Sunday, October 30, 2016

Church, Prayers, and my brother Ron

I was in Napanee at Hay Bay with my brother Ron and his family, Adell, Graeme, Andrew, Alan.  Tanya, Andrew’s wife has been there and Alan brought his friend Meagan.  Eva and Pepper the cockapoos are the going concern always.  Gilbert came out on my trip at the end of September when we took the SV Giri sailing. I was able to ride the Yamaha 250 motorcycle around the backwoods.  Ron had been in Kingston Hospital where his doctor, Dr. Tomiak has provided such thoughtful, loving care.  We’d been able to get him back home after that last visit.  His wife Adell is a real trooper.
Ron loves Hay Bay.  It’s so reminiscent for me of their home on the Red River by the University of Manitoba. He was to my mind so happy there and again so at Hay Bay   Beautiful wife. Proud father. University graduate. Hard worker. Haybay to me is just more acres and more square feet. There’s  something so similar for me in these homes. Ron acknowledged the similarities himself.  Getting home was so important to him. He’s planted so many flowers this last year. It’s been a while since he could kayak or bicycle. We did plant fruit trees together.  He has his salt water aquarium and guitars.  The wood burning fireplace created such a lovely fragrance at night. Adell is such a remarkable cooks. The dogs and boys are always on the go.
This last time though he wasn’t able to stand.  Adell had to take him in to the Napanee palliative care unit where "Dr. Tom” was caring and kind. The nurses were terrific too.  Ron hadn’t wanted to stay.  But his cancer had progressed. We considered options. Acceptance comes.  It was so sad to watch him wanting his body, and willing his body to move but seeing that no matter, the message was no longer getting through. His mind was fine and he was alert for long times, fully compis mantis and able to be with family. He enjoyed the company.  He didn’t want to go. Not afraid of dying but somehow not quite willing to leave the party.  Like a child yawning.
Always his family was there. Graeme sat by him all night, or Alan or Andrew. Adell was with him most of the time, day and night, a wonderful love story. . Days and nights I'd come by and find them holding hands.  I came and went  too.  My brother and I  talked of childhood and family.  I felt  a bit like the one with the watch.  Time ticking.   .  
Sunday Adell and I went to church. I took her to the St. Mary Magdalene Anglican church in Napanee. I’m now Anglican. We’d all begun as Baptists. Ron and Adell courted in the Trinity Baptist Church in Winnipeg. Adell and I have been to the Baptist church and the United Church in Napanee and enjoyed them.  I’d passed St. Mary Magdalene on the way to the Napanee Hospital.  I’d brought egg mcmuffins and coffee from McDonalds for our breakfasts.  Ron was able to enjoy a bite but I drank his coffee and mine.  He did like the red bull I brought him. It counteracted the morphine.
The church service was lovely. The church itself so British.  The people so friendly. Adell liked the music. I love her voice. She is a soprano and I’ve always loved the heavenly sound she makes when she sings. Ron and her sang together.  The Anglican music is more traditional. I listen to Praise music on the radio and love it. But this music just worked for me. The kind of Christian songs my mother and aunt sung years ago. The newer songs haven’t the same history, even though I so enjoy them.  I liked the priest.  I missed communion though. . Holy Communion service was early at 8 am.  I like those services.
We went back to the palliative care unit.  I talked more with Ron.  We have had a lot of conversations this last year, mostly about family and childhood.  I think of the songline, “there’s never enough time to say all the things you want to."
I like churches. I like worship in community. I pray.
Back home this last week Tom called. He was on his way to the Chinese Anglican Church, the Anglican Network of the Good Shepherd, near Ontario and 11th Avenue.  He said it was the opening of synod and there were celebrating Eucharist. The Archbishop of the Anglican Church of North America was there presiding. I liked the Chinese church immediately. It had what my friends in the Christian Medical and Dental Society  called  ‘bible based’  feeling.  So many of the Chinese like the Orthodox Russians I met in Moscow and St. Petersburg were persecuted for their faith and now take religion very very seriously.  It’s not an accoutrement but the centre of their lives.  Miracles happen in these places. The Gospel is truly the good news.
The joy was palpable.
I told Tom I’d been to St. Mary’s Magdalene in Napanee but missed eucharist so was glad he called.
The North American Anglican Synod was different from the Canadian Anglican Synod.  When Bishop Michael had been here the Anglican church split with the traditional congregations losing their churches and leaving the more modern Diocese of New Westminster, to which I belong. The Bishop divorced too.    I didn’t like that the diocese took the Christians to court but in the end the split created two churches, something going on since Martin Luther and certainly well established in Anglican tradition by Good King Henry.
I like eucharist. I believe in the body of Christ and the Blood of Christ. I believe in Jesus. I believe in Christ in the very fabric of existence which is essentially energy and matter is slow energy. The idea of Christ and the Holy Spirit and the historical Jesus and soul are all central for my life.  I struggle with the faith and courage and congregation but God has always been with me.  I like churches because I know that the majority of people there are spiritual seekers and somehow the meaning of that and the feeling of that lingers in this space for me. I feel edgy where wars have taken place though in general I like graveyards. I used to lunch in graveyards when I worked in Toronto and there was no other nearby green spaces.   I like hockey rinks,  playgrounds,  nature,  mountains, oceans and forests but I also like churches and temples and holy places of worship.
Now I’ve just come from St. James Anglican Church where I’ve attended for years since I left Christ Church Cathedral because of their anti dog policy.  Gilbert’s a therapy dog and was blessed by Dean Peter Elliott and Bishop Michael but he has other dog friends at St. James and he likes the kids there. His god brothers and sister are there and they all have group hugs.  I like the people too.  We missed Kevin and Anna today but expect the unexpected sunshine and heat of this day had them out with the kids. Laura said she expected Kevin would put up his incredible pictures of their morning with nature.
I say I’m a ‘winter Christian’. When the weather is good I’m so often out sailing or hiking or hunting, I miss a lot of days at church then. When winter comes I’m more likely to be in church because we’re in town on the weekend.
I’ve been praying for my brother, praying for his comfort, praying for peace. I’m praying for my family too.

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Persuasion and Behaviour Change

All behaviour is considered to have been innate or learned.  Having a dog is a real lesson in ‘innate’ behaviour, seeing how the lessons of breeding herding and hunting behaviours pass on ‘genetically’ so to speak.
In addition behaviour is learned.  You can influence all behaviour. This was the work of Skinner with conditioning and work with lab rats and mazes.   Complex human behaviours changed and are understood in a variety of ways.  Social sciences in general focus on understanding behaviour with a view to changing behaviour.
Naturally there are judgement calls.  A behaviour is described as positive or negative, healthy or unhealthy, useful or unuseful.  Each of these words is ‘packed’ with meaning.  It’s a window to understanding the ‘meaning’ of a behaviour for an individual.  It’s a way of finding a handle into ‘changing’ the behaviour as well.
Freud said there was a life and death wish.  It’s paraphrased today as ‘You’re on the up elevator or down elevator’.  “You’re going forward or backwards’.  Barack Obama said you are on the right side or the wrong side of history.
My friend who was in a concentration camp said the most potent behaviour change device was hunger and food.  My patient who was tortured described pain and stopping of pain as the most significant behaviour change he had known. Quantanamo was a study in ‘behaviour change’.
Administrators, employers,  police,  jailers have  a whole slew of options others don’t.  Working with adolescents one sees the power of money.  Kids will do a whole lot of things for money but once the money stops they stop the behaviour. They are not stupid.  The relationship are conceptualized in regards to ‘power’ and at the most basic derive developmentally from childhood with the ‘parent/child’ construct.
But as every parent knows one can ‘teach’ a child to do a behaviour but to have the child maintain that behaviour against distraction is a different matter.  In the ‘good old days’ a medieval parent ‘owned’ a child, like a master might own a slave.  There was the full range of choices for how to go about changing a behaviour. It was frowned upon if you killed the child, or slave or horse for that matter.  Doystoyevsky has a marvellous story about killing a horse and the whole discussion that follows is elucidating.
Behaviour change is also tied to the concept of ‘internalization’.  Can a learned behaviour change persist without the presence of the rewarding agent or the torturer.
To understand a behaviour such as ‘tidiness’ there is a need to grasp that each behaviour is not obviously superior in and of itself.  The nature of ‘culture’ is that there have been thousands of different ways found by humans over the length of our time here finding ways of doing things and after tens of thousands of years there remains preferred and not preferred ways by culture to achieving the same end.  Human behaviour is complex.
Changing behaviour in therapy begins with the idea of the least harm and least invasion.
In therapy with a psychiatrist in the community there is no ‘master/slave’ relationship and there is no ‘parent/child’ relationship.  The power politics of the relationship can be conceptualized in many ways and commonly a truth for a ‘group comparison’ is extrapolated to the individual context.  For instance aboriginals in a certain area of Canada are poorer relative to others so their power is diminished but in another area they are commonly richer and more powerful than most so that the power dynamics change.  This is lost in modern political correctness politics with their fixed debates.  The fact remains a female empress is more powerful individually than a male sharecropper just as a black president is more powerful than a white janitor.  It’s hard for people to see these distinctions because of their own inherent biases.
When a person comes for therapy they may see that the therapists is there ‘servant’, a kind of glorified ‘cabana boy’ who does their bidding.  A princess has many servants and the doctor and therapists are just another one. Her relationship with them all is ‘master/slave’ , ‘parent/child’, ‘employer/employee’.
The professional is in an interesting position because he is a ‘servant’ but he has obligations to the ‘profession’ and this is seen specifically in the complex arrangements for ships doctors relative to ships captains.  The whole dynamics of physical health are exploded to a whole other level when it comes to mental health. I do a whole lot of competency assessments for mental health and dearly miss the simplicity of the assessment from a physical health perspective.
Where you have real power everything is relatively easier. The rich can buy good behaviour. The physically threatening can bully good behaviour.
In therapy there is a ‘schtick’ a relatively naive and frankly ignorant notion that the therapist has ‘power’ as if the world is 1950 and ‘authority’ is respected and police are never questioned and children do as they are told.  I am daily aware that the world is mad and individually I hear of teachers who are only able to spout dribble because they are never in the field.  I talk with my military friends and we laugh at ‘academics’ because it’s all so easy when you are not in the thick of it.  It’s so obvious to anyone who is a Monday morning quarterback and our society is brimming over with everyone wanting to be a ‘consultant’ or an ‘analyst’ or a ‘judge’. No one wants to be in the ‘fog of war’ or actually do the hands on face to face work. It’s the least paid. The soldier in the line is the least paid. The most paid is the ‘oversight committee member’ who ‘reviews’ the behaviour.
Therapy can be about change or ‘collusion’.
The rich paid for psychologists to agree with them.  Today a fortune is made by divorcing people who hire counsellors who agree with them that their ex is a toad.
There is a fortune to be made in ‘agreement’ with tyranny.  There are countless tales of the deaths of advisors to kings who told the truth but didn’t live to see their genius.  The emperor has no clothes is the most eloquent of all the tales.
As long as a person is doing something having another discuss and talk about that behaviour indefinitely is not unpleasant.  The problem arises when there is an expectation of ‘stopping’ one behaviour and starting another.
One conceptualization of behaviour change that has served me well is to see a person on a mountain clinging to a couple of crevices and to move forward having to let go of their temporary safety and risk reaching for another hand hold. I love watching goats traverse such perpendicular surfaces.
I treated a hundred cutters. These are people who have learned that ‘cutting’ themselves with razor blades is rewarding experience.  It’s been likened to masturbation in the literature.  A slow crescendo to the ultimate release of blood flow.  It’s controlling and rewarding and attention seeking or secretive. It’s just one of thousand ‘behaviours’ I’ve treated over the years.  The words “I’ve treated’ don’t do justice to the experience.  Encounter is better.
Right now I more often have recurrent encounters with people who stick needles in their arms with unknown powders in the hope that the substance is heroin and not fentanyl. They know people who have died. Their motivation to change despite the risk of imminent death is little.
The cutter is a whole lot easier to treat.  Acutely suicidal people and violent people , perverts and such were more challenging.
The first step is always , in medicine, ‘observe’. To this end I ask a whole lot of questions about the behaviour.  When did it begin. What’s it like. What are the pros and cons.  What would it be like without the behaviour.  Generally we talk about the behaviour more than anyone ever before has.  I remember days of sitting in the stink of rooms smeared with faces asking an endless number of questions about the shit smearing behaviour.
Adolescents, borderline personality disorders, psychopaths, sociopaths, schizophrenics and rich and powerful people and people in jails and prisons will commonly stonewall you.
The term ‘therapeutic alliance’ is critical to therapy.  The patient and the doctor agree not just overtly but at the deepest level to work together to change the behaviour.
However if the person is in the office because of the police, or employer or insurance agent or because the wife or husband wants them there, the therapeutic alliance might well never occur. Duplicitous behaviour is common. Malingering is common. Factitious behaviour is common. In general a whole lot of people are happy to ‘go through the motions’.  They will do anything ‘but change’.  Alcoholics were happy to spend an hour a day with a therapist as long as they could have their drink after the session.  Workers sit daily or weekly in a therapists office to remain off work or collect their pay.
It’s naive to assume everyone wants to change.  Most people don’t want to change.
Whatever they are doing worked for them at some time and would work now if you just got out their face.
A whole lot of people have given up hope that they can change.  A whole lot more don’t see what the problem is.
The question is therapy is always ‘whose problem is this’.  It’s like who wants the bed made in the whole and who benefits from a made bed and even if both people benefit who can win the war and get the other person to be the one to make the bed. Commonly the only person who has a problem is the therapist.
Increasingly therapy is parallel behaviour in which the therapist is doing an academic procedure and the patient is going through the motions.  The two collude to get paid or rewarded for this unusual dance interaction.  If the therapist doesn’t ‘test’ if there is change then with endless resources this dance can go on indefinitely.
I will never forget a psychiatry resident in our psychotherapy training treating a psychopath thief who they saw for 3 years weekly all the while the theif continued to steal and amass a fortune all the while the therapy ‘interpreted’ their behaviour and discussed their ‘behaviour’. I thought of the psychiatrist seeing the mob member and considered that was okay since the mob member was paying for her ‘services’. He continued to ‘whack’ people but his marriage improved.  MAD comics once put out a funny issue describing the therapy of therapist and Hitler, and therapist and Stalin. But therapy is medicine and a ISIS jihadi executionist beheading people might get a head ache doing his job. No one would fault the pharmaceutical industry or pharmacist or the local doctor for giving him as aspirin so he could continue his work with less of a headache. So Tony whacked people and the psychiatrist paid by Tony helped him with his relationship with his wife and the other mob leaders. He gained ‘insight’ into what he was doing and his sleep improved.
When I work in the jails I’m working first for the jailer.
When I work in the government health care services, since the person I’m seeing pays taxes, I’m working for them but the Minister of Health and Medical Service Plan is paying.  When I’m working for a person seeing them for that but they have ‘private’ or insurance from another source I am working for them plus the government and always for my profession and responsibly for the community.  Commonly someone else wants my patient to do something they don’t want to do so they use therapy appearances to procrastinate.
A lovely lady didn’t want to get women to have sex with her husband . She didn’t mind threesomes per se but she drew the line at going out to bars to find willing women to bring home.  He was rich and powerful and she felt a whole lot of humiliation with this position.  After a bout six months of him paying me cash with the hope of treating her ‘depression’ she told him she didn’t want to do that. He stopped paying me and kicked her out and got a woman who apparently was more willing to provide this service. “My” patient got over her depression and may or may not in future get women for the next man.
In the US I was paid directly for services.  It was a lot clearer who I was working for.
When I was on salary to an organization it was a lot clearer who I was working for.
Increasingly as a therapist I’m being paid by several different people with competing designs and I’m already managed by a half dozen beaurocrats and others with competing plans. The government is always confused.
The patients are confused.  Do I really want to change. Is it worth it.  Should I give up picking my skin.
I use morbidity and mortality statistics to judge myself whether I’m doing anything. Increasingly I’m going through the motions like so many others. I used to really work at change but l was taught always to question who was doing more work you or the patient. Increasingly the third party is doing the least work. They don’t care. They fume and have temper tantrums and cut off funding or services but there’s just a whole lot of bullshit in the system these days that no one seems to want to change. Everyone wants to talk the talk but no one wants to walk the walk.
Harm reduction is the craze.
Divorce facilitation is marriage therapy.
I don’t want to go on and on about this but it’s the reality.
I rarely see a person who really really really really wants to change.  Those people change when they discuss the matter with there family, friends, or gp. By the time a person gets to me they have ‘failed’ in ‘changing’ for years and for dozens of therapists. Commonly the come to me and they are already seeing at least two or three other healers who are hoping that they can all blame me for their collectively not having changed anything in anywhere for five to twenty years.  I see really chronic negative behaviours.
And all I can do is ‘persuade’.
In contrast the administrator or employer can ‘punish’ by taking away their job.  I can’t even ‘fire’ a person without getting in trouble with some authority.  Look at the difficulty landlords have with eviction.  It’s no different than a ‘seat’ in an office. Once that person is allowed to ‘sit down’ hell can freeze over before you can move them or you can move them but at risk to your life and livelihood.
I used to be able to do things like talk about things, but today “I don’t want to talk about that’ is quickly followed by ‘If you insist upon talking about that I’m going to make your life miserable for years and cost you millions.”
People pull out guns and show me where they want the discussion to go. Others pull out knives. More and more people tell me the name of their lawyer.
Change my behaviour at peril.
Truly there are more who are truly perplexed by their inability to change a behaviour. “I thought I could stop cutting myself but I can’t. I used to be able to hide it, cutting under my clothing but now I’m cutting my hands”.
Education doesn’t work. But we all do it.  “Have you tried…."
Insight - this is ‘why'
What is the benefit , when and where,

Drugs are marvellous. Prozac in combination with therapy is twice as effective as therapy alone.  When prozac didn’t work and a dozen other as like drugs didn’t work one could punish the patient with ECT which would at least cause the patient to forget whatever it was that they were thinking about when they are cutting or it might well have not punished them but simply increased the serotonin which seems low in people who cut themselves.  But what happens when all the pharmacopeia has been used and they’ve had ECT and they’re still cutting.
That’s what’s happening today.

I see people who have tried ‘everything’ to stop their drinking, their cutting, their wife beating, their child fucking, their refusal to leave their homes, their inability to get on planes, their inability to work, to have sex, to eat, whatever.
All of what used to be seen in the hospital where the doctor had power and status and a ‘team’ is now seen in the community by an isolated practitioner who lives in fear about what the next angry person is going to do when you suggest, ask, hope they will change their bullying behaviour.
Patients take pleasure in ‘proving’ they can’t change. “See I told you no one could change me."
People said I should see you but I know you’re not going to help me."

No one listens to me.
No one helps me.
You’re just another stuck up asshole who thinks you know so much , well you don’t know me and no one is going to change me.

The world is full of toddlers and everyone with a connection to the internet is having a temper tantrum on the floor of the supermarket and getting a gang of other people who like doing whatever they do, including not going to work, including getting everyone else to pay for the, including being physically incapable of getting out of bed, including wanting their arms cut off, including having sex with animals and really thinking everyone else has a problem because all they need is more money and to be left alone and not judged and if you judge them you are just like everyone else.
The world is having a pout.
We’re on the verge of war.
War is a failure of diplomacy. No one seems diplomatic these days. Increasingly they bully and lie. Deceit in my experience is at an all time high. People say one thing then do another and I’m always wondering do they know that. We need cameras and recordings and I have done that, I’ve recorded every session and played back what people said and did but it’s just upset them and made them angry.  You’re bullying me they say when I record what they say and play it back.
Borderlines are the norm.
Everywhere I look I see the fear in peoples eyes.
Somedays I miss sitting in locked rooms with people who smear shit on the walls.
I’ve always understood that behaviour.

Saturday, October 29, 2016

Sailing with Andrew and Tanya, Loyalist Cove Marina, Lake Ontario

I actually thought the SV GIRI  motor trip and anchoring in Kerr Bay with Alan would be the last time I took working yacht out. However, Tanya who had painted the boat in the spring asked if she and Andrew might go sailing.
So off we drove from Hay Bay  to Loyalist Cove Marina. We backed the sailboat out of the marina then drove into the wind to raise the sails.  Once they were up I let Andrew take over. He was keen on sailing. Lots of gybing and tacking while I explained wind and sail positions.  We really were doing well making quite the clip in the light winds.  I even had a single reef in the main because my autopilot handles best that way. The genoa was all out.
Tanya and I liked the flatter pleasanter (hear Sailing, Sailing song in back ground) downwind sailing. But Andrew liked best heeling and racing close hauled into the wind.  Gilbert loved being part of the whole affair and especially loved Tanya who recognized his importance as Admiral.
I enjoyed drinking coffee, reminiscing about off shore adventures and wanted to keep on going.  We were out a few hours tacking back and forth across the strait.  I just want to go on forever when I get in my sailboat and put the sails up.   I’m not a day sailor but love expeditions.  Pacific offshore sailing has ruined me.   Sailing all day and ending up anchoring at an island then sailing all day again is okay. I loved sailing around Vancouver Island each time I did that, and sailing to the Queen Charlottes. Sailing in the Sea of Cortez with anchoring at night was also a lot of fun. I like being able to anchor at night and I love sleeping at anchor.  It’s really is a whole lot more exciting though when you just continue day and night at sea. But this was just a little sail.  It was a whole lot of fun even if it was  a bit of  tease.  Next year I hope to sail island to island for days on end, getting in some fishing and swimming and forgetting about all the landlubber concerns that accumulate. These are great sailing waters and remind me a bit of the Gulf Islands and even Desolation Sound. The difference is that while they’re both protected waters, these are fresh water.
Tanya and Andrew were terrific companions.  Fun and laughing and quick learners. I have the smartest fastest nephews, the oldest being Graeme who is an engineer and knows his way around boats, where as Andrew is into robotics and the youngest Alan first went boating with me as a teen and now is well on his way to being a psychologist.  Tanya is into computers and web design so understood the chart plotter and electronics immediately.  They’re all natural sailors and keen boaters.
It was all fun. Adell, my sister in law,  had even packed a lunch we enjoyed.   I was glad to get back without mishap.  This was the last sail for the Girl  I’d hoped my brother would have been able to get out again but he was really just glad to be out of the hospital and home at that time.  He’d had a lot of fun with the family sailing in the summer when I was down earlier and he was still doing well.
Now the boat is up on land bundled in it’s winter parka, thanks to Dave at Loyalist Cove Marina. I really love the care my boat gets here. IMG 20161002 121800IMG 1878IMG 20161002 133843IMG 20161002 132758IMG 1876IMG 1933IMG 1934IMG 1923IMG 20161002 135914IMG 1932IMG 1937  1IMG 2600IMG 2602

Psychiatrists -Keynote Address -Canadian Psychiatric Association Annual Conference 2016

I am going through my photos and catching up with blogging. I don’t have internet or the brochure of the CPA Toronto Conference.  I just have some spare time and these photos and fond memories.  

I arrived late for this presentation.  It had just begun. I took a seat at the back of the packed hall with my coffee.  A beautiful fine spoken intelligent woman was presenting. I remember she had many degrees and references but spoke lovingly of her family.  She talked of the stress and struggle of academic study and clinical work and the difficulty balancing the demands.  

We are killing ourselves.  Physicians and psychiatrists are suiciding a lot.  She questioned why.  She described the personality traits that distinguish caregivers from the go getters and hustlers and the smart businessmen and predators in the world.  A different sort goes into medicine than law or banking or business or police work.  Among physicians we as psychiatrists are even more different.  Obsessive, caring, self critical and even perfectionistic.  We’re distinctly different as specialists from general practitioners and surgeons.  

I choked up as she spoke.  I know the self loathing I feel as a psychiatrist.  I started in surgery doing the first tough year with 2 months of ICU and orthopaedic and neurosurgery rotations.  The chief resident who was an amazing surgeon friend graduated and couldn’t get operating time.  He was working as a general partitioner and coming in to assist on occasion, waiting. The surgeons were always struggling with the administration.  The administration cared more for the cleaning staff than clinicians.  The hospital unions decided when an operating room would be available.  Patients died waiting in the emergency while the whole operating team waited for the hospital administrator and cleaning staff to play politics.  I couldn’t stomach the politics.   One day listening to a sleazy young three pieced suit talk down to the most amazing neurosurgeon in Canada I didn’t think I’d be able to have the patience these brilliant men and women had. They were cutting costs with saving thread on needles and doing everything possible to improve yet administration was a party zone with endless wasteful meetings and more and more personnel with less and less relevance.

I went out into general practice. The hospital administrator in my first practice was caught misusing funds.  I did surgery, delivered a hundred babies and did 2 years of community medicine and psychiatry. I’d seen that in surgery and general practice I was doing ‘band aids’.  I was fascinated with the self healing capacity of the organism,  the new field of immunology and  psychiatry which was at the time totally committed to the bio psycho social and medical psychosomatics. I worked on ‘wet alcoholic Indian reserves’ where all manner of disease, deflation, death, abuse and sordidness reigned and ‘dry reserves’ where people and communities were healthy. I was fascinated by the ‘elephant in the room’ and the drunkeness in government.   Prevention was the buzz word in community medicine and I truly believed that if we could address the central tenets of disease behaviour we could succeed. I was so young, so idealistic, so politically naive. Thank God my teachers taught me all about ’secondary gain’. I was at least given a key to the prison of my stupidity.  I became a hypnotist and did minor surgery on patients under hypnosis and later hypnotherapy, just like Sigmund Freud, but with the learning and faith of Dr. Milton Erickson. . I studied non compliance and found that 50% of disease progression was related to patient factors.  So many of the paradigms of medicine of the day came out of the era of the ‘magic bullet’.  Psychopharmacology was complementary to psychotherapy but I was specializing in family, group, psychodrama and individual psychotherapies and began moon lighting in the detox.  I found at the time only psychiatry and immunology were addressing the issues important to me. 

But my physician wife was disgusted with me leaving surgery then family practice and finally becoming a psychiatrist.  “Only failed physicians became psychiatrists, ‘ she said.  “You’re top of the class,’ my colleague said.  “Psychiatry is a filled for losers and immigrant doctors who can’t speak English so work in asylums.’  “You’re not Jewish.  Psychiatry is jewish.” I was told.  “You have such good hands, you were so good in surgery, you said you were going back to surgery,” my wife said. Her family were insane.  I learned in psychiatry I loved sane women who came with insane families. I suspect it helped them relate to me.  But that divorce ended badly.

I was suicidal and drank and smoked dope. The psychiatrists in my first full time university appointment and hospital psychiatry “job” were big on ‘better living through chemistry’, sold drugs out of their offices and drank like fish. I was a light weight compared to my superiors.  But my partner had a worse addiction and while my colleagues had wives that cleaned them up and children to police them I was more and more taking care of and covering up my wives worsening addiction and increasing negligence.  It was all too overwhelming.  One day I walked out.  I stopped drinking wine, I was a respected ‘wine connosieur’. My psychiatrist didn’t think I drank too much and thought smoking dope was good for me because my partner’s erratic behaviour were so anxiety producing.    Christians friends thought my stopping wine and marijuana might help my wife get off drugs.The psychiatrist I saw at the recommended marijuana and I was buying the marijuana from doctors. I never did smoke dope with Justin Trudeau at the time though Margaret Trudeau was a famous pot head in the circles I touched.  

So I stopped everything and went back to church.  I had always been interested in spirituality and felt something in my life had gone awry in my residency when I left the church and was introduced to Aleister Crowley teachings by my staff man supervisor, attended a small group of Aleister Crowley followers and was sexually abused by this residency psychiatry professor. At the time I was so drunk and stoned on the drugs he provided that I really I could only ‘lie back and think of Canada.’   It wasn’t the homosexuality/bisexuality that confused and disturbed me.  It was the relationship and betrayal.  He was a truly amazing man.  I took years of therapy and finally talking with Dr. Susan Penfold, who herself had been sexually abused by her psychiatrist and written a book about it,  to appreciate the betrayal of trust and the dominance and abuse of authority involved. I rather liked the physical experience and wished so often the professor wasn’t such a damaged individual that in his personal inadequacy he abused his position and preyed on vulnerable people. I learned a lot later about this Aleister Crowley cult too and the difference between that dark path and the opposing incredible lightness of being. .  The drug dealer bikers I subsequently knew were also Aleister Crowley followers. Drugs and sex and infanticide were his trademarks.  I was sick to my stomach after  I did my second abortion as a physician and couldn’t go on.  The obstetrician who had agreed to train me said that I was human, that he only did them as a last resort, to save the mother or to stop a monstrosity.  There were anti abortionists who were far more extreme and restrictive than him,  but he told me,  that the few full time abortionists he knew,   were dead inside. “Killing does that to a person.”    

I’ve been blessed in my education. I’ve been profoundly thankful for the learning that I have had and the psychoanalytic therapy and the people I have met and the pain I have alleviated. I once told a College assistant registrar, “my patients have been my greatest teachers’ and she flew into a rage and said ‘its the job of the doctor to teach the patient, not vice versa.  You don’t learn from them, you tell them.”  Among the psychotic I’m always questioning ‘Is it me or is it them that’s insane.’  There’s a fluidity.  The psychopaths and sociopaths are most illustrative. I’m thankful for the research of Dr. Robert Hare for elucidating the differences. Given my work with the dangerously insane I’m often anxious around strangers and not just a little scared when I’m dealing with sketchy authority figures.   

After any unusual encounters with patients I’ve gone to colleagues and text books. I loved seeing true Capgrass Syndromes working in the islands. Capgrass syndrome was the basis of the movie Invasion of the Body Snatchers.  Over the years it’s been a joy to follow in the footsteps of the greats like Freud, Jung, Kraepelin, Laing, Horney and Kohut, seeing that the earliest researchers described phenomena that persist and today we know so much better thanks to their observations. I’ve been blessed to be able to treat so many thousands of patients successfully, getting them over the hump in their life, through a depression, out of a delirium or psychosis, out of an addiction, over suicidal compulsion, whatever.  Unfortunately there is no ‘cure’ for life, but death.  Many people have criticized psychiatry because we don’t provide eternal ‘bliss’ .  Once treated a person is no more impervious to future life and  harm than a person who a surgeon has set a leg fracture for. Treatment and education may reduce future risk and prevent future harm.   However if a parachutist returns to the sport , they might well face another fracture. Lots of people enjoy high risk living, emotionally and otherwise. I’ve had more than one heartbreak in my life but am very thankful for the psychiatrists who helped me through my divorce.I credit their wisdom for helping me decide against joining a  criminal biker gang and return instead to more harrowing work and  extortionist criminal taxation.  

I’ve loved my work.  I truly believe being a psychiatrist has been ‘right livelihood’ from a Buddhist eight fold path perspective and like Jesus I have been a healer. 

But I always tell people I am a physician, when I tell them I’m a psychiatrist.  I am also an addiction medicine specialist now and have little problem admitting to that. I have quite a few letters  more after my name and mostly white hair where I still have it. .  Still I  am  stigmatized as a psychiatrist.  I’m appalled at how poorly I’m paid compared to other specialists.  I am furious in hospital encounters with the denigration I hear in the voice of two dimensional family physicians, internists or others. I’ve done what they do and left it for what I really believe is a three dimensional chess game with far more complexity but that much greater reward.  I’m sensitized to  judgement, probably from my marriage to a ‘real doctor’ and her scorn of psychiatry.  I intellectually know it’s  also from the community’s collective fear of mental illness.   I’m a ‘shrink’ . I’m a ‘flake’.  You know, “psychiatrists are crazier than their patients’.  I experience the same stigmatization that leper doctors experienced treating lepers. I felt that when I treated HIV patients with HIV dementia early in the epidemic.  

I cried during thisCPA  presentation. This woman psychiatrist was so attuned to the issues.  She was right on the money. Still I cried  discretely.  We are a war and death culture. It’s okay for women to show emotion and it’s okay for juniors to do so but ‘real men’ and real leaders are ‘tough’ and it’s even better if they can ‘fake an alligator tear’ on command with pepper on their fingers. I’ve watched our politicians do this with the same skill that I learned to do it in acting classes.  But the predatory eyes are always watching and even Freud said, “maybe the paranoids’ are right.

So I really loved this presentation. It brought to mind my life of failure as a physician and my own judgementalness of some of my psychiatric colleagues who seem caught up with Psychology Today and People Magazine.  I am not a ‘counsellor’ and take offence when people call me a psychologist . My female psychiatrist colleague impressed me when she turned on a person talking with us who made this mistake.   She told them that calling a psychiatrist a psychologist is like calling a doctor a nurse. I remember my female medical colleagues taking the same offence when they were called nurses as  a daily occurrence. Today a counsellors  with 3 to 5 years of relatively easy academic training and less responsibility or accountability or a nurses  with 3 to 5 years of clinical training and less responsibility or accountability, may politically correctly  in their mind consider themselves ‘equal’ to us, however  10 or 12 years of academic and clinical training, and all the consequent accountability , risk and responsibility, “social justice’  doesn’t work for me. I don’t like the communization of the ‘heath care worker’ reductionism. I think it will eventually go the same way as the military attempt to reduce the three branches to the one.  Administrators are really legends in their own mind but the cost and harm of their hair brained decisions are rarely accounted for in law suits and public humiliation.  I would encourage administrators to accept that ward clerks are their equals and take the approrpriate pay cuts. 

 There’s simply a lot more training, responsibility and risk involved in being an MD than a PhD though no PhD will have the humility to admit it usually.  Yet all my life I have seen what unions would call 'scab labour’ take the positions that were and should be restricted to psychiatrists.  

After this presentation, I joined the Medical Psychotherapy organization. I think most counselling is ‘massage’ and that what I do is ‘surgery’.  My hypnosis training and hypnotherapy and strategic family therapy training combined with psychoanalytic foundation and spiritual practices has resulted in a highly effective eclectic psychotherapy that gets me in trouble because increasingly the ‘counselling’ model that has no ‘negative transference’ but ‘soothes’ and ‘reduces’, is the norm. I last had a meaningful conversation about this ‘personal issue’ with the head of the Moscow Psychiatric Institute after he gave an amazing lecture on the limits and  stupidity of certain parts of  DSMIV   I loved hearing the challenge to the western consumer ‘reductionism’ by a man steeped in philosophy and theology, a regular 21st century Carl Jung. A Freudian Israeli psychoanalyst joined us in this conversation and I had a moment of feeling thankful for having studied psychiatry. Normally I feel 90% of what I learned and loved in psychiatry has no place in the modern administrative medicine world of Me Tarzan You Jane.  How can I explain this to a family physician or an internist. My surgical friends are the most receptive and appreciate they don’t want their patients speaking and that they are in control whereas I’m always ‘persuading’, that ugly word, the patient from the much more “ seductive”  and “safe" known illness behaviour to the frightening, unknown and initially less appealing healthy behaviour.  But I succeed. My teachers taught me well.  The patients innate self healing kicks back in.  Over and over again I have patients who were wholly non compliance with their treatment, begin to take the medicine. Addiction is the most interesting and most rewarding when you get patients to give up killing themselves and start living. Like Freud you move the thanatos to eros equation.  And all you have to go on is ‘persuasion’ because you don’t have the benefit of a person bleeding to death or seizuring to get their attention.  Psychiatry mostly deals with subtler forms of self harm. 

I’m at the end of my career. Another 10 years of work at best but most of my life has been fighting the Nazis.  Im tired and I can’t recommend for anyone to go into psychiatry given the reductionism of intelligence in this country with legalism, totalitarianism, and "drug them and shut them up" or "give them heroin or marijuana and shut them up". Marginalize and warehouse the mentally ill and the psychiatrists are a bunch of wankers. Better to get rid of them and use counsellors with 2 years of training. Better still lets use drones.  If people want to suicide, assist them. Who cares about ‘happiness’, “maslow’, Seligman, Kernberg.  It’s all bonkers.  Kardasians and Mila Cyress and designer drugs.  Hooray!

So I loved this presentation. Sitting with a thousand other psychiatrists and hearing that we had value, and thinking once again that maybe life was worth living, and as much as I am denounced and ridiculed, and as much as psychiatry is persecuted by the brownshirts, and as much as society is dumbed down by consumerism, materialism and robotics,( the ‘computer’,  the new ‘clock’ of the age of rationalism in this super modern era, deceitfully labelled ‘post modern’) well maybe , just maybe,  someone cares.  Maybe I should care, burnt out and overburdened as I am  Apparently I am just like a whole lot of other psychiatrists in Canada.  I know doctors  in Canada in general ,are ever on the verge of strike these days.  Increasingly md’s don’t specialize but get law degrees and MBA’s because FRCPC’s just don’t matter much anymore. The point is, I”m not alone.  The presentation really made that point.   I took the kleenex from my pocket and discretely wiped away another tear and used the kleenex to clean my glasses, as if they needed cleaning. The rose tinting went years ago.   

I hate myself for caring. It’s cost me millions in dollars and 19 years sober, attending AA and church and still seeing psychiatrists I don’t know if it’s a good life or if I could muster a ‘good death’ but this lady seemed to make living and working as a psychiatrist seem okay again.  I loved this year’s Canadian Psychiatric Association Meeting but especially this meeting where I felt something, something special.  I could have been any doctor and was other doctors but I chose to be a psychiatrist and loved my teachers even the one who abused my trust and those who protected him and those who covered it up. At the end of the day it’s helped me help my patients who so often are not believed or heard until they meet a psychiatrist who cares and knows and takes the time to listen and challenge them to live again, to get up one more time. 

(Dec. 2, 2016 - I just learned the name of this exceptional psychiatrist speaker is Dr. Mamta Gautam.)

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Friday, October 28, 2016

Dementia - Canadian Psychiatric Association Annual Conference 2016

I forget the names of these gentlemen but I checked and I still do a mean clock face.  This was by far the best ‘academic’ presentation with far too much information for me to type down all the key points.  The three brilliant and humble doctors who did the presentation really need to write a book for aging practitioners. I took a series of screen shots with my iPhone of their presentations hoping to ‘catch’ the essence of all the advances made in this area of psychiatry.  Having been around a few years I’m fairly up to date with the general areas along with my own sub speciality interests. I keep abreast of traumatic brain injury and chemical brain assaults but chose to attend this lecture series because  in creasing numbers of my patients are older and several are worried about dementing.  I tell them that we used to say a patient didn’t have an alcohol problem unless they drank more than their physician.  Today, just has addiction psychiatry has advanced with leaps and bounds rather than staggering forward I was thoroughly amazed at how much has developed in the fields of dementia.  Every day there are breakthroughs with medications for rats which are indeed addressing plaques and making them more capable of mazes.  We’re on the cusp of real human breakthroughs with already many psychological, sociological and biological approaches to something that was once thought to be ‘natural’ but now is more and more known to be more complex.  I will find the program and list the names of these gentleman.  They really were impressive. I hope the slides give some inkling of this. I captured those bits that I wanted to remember personally and share them here. There was a whole wealth of material. Great slides, great topics, great presentations and incredible research.  Thank you so much.
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