Saturday, October 29, 2016

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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