{"id":19913,"date":"2012-02-19T12:50:48","date_gmt":"2012-02-19T17:50:48","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=19913"},"modified":"2012-02-19T13:12:49","modified_gmt":"2012-02-19T18:12:49","slug":"the-other-world","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/02\/19\/the-other-world\/","title":{"rendered":"the other world<\/em>…"},"content":{"rendered":"\n

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.’ <\/p>\n

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<\/em>‘ 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<\/em> 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.<\/p>\n

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<\/em>‘ by their grandparents. In fact, it’s not uncommon for their later children to be ‘raised up<\/em>‘ by the parents that didn’t<\/strike> couldn’t raise them. Nor is all this moving around that unusual. One frequently hears ‘and then I went to live with<\/em>‘ or ‘they took me in<\/em>‘ 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<\/em>‘ – 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<\/em>‘ who lived in a nearby State, married with two kids ‘of his own<\/em>.’ <\/p>\n

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<\/em>, and that’s why she asked me to see him. He was spending most of his time in the other world<\/em> these days, and that frightened her.<\/p>\n

\n

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<\/em> friend was much more important to him than previously mentioned. He talked nervously about his other world<\/em>, 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<\/em> he was a teen. Now as a teen, in the other world<\/em> he was ‘grown<\/em>.’ 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<\/em>‘ – more like a blog than a conversation. In those conversations, he’s never<\/u> anxious. In the ‘real world<\/em>,’ he has never<\/u> 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. <\/p>\n

Yes, he does go to the<\/em> other world when he’s glancing away into the woods while we talk<\/em>. 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<\/em>. I think the trips to the other world<\/em> 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<\/em> 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.<\/p>\n

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<\/em> 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.<\/p>\n

He said he felt neither depression nor anger. In fact, recently he didn’t feel anything much<\/em>. He agreed that he was going away to the other world<\/em> a lot more lately and had no interest in school, spending most of his time in class in the other world<\/em>. At some point while we were discussing his bind I commented, "no wonder you’re going to the other world<\/em> 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.<\/p>\n

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.<\/p>\n

\n

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<\/em> 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<\/em> to the other world<\/em> 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<\/em> 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.<\/p>\n

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.<\/p>\n

Almost always when I find myself writing about a case here, it’s a case where the psycho·<\/em><\/font><\/strong> and the social<\/em><\/font><\/strong> are on the front burner [of bio·psycho·social<\/em><\/font><\/strong>]. There are plenty where the bio·<\/em><\/font><\/strong> part is more prominent, but bio·<\/em><\/font><\/strong> isn’t an endangered species. If anything, there is an overpopulation of bio·<\/em>bio·<\/em>bio<\/em><\/font><\/strong>… <\/div>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-19913","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/19913","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=19913"}],"version-history":[{"count":23,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/19913\/revisions"}],"predecessor-version":[{"id":19936,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/19913\/revisions\/19936"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=19913"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=19913"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=19913"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}