{"id":36179,"date":"2013-05-07T23:02:19","date_gmt":"2013-05-08T03:02:19","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=36179"},"modified":"2013-05-07T23:02:19","modified_gmt":"2013-05-08T03:02:19","slug":"interlude-2","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/05\/07\/interlude-2\/","title":{"rendered":"interlude…"},"content":{"rendered":"
It was a working morning for me at the free clinic where I volunteer. As always, a full schedule. By the standards of the urban set I’m used to from Atlanta, the people of Appalachia live pretty hard lives; often out of work; a lot of alcohol and drug abuse; "broken homes" in more ways than one; most of the sequelae of low education levels, poverty, and cultural isolation. A lot are not used to being paid attention to, so they’re very responsive if you take the time to talk to them, and a little insight goes a long way. They’re often on a pharmacopoeia of medications, and I had to learn to accept that and wait until we knew each other before trying to whittle things down to size, but they’re amenable if they think you’re trying to help. A lot have been on a string of antidepressants, often with the next one started without stopping the last one. <\/div>\n

I say, "Looks like every time you go to the doctor, somebody starts another drug." They say "yes" as if that’s normal. They often know about the "withdrawals" from personal experience, running out of money for medications. I’ve been there for a while, and I’m beginning to notice that if I can get them off of the compendium of drugs, and later start one in what I consider to be the right way – low dose first, minimal expectations, they [and I] are often surprised at the response. There are always things in their lives that need attending to, and I find myself often sayingt, "These medications aren’t for life, and they’re only minimally effective when they work. The point is to feel better so you can ___." Fill in clean up your life, marriage, etc. etc. I’ve come to realize that they basically don’t know in any useful way that their symptoms have something to do with their lives.<\/p>\n

An outrageous number have been told, "you’re bipolar," and they incorporate it in what seems at first like a useful way, as if it legitimizes their depression, but in the long run it becomes something of a "fate neurosis" – a life sentence. I have had to learn that in addressing that, I am taking something away from them if I challenge that diagnosis, so I have to walk softly, but it pays off in the end. There are some people with genuine Bipolar Disorders, but it’s obvious who they are [and they are in the minority]. When I first started, a lot of drug-seeking character disordered people wandered through. I must’ve done something right, because I rarely see such patients any more. <\/p>\n

About once every clinic morning, some patient shows up with the kinds of problems I treated in practice. Today, it was an attractive talented girl who is almost home-bound because of a malignant envy problem. I’ve seen her occasionally over the last several years, and she’s finally begun to hear that her intense feelings are not truth, but the problem themselves. Today, she brought her mother to apologize to her for "being a jerk." "I thought it was your fault." They talked about her getting a job to practice being among people and planned her starting college in the Fall. If you had asked me if you could treat show-stopping envy by a few sessions in which you mainly just explained that her feelings were a bad compass, I would’ve scoffed. But I would have been wrong, as I saw this morning. <\/p>\n

Actually, that little clinic in a couple of old trailers run by a bunch of do-gooder retirees has been sustaining in writing this blog. It’s so easy to get cynical and discouraged reading the APA, PHARMA, DSM, NIMH goings on. In the clinic, I rarely think of such things. Back when I directed a residency program, I used to tell a story to graduating residents when they were nervously planning their next step. When I finished my Internal Medicine Residency, I was the smartest person on the planet. I could roll off differential diagnoses, treatment algorithms, quote journal articles. I was a giant. Then I started practicing, and was humbled by the experience. When I finished psychiatry, I felt like an idiot who knew nothing. It wasn’t until I practiced that I realized how much I’d learned. So I suggested they take a clinic job where they knew what they were doing already, and only gradually build a practice. Most did that, but within a year or so were too busy to stay in the clinic.<\/p>\n

I don’t know how it is now with all the short visits and focus on diagnostic categories and medication management. I don’t think I actually want to know. There’s a for-profit, contract mental health clinic in the county with "tele-psychiatrists." We get a steady stream of people at our clinic looking to talk to a person. There is so much more to the care of patients with mental health problems than is talked about in our blogs about PHARMA and the DSM-5 and … I feel lucky to have a place to go remember that. I don’t think I could continue to write this blog without it…<\/div>\n","protected":false},"excerpt":{"rendered":"

It was a working morning for me at the free clinic where I volunteer. As always, a full schedule. By the standards of the urban set I’m used to from Atlanta, the people of Appalachia live pretty hard lives; often out of work; a lot of alcohol and drug abuse; "broken homes" in more ways […]<\/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-36179","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/36179","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=36179"}],"version-history":[{"count":2,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/36179\/revisions"}],"predecessor-version":[{"id":42785,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/36179\/revisions\/42785"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=36179"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=36179"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=36179"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}