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Wednesday, September 13, 2006

If you're wondering why no new posts, it's because I'm now HERE. You should be re-directed in 10 seconds. It's a long story, but it has to do with Blogger-BETA. I was blocked from this site for 2 weeks, so I moved everything. Same content, different setting. Hope to see you!

Wednesday, August 30, 2006

Are We Clear? Crystal.

My first patient had me thinking of a number of things at once. The first thought was of one of my first clinical instructors, who described his process of differential diagnosis: "I ask questions, and I keep asking questions until I have a crystal clear image in my mind of what might be wrong with this patient." I also thought of the "clinical tales" of Dr. Irvin Yalom, where he initiates the assessment with the simple words, "What ails?" Questioning. "What brings you here today?" "How can I help you?" And, of course, the ever-poular, "So, what's up?" Now, be sure to read Dinah's interesting take on what people talk about in therapy (before she thinks I have again stolen from her): "I've taken to giving patients fairly specific instructions about what I want to hear, what I think will be helpful to them." This, I believe (and feel free to correct my presumption, ShrinkRap), presumes you have already determined what is wrong; what needs to be "helped."

This patient presents with the textbook affect of major depression: sad face, slow shuffling walk, eyes averted, shoulders hunched. He has a fundamental lack of animation, absent range of emotion, soft and pressured speech. Yet, when he speaks, his vocabulary, thought process, and general "fund of information" suggests that he is quite intelligent. But like a prepared witness, he offers no more than what I specifically ask. Sleep & appetite disturbance, lack of motivation, doesn't seem to enjoy much of anything; about two years ago, when he was especially depressed, he admits to hearing voices. The voices have continued, and now he "sees shadows or ghosts" in his peripheral vision; "When I turn to look, they're gone." "Why are you here to see me?" "I need to re-apply for Social Security Disability." Disability? This is an anomoly among these patients, generally, because to qualify, you must have an actual history of work, "on the books," and have actually paid taxes & FICA. This is only the second request in as many years.

It turns out he has an AA degree, was going to night school to get his BA, and had a "niche" job in a major technology company because he had training in an unique specialization. Until the "accident." "How did you get on disability?" "I got in an accident at work and was injured." "What happened?" Nothing. Silence. He is looking at the floor and remains unresponsive. I wait a reasonable moment and gently say, "Can you tell me about the accident?" Tears begin rolling down his face, but he makes no eye-contact, nor provides a response. He has now dropped his head in his arms onto the table. Again, I wait a reasonable moment and gently say, "In order for me to help you, you have to help me understand." Another silence, and finally, "I'm sorry. I just can't talk about it." Wow. OK.

As I consider the next course of action, I offer him some water, and finally ask if he believes he can continue. Factually, if he is filing for SSDI for a physical disability, I really don't need a psych work-up, and I also realize that under these circumstances, I shouldn't be seeing him in the first place. This fact is made more prominent when he tells me that he has a $50,000 brokerage account and a trust for his children. But equally factual is that applying for disability doesn't take a lot of time or effort, and there is no harm in helping him. He signs the forms, I ask the minimal questions, and we're done.

Lastly, I ask, "What is your controlling case?" (i.e. the crime that brought you to prison). Without a hesitation and with direct eye-contact he casually says, "Forced oral copulation of a minor with violence, and possession of a controlled substance." WTF! I am shocked at the bluntness of his statement; like he had just told me the Padre's score. After he leaves I get his chart: First-time offender. Depression NOS, Mirtazapine 45 mg. q hs. Axis III, "lower back pain." Report of radiology consult of the lower back: no evidence of trauma or derangement, inconclusive. Absolutely no reference, not one, to any accident.

"You can't handle the truth!"

Monday, August 28, 2006

My Friend Sophia: About Pride & Joy

Today, my friend Sophia, a Deputy District Attorney, spoke to my team about prison gangs, at my invitation. Her presentation (yes, PowerPointed) was exceptional, and staff told me that it was among, if not the single best presentation in the 2 previous years. To be honest, I was hardly surprised, because you have to know Sophia.

Sophia comes from an unique family: her father is a second-career teacher (after computer support of medical software), and body-surfs in the Pacific every day of the year; her mother is a second-career Public Health Nurse, investigating infectious disease; her brother, now "retired," is a world-champion surfer, whose unique pose adorns many a surf shop in CA (When I worked with adolescents, I had a signed poster, and kids would say, "You know Paul!!!" Yup); one sister received her doctorate in Literature and teaches in the UC system; and her younger sister is a gifted poet and artist.

Sophia graduated from high school and immediately wanted to get married. Her parents were not pleased, but eventually supported her. Her husband came with 2 very young daughters in his custody. Her husband turned out to be a "drugado" and a jerk. Sophia booted him to hell out and divorced. But there was the matter of these 2 young girls. Her ex-husband was nowhere to be found; the natural mother had lost custody because of her drug use; and the only options were keeping them or placing them in foster-care. For Sophia, there was no choice, and she became their foster-mother. They lived on ADFC & the foster-care stipend - the father was ordered to pay child support, but obviously did not. Sophia struggled, worked, and went to college at night. Given the circumstances, and undoubtedly the genetics, Sophia's daughters posed many behavioural and emotional problems; problems that led some to gossip, and others to outright suggest that she "bail" - "They're not your kids." This was the wrong thing to say to Sophia, and only strengthened her resolve to do what was right: she was the only parent they had known.

Sophia tested, applied, and was accepted into a prestigious law school, and everything was upward from there. Upon graduation, she was immediately hired by the District Attorney's Office, then passed the CA Bar Examination on her first attempt. She began with arraignments, moved to prosecuting domestic violence, headed the Task Force prosecuting gangs (in a corridor where most drugs are moved from Mexico, through San Diego, and on to LA), and now she prosecutes some of the most notorious and publicly-scrutinized cases in the County. More importantly, both of Sophia's daughters graduated from high school, and live lives beyond what anyone could have imagined - except Sophia. In my mind, they will always be a tribute to her love for her daughters.

And so, I hope the extent of my pride, admiration, and respect over a "presentation" is obvious. I have felt honored all day by my friend Sophia.

Wednesday, August 23, 2006

On Innocence

I called out the name of the next patient into a room of approximately 50, lined up on benches facing each other. A young man stood up at the farthest end, dressed in orange, blond hair that exposed and inch or so of black roots, He leaned over and hugged the man next to him, then literally bounded across the room with a smile on his face. I said, "Good morning," and he extended a limp hand, which I reluctantly shook.

I have a general rule about not touching patients. Perhaps I was unduly impressed by a lecture that focused on touching as "manipulation" (e.g. giving the message of "Please like me; don't hurt me"), perhaps I am overly-sensitive to professional "boundaries," and it certainly flies in the face of "auscultation, percussion, and palpation." Likewise, many of my colleagues emphasize that prisons, in general, are "filthy places," and the alcohol-gel hand cleaner is as common to them as a whistle. All of which is humorously ironic when a delusional patients says the same thing; one man told me he makes a "paste" of liquid handsoap & toothpaste, convinces the CO's to give him a pair of surgical gloves every Sunday evening, and by coating his hands for an hour he is "protected" from prison contamination for the week. Some colleagues use the "technique" of always having a pen or paper in hand, thereby discouraging touch. I emphasize that I am never rude - if a hand is extended, I will generally shake - but I am always cognizant of the level of violence & danger. But this is a post about innocence.

My young patient took a seat across from me, and the first thing I noticed were the long scars of self-mutilation on the top of his arms; easily a dozen on each arm. He had large doe-eyes that were locked on me, but he had little range of affect. He had fixed delusions, mainly of a judgmental. religious nature. Voices tormented him with deprecation of his past "evil life," which included his father who was murdered on the streets by gang members over drugs. A father with whom he learned to get high at age 14. Now, his father's voice scolded him as a "loser."

The first thing he said to me upon being seated was that he was not going to accept the disability "discount" the county gives for a monthly transit pass, because he was not "grateful enough" for being saved from death. He was so concrete that I found it necessary to be careful what I said, but when I asked what activities or hobbies he enjoyed, he said, "I love to fish, feed the birds, go to the mall," and very pointedly, I love girls." I spontaneously laughed, and for a moment his face was blank, wide-eyed, but just as spontaneously, he too began to laugh and extended his hand in a sort of "high-5" motion saying, "dude." Now, in prison inmates tap fists in greeting or dismissal, but staff never engage in the same manner with them. One CO even complained to me that a group of CO's had seen one of our staff exchanging "fists" with a patient. "What is he? One of their buddies?"

With a pen in my hand, I gently returned the hand motion. Why? In my heart, he was so sick, so disabled, so helpless, that he was an innocent. And as it turned out, he was a non-violent thief; stealing things from stores to sell for drug money, stealing from his family. I did not know this at the time. When we finished, walking him back to the CO's, he was grateful for my help, but he did not attempt to shake hands. But he did wait until I had gotten the next patient, and as I passed he waved good-bye.

This has only happened to me on one other occasion, and it was in the hospital at San Quentin. A man in his late-50's, who had served 24 years of a life-sentence for murder, much of it spent in the hospital, was now about to parole. He too was very ill, very gentle, very child-like. In fact, he could think of no positive reason to be leaving: his day was structured & predictable; he had his own cell with a window he could open to both see & experience the bay through bars; and he could feed the birds. His only concession was that he did want to see his elderly parents before they died, but he would gladly come back. As is typical, I interviewed him in a room barely large enough for the two chairs we sat upon. When we finished, we stood up, he thanked me, and suddenly and unexpectedly, he hugged me. It happened so fast that I didn't have time to feel either threatened or shocked. He then turned and went out the door. When I got into the hall, I told a female CO what had happened, and she literally gasped: "Oh. my God, are you OK?" When I got back to the office, my colleagues responded in exactly the same way, "You could have been killed." But he was an innocent.

This is the daily dilemma of working with the gravely impaired, dangerous, and violent. Walking a maze of professional behaviour, providing a level of care that approximates the community, acutely aware of your own safety, and the demands of your humanity. It's a bitch.

Tuesday, August 22, 2006

Do You Solemnly Swear?

A member of our clinical team did an assessment of an inmate two years ago, whose diagnosis was Major Depression. A year latter, apparently after using PCP and marijuana, he he got in a morning dispute, shot one man to death and injured another. By noon he was in a second dispute, killing another man and injuring the man's brother. By afternoon, he had killed another man and injured another. By the time the police caught up with him, he had terrorized two more people with an empty gun, the fact of which they were unaware. He was reported as shouting "I am the devil" as he was shooting. He was charged with 3 murders and 4 attempted murders, and in CA, the circumstance of multiple-murders qualifies you for the death penalty. He refused to allow his attorney to raise the issues of drug use or his psychiatric history. He was convicted after 4 hours of jury deliberation. The sentencing phase began today, and my colleague was subpoenaed by the defense for this coming Monday, as it attempts to convince a jury to spare his life. In my mind, this is a clinician's nightmare.

As I read the clinical note, it basically described a man who had been in jail a majority of the past 20 years, apparently had a difficult time on the streets, and reported that he occasionally, purposely, committed a crime in order to "get a roof over my head." While he reported feeling "a little depressed," he was taking medication which he indicated as "helpful." There was no evidence of frank delusion, thought disorder, psychosis, anxiety, or cyclical pattern of depression; in other words, he met the diagnosis for Major Depressive Disorder. He was diagnosed as Antisocial Personality Disorder - and I am usually cautious with this diagnosis, in that some who are "difficult" forensic patients are given this diagnosis without a corroborating psychiatric & criminal history. But in this case, the suggestive criminal history was present.

In hindsight he made two comments, that my colleague quoted in the note, that are suggestive. When asked if had thoughts of harming or killing anyone, he denied them. I have had numerous patients tell me sarcastically, "I'm in a maximum security prison; I have them [thoughts] every day." But do you have a plan? This patient stated, "I have gotten mad enough where I could have killed someone." When asked of his future plans he said, "When you have nothing, you have nothing to lose." In and of themselves, these two comments are certainly not predictive, but they are undoubtedly open to interpretation. My colleague is being asked to provide context to these comments.

A small group of us sat around this afternoon discussing this situation. As you might expect, my colleague is anxious. I suspect that too many movies and too much Law and Order has her believing she will be "torn apart" by an attorney. Factually, she did not diagnose or provide him with any form of treatment. Apart from her case note, she vaguely recalls this patient and her single interaction with him. We "Googled" the case to get the details, of which we are now intimately familiar. We don't belong in court. We work in a forensic environment, but we are not forensic experts.

I have been thinking this evening that if a defense team (and I suspect an underfunded court-appointed defense team) feels compelled to utilize the testimony and single-page case note of a one-time interaction with a truly peripheral clinician to aid in a Death Penalty defense, "justice" is an extraordinarily loose concept. In fact, I find it too pitiful to imagine.

Saturday, August 19, 2006

Put Your Hands, Put Your Hands in the Air

After reading that NeoNurseChic received her passport and eagerly awaits a trip, I recalled that, for whatever reason, I have difficulty traveling. Well, to be honest, whatever reason isn't exactly accurate.

I have previously alluded to my generalized scruffiness, an issue over which I am not particularly apologetic. I have yet to have a convicted murderer tell me that I was inappropriately dressed for the setting. This generalization, unfortunately, has made its way beyond my mere persona, and invaded my documents: my passport. Anyone who has seen my passport photo comes to the conclusion that I "look like a terrorist." It's a combination of the tan (SoCal - walking the yard), hair (too much & too mangey), black t-shirt & dungaree jacket (with up-turned collar), and gross profiling. I have been heartily "examined" by customs agents in foreign countries, and every single time I have returned from Canada, I have been pointed to the "Secondary Inspection" and my car has been searched. But I also add that in order to be admitted to a CA Sate Prison, I have been "background checked" by the US & CA Depts. of Justice, fingerprinted twice, and photographed & background checked yearly. This leads to a description of a visit to Mexico.

It is simple to cross the border into Tijuana (and notice the spelling - it's generally pronounced TIA-wana, when, in fact, it is pronounced ti-WANA). You walk through a tall turnstile, like leaving the NYC subway, where you can enter but not return. About 25 yards and a marker on the ground delineates the actual border. Keep walking and you come upon an office posted with a, generally, young man in a uniform with a large automatic weapon. Oddly, on the right is a traffic (people?) signal, mounted at about eye-level on the wall. It is never lit, and I have yet to determine its purpose. Within walking distance of the border are large plazas with more pharmacies than you have ever seen in one place in your life: "Lowest prices in Tijuana!" Intermixed are jewelry, leather, and liquor stores; dentists, especially the very notable Dental Felix (amazingly in Google Images!); doctors, known for just providing "prescriptions" (some medications are controlled in Mexico); and many restaurants and clubs.

My purpose on this particular day was to have lunch with a friend. It was "June gloom," the time of the year when overcast skies rules. I had a sweatshirt on, but as the day progressed, I removed the shirt and tied it around my waist. With the increased security at the border (except for the Arellano Felix family, who apparently could get anyone & anything across the border with no difficulty), the auto traffic wait is horrendous, and now even the walking wait was equally horrendous and can take more than an hour. The sign says, "busiest entry point in the world." WTF, I've been to Motor Vehicles in NY. Cue up.

Now, I interact with law enforcement frequently, but I mysteriously experience anxiety around local police and "La Migra," the Border Agents, INS. I immediately begin to feel guilt and I have no insight. Anyway, the first odd thing to happen was that I was approached by an officer leading a drug dog, in this case, it was a small Springer Spaniel; not exactly my idea of a "border protector," but the officer was kind enough to explain their sniffing ability. I learned something.

To enter the US from Mexico, you must first pass the INS; generally, show your driver's license, they may or may not ask where you were born, and keep moving. There are computers available at every INS agent station, but I have never even seen them turned on. Whatever... Next, if you have anything to declare, US Customs officers are waiting with x-ray scanners. I had brought nothing back, but as I passed by, an officer called out and asked me to approach. He asked me, "Sir, what is that in your waistband?" I started to say, "It's just my sweatshirt tied.." and as I reached to raise my t-shirt, he screamed, "PUT YOUR HANDS IN THE AIR!" I didn't even have time to panic. "I will check your waistband." As he checked, I weakly said, "It's just my sweatshirt." When he finished, I asked if this really had been necessary. "It was for our protection. You're free to go." As I walked away I heard him say to another officer, "You have to be very observant about things like that."

When I get a haircut, I usually begin the negotiation with, "I am not in the military," this being a big military town and all. But maybe in 6 months when I go for a haircut, I shall reconsider. My passport expires in December.

Friday, August 18, 2006

How Different is Dangerous

I saw a transgendered inmate today, and it caused me to inquire how she fared in an all-male prison. She said, "I'm really harassed by the Neo-Nazis, but I have a group of people who watch out for me, and I draw strength from them." Hmm. Yea, I kind of feel the same way about the Neo-Nazis. But what was most disturbing was her discussion of how she is treated by staff, given the circumstance of the Plata decision that placed the CDC medical system in receivership. This patient has chronic hepatitis B and hepatitis C, leading to cirrhotic asceties and esophageal varicies from Portal hypertension (This was of notable interest to me after a recent seminar on HCV/HCC/HIV that I recently attended - who would have thought...). He was vomiting blood one night, and no staff would believe anything was seriously wrong. He bled for several hours before his cellmate "acted the fool" to draw attention and they took her to an outside hospital. This reminded me of the story of Jennifer Sutton.

I attended safety training ("Block Training") at a prison that is a medical facility. It is always a mixed group of employees - from physicians to gardener's - and you sit through discussion that have no application to your duties (you may know how fond I am of such occasions), such as 2 hours of "Weapons and the Use of Deadly Force." Whatever... At some point in my wilting afternoon, a person from HR came in to do a presentation regarding sexual harassment. Now, for an environment known for the harassment of women, this was a truly lame presentation (and God bless all female CO's and Clinkshrink). Lame enough that some support staff broke into a discussion of transgendered inmates: "If one talks to me, could that be considered sexual harassment?" Yikes! This quickly evolved into hostility, religious belief, and discrimination. I suffered this as long as possible before, in a polite & professional manner (and you know I am), discussed the conflict with these "opinions" and California law. Yea, there are definitely some conflicts. The HR person stood there without comment. I left the training watching my back.

I cannot say I conceptually grasp the developmental transgender, or for that matter, gender assignment and sexual orientation. Is it genetically influenced, bio-psych-social-environmental as is evidenced-based medicine? On the single occasion a patient came to me for therapy, required for gender re-assignment, as is living as the other gender and receiving hormones, I had to honestly say that I was unqualified to provide what I believed to be and appropriate treatment, and made a referral. I will not end this without commenting on the issue of countertransference & prejudice. Since this is an unconscious process, it would seem incumbent upon a clinician to become aware of their operation and influence. Further, I recall once asking Dr. Otto Kernberg why I had felt increasing anger as I evaluated an abused woman, given that countertransference is classically thought to be based in personal experience (and I've never abused a woman - thought I'd throw that in), he described the phenomenon of projective identification, whereby an individual will "project" a feeling, thoughts, or beliefs onto another, and the other will feel or act as if they share the feeling or thought. As with countertransference, projective identification is an unconscious process..

All of this is to say that the difference between countertransference and prejudice is that, while the former is unconscious and the latter is conscious, both are equally capable of destroying therapeutic relationships. Likewise, the former is discoverable & correctable, and the latter is ignorant and ugly.