Maggie's Farm

How Patient Suicide Affects Psychiatrists

Mental-health practitioners whose clients kill themselves can face stigma from their colleagues, lawsuits, and a toll on their own psyches—making them less likely to take on suicidal patients who need their help.

Unlike most other medical specialties, where deaths are routine, suicide is imagined to be preventable. Very often it is not, any more than death from most cancers can be prevented. If all suicides were caused by simple depressions curable by a pill, that would be different. However, it's not like that. Intractable, relentless emotional pain is only one of many paths to suicide.

Like most Psychiatrists, I have had a number of them in my practice. It happens if you take on difficult cases or cover ERs.  Despite all I know about suicide, it still does shake one's confidence and excites the ambulance-chasers. Most suicides, of course, never seek any help from physicians, and some who do, lie.

I recommend this game to those who are hypersensitive to rejection: By Making A Game Out Of Rejection, A Man Conquers Fear

Look, everybody must come to terms with the fact that most people will not like us, or be interested in us, or want to help us. That's part of growing up. Despite that, there are plenty of people out there who want a friend. We have to understand that others, like us, are discriminating in their own ways. When friendships and relationships do click, it sure is fun and life-enriching, isn't it?

I once helped a very shy young fellow deal with his fear by commanding him to introduce himself to a pretty girl on a daily basis - including in NYC stores (eg Bloomingdale's), gourmet food markets, and supermarkets. He complied bravely with great faith in my advice, and in a very few instances somebody liked the cut of his jib and his (apparent) confidence and phoned him. Cured by Reality Therapy! He did not become thicker-skinned, just realistic.

I always admired Victor Frankl, but I am with Schneiderman (and David Brooks, et al) on the essential narcissistic delusion in "the search for meaning."

It has always seemed grandiose to me, but I understand that Frankl needed to find some purpose or reason to hang on, as do most people in prison camps. In the end, he produced a work which is inspiring to many.

It's easier for me, with an ordinary life, to get my mind around the search for simpler things like money, good food, romance, being useful, raising kids, living with integrity, being a good friend and spouse, and the like. When it comes to ultimate meaning, I'll go with Jesus and won't presume to invent my own. I am not smart or inspired enough to do that even if I wanted to.

From Richard Friedman,  You’re feeling down, and your doctor or therapist has confirmed it: You have depression. Now what?

Anybody with clinically-significant depression needs psychotherapy at the least.

Why elderly couples often die together: the science of broken hearts.

No matter how much you may fight and argue, you become bonded tight over years if you are even half-normal. It is a wonder, given all of our annoying flaws.

Ladies do love their orgasms and tend to value them more highly than men do. They are deeper, and last longer, than the male version.

I have known women who come to orgasm when just making out with their hubbies, and women who cannot achieve climax after an hour of rambunctious bedroom fun. Quite a few women have orgasms with exercise in the gym, on horses, or with a quick masturbation. It's a spectrum, and I do not think that it is mainly psychological. Male primates were designed to spread their alpha seed by any means possible, and they did, and still do, often selfishly without extensive attention to female satisfaction. Biologically, the female pleasure component is just gravy but it makes the fellows feel extra happy.

Women envy those hot women who can orgasm after a minute of sexual activity. Most can not. One lucky gal I spoke with told me that she orgasms the instant her husband's organ touches her labia, and goes on for six or seven more thereafter in twenty minutes. Guys love women like that but it is relatively rare. It seems to be mostly about the anatomy of the clitoris although in the first episodes of a hot new romance anything can happen.

Oxytocin is good stuff.

What do most men need and want for a good life?

An update from Dr. George Vaillant's remarkable long-term study (since 1938) of men's lives: Insights from the Longest Longitudinal Study on Men Ever Conducted:

 Character traits matter too, but even then their real importance is helping us replace a scattered narcissism with the steady maturity that leads to rewarding relationships. Perhaps it sounds cheesy, but we are ultimately here to love, and to be loved. Love leads to our ability to “put our trust in life” and the confidence to tackle our goals. Thus if we fill our lives with warm, rich relationships, all the other good stuff – career success, prestige, adventure – will be sure to follow.

It's time for 2015 travel planning if we have not done that yet (most have done so already, I suspect, but some people are last-minute "planners").

I have a new case of a fellow who has developed a travel phobia. To be accurate, he has not really developed it, it has just been exposed by his frustrated family.

Many people with fears of all sorts never have them exposed because they find ways and excuses to avoid the things that make them uncomfortable. Typical excuses: "I hate cocktail parties," "I hate going to sports stadiums," "I don't want to go to that stupid place," "It's dangerous," "I hate cities," "Airplanes suck," "It's too expensive,"  "I don't need any new friends," etc etc.

Phobias are more often identified by avoidances than by real episodes of fear or discomfort. How does one tell what is a phobic avoidance from a plain dislike? Well, a little ruthless dose of self-scrutiny can answer most of your questions about your own fears and insecurities.

Like agoraphobics, travel phobics dart from place of safety to place of safety and familiarity no matter how often over-visited, never enjoy the trip or the adventures of life, and constrict their experiences and the richness of their lives in the process. Carpe diem. Life is short and shorter with each new day and each new year.

Men are particularly reluctant to admit flaws and weaknesses.  Pride and shame prevent people from owning up to the personal weaknesses of their fears and frailties. I give blogger Ann Althouse, for example, credit for acknowledging her travel phobia (she feels that a driving trip from Madison to Austin is a daunting adventure). Properly naming one's fears, instead of making excuses, is the first step towards addressing them and conquering them.

What we term "simple phobias" are among the easiest things we shrinks have to deal with. In my experience, people with travel phobias and adventure phobias, once mastered, want to go everywhere and do everything.

Reposted and revised -

It's a cliche, isn't it? (I don't know how to put accents on words on this machine.) Lonely and isolated people feel lonelier during holidays.

Let's all think about, and try to include, the lonely this year.

We are told that holidays are supposed to be times of special social fun as well as family time, whether the 4th of July, Thanksgiving (we always try to include some close friends), or Christmas season which many like to use as an excuse for throwing a party for all their 200 closest friends or just a fish supper with a handful of good pals on Christmas Eve after church (with Eggnog of course).

People obviously vary a great deal in the extent of their social connections and (cliche again) one can easily be lonely in a crowd. Many prefer to be isolated but I think there is a basic human need to be "in community," to have human connections of all sorts outside of family. We are tribal creatures. I feel sad for those who lack tribes with whom to touch base and reconnect during the holiday season. That makes it depressing indeed because it's supposed to be about fun fun fun and party party party, right?

(As an ex-drinker who used to have some degree of social insecurities, I have learned how to have a good time at parties anyway. I like to touch base with the people I enjoy, and I like to walk up to strangers and say "Hi. I'm Joy. I don't think we've met." If they don't love me, it's their loss but maybe mine too. Rejection is just part of life, and many people seem to feel that they already know enough people unless you wow them in some way.)

There are many ingredients to constructing a satisfying life, but what a satisfying life means is different for everybody. However, I believe that to be in community, or really a part of multiple communities, is a key component. Some care about it more than others, for certain. With a little luck, the construction begins with an anchor solidly lodged in immediate or extended family, and extends, in separate but often-overlapping circles, out from there depending on what one does or decides to build.

And I do mean "build." Like career, community is never handed to you on a silver platter. I like to connect with interesting, intelligent, positive, and amusing people with interesting and adventurous lives. Who doesn't? On Saturday night, I met a gent, a retired banker, who covered the erection of the Berlin Wall for the New York Times when he was 21 years old. He had taken his grandkids to the Checkpoint Charlie museum in Berlin this summer. I want to include him, and his wife, in one of my circles.

More below -

"As opposition to the war on drugs grows louder, a movement to challenge traditional ways of treating—and doing treatment with—people who have difficulties with drugs is also reaching critical mass."

A Struggle for the Soul of Addiction Treatment

After 30 years of Nixon's politically-motivated War on Drugs - the criminalization of almost all drug use and sale except for alcohol - has failed. Anybody who wants illegal drugs can buy them almost anywhere in the US within 30 minutes. All prohibition does is to raise their prices, to create abundant new criminals, violence, and gangs, and to make drugs more appealing to defiant youth.

Things were better before The War on Drugs. I think that drug addiction is a terrible, often soul - and life-destroying thing, but many drug addicts do quite well in life in places where criminalization is less harsh.

We can't criminalize everything we disapprove of. Help for addicts and abusers is plentiful anywhere for anybody who wants it, for free or close to free. I think every sort of help is fine and not worth fighting over, but I remain an advocate of AA.

This week is the 81st anniversary of the end of Prohibition in the US.

Rape is forced sexual interaction. Rape is a felony in the US and no 18 year-old does not know that. It's a male crime. Women can seduce, and they often do quite easily because men can become aroused with little effort, but female use of force for sex is a rarity. Why on-campus rape and sexual assault is such a hot topic today I cannot figure out. From my standpoint I do not see why it should matter where you were raped.

Maybe the growth of co-education brought rape out of the shadows and onto campuses. In any event, rape and any other crime are matters for the police no matter where they occur.

College administrations need play no role in that. Colleges can, however, try to do what they used to do in the good old days: require honorable and gentlemanly behavior from the men and honorable and ladylike behavior from the women. Punishment is expulsion. Why does that sound quaint today?

Where UVA Went Wrong: Students Need to See Rape as a Felony, Not Just a Campus Infraction

UVA Should Help Police Catch Alleged Rapists -- Now.

The Right and Campus Rape - Calling in the cops is not enough.

“It is impossible to overstate the growing weirdness of the college sex scene.”

The Real Roots of Midlife Crisis - What a growing body of research reveals about the biology of
human happiness—and how to navigate the (temporary) slump in middle age. A quote:

 “I think it must be something internal,” my 45-year-old friend S. told me. He described his 20s as exciting and fun (“I was really dumb but thought I knew a lot”) and his 30s as a time of hard work and steady rewards (“I felt on track … Things looked like white picket fences and the American dream”), but said he was bushwhacked in his 40s by an unexpected divorce, unmarried fatherhood, and a heart attack. He said he now experiences difficulty feeling contentment, leading to some of the same self-doubt that I felt: a creeping suspicion that he is fated to be whiny. He also wondered whether his dissatisfaction has been a cause of some of his problems, not just an effect. “Professionally, things looked pretty good,” S. told me. “But maybe something was going on. Something sufficient for my wife to leave. If I did a deep psychological dive, I might say that nothing will ever make me content. Maybe there’s something deeply psychologically wrong with me. I see life as a challenge to overcome rather than an adventure to be enjoyed. I’ve thought of running away to Brazil—changing my name and becoming a hotel clerk. Maybe that will change in my 50s.”

On reading about this piece, I found myself wondering about the premise of the questions in the surveys. A question like "How satisfied are you with your life these days?" seems like a very American question to me. Most people on this planet think about whether they are satisfied by their meal, or whether their god is satisfied with them, and all sorts of other things other than narcissistic or hedonistic satisfaction.

The gigolo industry is gradually coming out of the closet: Male escorts - Is the growing market for male escorts a sign of female sexual liberation or just a re-run of the same old stereotypes?

This has nothing to do with "liberation."  Women have always had healthy sex drives, but just kept quiet about it. The illusion of genteel innocence can be sexy to men. On the other hand, the image of dirty, nasty and accessible femininity can be sexy to men too. Almost anything can be sexy to men.  Despite modern lesbian feminism, men should never underestimate female sexual longings and fantasies. Female fantasies are at least as reckless as those of men.

Women are, perhaps, more discriminating than guys but their needs for sex are abundant, especially in middle age. Perhaps Mother Nature wants us to get knocked up before it's too late.

There remains a trail of destroyed lives from that quackery:

The belief that hidden memories can be “recovered” in therapy should have been exorcised years ago, when a rash of false memories dominated the airwaves, tore families apart, and put people on the stand for crimes they didn’t commit. But the mental health establishment does not always learn from its mistakes—and families are still paying the price.

New book from Dr. Allen Francis: Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life

I endorse this book. The mini reviews on Amazon are informative.

It's a difficult subject to study because people are not likely to reveal their more taboo fantasies. Furthermore, in my field we tend to believe that most of our fantasies (sexual and otherwise) are kept safely beneath our own awareness.

As a Psychiatrist, I can tell you that quite normal people commonly contain all sorts of aberrant and "abnormal" fantasies which they would never act on or tell even their spouses about.

For what it's worth,  Sexual fantasies: Are you normal?

Addendum,  There Are Very Few 'Uncommon' Sexual Fantasies:

 The study found that one of the most common sexual fantasies, after the five “typical” ones, is submission, with approximately 65 percent of women and 53 percent of men fantasizing about being submissive. More men than women fantasized about dominating their partners. Still, there remains a distinction between fantasy and reality.  Of the women who fantasized about being dominated, half said that they wouldn’t want to actually be dominated in real life. Reading 50 Shades of Grey, for example, could be an outlet to imagine these fantasies without acting on them.

Some people love horror tales and frightening, high-suspense movies, while some cannot tolerate them.

Every person has his own zone in which fearful things are exciting and interesting.

The scariest costume this Halloween would be to wear an ebola costume. The Psychology of Irrational Fear - Why we're more afraid of sharks than car accidents, and of Ebola than flu

The more confident a person is in his own wisdom or understanding, the more likely he is to be off base. That's the old Dunning-Kruger Effect. 

More info on the topic:  We Are All Confident Idiots.  A quote:

Because it’s so easy to judge the idiocy of others, it may be sorely tempting to think this doesn’t apply to you. But the problem of unrecognized ignorance is one that visits us all. And over the years, I’ve become convinced of one key, overarching fact about the ignorant mind. One should not think of it as uninformed. Rather, one should think of it as misinformed.

There is reason think so, at least for the moment.

Sad to say, Psychiatric meds cannot really fix anything, just ameliorate and prevent. But that is true of many meds. I do not think that our meds have anything to do with the underlying problems whether in the soul, in the genes, or in the wiring. As I am wont to say, a headache is not an aspirin deficiency disorder.

Our ability to control or prevent psychotic episodes is remarkable, but still the patient is never fully well. Quit the meds, and it can return.

Seems like everybody wants to be a therapist or counselor these days.

Everybody has problems of various degrees, and indeed sometimes it is helpful to talk it over with a trusted person. I have no problem with Biblical counseling. Anybody in a "helping profession" needs to know his limits and needs to be humble about his capacities.

My guess is that biblical counseling as some form of psychotherapy (as opposed to help with relationship to God which I would call Pastoral Counseling) can be most helpful for those whose guilt is honestly come by. By that I mean people who have every reason to feel troubled by guilt and remorse because they have done wrong, have not earned self-respect or earned a feeling of deserving God's love (which is another complicated topic). In other words, non-neurotic guilt.

The Rise of Biblical Counseling

Discussions about free will are too often binary. It does not take a neuroscientist or a philosopher to see that choices of action (or inaction) occur in the context of a complicated web of culture and tradition, peer pressures, character, emotional state, etc.

From Daniel Dennett's  Are we free? Neuroscience gives the wrong answer:

 What a coup it would be if your neuroscience experiment brought about the collapse of several millennia of inconclusive philosophising about free will! A curious fact about these forays into philosophy is that almost invariably the scientists concentrate on the least scientifically informed, most simplistic conceptions of free will, as if to say they can’t be bothered considering the subtleties of alternative views worked out by mere philosophers. For instance, all the experiments in the Libet tradition take as their test case of a freely willed decision a trivial choice—between flicking or not flicking your wrist, or pushing the button on the left, not the right—with nothing hinging on which decision you make. Mele aptly likens these situations to being confronted with many identical jars of peanuts on the supermarket shelf and deciding which to reach for. You need no reason to choose the one you choose so you let some unconscious bias direct your hand to a jar—any jar—that is handy. Not an impressive model of a freely willed choice for which somebody might be held responsible. Moreover, as Mele points out, you are directed not to make a reasoned choice, so the fact that you have no clue about the source of your urge is hardly evidence that we, in general, are misled or clueless about how we make our choices.