Wednesday, March 14, 2012

Bioethics March 14, 2012

Bioethics today and here refers to decision making regarding some matter of health care.  Every day I make moral and ethical decisions in my office regarding my patient, independently or in combination with my patients.  In contrast to the classroom setting in the clinical office the decisions come back to haunt you.  If you make a wrong decision a death may result which is an obvious failure if your orientation is 'pro life' in the broadest sense.
In Bio Ethics there are a lot of a priori 'assumptions'.and a wide range of philosophical positions involved in a most complex and difficult to discern way.  People are not simple and do not respond as predictably as pin ball machines.  So consider first the players, context, scene and some of the ingredients that go into any health care decision by looking at a real life example.
"Doctor, I'm tired. I don't feel like going on. Life is too difficult. "

Naturally, being a psychiatrist I ask, "Do you want to die".  I would probably ask , 'what do you want?" , "what do you want me to do" and eventual get around to asking "do you want to kill yourself".  Clinical skill is related to how you sequence these questions, the tone of voice, the body language, and how open you are to the response.  In Freudian genius these interactions were called 'transference' and countertransference'. All the patient brought to the exchange and all the therapist brought to the exchange.
People afraid of death, especially there own, shut people up, shame them and discourage them from communicating their inner fears and resentments.  Something like 90% of suicidals have talked to someone about the suicide in days before they do it. The conversation or whatever that was didn't go well in those that committ suicide finally.
Leaving off on the clinical aspects of suicide, and forgetting that the patient may be famous, beautiful, young old, diseased, assenine, crimiinal or just plain irritable, there are a whole range of philosophical, religious and spiritual aspects to this exchange.
Kurt Vonnegut said 'we are all just peep holes on reality'.
The patient said in the example 'Doctor'.
Philosophically, the term 'doctor' evokes a wide range of relational and significant associations.  The first that comes to mind is the incredible stupid and painfully boring notion of the marxist lennist proletariat bourgeosie , doctor as more powerful and patient as weak and powerless. The radical feminists hawked this paranoid position for their own self serving ends claiming men were strong and women were weak and ironically wanting women to dominate men because they were weak.  No greater silliness has been purported and this in a country where the Queen reigned and half the population were female and the society was increasingly matriarchal.  I mention this because all manner of nonsense will be lurking in the unconscious or the background and maybe relevant to the discussion.
In my office, there is emphasis here on 'my' suggesting even the philosophical term of 'ownership' and bringing to mind all manner of ideas around whose office it really is ( the fact is, no one owns anything really, because the state is all powerful, has been forever it seem and the the king or whatever he's called these days can with varying levels of ease take whatever he wants from plebians such as myself and my patients.  Even the multi millionaires I've treated are small fry compared to the billionaires who scare them)
The oldest law of fish, is that there are big fish and little fish and the little fish must be fast and numerous.
I say 'my' office to designate that this person has come to me to tell me this 'thing' because there's a societal arrangement whereby people go to doctors to talk to them about their genitals, assholes, ear lobes, stomach pains, and suicidal ideation.  Once they talked about suicidal ideation with a different person but today a person comes commonly to the doctor.
People needing water go to a well because it works.  For whatever reason when I entered the field of medicine, thanks to my colleagues before me and the amazing miracles that the profession of medicine has accomplished in the last hundreds of years, patients came to doctors with a positive idea about getting something beneficial.  Patients rarely go to police, judges, the military, or vacuum salesmen and say they're feeling suicidal today.
All of those relational issues are a priori.  They are therein the first interview and I personally have not specifically established them but they exist before the interview. The patient who comes to me brings all the relationships theyve had to the table when they say the word 'doctor'.
Doctor in my world was the man who came to my home was I was sick and my parents were distraught. The doctor calmed the chaos and restored me to wellness as a child. The doctor poked me and prodded me and crossed all manner of social boundaries looking at my privates as a child and sticking things in my ears and throat.  The doctor, like any good witch doctor, had strange smells and technological things and pretty medicines and lots of confidence and assurance and oddness.
I don't know if anyone gets to see me before having seen dozens of my colleagues.  It's like I'm the 20th black man this white honky sees. If the 20 before me beat the crap out of him I'm in for a whole lot of trouble establishing a 'therapeutic relationship'.  If on the other hand, as is normal and common and covers the vast majority of occasions my patient has had an overall positive experience with doctors, at least sufficient to deign to speak to one about personal matters.
When I began the doctor patient relationship was really quite simple. It was no different from the corner grocery store. People came to me to get help. I gave them help and my fame grew.  At the local grocery store the same happened and people came to the store and felt good about getting the jelly beans or whatever they came for.  There was a predictability to this all.
Things began to change over time. More often than not people came through the door and said things like 'you're trying to kill me, 'aren't you'.  "You're going to stop me from killing myself aren't you?"
These interactions were rarely related to their having met doctors before me who did such things. The fact is the media went nuts in the last decades, propaganda infiltrated everyone's brains like alien nanoprobes and society had a hissy fit. The internet is an insaneity maximizer. It may bring saneity to but I'm not in the office where I get to see that as often.
This transference/counter transference 'shit' is critical in any dyadic relationship and especially important in the life and death questions.  We haven't even passed the word 'doctor' and the person has entered the room I'm sitting in already, or maybe I've walked into the room with them , having chosen to greet them in the waiting room.  Maybe I have a secretary and the secretary has spoken to them. I had this one secretary who chose to tell all my patients how suicidal she was before I saw them and I didn't know until a few months passed and patients told me about the crazy lady I'd hired from the reputable sources only to find out I was working with something out of the twilight zone and the Government of Canada had a legion of laws like armed demons arraigned to interfere with my getting this noxious irritant out of the lives of my patients and my own life.  Nobody taught me anything about what to deal with 'work relations' in medical school and how to protect myself from psychopaths in high and low places.
So the patient says 'doctor' and thinks something and I think something by the use of the term.
Ethnocentricty refers to the idea that because you had an experience in your family, community, neighbourhood, culture that others have the same experience.  A simple association to a any 'role' and 'role theory' is a whole philosophical area of discussion is to consider them in term of your 'family' .  Freud described our internal relationships with ourselves as superego, ego, and id.  Eric Berne described these as 'parent, adult, child'.  I've further refined my relational analysis to include all the family and extended family considerations.  So when I interact with a person the generic template that I'm using is related to that first template laid down in a child's life, father, mother, sister, brother, and later grandparents, aunts, uncles, cousins.
So the word 'Doctor' for the patient may be 'Father". The priests got off on that one and it served them for a long time, well past the era of lords and ladies.  However, when I began my practice I was really young and most of my patients were older than me.  That's one of the reasons I was so gobstruck by the stupidity and silliness of the radical feminists that insisted that patients saw doctors as god like father figures.  These same people sometimes female doctors with huge axes to grind had no experience of being a stupid young man faced with an old man in a doctors' office trying to help him. I was like a liutenant with a sgte major in a war zone and as likely to get 'fragged' and to have anything I said be respected.
Most of my medical practice I've worked the 'older brother' side of the transference. I don't do father well.  I don't have children and only now have I the grey hairs and awful burden of experience that I can pull that one off.  I have over the years done a whole lot of things to 'work that 'older brother' or 'uncle' transference.  If I wanted to be 'father I'd have a bigger desk and dress in 3 piece suit. All the judges in the court rooms are hustling the father image, even the women. The court room is as antequated as the wigs but it is where the radical feminists refuse to 'fight' because deep down inside radical feminists want that power and like all revolutionaries are driven by envy as much as any of the more positive emotions. So the radical feminists got into power and abuse it right off.  Lots of bad mommies out their hawking the doctor brand.  As many bad mommies as bad daddies.
Now in my office I'm working the 'older brother' angle. I've got a great older brother. As a kid i talked to him about problems more often than I talked to my father. When I began to work cross culturally I found that the 'older brother' was a standard motif in the relational worlds of my asian patients and generally it's worked well. Everyone tells me everything and I'm often stuck talking to the 'father' and 'mother' figure colleagues who know nothing about the patients we share.
Skip the doctor as 'God'.  It's a political crapola that I only encountered when I worked in a third world country.  There the division between wealth and poverty and the classes was such that people sometimes came to me like they were crawling on their knees up a staircase to beg for some medicine that would cure them having already had to pay backsheesh to countless people just to get to see me.
I've never known that 'relational experience' in North America except when I worked in the north among the Indians and Inuit where the 'white man' was not surprisingly the 'enemy' and the 'doctor' was 'suspect'.
In countetransference terms and philosophically I've had to work with assholes who think of patients as 'children', especially the managerial bad mommy sorts who are control freaks and have all manner of emotional baggage they want to work out everywhere but don't know it.
So when a patient walks in the door I see them as a variety of people in the 'cast' of family characters and watch the 'play' of relationships like a moving screen in all of the interactions.  I've done this with film and stop gap minute by minute analysis of relational body posturing, tonal and all manner of things. It's what was foundational to my training in psychoanalytic psychotherapy and especially as a hypnotherapist.  I had to be sensitive to all this and aware of all this and then play my body and words like a piano to get the tunes I wanted in the room.
Note the 'I wanted'.  In an interaction two people bring to the table a whole set of 'expectations' and 'desires'.
Philosophically how that relationship is described can be as a 'transaction' , a 'Consumption', a 'barter', a 'buy and sell', a 'sharing', a 'religous experience', a 'meeting of minds', 'a 'politically correct coffee clutch' , a 'conversation', a 'meeting'., 'an interview'.
So that goes into the soup of the interaction.  I loved studying logic.  X - Y-Z  where x is person one, Y, is the space and activity between and z is person b.  Oh were it so simple!!!!
When a person comes through the door and says 'doctor' the dance begins.
As I've already said I started with the 'doctor' sometimes being accompanied by the phrase, "you are the doctor', 'you seem too young to be a doctor', "are you sure you know enough to be a doctor', don't you think you should get your father, isn't there someone more experienced I can see, you've got a lot of degrees but that must mean you've only spent time in school and don't know anything about real life, I really wanted to see a woman doctor, I don't like doctors and wanted to see a psychologists but I can't afford a psychologist so have to see you because you're free, if you were as good as a psychologist you'd be paid as much as they are, I' d rather see a counsellor but my doctor sent me to you, I didn't want to see a doctor but the police insisted I see someone, I don't think a stupid white guy is going to be able to help me, what makes you think a doctor is going to be able to help me.I don't need to see a psychiatrist. You need to see a psychiatirst'
That's the reality which beaurocrats are utterly ignorant of.  Their ethnocentricity is so embedded that they actually think 'doctor' means one thing.
I could have a list a mile long with as many permutations and variations of the line that followed doctor.  Now at 60 I generally get a little respect in a culture that doesn't respect it's elders and I am now a grey haired elder.  So today I have to watch the 'father-child' 'moses and the people' 'judge' and all the other shit and good that attaches to the 'old man' relationship when I meet with people.
Did I tell you that when I am with people, pretty well everyone, it's like having people shouting at me.  My world with people is incredibly loud. It's like a heavy metal band experience.  There's all the body language. There's the studied and the unstudied clothing messages.  There's the tones of voice. There's the eyes and crossing of legs and arms and uncrossing of legs and arms, theirs the hand messages and the twitches and the emphasis on words and lack of emphasis on words.  There's this cacophony of information people are putting out.
And when they're 'bleeding emotionally in my office the smell of the psyche is like feces and urine.  The fear smells and the anger and the rage and the sex and pity and all those other emotions and thoughts that play across their faces.
There's also all this supplication and seduction and coercion and pleasuring and wanting to please and all that 'baggage' or 'stuff' going on.
Even the word 'Doctor' is loaded with a hundred messages.
Now my secretary sometimes gives me the wrong folder. She doesn't think it's a big mistake. I walked into the room with a homophobic policeman and called this guy Henry Sarah.  It was the name on the chart and he was walking beside me with all the rage and threat that policemen often put out when they are in unknown places and feel insecure. So there I was back pedalling and dancing and wanting to kill my secretary because all this guy wanted to do was control me and dominate me and discredit me and get rid of me becuase he didn't want to cry with me and he so needed to cry with me and it took so much longer till he cried with me because my secretary had a bad hair day.
It's the little things. I'm always watching these tiny little things.  The patient is going on and on and on and I'm watching a 'tell' on the eye lid.  I'm watching as they blink and which words they blink on and how the blinks indicate honest responses and non blinks indicate dishonest responses. I've sometimes got a folder with a whole lot of 'collateral' information, what previous doctors have said about a person andwhat a person has said to them and there's a wealth of information to compare to his data and that data like looking at two xrays.
And eventually we can move on from Doctor.  With radical feminists it's months before you can actually get out of the vagina and penis. With some black people it's weeks before you can get around the colour issue. Then there's the single mother or the addict and the rich man is almost as difficult as the rich woman.
Carl Jung used the tarot deck to look at the 'archetypes' a whole range of 'roles' or 'position's society at large has given it's players. So once you've figured who the family relationships it's good to consider the archetypal ones that are being played out. I'm the hierophant as a physician though as often as not I can be the hanging man in an interview.  I can be the emperor but I can also be the fool. The question is what 'role' is the person 'vying for.
So leaving 'power politics' and all the silly radical feminist and boring marxist lennist big dog little dog shit behind we consider the nuances of relationships.
The patient says "I'm tired'.
This is a 'one down" statement in an exchange.  This is a supplication. This is "I'm hungry, feed me.
This is a trap.
If a person jumps to the conclusion that "im tired' means that the person hasn't slept well and they're working the billings and doing the factory medicine power trip, which puts them in line for promotion and a fast track to success with all the money they make and all the power brokers who admire them for their wealth, they jump right in and say "heres a sleeping pill" quickly writne the script and shout "next'.
That 'commodity' patient is out of the office and the 'transaction' of the 'drug company rep' is done and ker ching ker ching the registry rings.
It's equally painful to see the counsellor lean in and solicit more 'sadness' and be 'sympathetic."
I watch new patients come through the door like I watch snakes.
I've had people threaten my life in the first minutes of a session.
I was taught by my mother to beware of strangers.
I show patients respect by my wariness.
Humans shake hands to demonstrate they don't have weapons.
Women are the most dangerous of almost any species.
I was kicked by a female patient when I asked her 'how are you'.
I am experienced.
I had the very best teachers and they tried to prepare me for my medical and psychiatric practice but the world of my superiors was like a Rockwell picture or a Hallmark Post card compared to my world.
I've been held hostage for hours and my life threatened to the point I was only concerned about fouling myself.
I have had patient threaten me in countless ways. Last year two patients said to me in the first minutes of the interaction 'essentially'.  "if you don't do as I say I will complain to the college of physicians and surgeons".
The college of physicians and surgeons is an all powerful body of big dogs, big daddy dogs and big mommy dogs and they have the power to take a doctors license and shut down his practice.  I've seen it happen to countless doctors.
Working as a psychiatrist I've had countless complaints to the College of Physicians and Surgeons and everyone has cost me $10,000 or more and caused me endless nights of sleeplessness because I've invariably tried to explain my behaviour as a psychiatrist, never to a psychiatrist, but to a lawyer and to a gp and to an administrator.
And they are all 'politicos' and none of them would stand where I stand and they are all terrified of what is out there and it shows in their faces and their eyes and their need for control and their nice clothe and nice offices and the thin veneer of civilzation. They hide far away from insneity. And they scare me. They scare me like all the people in business suits and businessskirts and military uniforms and all those powerbrokers whose existence is so fragile and depends so much on the illusions of power and the threat of guns and the hierarchies and all manner of assumptions.
Ker ching. Ker ching.
Most of the people at the College are pretty good folk. I've even got my favourites. I've learned lots from a couple of registrars and had one in particular help me out in a real personal crisis. I loved one who was an old chain smoking surgeon so human she touched me heart and I looked forward to seeing her whenever I could. The college lawyer has always been a peach, perfect skin and teeth wearing a rock as bride price showing some rich man owns her as she spouts radical feminist jargon and pouts like a little girl.  Thankfully my lawyer in that exchange told me she was good sort, a mother and a friend and not just the power broker and blond image maker that she presents, shallow and clever without wisdom or substance, but actually human, but then the lawyers are all friends. It's a challenge dealing with their egos. So much of the court room stuff is dogs pissing. Administrative meetings have all that ass sniffing going on too.
So patients who the College, the Politically Correct and Government say are 'powerless' weild a mighty big stick and no doctor I know, including the most powerful today isn't afraid of 'complaints' or patients because 'patients complain' and complaints are law suits and huge costs and spending time in the principals office when you joined the school to play ball. This is the office world that lawyers and administrative types love. This is where they style and strut and they love to have doctors watch them and they absolutely delight in all the 'power' and 'status' and the doctor on the other hand is always the 'bad' boy , or 'bad girl',  'guilty until proven innoscent' and the doctor doesn't make money going through complaints, in fact, sitting with lawyers, talking with colleges and all those people is not 'billable' so even if you are 'proven' right and the patient is a wing nut frequent flier who complains about everyone or who has an axe to grind against doctors or whatever, the doctor is 'punished' big time
It's the high price of doing business.  It's the reason for the high cost of medicine too.  It's also philosophically associated with the fallacy of the 'ends against the middle'
When I came to BC the university department of psychiatry and most of the leading psychiatrists and psychiatric services actually had signs 'No borderlines'.  "I don't see borderlines'. I don't do borderlines'.  They still say "I don't do addicts'.  I don't see alcohollics.
Being a 'borderline' in British Columbia was like being a Jew in Nazi Germany. It was like having AIDs. Doctors rarely would say "I don't see Aids patients' but they had no difficulty saying I don't see 'borderline personality disorders' or "I don't see addicts or alcoholics."
The stigma of psychiatric and psychiatric patients is extraordinary. It's palpable and it stinks like horse manure everywhere in the university and especially in the College of Physicians and Surgeons of BC. The stigma against the psychiatric patient is held against the psychiatrist too.  In medical school surgery was for boys and psychiatry was for sissys.  There's a gender bias against male psychiatrists today and 90% of the recent graduating class was female with the feminization of psychiatry happening faster than the old men can die off.  But women in psychiatry is not new and when Freud said women had penis envy his female colleague said men have womb envy.  The joke among psychiatrists was "I'll see you on my couch before you see me on yours."
I joined the organization Psychiatrists against Political Abuse of Psychiatry because it was clear that increasingly psychiatry was becoming a controling arm of the state and abuse of power was greatest in the asylums, even greater than the jails.
Borderline personality disorders are by nature' complainers'.  They are 'litiginous'.
The insurance company of the the doctors notified us one year of patients which doctors should avoid seeing.  The list was compiled from their experience of what patients complained.  The list was a description of my psychiatric practice. If I were a lawyer I wouldn't see any of my patients.
Cherry picking is the standard model of capitalist based psychiatry.
At one time patients were selected on the basis of could they pay, so the rich were the best patients because they could pay the most. The American Psychoanalytic Society principally saw very rich patients because a year of therapy in the 60's ran in the tens of thousands of dollars.
Borderline personality disorders are intermittently psychotic.  They think you are 'raping them with your words'. If they want to have sex with you they will say 'you want to have sex with them' . If they hate you they will say you hate them.  They don't relate, they merge.
They are also chameleons. One of their descriptions has been 'female sociopaths'. Most borderline personality disorders are female. They use sexuality and sensuality as weapons.  They lie as a matter of course. Where male sociopaths will steal your wallet female sociopaths will steal your address book.
A colleague of mine had a female borderline patient who stole her address book and texted all her male patients with seductive messages and all the female patients with nasty little messages.  The damage took months to clean up.
I specialized in the treatment of borderline personality disorders. That was my principal interest when I began as a supervisor in the Vancouver General Hospital Psychiatric Emgency.  Borderlines were the frequent mainstay of the overnight psychiatric practice. They fared best with short stay admissions and did really poorly deteriorating into schizoaffective disorder is put in longterm institutions.
I was an idiot to come to British Columbia. To this day I think a psychiatrist with an interest in borderline personality disorder would be wise to just shoot himself rather than practice in BC.
Borderline Personality Disorders are the most sophisticated of patients with the most complex strategies of coping mechanisms and they run circles around the university and colleges that actually put of signs saying "no admittance'.
Judges and administrators are generally ignorant of borderline personality disorders except they call them all 'trouble makers' and military leaders like to line them up against the wall and shoot them.
Untreated borderlines cause havoc, treated borderlines go onto be university professors and great artists, writers and scientists.  High functioning borderline personality disorders often have genius iq's.
The fundamental flaw in the borderline is a love hate relationship with themselves and a tendency to see the world in black and white, the classic paranoid position, so they love you unconditionally, then hate you for life.. THey are as powerful in their own right as the head of the Mafia is in the criminal world.
They often succeed in some types of business, things like law are attractive to them so, males and female borderlines often do well as lawyers but their difficulties show up in their inability to maintain intimate realtionships beyond 3 years or stay in one place for more than three years. They are hunter gatherers in an agrarian or industrial world, they use up resources, and run through people and institutions and move on to their next hinterland as long as they can.
They're very sick people. They are commonly misdiagnosed as BIPOLAR II and they are most commonly PTSD untreated and they are hell on wheels if they have a drug or alcohol problem.  They're also commonly sex addicts.
To treat them successfully you have to go through the "I love you" phase and the "i hate you" phase, It's like parenting an adolescent or being a friend to someone going through a divorce. It's like riding a bucking broncho. If you can just hang in there their fear will settle and then they will blossom.  Their anxiety is just short of schizophrenia.  Treated they can integrate themselves and those around them. I have had tremendous joy watching patients who were borderline personality disorders go on to be successful leaders in society with families and high paying jobs.
No psychiatrist today can afford to go through the "I hate you" phase because the College of Physicians and Surgeons in collusion with the state in general has denounced these individuals denying them resourdces in exactly the same way as male anti socials are denied education these days in the jails.
Tough people making tough decisons.
Cherry pick. Treat the elite and ensure the elite get care and avoid any 'hazards' to upward mobility, a good life, and a rich practice.
I have a few dozen borderline personality disorders in my practice at any one time.  They are commonly labelled bipolar II or addiction or just personality disorder.  The higher functioning ones are called 'hysterics' or said to have 'borderline traits'.  Having a personality disorder is a wholly different matter than having 'personality traits'. We all have anti social traits but that doesn't make us antisocial personality disorders.
With borderlines you're always playing good cop bad cop because they're always switching from trusting to not trusting you, and that's their modus operandi, while they're said to be Post Traumatic Stress Disorder , untreated, until otherwise proven. Their histories almost invariably reveal childhood neglect so they are very good attention seekers and trauma of a sexual nature, either sexual abuse or rape because they are usually very attractive and intelligent and some bully has got off on humilating and demeaning them. Working with them you get to see in the mirror of the relationships disguises all the people who hurt them. They use you as they have been used.

I derailed into a favourite area of discussion in psychiatry for me when I consider philosophical issues. Philosophy is about the 'conscious' and 'rational' in general and many philosophers deny the 'unconscious' and avoid borderline personality disorders like the plague.

Borderline Personality Disrorder got the name because these people straddle the world of the rational and irrational. The schizophrenic lives full time in the other world and only with long term help comes back into the collective realitiy. In contrast the borderline personality disorder is at home in both the rational and irrational. 75% of borderline personality disorders are female and in contrast 75% of anti socials are male.  More men are presenting borderline than previously and more women are presenting antisocial.
Historically bad men went to jail and bad women went to asylums. Bad was societies word for anything that wasn't normal and 'like me' according to the 'judge' and military.
It was said a psychiatrist should never have more than 1 borderline personality in his practice.  As I've said I've got dozens.

When I started out the obstreticians did the easy deliveries and the hard deliveries.  Then the gps and mid wives took all the cream so today obstetricians only do incredibly difficult deliveries. The same occurred in psychiatry for people like me. I started out seeing lovely depressed people from suburban neighbourhoods with jobs and kids and university degrees. Those people now go to counsellors and psychologists.  Today I still see a few of them.  I have rich patients with a wealth of knowledge and life experience. I call them my ferraris that need tune ups.  When I started all I saw was ferraris. When a car needed an overhall, especially a chevy that had been rolled and crashed or used in derby race, I saw them in the asylum with guards and nurses.  Today I still see the ferraris but mostly I'm seeing people that need complete overhalls and some are makeshift bicycles that had an engine attached to the pedals. My patients tell other care workers that they take guns to the office when they see me or knives and they're going to kill me.   These are my young drug addicts whose parents had them prostituting for their drugs when they were six years old and they are wholly uncivilized and have been abused in the worse of the foster homes and beat up in youth detention centre. They are the real low functioning borderline personality disorders and usually they have had a major head injury added to their drug addiction and history of rape and violence.  They are like the 12 year old pregnancy my obstetrical colleagues delivers twins for with the attendant drug addiction and poor nutrition, homelessness and diabetes.
The big bucks aren't in treating sick people. Sick people haven't the resources. The money is in treating the 'worried well' . They have power and resources and don't smell.  You don't have to use air freshener in the office after those patients leave and you have all the time in the world to become powerful and those patients never complain to the Colleges because you 'understand' them and they aren't the sort to complain. You get to be a 'good daddy' or a 'good mommy' with these patients and they get to feel all warm and fuzzy and that is all they need to carry on. When they come into the psychiatrists office they just need a little 'pick me up' , a 'valium visit' because life with all it's sex in the city shopping demands has overwhelmed them a bit. They wouldn't really be really suicidal and wouldn't think about really killing themselves because frankly their lives are made. But they 'threaten suicide' and say 'they 'feel like killing someone' and they stamp their feet and cry and it's like obstetrics delivering that second baby to the strapping healthy Swedish farm wife.  It's medicine and it's psychiatry but it's not where the rubber hits the road.

I envy the counsellors who are the 'nice guys' and I 'envy" the 'good cops' and I 'envy' the 'managers and bosses' with all their rational power, their money and prestige and power to remove this. Often I want  to be anywhere else but meeting this latest 'new person' this 'stranger' coming through my door.
"I'm tired."  I can relate.
"I don't feel like going on".
As a society we are entertaining 'death' collectively as a viable option. Abortion and now Euthanasia are the really sexy topics.  CBC, the Canadian Broadcasting Association orgasms over death. It can't get enough.  Ironic. isn't it. Save the planet, kill all the humans was what one ecologist said.
So the assumption or hypothesis is that somehow I the doctor, will help the person 'go on'.
What does it mean to 'go on'.
In this one sentence the person has implied that they see life as a kind of 'journey'.  i could assume that but I really don't know as yet if they are referring to 'life' or their 'relationship' or 'this interview' or their 'role' or 'their lie' or what.
When I am in the room with a person I msut realize as part of the transference counter transference relational material we have each assumptions about life and the meaning of life and the meaning of relationships.
When I am in the room with someone I have to early figure out if they are 'psychotic'. Are they really in touch with reality. More and more people are smoking dope regularly.  More and more people are on tranquillizers.  More and more people have a network of friends on facebook who agree with them and when they see a psychiatrist they may well be taping the interview or having their friends listen in.
There is everything going on in those crucial few minutes when I've had people show me knifes or cut wrists or breasts or genitals.  It's happened.  It's a person's way of 'shocking' you and 'getting your attention' by taking off their clothes in the first five miniute or leaning over top of you and shouting down at you, or grabbing your lapels and talking spitting straight into your face or letting you know they are a federal cabinet minister or a member of the Hell's angel.
The first minutes of an interview are dogs sniffing.
I'm watching like I would any dance or television show or performance. It's all art.
The person in these first minutes is telling me volumes, whole encyclopeidas are given away in that first encounter.
First impressions don't mean a whole lot in social situations. I meet a person at a coffee shop and I have a whole lot more information than a person who works as an electirician. I'm traiined to read people like he's trained to read circuits. I'm experienced in the person like a computer tech is experienced in computers.
But in my office the variables are dramatically reduced and I have met people in my waiting room and in my office by the thousands. So like a bell hop I can very quickly recognise who drives a chevy and who drives a porche.  It's in a myriad of cues and it's all about 'pattern recognition'.
Those are the assumptions that are goiing on.  You are listening and the person is doing their performance and you are saying to yourself this is a country and western song or this is classical music or heavy metal. it's not rocket science. These opening gambits in the chess game are happening and how you play your part can completely change the game.
Most country and western singer counsellers witll start yodelling when the patient says the second line. I'm tired. They will sign and fuss and get in to that reall comfortable for them 'I'm a good mommy' and you're a poor little girl.
Ethiclally there's lots to be said about the controlling behaviour of therapists.  Therapists will let you know in a thousand ways what's acceptable. I swear in the office and my patients know it's okay to swear.  If I don't swear I'm telling them it's not okay to swear. I can make the interview 'formal' or 'informal'.  If I want to have them talk only about their 'diarrhea' I can manipulate them to talk only about their diarrhea. It's all the rage in psychiatry to play the game "I'm the healthy well psychiatrist and I'm here to fix your brain disease with a magic pill". Alternatively I can play the game 'I"m your 'cognitive therapist' and I'm here to change your way of thinking so you think like me and when you think like me you too will be a happy fruitcake.'
Eric Berne wrote about Transactions' and developed a whole lot of 'transactional analysis' models.  When people enter into a relational space they begin to 'play a game'. it's like two kids meeting in a sand box.
My training, thanks to my teachers was to let the patient "pick the game" . As the psychiatrist I might well change the ending but I wait until i can see what game the patient wants to play.
Most of my patients have been to dozens of counsellors and psychiatrists and most of those people have used the traditional relational roles like 'good mommy'.  I love good mommy. I really play good mommy very well. I also play stern daddy like the judges and managers. I can play the whole gambit of roles but the question is what role is the player playing and what is the response going to be.
So I'm tired and they're tired and I don't know if their being tired is because they have anemia, or didn't sleep or just killed a dinosaur.  I'm tired because I'm soul weary.  They may be soul weary too but I 'm a physician before I'm a psychiatrists so as a physician I have to consider that my patient may have a biological basis for being 'tired'.  So thousands of my patients have come through the door and said they were depressed and they were 'tired' and 'depressed' and the reason was quite simply they had hypothryoidism, diabetes, anemia, congestive hearts disese, a brain tumor or whatever. A week doesn't go by that I'm not diagnosing a half dozen or more physical illnesses that contribute to the patient feeling badly.  So I am a doctor.  One year I diagnosed 4 brain tumors. Of course there was a complaint (the paymaster) and I had to explain why I ordered 6 MRI's (brain scans) .  I said I found 4 brain tumors and ordered 6 MRI's. Show me somebody with a better diagnostic track record than that and should I have missed the brain tumors.  The beurocrats criticize but never apologise. I've never in my whole career had an apology from a beaurocrat but I've seen them make countless errors some which have cost my patients their lives.  Yet they never acknowledge they can be wrong.  They never apologise.  There is nothing more arrogant than a beaurocrat. They're best when they're passive aggressive too.
When I order an MRI or any test it takes time. I have to read the results. It's easier to tell the gp to do it. But alot of the time the gp won't do it.  Most of my patients don't have a regular gp . Most of my patients don't really know their gp.  I do a lot of sexual disease screening and liver testing. Alot of my patients who are fooling around and have drug and alcoholl problems dont feel comfortable talking to the gp about this stuff. I know most of gps and those ones are really good talking abut this stuff. I copy results to them and tell the patients to discuss treatment with the gps. I get the gps and my patients to have real relationships when they sometimes previously didn't realize their gps were human.
So I'm tired can mean a whole lot of things to me and my brain in doctor mode goes into over drive ruling out endless numbers of equations, looking at the colour of the patients skin for anemia, the colour of their eyes for jaundice and all that medical boring and hum drum stuff goes on at hyper speed.
When I was an intern we bet on who made diagnosis of patients walking into the hospital for admission. We'd take a coffee break and watch them walk into the big hospital admission. Then we'd follow up to see who won. Mostly I won but this one east Indian internist who'd seen tens of thousands of patients won all the time. A female psychiatrist and I played the game in the asylum admitting area too and I never could beat her.  It was the way we trained in observation. Like a symphony conductor does to know the second violin is off. We did that. It's what keeps me going. I'm learning new stuff all the time.  I'm entertained by the human condition.
I know disease like I once knew hockey playing cards and types of cars.  It's basic biology.
Next comes the psychology. And after that the sociology and then the anthropology and finally the spirituality.
My patient says "I'm tired and I can't go on" suggest depression but depression can be hundreds of things from a brain infection, to a bad boss, to an upset stomach to a bad marriage to an addiction or a depth of shame and remorse or grief. The reduction says its 'the shortage of this special pill" or your brain needs more 'electricity' and we give ECT or even better, 'let's do brain surgery'.  Every medical and surgical treatment known to man has at sometimes been used to 'treat' depression.  Every health food store makes millions off of it and every snake oil salesman loves the depressive almost as much as the cancer patient.
"life is too difficult'.  "You said it sister!"
Anyway the ethics of this dyadic relationship are the basis of a daily discussion in my office.  My patients commonly want to die and I want them to live. That's it in a nutshell.  I'm pro life and they are at that moment pro death.
There's a bioethics happening in that life and death decision.  What is life. What is the meaning of life. what is death. what is the meaning of death. What do you believe death is. What do you believe your family sees death is. What is your value of life. What is your value of death. What is suicide. What is the after life.
And that's just the discussion that will begin sometime soon and that's where one has to avoid 'intellectualization' and 'rationalization' and 'emotionalism' and 'preaching' in the real world because all of that 'philosophising' can get people killed.
I've actually had patients come in with a desire to kill themselves and kill me with them.  Never seen them before in my life and that s the way the dance begins.
Boom boom aint it great to be crazy!
And at the end of the day I'm always afraid I've made a mistake, missed something, and worry. And at the end of every day I pray.  And in the morning I pray.  Something I didn't always do. Often I've cried alone in my office. Often I'm been angry, afraid. Often I've called a senior colleague and gone over something with him.  Alot of the time I try not to think about my practice.  Often I'm heading out to nature where I seem to shake all the stuff I've picked up.  I think mental illness is infectious too.  I itch around people with scabies.  But I get up and go to work and see patients and I know a whole lot of people that don't. I'm still in the front lines on the trenches and there's something to be said for that. I'm not an arm chair quaterback or 'rear' admiral.  I'm participating.  Thoreau said lots of people 'lead lives of quiet desperation'. So many of my patients are deeply lonely and hiding in corners and apartments or wandering aimlessly.  Alot of my patients have lost the way but quickly realize the wrong turn and get back on the track they chose . They're the lucky ones. I celebrate with my patients too. I love when they have birthdays. So many of them might not have seen another birthday if they hadn't decided to invite someone like me into the darkness.
And that's a whole bioethics issue too.

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