and one’s identity over and over again.
Faith and spirituality. If a patient is so inclined, suggest they attend church or synagogue or seek spirituality. Encourage meditation if a patient is so inclined. One psychiatrist I know of actually prays with some of his patients. They love it! He has the confidence and courage to be himself in a large corporate counseling office.
Tell patients, if true, you have seen an improvement since they began seeing you. If you haven’t seen an improvement, figure out, with the patient’s help, why not. The shaping of a human life is like the nurturing of a child. You bring out our best possible self.
Process your own thoughts about each patient. By writing your notes you can process your thoughts and feelings about the patients. These are intense encounters you are having with another human being and need to be processed, either in your notes or your thoughts or with a colleague. Not easy in today’s helter-skelter rushing world where some psychiatrists feel like they’re on the assembly line doing med checks.
Take plenty of time out for yourself. Working on an intense level is rewarding but you also need a break from it to avoid burnout. Go on frequent vacations. A psychiatrist friend of mine, a wife and mother, goes off on Caribbean vacations by herself several times a year to feel refreshed.
It’s fine to show emotion to a patient. We see all phases of life, from birth to death. If something wonderful or terrible has happened to a patient or his family, express natural emotions – even tears – for the patient. This is very healing and comforting to us. I know of a psychiatrist who cried with her patient who lost a loved one to death.
I learned through the grapevine that a former patient of mine, about my age, was dying of cancer. I still keep my old phone book of all the patients I’ve ever had – and I called her up to extend my sympathy to her and let her know I was thinking about her. We had a very loving talk and we each knew it was our farewell talk. Hers was one of the most beautiful spirits I had ever met in my life. All the patients you’ve ever had are a part of you forever!
Encourage patients to write notes about how they feel between psychiatric visits. Very important because there’s no way they can possibly remember everything without writing things down. Suggest they present you with their version of a mood chart. The classic mood chart, developed, I believe, by Gary Sachs, is important, but is very tedious to maintain. When I used to go on new meds, I’d simply write it on my kitchen calendar. “Started X Medicine today, 25 mg.” Then I rated how I felt on a scale of 1 to 5. And any side effects.
Psychiatrists may wish to give homework assignments to their patients. This can be extremely effective. Make sure the patient follows up on this, and ask them about it. This, again, is all about whether a patient truly wants to get better or is not yet ready to move forward.
Your attire is very important. Always look professional. That’s part of the “first impressions.”
4 – CURRENT ISSUES TO BE AWARE OF
Many if not most people with mental illness feel like second class citizens. Often, their family doctors do not understand them and treat them “differently.” This is not our imagination.
Always believe what we are saying. Question us if you have doubts about the veracity of our statements. Again, if you succeeded in establishing a good therapeutic relationship there will be no question that we will tell you the truth.
Always be curious and learn as much as you can about the patient’s experiences with other psychiatrists, family doctors, inpatient hospitals, and emergency room treatment. In this way, you will know what is going on in the larger community as to treatment of folks with mental illness. I make it a point in our group to find out about every treatment contact a patient has with a “provider” (I hate that word) or a facility.
If interested, become familiar with Advocacy Issues such as what Legislation has been passed by our State or our Congress to help people with mental illness. Give your patient an assignment, should you wish, to keep you up to date on these matters. After all, it affects you in a direct manner.
“Psychiatric Times” is one of my favorite magazines. Dr. Glijansky introduced me to it years ago. It’s reader-friendly and you can keep up to date on what’s going on in the mental health world, if you like to read, rather than go on the Internet.
Patients go on the Internet. Expect this. This is good, as they should be curious about medications and treatments. But it has its downside. Inquire what sites they visit so you can recommend these to other patients.
Be cautious, however, if patients tell you about participating in Chat Rooms. Question them about their participation. Chat Rooms can be therapeutic places – but may be dangerous as well. You can’t prevent patients from going on chat rooms, but tell them about the risks. Believe me, they already know. I myself have never been to a chat room, though many of my therapy patients have been “regulars.”
I’ve saved the most important point for last. Most bipolar patients are exceptionally talented and bright. Encourage them to use their gifts. Encourage them to work, even when they’re sick. Tell them it’s OK if you only use 40% of your brain power instead of 100%. No one will ever know. Taking to one’s bed is disastrous! It becomes a habit. The psychiatrist of a friend of mine called her every single morning to make sure she got out of bed and went to teach her kindergarten class.
We must stay busy and keep our circadian rhythms in balance until our medicine kicks in. Always reassure us it’s just a matter of slugging through, that our inner strength will carry us through until such time as we’re back to our old selves.
Paperwork – This is the bane of modern medicine, and modern psychiatry. Check with your professors and colleagues on what to use to manage the massive amounts of horrific paperwork required in modern medicine.
Congratulations on your decision to become a healer. I believe psychiatry is one of the most important jobs on the face of the earth. Good psychiatrists change people’s lives, give them hope, and a reason to live. We need you, our Future Great Psychiatrists!!!
The author wishes to thank the following people for their invaluable help in writing or reviewing the article:
New Directions’ Board members: Ada Moss Fleisher, MA, CCC/Sp. and Loran Beth Kundra, JD, of the University of Pennsylvania Collaborative on Community Integration of Individuals with Psychiatric Disabilities; Simon Baniewicz; Laurence M. Schwartz, MD, of Abington (PA) Memorial Hospital. And a special thanks to New Directions’ members Rob Lokoff, and, the final editor, Susan M. Hollander.
Feb. 21, 2005
NIMH (National Institute of Mental Health) – Your preeminent source of information about mental health/mental illness. Order brochures for your patients from here. Also obtain grants.
NAMI (National Alliance for the Mentally Ill) – The only organization which approaches being a “household word” for mental health advocacy. Click on their website to find chapters near you.
BAZELON CENTER FOR MENTAL HEALTH LAW, Washington, DC. Offers legislative alerts, which are vital in the passage of legislation affecting treatment for mental health.
NATIONAL EMPOWERMENT CENTER of Lawrence, Mass.
Daniel B. Fisher, MD, PhD, executive director – he’s a psychiatrist diagnosed with schizophrenia who has “recovered”
NARSAD (largest charitable organization for research on mental illness)
http://narsad.org. Awards grants to researchers.
DBSA (Depression and Bipolar Support Alliance), out of Chicago – offers support group chapters for mood disorders throughout the country.
TEC FAMILY CENTER of Philadelphia, of the Mental Health Association of Southeastern Pennsylvania, Director Edie Mannion teaches excellent classes for family members on how to cope with mental illness.
http://MHASP.org, type in “TEC”
NEW DIRECTIONS SUPPORT GROUP, INC. of Abington, PA for patients and families with mood disorders. We welcome mental health professionals.
Be prepared when patient enters session. A quick going-over of your notes before they enter. Be welcoming and eager to see the patient.
Learn as much about the patient as you can. Patients love it when you remember details about them.
Compliment and praise the patient.
Involve family occasionally if the patient wishes.
After you are certain of a patient’s diagnosis, figure out how to nicely communicate this to them.
Sometimes the patient feels relieved to hear a name put to their condition. Other times they feel traumatized.
Work with patient on early warning symptoms of mania or depression.
Give parameters of PRN medication.
What to do in case of suicidal ideation.
Make use of present moment – “Let me stop you here a moment. Do you see how you’re arguing with me?” – “What are you looking at out of window? – “What are you thinking about?” etc.
Silence. Let patient fill up silence, not you.
Never make assumptions.
Only the patient knows how she or he feels inside.
Stress good diet and vigorous exercise.
Convey hope and optimism to every patient and family.
by Ruth Deming
You are faithful, I’ll give you that, coming ‘round just in time for Valentine’s Day.
You snuggle close and ask me to be yours. I smile knowingly, and say,
Show me your virtues… if you have any.
You, in the guise of a gypsy, with pots and pans strung across your back,
take down a few tarnished wares and hold them out to me.
I snort. Haven’t we been through all this before?
Then, as I touch your rouged cheek, I ask, Why won’t you give me up? What am I to you?
Your gypsy eyes, ringed with soot, brush my face.
Okay, I say, it was good. I admit it.
I saw the stars with you.
We ran with the moon at our backs,
leaped across the sleeping earth.
You showed me the future in a
dead dog’s eye, then led me away
lest I drown in my own dream.
You spun sweet songs from the morning breeze
and trickled them through my hair.
You peeled back the world so I could dip inside.
Took the fire from the sun
and winked it in my heart.
Okay, I say. You’re a friggin’ marvel, a regular storehouse of miracles.
But can’t we say goodbye?
It’s February and you’ve come back.
You always do.
I hear you breathing at my front door, soft as a kitten.
I’d know that sound anywhere.
Let me in, let me in, you whimper.
Can’t you be more original?
I followed you
never dreaming of deceit,
dazed by your taste for light and color
awed by your contempt of boundaries
so like my own
which you swept away
with a lion’s paw
while I cheered you on from the sidelines,
until I found myself
to a hospital bed.
And forgot I had a name.
Amid the tumult,
amid the sea of screams,
the broken minds a-bob the
slicing waves like so many
wind-up clocks jangling out of time,
who should come ‘round but you.
There, amid the black,
the granite slab of eternity sawing through my chest,
Your shadow on the wall.
You kissed my eyes
and bid me see.
My debt to you is incalculable,
simply beyond measure.
But no pots and pans today,
Put them away.
Today I shall travel the world alone.
Fishing for words,
as I do.