Tag Archives: psych

Colored glasses

I just finished reading Anna Karenina.  One of the things I liked most was the way Tolstoy shows a character’s mood not by talking about how they feel, but by showing the world through their eyes.

Here’s a despairing Anna boarding a train:

A bell rang, some young men, ugly and impudent, and at the same time careful of the impression they were making, hurried by. Pyotr, too, crossed the room in his livery and top-boots, with his dull, animal face, and came up to her to take her to the train. Some noisy men were quiet as she passed them on the platform, and one whispered something about her to another—something vile, no doubt. She stepped up on the high step, and sat down in a carriage by herself on a dirty seat that had been white. Her bag lay beside her, shaken up and down by the springiness of the seat. With a foolish smile Pyotr raised his hat, with its colored band, at the window, in token of farewell; an impudent conductor slammed the door and the latch. A grotesque-looking lady wearing a bustle (Anna mentally undressed the woman, and was appalled at her hideousness), and a little girl laughing affectedly ran down the platform.

Here, Levin has just gotten engaged to the woman he loves and goes to a political meeting to kill time until he can see her again:

They arrived at the meeting. Levin heard the secretary hesitatingly read the minutes which he obviously did not himself understand; but Levin saw from this secretary’s face what a good, nice, kind-hearted person he was. This was evident from his confusion and embarrassment in reading the minutes. Then the discussion began. They were disputing about the misappropriation of certain sums and the laying of certain pipes, and Sergey Ivanovitch was very cutting to two members, and said something at great length with an air of triumph; and another member, scribbling something on a bit of paper, began timidly at first, but afterwards answered him very viciously and delightfully. And then Sviazhsky (he was there too) said something too, very handsomely and nobly. Levin listened to them, and saw clearly that these missing sums and these pipes were not anything real, and that they were not at all angry, but were all the nicest, kindest people, and everything was as happy and charming as possible among them. They did no harm to anyone, and were all enjoying it. What struck Levin was that he could see through them all today, and from little, almost imperceptible signs knew the soul of each, and saw distinctly that they were all good at heart. And Levin himself in particular they were all extremely fond of that day. That was evident from the way they spoke to him, from the friendly, affectionate way even those he did not know looked at him.

I’m sometimes surprised at how much my view of reality shifts given my mood.  Apparently Tolstoy noticed the same thing.

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Where there’s life

Today at work, an inmate told me about someone he knew who had committed suicide.  “I just can’t believe someone would do that.  You only have one chance — my mother told me that.  You get one chance at life, and you can never come back.  You can never see your family again.”  He was completely boggled that someone with an apparently good life would want to end it.

It reminds me how differently people’s minds are programmed.  Of course, there are plenty of suicidal prisoners.  But there are plenty who, no matter what humiliations and deprivations they experience, cannot fathom wanting anything other than life.

Recently another client spent a while telling me about how she was homeless, broke, addicted to heroin, and not sure where her husband was.  At the end of the meeting, she gave a dreamy smile and casually mentioned, “And I think I might be pregnant.  I hope I am.  I’ve been trying to get pregnant.”  To me, these seemed like the worst possible circumstances to be pregnant in.  But to her, it was her life, and a baby seemed like one bright spot in a very dingy world.

Who does behavioral health care?

Warning: serious alphabet soup ahead.  A helpful guide.

People get confused about who does mental health care.  (Or, as insurance companies call it, behavioral health care, because that encompasses not only what’s wrong with your brain and your childhood, but also your drinking problem and your marriage.)  If you talk about a “therapist,” people think you mean anything from a 15-minute medication checkup to hours-long Freudian-style psychoanalysis.

The old stereotypes are that a psychiatrist sits behind the couch and says, “I see,” a nurse takes your temperature, and a social worker takes your children.  More modern people think that psychiatrists prescribe your medication, psychologists do psychotherapy, and social workers shuffle papers or work with the homeless or something.

I wanted to see how true any of this was, so I decided to start with a listing of who insurance companies list as behavioral healthcare providers.

Methods: I got the list of behavioral health providers within twenty miles of me (this encompasses the greater Boston area) from my insurance website (Anthem/Blue Cross). I drew a list of 100 practitioners.

Limitations: I started with the Zs and drew 60 names before realizing they skewed Jewish, which might affect career choice, so I switched to names starting with T, which seemed to be more ethnically mixed.  Also, Boston may be skewed in various ways because it has a lot hospitals and a high cost of living.  And maybe providers who take Blue Cross are skewed in some way.  Plus there are people practicing (not-yet-licensed folks under someone else’s supervision) who aren’t going to be listed officially.

Results:

social workers: 43
psychologists: 31
psychiatrists: 15
nurses: 5
licensed mental health counselors: 3
licensed marriage and family therapists: 2
licensed clinical mental health counselors: 1

behavioral health

Within some of these fields, there are multiple types of license. The psychologists were PhDs (doctors of philosophy, presumably in psychology),  PsyDs (doctors of psychiatry), and EDDs (doctors of education).  The nurses were RNs (registered nurses) and NPs (nurse practitioners).  Some of them can prescribe medication.  All the social workers were LICSWs (licensed independent clinical social workers).

Discussion:

This is a measure of providers, not visits.  A prescriber might see three or more patients in an hour for medication adjustment, while anyone doing psychotherapy is probably only seeing one client an hour.  (Rumor has it there are still a few psychiatrists doing 50-minute psychotherapy sessions, but I’ve never met anyone who’s actually met these people.)  So those 15 psychiatrists and 5 nurses might be seeing the same number of patients as the other 80% of non-prescribing practitioners.

While there certainly are social workers out there running domestic violence shelters, etc., it also seems that most psychotherapists are social workers.  (I’ve heard that psychologists do a fair bit of administering tests, which might pay better than therapy.)

This is the result I was hoping to find, but I promise I would have published even if it hadn’t been.

Triage

I hear that in other countries, people acknowledge the existence of medical rationing.  In the US, we like to pretend it doesn’t exist.

A jail is a microcosm of this: there is only one source of medical care, and the limited number of hours must be divided somehow among all the possible recipients. With 1600 prisoners (many of them with mental illness) and less than one full-time psychiatrist, there are never enough appointments for all the people who want them.

Where I work, the mental health clinicians are the gatekeepers for those appointments.  When one of our clients is in crisis, the mental health clinicians can make an argument to the rest of the team on why this person should see the doctor sooner.  A debate follows about symptoms, history of hurting self and others, risk factors, and whether medication is even likely to help.

During those debates, part of me always wants to say, “Yes, get him the damn appointment! I can’t stand to go back and tell him he’s not getting a med change for another five weeks!”

The other part thinks, “Who will get bumped if I move him up? Is it Angie, whose nightmares are waking her up screaming?  Khalil, who says the voices are getting louder?  Ernesto, who’s having panic attacks every time he leaves his cell?  Can I make them wait another week?”

These are the things that are happening every time we distribute resources, but they’re usually not as visible.

What things are like inside my mind

Ever since we had to take the Meyers-Briggs in 7th grade, I’ve known that I was an introvert: “Those who prefer introversion expend energy through action: they prefer to reflect, then act, then reflect again. To rebuild their energy, introverts need quiet time alone, away from activity.”

I had this idea that introversion was related to autism somehow, that introverts are more involved with their own thoughts rather than thinking about other people. Lately I’ve realized that my introversion is driven by quite the opposite problem: I model people almost all the time.  It gets overwhelming, and that’s why I need to be alone sometimes.

I remember being in high school and my school bus driver telling me why things didn’t work out with her first husband. We were stopped at a traffic light, and she pointed to the driver of the car next to us. “He was the kind of person who would care what that person in that car thinks of him,” she said. I thought, I care what that person in that car thinks of us. It must be nice not to care.  She must feel so free.

I get embarrassed easily. I have to be pretty good friends with you before I will turn on a radio around you, because you might not like the station I choose, or you might think the volume is up too high. After two years of living with my in-laws and exactly zero negative feedback from them, I am still scared to turn on music near them. If I do so, I will spend the entire time analyzing what they must be thinking of it.

Even with people I trust very much, modeling them gets exhausting if I have to do it all the time. When I lived in a studio apartment with Jeff, I was almost never alone. At times it got so overwhelming that I was hiding in closets or under the blankets just to be away from his eyes. (This is a good way to make your partner upset and sad.) It’s not even that I had any reason to think he was judging me badly.  Most of the time it was fine.  I just couldn’t ever fully shut off my awareness that I was on view, and when I was feeling inadequate it was unbearable to not be alone.

But modeling other people’s minds isn’t just something I do out of anxiety. It’s also something I do for fun.

I do like being around people, and people are often surprised to hear that I’m an introvert. I like it as long as I’m coming off well. I like people looking at me as long as I’m pretty sure that they like what they see.  If I’m in control and things are going well, I like having an audience.  That’s why I have a blog.

I’ve had imaginary friends for a very long time. I used to pretend that the people were actually in my mind, seeing and hearing everything I saw and heard. We could telepathically discuss everything that was happening. Sometimes they were famous people: the first one I remember was Elizabeth II.  I remember explaining light bulbs to George Washington. For a while there was a Soviet girl and her younger brother. (They couldn’t actually speak to me because they only spoke Russian. I did all the talking.)

These days, my imaginary friends are people I actually know. As I go through the day, I pretend they’re there with me (not literally inside my head, but walking next to me).   I think of clever things to say to them. We talk about things that are happening. I imagine what they would say back. Usually this is all silent, but sometimes I talk to them out loud.  It looks like I’m talking to myself, but I’m actually talking to someone who’s not there.

The imaginary friends are only there when there aren’t real people around. If there’s a real person present I’m busy modeling them and don’t bother modeling imaginary people.

Imaginary friends are not scary like real people are. They never disapprove of me.  They are interested in everything I find interesting. There are no miscommunications.  They’re an outlet for showing and teaching.  I get to show them my world and tell them what I think about it.

This is why being alone is relaxing: modeling an imaginary person is much less stressful than modeling a real (and thus unpredictable) person. And sometimes I’m not modeling anyone and I really am alone, and that’s nice too.

Being around young children and animals is mentally relaxing in the same way that being alone is.  I know they don’t care what I look like or whether I come off as clever.  I like being with young kids because I get to show them the world and not worry about whether they’re judging me.

…So.  This mental model feels very normal to me, but when I lay it out like that it sounds very strange. I have no idea how common it is.  Does this sound familiar to anyone out there?

A therapist who speaks geek

Cultural competence is a pretty big deal in social work.  Ideally every client has a therapist who’s well-versed in their culture.  If you see a Cambodian child with red marks on her skin, does it mean she’s being abused or that her family is practicing traditional Khmer medicine?  It makes a big difference when you’re deciding whether to call child protective services.  Even if clients just have to spend a long time explaining that what they do is normal in their culture – that’s a waste of time that could be better spent on actual therapy.  And sometimes you just want someone who gets it without you having to explain it.

And so there are practices that specialize in subcultures.  I know of several Afrocentric therapy centers in Boston and one center for Latinos.  My father-in-law says a lot of Jewish clients pick him because he has a Jewish last name.

But culture isn’t just about ethnicity.  You can find listings of therapists that specialize in transgender clients, or in BDSM.

I was talking to a friend recently about the intersection of depression and Asperger’s syndrome.  And I was thinking about how hard it might be to find a social worker who was competent in geek culture.  Psychiatrists, probably easier.  I don’t know any psychologists, so I couldn’t tell you.  But I was far and away the geekiest person in my social work program, and I’m not even that serious a geek anymore.

I remembered reading a good article (which I can’t find, but here’s a similar one) by a social worker who specialized in gamer culture.  She found her clients who were in to video and computer games had a hard time finding therapists who didn’t consider their hobbies pathological.  Most therapists wouldn’t feel the need to “fix” the fact that a client played golf every weekend – so why should they treat World of Warcraft so differently?

Geek competence isn’t just about culture, either.  It’s about how you use information: do you Google “Asperger’s and depression” to see what’s out there?   Did you read the Cochrane reviews on how well antidepressants work for his age range?

And of course it was Google that answered my question: are there therapists that specialize in geeks?

Why, yes!  In Seattle.  (“Also treating nerds, dweebs, dorks, gamers, and bronies.”)

There’s an enjoyable series of web clips about a fictional therapist who helps her clients “find their inner geek”: Geek therapy

There’s also an unrelated Geek therapy podcast.

I’m excited that this exists.  This seems like a niche I would really enjoy working in.