The last case of Friday’s clinic day was a fourteen year old boy who weighed in the high two hundreds, but didn’t look obese, more like a lineman for the Packers. He was soft-spoken and shy at first glance. He was on probation after being caught with Marijuana at school last year, and was referred to the clinic by his probation officer who had worried about him recently because though he had been a good student in the past, he was now flunking all of his classes. He seemed ‘down.’
Listening to his narrative, it wasn’t hard to understand why. Before age six, he and his older brother had lived with his single mother who worked or ‘went out‘ most of the time, so they spent a lot of their time alone. At age six, his mother married. She and her husband moved in together, but the boy went to live with his new step-grandparents. Whatever the reason for this odd arrangement, the step-grandparents functioned well as parents. They lived in a rural area. There he made friends with a boy who lived [sort of] nearby – an on again off again companion since that time. Then earlier this year, his mother and step-father had a ‘physical’ fight and divorced. The step-father moved back in with his own parents, and the boy was taken back by his mother – now living with she and her fiance [where the fiance came from is unclear]. That’s when his grades began to plummet and his teachers and probation officer started worrying. He seemed down.
At first glance, this isn’t a story that you’d expect to read in Parent’s Magazine, but in the rural South, it’s common for the children of teenaged parents to be ‘raised up‘ by their grandparents. In fact, it’s not uncommon for their later children to be ‘raised up‘ by the parents that didn’t couldn’t raise them. Nor is all this moving around that unusual. One frequently hears ‘and then I went to live with‘ or ‘they took me in‘ several times in the course of a story. It’s not even that odd to hear about this fiance that materialized out of the ether. Another common story line – both the step-grandfather and the fiance are ‘on disability‘ – a crippling mining accident and Viet Nam wound respectively. Oh yeah, he’d met his biological father the year before [who didn’t know he had this son] -a ‘nice guy‘ who lived in a nearby State, married with two kids ‘of his own.’
But there’s another piece to this narrative. The counselor who worked with the courts had gotten a story from this boy about his other world, and that’s why she asked me to see him. He was spending most of his time in the other world these days, and that frightened her.
His interpersonal anxiety was palpable when I met with him. He didn’t intitiate anything, elaborated on nothing, but answered questions willingly [glad to have a break from silence]. If there was a lag, he broke eye contact and looked into the woods that adjoin the clinic. His version of his history fit the story I’d been given fairly closely. The only difference was that it was clear that the on again off again friend was much more important to him than previously mentioned. He talked nervously about his other world, but I had the sense that it was not that he wanted to hide it, but that he genuinely didn’t know how to discuss it and really had never talked about it with anyone. It had always been there, this fantasy space. In it, he was himself, but he was older. When he was a child, in the other world he was a teen. Now as a teen, in the other world he was ‘grown.’ As best I could tell, in the fantasy, he was mostly alone, in the woods, exploring, building ‘shacks,’ living off the land. There was no magic or mythology – it was the world as it is. Sometimes there were people ["people I make up"] that he talks to about whatever’s on his mind, usually a narrative about things happening in the ‘real world‘ – more like a blog than a conversation. In those conversations, he’s never anxious. In the ‘real world,’ he has never had a conversation with another person free of anxiety. What he likes to do in the real world is "work." By which he means building things, fixing things around the place, doing chores, etc. When he is "working," he doesn’t go away and feels content.
Yes, he does go to the other world when he’s glancing away into the woods while we talk. Is it dissociative? Not exactly, in that coming and going is under his control and within his awareness. On the other hand, he’s really there. I think the trips to the other world are most often when he’s around people, but I’m not sure that he understood the question well enough to answer it clearly. In response to a question "Are there other ways you go away?" he said "I write stories." The stories are fantastic – elves, dragons, aliens, etc. He is a voracious reader of fantasy novels, currently eagerly anticipating the arrival of the fourth installment of some fantasy series. He likes to go away with Marijuana, but he prefers "spice." It’s labeled "incense" and it’s sold legally in convenience stores. Kids smoke it and go on "trips" – that he says are usually "bad trips." He doesn’t mind that. It’s the going away that matters. He’s only done that a few times since being on probation, even though drug screens don’t pick it up.
As we talked, he seemed a bit more comfortable, elaborated a few things on his own. When we got to discussing his living situation, the story was different from the one I’d been given. He wanted to live with his step-grandparents, but it was mainly because of his friend. I had the impression that he shadowed this friend and felt lost without him leading – though that was a guess. On the other hand, he didn’t want to hurt his mother’s feelings. When he visited his step-grandparents and didn’t want to come ‘home,’ his mother was devastated. When he didn’t visit his step-grandparents, they were devastated. The step-grandparents had recently turned his mother into DFACS in an attempt to get him back – claiming neglect. When I framed his situation as a double bind, he knew exactly what I was talking about – an impossible situation – nodding with animation at that term.
He said he felt neither depression nor anger. In fact, recently he didn’t feel anything much. He agreed that he was going away to the other world a lot more lately and had no interest in school, spending most of his time in class in the other world. At some point while we were discussing his bind I commented, "no wonder you’re going to the other world more," he agreed and then made his first spontaneous comment, "I don’t want to lose it. It’s my real world, more real than this one. I don’t want it taken away." I said I understood that, and that it was where he felt safe. I said we weren’t interested in taking anything away from him, but wanted to see if we could help him be more comfortable in this world. He seemed reassured by that comment. I met his mother and the fiance briefly in the waiting room. They seemed clueless but concerned. He and I planned to meet again the next time I’m in the clinic, and he seemed eager for that to happen – surprisingly eager.
His story makes sense, a shy lonely boy who retreats to an alternative reality in fantasy where he doesn’t feel anxious – like a coping mechanism. Now, when in an impossible situation, he’s doing the only thing he knows how to do – to his detriment. Is he depressed? We would probably think so, but what he reports is more like numb or dead. It’s clear that the judge, the probation officer, and the counselor all think that he needs to be returned to his step-grandparents – that environmental manipulation is the solution. I kind of agree with the boy, there is no clear environmental solution. Right now, all he’s thinking about is how other people feel, and that somebody is going to get hurt no matter what he does. He doesn’t want to be an agent of harm.
Driving home, I felt like a psychiatrist. I wouldn’t know what diagnosis to write down on a form if I had to since I’ve never seen a case exactly like his [I doubt anyone else has either]. Maybe something like Schizoid Personality Disorder. I don’t know of any algorithm to guide his future care, or any medication that treats this particular presentation. I don’t yet know the solution to his current dilemma. But I still felt good about the interview. I think he did too. I know that putting his impossible situation into words was something he’d never done. I think he talked about the other world more than ever before, and I don’t think he’d ever consciously considered its function. Talking about these things seemed to engage him and help him think. You could see that in the interview. All he could muster in the face of the confusion before was to go away to the other world where things made sense. I thought the importance of the friend and his enjoyment of "work" were hints about how to help him somewhere down the road. In spite of the seeming chaos in this story, he has a number of resources – people that "want" him; a judge, a probation officer, and a counselor who are involved, concerned, and genuinely want to help him; he is on Medicaid for what that will be worth; DFACS is going to investigate the living situation. And my job is clear – the interior. So there’s a treatment plan in all of this – we just have to locate it. This isn’t rocket science nor is there a p value. But I’m pretty sure that we’re way ahead of placebos. I have little doubt that we’re going to help this boy.
In my view, this is what psychiatrists do. It’s why I changed specialties. And continuing to do it part-time is how I tolerate reading all the other stuff that I write about on this blog. Otherwise, I would find it too depressing and reductionistic. I expect I’d stop reading it or writing about it for personal peace of mind. Then I have a clinic day and have cases like this interspersed among the routine visits, and I remember in a felt way why I changed to psychiatry from medicine proper. I just felt drawn to trying to tease the sense out of the confusion. I had to learn to tolerate the ambiguity and the impossibility – to accept that increments of clarity are incomplete and hard won advances that take a while to build on each other. It feels like research to me [n=1 research]. And it’s fun.
Is his older brother in his life? From the description, I get the impression that he’s being used as a pawn. It’s not that he’s wanted so much as the mother/step g’parents don’t want him with the other party. Like playing keep away with him. Maybe that’s a place for him to be free of guilt as thinking of himself an “agent of harm”. And perhaps an OK from you to be angry/sad/anxious/have emotions about it.
Since he’s writing, and he can enter his other world via that route, is it possible to get him enrolled in a creative writing group of some sort? That would give him much needed social contact, expose him to coaching, let him soar/excel in something which brings him comfort/satisfaction, and would provide a vehicle which would provide a confluence of his fantasy and real worlds.
Another potential option might be to explore whether he has any interest in participating in a therapeutic riding program either as a rider or a volunteer (they need all hands on deck, and there are always chores, repairs and labor of all sorts to be done). Accredited programs will have licensed therapists on board, and the level of social interaction, camaraderie and self-mastery/acceptance are usually pretty high.
I got the sense that he’s populating his world to buffer himself from overwhelming isolation. Although it isn’t within the norm, it seems to be adaptive for him.
Thanks so much for writing about this remarkable teen. I think he’s pretty darn resilient, and I’m glad he found you.
This is beautifully written. I also wonder: is he on the borders of the autism spectrum? Many autistic and “broader autism phenotype” folk are deeply engaged in science fiction/fantasy.
I second what aek said about a therapeutic riding program — there are a lot of ancillary roles and benefits.
From Assessing Adult Attachment (Crittenden and Landini): ‘Idealised images of place may substitute for security and comfort in human relationships’.
More functional than booze or harder drugs. What you describe sounds exactly like the kind of psychiatry he needs.
I’m a long time reader – first time commenter. Thanks so much for your thought provoking and insight full blogs.
As educational as I find your BigPharma posts, I find this post exceedingly interesting and familiar. I am a struggling so far survivor (diagnosed with MDD with elements of Schizoid PD, Avoidant PD, Borderline PD and OCD) of the Australian Public Mental Health system (McGorry, Hickie, Burrows and co aren’t helping), and feeling like a Pharma guinea-pig.
You don’t mention if this boy has been prescribed any psychiatric meds but in todays bio-pharma world I would have presumed it almost compulsory, unfortunately. Possibly the most empowering and positive thing you said was “… we weren’t interested in taking anything away from him, but wanted to see if we could help him be more comfortable in this world.“. In saying this you aren’t making a threatening, judgmental ruling by removing the other world where he feels safe, but enabling him the option of a better, safer real world that he can open up to. Psych meds would more than likely remove his safe other world leaving him with no choice but the threat of the real world and therefore worse off.
He is lucky to be seen by you.
In anticipation of your next real psychiatry posts,
David.
p.s. Ironically it was after reading this post that I consciously noticed the content of the masthead image “two seats in the woods”.
OH MY gosh–I used to fantasize about living off the land , alone in a hollow tree, so if anyone searched for me they would not discover where I live. — I would spend hours thinking of the details of how I would survive and get through winters etc. Then I started reading all about survival [the library was my fave place].
I used to be bullied terribly and my parents misunderstood my sensitivities as “rebellion” and would say that they need to turn me over to the police.
Getting obsessed about one topic after another was part of the cycles in my life. My parents took me to the local universities [San Jose State] and a few psychologists who once said “she’s almost autistic”. It turns out that the psychologists now think I had[have] Asperger’s or some type in autism spectrum disorder. I was almost like Temple Grandin in some aspects as a child, but I was verbal most of the time.
It took 40 years to nearly adapt to neurotypical society, then I get told that I did not need to beat myself up as much as I did. Of course there is much more than just fantasizing and getting bullied to my childhood, but this is not the place to tell my life story [or so I have been told].
yeah, but we are not paid to think as doctors anymore, just assembly line workers.
No offense, truly, but for those of us in the middle of our careers, having been burnt to near third degree burns by insurers, pharma, and our whore colleagues who enjoy being tied to the bed and tormented by these profit mongering pimps, what can we do to practice biopsychosocial psychiatry?
Rebellion is not a word, but to most of those who claim to really care and want change, why are you all waiting around for something to change for the better with the support of our alleged leaders.
What was it Einstein said about insanity, the people who do the same things over and over and expect different results,…?
@ Joel: Your response implies that you practice only by responding to payment. If so, you are no more a professional than a fast food worker. You (and everyone who holds a license in the helping professions) have a license – and a social contractual obligation – to practice medicine based on patient beneficence. Not reimbursement.
I take this very personally because as one who was licensed and did stand up and do what was ethical and best for patients (and physicians and nurses), I lost my career, and every aspect of my life was – and continues to be – destroyed. Not a single person who knew what was happening did a single thing to help me or to stop the problems. As far as I know, they continue. The people who knew what was happening turned their backs and hid. I don’t even need a telephone because no one ever calls or returns calls. I live in total and complete isolation and ostracism. The people who destroyed my life were – all of them – promoted or otherwise rewarded.
As a patient, I received psychiatric care that was deceitful, harmful and traumatizing. I don’t use that term casually. There is not a single resource for me to find quality, evidence-based care, and so I have a lovely insurance premium I can’t afford for care I cannot access. I am not alone. As you know, the suicide rate for psychiatrists is among the highest.In the single study that was done of whistleblowers, 17/35 admitted to active suicidality. 100% had active health problems. I’d say that the degree of insight into the options for effective care are well known, and that this directly contributes to hopelessness.
I suggest – with all due respect – that you start to organize with your colleagues and create an action plan to address your patients’ needs along with your professional needs. That you advocate for and protect your patients. And if you are not able to do so or are not willing to do so, that you surrender your license, absent whistle blowing (which I would never recommend to anyone). There’s great money in for-profit health insurance and pharma.
Well as for bio, bio, bio… 60 Minutes sure did a number on the antidepressants tonight. The Emperor has no clothes….
Aek, don’t try to lecture me about my duties as a doctor, as you come across above. Hey, I was a whistle blower in my past, and it got me ostracized by my alleged peers to a point of having to move. So, to those who want to try to take shots at what I write, know me before you judge me.
Google me and read what I say and advocate for at Carlat, psychcentral, and other mental health care blogs. I am the deal with my training and practice.
Dr. Hassman, I am dealing with a medical issue that I suspect may have been caused or aggravated by psych meds. I have no proof as an FYI but that is why my activism is limited right now.
But as an FYI at this site, http://survivingantidepressants.org/index.php?/topic/988-recommended-doctors-therapists-or-clinics/, we are looking for doctors who understand withdrawal issues and can help patients safely get off of meds. You seem like a good candidate for this list.
Just so you know, the board depends on donations and is not affiliated with any group.
Anyway, take a look and see what you think. Just be aware that some comments may seem overly harsh because so many people have had horrific experiences with psychiatrists. But I think many posters understand there are good ones out there.
Thank you for telling the truth.
I am sure the administrator would love to talk to you about becoming part of the list.
Thanks!
I appreciate you asking for help, AA, but I am a believer of providing care in person, at least for the initial part, but in the end do not have a comfort zone using the internet as a primary form of communication. I will check out the site, but if you are familiar with my writings at sites like this one commenting at now and others like Carlats, and psychcentral’s, I am not a big fan of rhetoric and hostile debate that seems to be about dissing and demeaning first and then later entertaining any possible honest discussion. Catch what was going on at a site called Shrink Rap a few weeks ago?
The “trick” to working through withdrawal symptoms or somatic problems exacerbated by psychotropic meds has historically been a multifactorial process of 1: finding a formulation of said med (best would be a solution) causing withdrawal and taper by 10% every 7-10 days once past 50+% of the original highest dose, 2: having a primary care physician who is psychiatric friendly in ongoing consultation with prescribing psych doctor to make sure any true somatic problems are being defined and continually accounted for, and 3: if having had numerous med trials and exhausted tertiary care med regimens, it is time to at least entertain that some people are not suited for psychotropics.
I know the above is much easier said than done, but, in my travels for almost 20 years now, and with the growing false promise of answers galore via the net, patients are not willing and able to hear what are realistic and fair limits. I hope that does not apply to you, AA, but I make the comment for others who are still between waves and ready to ride the next tall one to a hopeful fun conclusion (surf the web).
My mainstay is still pushing for psychotherapy until realistically and mutually concluded as exhausted and hopefully effective. People still come in to meet with me and not be receptive to that recommendation. Sorry the system seems to be echoing that therapy is not much an option too, just even more sorry to hear colleagues allegedly practicing therapy sell out so quickly these days.
Thanks for the recommendation. Hope the Holiday Monday is fun.
Joel H
Well done Mickey.
Dr. Hassman,
Sorry, I wasn’t clear as I didn’t mean to infer I was asking for help. I have been off of psych meds for close to two years. I am dealing with another medical issue that has nothing to do with that in which I seem to have a good doctor. Definitely don’t need the internet for that. LOL.
Unfortunately, your tapering schedule may be way too fast for the people on the board. Most people need to taper at 10% of current dose every 4 to 6 weeks.
Going too fast is what brought them to our board. But check it out and see what you think.
I am perplexed as to why hostility is threatening to you. One of your colleagues, Dr. Chris Gordon, a psychiatrist, said in podcast that psychiatry needs to understand that people have been greatly harmed by the profession and to keep that in mind when seeing a patient.
Of course, everyone should be respectful at all times but at the same time, I think you have to understand why people may be hostile. By the way, being willing to listen is the quickest way to defuse most people’s anger as they want to feel heard.
Clink on Shrink Rap, is a good example of that. I don’t completely agree with everything she says but she seems to be a good listener. That is all I can ask of anyone.
You make a fair point about having realistic expectations of your doctor.
At the same time, having realistic expectations is a two way street as doctors need to understand why patients might not be able to comply with the treatment protocol suggested by physicians and it isn’t because we’re bad patients.
When I was a child and teen, I read a lot of fantasy and often escaped into this imaginary world.
I was shy and there was a lot of conflict in my family. There’s no doubt my imaginary world was an escape, but thank God I had an imagination.
No one has ever suggested I have Schizoid Personality Disorder. I became a writer, of sorts. I still love to read.
Why should this kid be “corrected” for experiencing the intellectual stimulation (and emotional escape) of fantasy? Isn’t that what stuff like Harry Potter is supposed to do for kids? What would Michael Chabon say if he saw this case history?
(Recently read the 5 volumes of the Game of Thrones series and partly recaptured the fantasy world magic. Recommended!)
It’s not having an active imagination that’s this kid’s problem, it’s having no emotional support or nurturing of his abilities. I hope to God drugs are not recommended for him.
(PS Dr. Hassman — SurvivingAntidepressants.org is my site. I know you’re busy, please don’t write it off without looking at it. Thank you.)
Me too [active imagination, Game of Thrones fan].
“It’s not having an active imagination that’s this kid’s problem, it’s having no emotional support or nurturing of his abilities.”
True for sure. I don’t want to be defensive here, but I did say, “I wouldn’t know what diagnosis to write down on a form if I had to since I’ve never seen a case exactly like his [I doubt anyone else has either]. Maybe something like Schizoid Personality Disorder.” And I didn’t say it in the post, but he, himself, sees “In the ‘real world,’ he has never had a conversation with another person free of anxiety” and “… what he reports is more like numb or dead.” as really big problems…
But I take your point.
Dr. Mickey, just having talked to a understanding authority figure may have already made a big difference in this kid’s world view.
A little caring, intelligent company goes a long way. Thanks for being there for him.