The kids had started to call me Dad...

I thought about family and how it's constructed after hearing a patient say this one day. He had ended his brief relationship with a woman and his regret was expressed in the statement about the children starting to accept him into the household.

The word pitiful keeps coming to mind, not because I despise what he is saying, but because I pity his fear. The subtext of what he told me was that the child calling him dad had actually provoked fear in him and then he had left the relationship. Either he did not want to take on that role in the family (or at least not yet) or he was afraid of failing if he stepped into it.

I think we ignore the transience of family in our current culture. I do not generally talk of classes of people, but I think there is a group (or perhaps) class of people, in Australia, who operate in a very matriarchal fashion. Family units are made up of a woman with one or some children, and men transiently move in and out of families. Relationships begin explosively and intensely, bringing new partners quickly to assume to male role, which children link with dad. Men relate to children because of their connection with a child's mother rather than because of a distinct and precious connection with the child.

With time, this can develop to be more balanced and the male can become and effective 'father' in the family. However it can be really difficult for a man, in this dynamic, not to feel like an interloper who must compete with the kids for the woman's attention or love. I am not arguing that blended families are bad, only that they can promote unhealthy dynamics when they begin so quickly and reactively. We also see the effects of uncertainty about male members of the household and where they fit, later on when teenage sons have difficulty in behaviour and discipline. This is not always the result, but I'm postulating that the insecurity of the male position in this style of family would influence how a maturing male will relate within that family.

What do you think?

Is she playing with my mind?

What is a mind?

The brain is a physical organ of the body, a collection of neural networks, but is the mind just the brain? Are thoughts just electrical impulses down nerve cells? As people test and examine the brain in part or as a whole, its complexity is becoming more and more apparent. To persist with the idea that the physical brain cannot carry out all the functions of the mind is becoming more difficult.

Yet each mind is different. If brain structure is so clearly uniform in many ways, how can minds have such individual prints? My mind encapsulates my self. I cannot separate who I am from the processes of my mind.

This question (Is she playing with my mind?) finds its key in the self. When someone asks if their mind is being played with, they are ultimately questioning whether someone is playing with their self. Is she playing with ME? No wonder the question is so deep and desperate. It is founded on a real sense of invasion and being controlled.

The person who asks this question, feels out of control. They cannot change what is happening to them and are desperately seeking stability. It indicates an external locus of control (that is the sense of my life being controlled and affected by events and people outside myself) which puts this person at greater risk of a depressive illness.

And the question is asked because reassurance must come from outside the self to be believable. He cannot trust himself to be able to read the situation, let alone control it. Providing reassurance (an answer) can be counter-productive for the questioner because it reinforces the sense of being ineffective and powerless, that he so clearly has.

Responding to questions

I am going to post a series prompted by the questions and statements I hear, mainly at work, but some will be interesting ones I hear in other places. The thread of similarity will be the ideas about mental health that each prompt raises.

There will be post here, from a psychiatric perspective and a linked post on my personal blog which will be framed more, (need I say), personally.

Selling my soul

If a drug company buys the lunch does that mean we've sold out? Maah. Undecided.

If the lunch comes with a medication spruik by a top 6 Master-Chef Contestant then is the sell-out worth it?

Possibly.

Alvin has a PhD in biochemistry and comes from the science dept. of Astra-Zeneca. As a science bloke he can talk about off-label prescribing (research into using a medication for an illness not covered in its current PBS + or - TGA indications). Our friendly (and lunch-bearing) sales rep is not supposed to talk off-label.

So Alvin gave a teuously linked talk about anxiety and being on Master Chef. He recommended taking a little S-----l XR to cope with performance anxiety on the show.

I hope he was joking....

Seriously, the impact of drug company involvement and visits are subtle. I hope I don't prescribe on the basis of who talked medication with me last or who made me feel good. But the evidence, discussed here, and reported here, is that I do. Drug companies spend money this way because it works.

We have a lunch to get registrars together. People come if there is food, and we want them there to give an opportunity for support and feedback in a stressful job. I am trying to think of some ways to get food there but not be unduly influenced.

Story of Anorexia

One of the fascinations of psychiatry is to hear each person's story. Each unique journey.

Emily has written about some of her experience of anorexia and the anxieties underlying it. I recommend reading her honest and brave words.

And here is part two.

And part three.

Skills in Psychiatry #2

Asking difficult questions - being tactfully direct.

A conversation that may include questions about hearing voices, thoughts of killing yourself, childhood abuse and sexual dysfunction can get uncomfortable. And at the end of the uncomfortable conversation, there needs to be enough rapport to engage someone into a treatment plan. This can be a delicate juggle.

I find it helpful to...

• Normalise - "Some people with the symptoms you describe, also get ... . Has that happened to you?"

• Ask open, general questions first - "Have you had any strange or confusing experiences?" can yield all sorts of answers.

• Acknowledge the intrusive nature of questions - "I know this can be embarrassing/difficult to talk about, but the answers can give us information that really helps."

• Ask an important question in a couple of different ways.

• Listen carefully, and use it to direct further questions - "You mentioned ... earlier, I'm wondering how often that's been happening recently?"

• Say clearly what you mean. Try not to use euphemisms. - "How often do you drink alcohol?", is preferable to "Are you a drinker?". Even better is "People who are having trouble sleeping sometimes find alcohol can help get them to sleep. Is that something you have done?"

Having said all this, sometimes words just come out clumsily. I have asked a 15 year old boy if he was "still having thoughts of killing people?" Unfortunately, he'd never had such thoughts and from that point he wanted to escape from the room as quickly as possible. I never saw him again.

Trouble with rapport due to uncomfortable questions can be repaired with patience and listening well. Just be willing to laugh and acknowledge your mix-up or faux pas. Most people cannot resist humility and someone who can laugh at themselves.

Denial #2

We each lay our hope and dreams in the vessel that is our children. The child-to-become lives vivid in our minds as we plan and prepare.

A child's diagnosis with any serious illness is a jagged knife tearing this mind's eye picture to threads. The dreams recover, but always bear the seams of patient mending.

Talking to a parent whose cusp-of adulthood son or daughter carries a heavy mental health label is a glimpse of the rending knife. I struggle to disagree as he desperately clings to the idea that she is not really ill. That she will be fine with good nutrition and enough sleep. That if she is at home they can love her back to clear thinking.

He thinks I am deluded to insist she must stay in hospital. That I have been tricked by Evidence Based Medicine and Pharmaceutical Companies and teams of Psychiatrists who see disordered minds every day.

He denies her brokenness. And I understand why. The tears of the knife are sheering him and he can't bear it.

He will not be convinced. He insists I have disappointed him and failed him by not having enough faith. Not religious faith, just faith in him and in his daughter, who is unbroken. He knows she cannot bear the mark that will brand her different and break his dreams.

I write emotively of his struggle, because sitting in the room with him, face to face, was a glimpse of his grief and his wail of terror. He sat impassive and patiently pleading, but still I saw his anguish.

What would I do if my child were involuntarily in hospital, receiving strong psychotropics? What if my child were entering a world of labels and stigma and CTOs and stays in strange hospital wards?

I am scared about the answers.

Defences - Denial

Denial is saying "I don't drink alcohol", when your blood alcohol level is 86mmol/L*

Anna Freud proposed that we have a range of possible psychological defences which protect us from extreme anxiety about our experiences and situations. Everyone uses them, and we have favourites. We learn them from those around us (either by imitation or reaction), and we use them without conscious reflection.

"Defenses operate to protect us from uncomfortable or unacceptable self-awareness."

Denial is believing that something has not happened (a death, a diagnosis, a disagreement, a failure) in order to avoid consequences of that information. Avoidance of the consequences is because they are too distressing to face.

Denial is a more 'primitive' defence and becomes difficult to sustain as an anxiety-provoking situation progresses and remains present. Denial may be part of a coping progression, with rates of denial falling as time from diagnosis with cancer elapses. Michael Kinsley reflected, in Time Magazine, on the role denial played in his experience of having Parkinsons Disease.


*0.05 (legal driving limit) = 10.9mmol/L

"He uses statistics as a drunken man uses lamp posts - for support rather than illumination."

Andrew Lang (1844-1912), Scottish writer.

Skills in Psychiatry #1

Negotiation - learn how to do it or get a very sore head.

Whether it's getting a mentally ill patient to participate in treatment, or juggling demands on your time from other staff, making deals is bread and butter psychiatry.

These are general tips for dealing with competing demands on your time or management plans.

• Know what is important, so you know what you can afford to yield. Agreeing to take a smaller dose of medicine, might be a better outcome than an adamant 'no' to the reccommended dose.

• Don't argue with someone who is acutely psychotic. They will not suddenly say "OK, your flawless logic has convinced me. I think I will have that medication I've steadfastly refused for the last 6 minutes/days/months. Thanks." Do what you need to do and talk again when they are more settled.

• Tell people clearly what you are planning to do. Let them know what to expect. Then let them ask   questions if they need to.

• Don't talk down to people. They will not appreciate or respect it. And they just might ignore what you say.

• Listen to what the patient/family/case worker is saying. Don't dismiss it. You might disagree, but listen first.

• Answer your pager when it goes off. I am allergic to my pager. But when I answer reliably, people get much less frustrated with me and complain to their supervisors less about me. They even start to cut me some slack.

Why a new blog?

I am branching out, in blogging, by starting Circumstantial. Over the last 12 months I have discovered some satisfaction in writing, and would like to keep it up. Blogging has been a way to motivate thought and action (ie. actually write something). I do not label myself a 'writer' but those who do, say that writing is improved by doing it. I trust what they say.

I am also at a point in my work where I need to devote more time to learning and growing professionally.

So I've decided to write more about what I do. (Were I into killing birds, this would be a well aimed stone.) Three days a week, I work as a psychiatry registrar in a public mental health service in Sydney (Australia).

At my other blog (more personal in its reflection) I write but don't reveal everything. I will continue to keep a bit of anonimity here.

Your feedback, ideas and questions are always welcome. I'd like to hear from you by comment or email.

Great to see you here.