Monday, April 30, 2007

Fair Trade - A Green Acres Interlude

Dr. Turbo: I think you have a problem with substance dependence.

Patient: I do not have a problem with substance dependence!

Dr. Turbo: Well, I see that your outpatient doctor was prescribing you 12mg of Xanax a day. That’s a huge amount of Xanax. I suspect you’ve developed a tolerance to it.

Patient: Yeah, but I wasn’t using all that Xanax! I was selling at least half of it to buy marijuana!

Sunday, April 29, 2007

Madness, Sanity, Sailing

Another passage from Maté, in his review of the Aleutka 26:

"I think we have gone mad. We rave about our unquenchable thirst for peace and tranquility, and sail for days to reach secluded coves, and yet the anchor barely hits the bottom before we are off in a dinghy with the outboard screaming and the hull slap, slapping the water, as we race up and down the shoreline "discovering nature". Madness. What can you discover with everything a blur and on top of that with your eyes rattling and your ears thundering and your nose filled with the smoke of half-burned gas and oil? To discover anything at all your have to watch and listen and to do that you have to move very slowly. You have to move slowly to see how a hawk spreads its pinfeathers as it circles over the trees, or how the rock crab moves among the crabgrass as it hunts, and you have to listen carefully to hear the wild goose cackle as it leads its young, and the oyster catcher cry "whee, whee, whee" as it's organge beak flashes among the rocks. And to see and understand it all deeply, you have to think-- think about the flooding of the tide, the ebbing of your years. To rob yourself of these joys is to rob yourself of understanding the world around you, and if you don't care about the world around you then you don't belong in it. Go away."

Nothing Wrong With Being Dead

I just wanted to share with you a couple quotations from Ferenc Maté, from his book Best Boats To Build Or Buy (1982). Ostensibly this is a book of sailboat reviews, and inasmuch as it is such, it is completely outdated. But Mr. Maté weaves into his surveys wisdom, philosophy, and personality. I think he is one of the greatest explicators and apologists for the mysteries of sailing.

Here's one, from a review of the Spencer 1330. Another to follow in the next post.

"There is basically nothing wrong with being dead. Some of my best friends are dead, and one of them cited just the other night the wonderful freedom from the evils of this world you gain, like not having to get up on rainy days, or cross the street to avoid someone you hate, or nod and grin stupidly for fifteen minutes each time Mrs. Lukovitch corners you at the bottom of the stairs with her enormous body, and for the nineteenth time itemizes for you examples that confirm the incurable audacity of her daughter-in-law, who didn't really go to Oshkosh for a seminar at all, but snuck off to New Jersey for a nose job and came home looking like Bob Hope.

No, Death can be okay, provided it comes at a prearranged rendezvous, after all deeds have been done and race all been run, and not sneaking up from behind on a cold stormy night when you are untangling wet lines-- with your dinner gone cold, and your shirtsleeve soaked in honey-- and unloading the mast on top of your head, as if you didn't have enough troubles already. And that is just because some horse's patooty decided to save a few dollars on your hull construction, or on the bolts that hold your chainplates where they should.

That won't happen to you if you own a Spencer..."

History Unpredictable

I've just been re-reading one of my favorite books from training: Short-Term Dynamic Psychotherapy, edited by Habib Davanloo (1980). In the first paragraph of the introduction, Davanloo describes the changes driving psychotherapists to seek a faster, more efficient method of therapy. Prime among these, he notes, is "the imminence of some form of universal health insurance limiting coverage to 20-30 sessions."

It's hard to know what country Davanloo is referring to. He was in Montreal; other contributers to the volume were in London, Boston, Nashville, and LA. Canada and Britain have national health plans now, but I'm pretty sure they already had them in 1980. Here in the states, universal health insurance seems anything but imminent-- in fact, seems much further away today than it did in 1992.

Any what of the gathering threat of "coverage limited to 20-30 sessions"? Managed care, in its capitalistic wisdom, has seen to it that coverage is limited to something more like four to eight sessions. Davanloo, come back and write us a volume on "Extremely Short-Term Dynamic Psychotherapy"!

Friday, April 20, 2007

Motivational Posters Of Green Acres, Part V

The text on a motivational poster in the nursing office reads:


The accompanying large, glossy photo shows a bald eagle in rapid descent over open water, wings back, eyes focused downwards , legs extended below, talons outstretched. Anyone who has seen an eagle fishing knows what happens next-- the eagle drops to the water, snatches an unsuspecting fish in its vise-like claws, and flies off for lunch. I guess there is a bit of “challenge” in this, for the eagle, because now and then they miss and have to swoop around for another shot.

But what of the fish? One moment he is minding his own business, unaware of any “challenge”, and the next he has eight razor-sharp talons lifting him into the sky while piercing his internal organs. Are we to encourage him to think of this situation “not as adversity”? Sure, the fish will “show the eagle what he’s made of”-- but only in the unfortunate literal sense, when the eagle rips him into little pieces back at the nest.

Overall this “motivational” advice seems applicable only in situations where the challenge is of moderate proportions, and only to the party likely to prevail.

I would re-write the poster thus:


Wednesday, April 11, 2007


For some years, Green Acres has asserted that it is a “Center of Excellence” which follows “best practices” and aspires to deliver “evidence-based care”. In my understanding, this means taking a hard-nosed look at scientific study of various treatments, to see how they will compare. Those without evidence are tossed out.

Recently, however, we seem to be going down a slightly different path. A decision was made, by someone upstairs, that one of our meeting rooms should be transformed into a “multisensory room”. You might ask (as I did) what this means. Well, a consultant from New York came in to tell us about it. The room is to be re-decorated according to a visionary , therapeutic concept called “snoezelen" (pronounced SNOOZ-eh-len). According to Wikipedia, “snoezelen” is an amalgam of the Dutch words "snuffelen" (to sniff, to snuffle) and "doezelen" (to doze, to snooze). In other words, it means “to sniff around and fall asleep.”

This is not exactly the outcome that I generally have in mind for my patients when they are admitted. But no matter, because from what I’ve seen, the term “snoezelen” more accurately translates to English as “tangible representation of a bad acid flashback, accompanied by objects you have not seen since your last visit to a Spencers Gifts back in 1981.” It might also translate to “Strange Euro-décor hand-picked to go with endless-loop tape recordings of ABBA.” Also, based on this map of an idealized "snoezelen room", it might translate as "the room I described in my 7th-grade essay entitled 'My Perfect Pre-Teen Bedroom'" I mean, just check out the mirror-ball and solar projector music system!

Now, here are a few photos of actual "snoezelen rooms" I pulled up at random on the web. As you can see, the only adjective really appropriate here is “trippy”. The idea, as best I can gather from "official" websites, is that providing intense, artificial poly-sensory stimulation to certain types of patients can help to “bring them out of their shells” and calm agitated behaviors. Generally the populations suggested for snoezelen are those with autism, developmental delay, and head injuries. I actually think it might be a good therapy for such people. However, it's hard to know for sure, because “There is no formal focus on therapeutic outcome”. Nor, not surprisingly, much in the way of scientific evidence that this therapy has any particular effect.

But what about our acutely psychotic, paranoid, delusional, agitated psychiatric patients? Should we prod them into the snoezelen room? I will keep an open mind, but daresay this environment may be disorienting to say the least. Peculiar bubbling potions? Weird, unidentifiable noises? Odd, wafting smells? And check out the glow-in-the-dark skeleton—- that’s got to be among the worst ideas I’ve ever seen for people in a mental hospital.

One snoezelen website even suggests constructing the floor of the snoezelen room somewhat off-kilter, so as to “stimulate the sense of balance”. Will this help with reality-testing? There is a fine line between “stimulate” and “freak out” which this whole idea crosses several times.

Also, lest you think this feel-good concept is entirely promulgated by selfless folks trying to help the afflicted, take a look at some of the official Snoezelen-room merchandise on offer by the people who have trademarked the word Snoezelen. Perhaps you need an “aquarium bubble tube” ($1,590)? In functional use, it strongly resembles the “orb of ecstasy” hoarded by Miles Monroe in Sleeper (see side-by-side comparison:)

If your hospital has deeper pockets, you might consider other cost-effective items such as the “Pediatric SUV (Sensory Ultimate Vehicle)” for only $5,350, the Musical Hopscotch Pad ($2,750), and the Ultraviolet Metalophone (which cannot be distinguished from a common toy xylophone except that it costs $1,275.) Finally, for the ultimate experience, there is the “Personal SNOEZELEN Sensory Satchel” at $999. Frankly, I find this a rip-off— we all have built-in “personal sensory satchels” which we can access anywhere, anytime, for free. I think maybe we should be promoting more of that, instead of stroking giant glowing plastic bubble sticks.

Monday, April 09, 2007

Judgment Day

“What would you do if you found a sealed, stamped, addressed envelope lying on the ground?” This is a standard question many shrinks have been taught to ask patients as part of a mental status exam. It’s purpose, supposedly, is to elicit some information about the patient’s “judgment”. Most people believe that the “correct” answer is “I’d put the letter in a mailbox.” Obviously, there are many permutations of “wrong” answer (e.g., “I’d call the fire department” or “I’d burn myself with a cigarette” or “I’d put it in the toilet at the 7-11 and run away fast” all show less-than-stellar judgment.) However, it has always seemed to me that mailing the letter is not, necessarily, the best choice. Suppose it is a “Dear John” breakup letter that the person thought better of mailing? Or any number of other letters that are better off never being mailed?

Last week, for the first time, I actually found the proverbial sealed, stamped, addressed envelope. It was stuck inside an old psychiatric textbook that I had acquired a few days earlier. It’s a business-reply envelope addressed to the benefits department of a large disability insurance company in Smallish City. The handwritten return address is for a man living in a small town up north. It’s not the same name as that of the doctor who owned the book, which is inscribed inside the front cover—I’m guessing, perhaps, it was one of his patients. Who knows what happened? He was eligible for disability and didn’t get it, because the doctor forgot to send in the form? Is he still waiting to hear back from the company?

There’s a 25-cent stamp stuck on the letter. Quick research on historical postal rates dates the letter to between 1988 and 1991. I considered the possibility that the letter was written recently, the sender had only a 25-cent stamp, and was just waiting to find another 14 cents more in postage to mail it. But the corner protruding beyond the pages of the book is heavy with dust and yellowed with age. It’s been sitting for a decade or two for sure.

Anyway, what to do with the letter? The insurance company is still in Smallish City—should I add an extra stamp and send it there? Should I try to track down the doctor who owned the book? I looked up the man on the return address—he’s no longer at that address, but someone by the same name is on a different street in the same small town. Both his first and last names are common, but luckily he included his middle initial, so I’m pretty sure it’s the same guy. I guess I could send it back to him? Or I could open it. Or shred it. Or flush it down the toilet at Green Acres and run away, fast.

Saturday, April 07, 2007

The Snow Bunny Says:

Things are pretty confused in the Smallish State this week. Supposed to be Easter, but looks more like Christmas.

Loud Noises Can Cause Avalanches, I Guess

Photo from last month's trip west-- I just liked the part about "DANGER! ROCK BANDS!"

Thursday, April 05, 2007

She's Going To Fit Right In

I often complain that at Green Acres I spend far too much time filling in absurd forms and signing my name to things over and over, all day long.

Today I reviewed the CV of a shrink applying for a job here. At the end, she lists her extracurricular interests as “Reading, music, sports, rubber stamping.” Truly I don’t understand this—but she’s going to love it here, I think.

Global Warming? What Global Warming?

Guess I was a bit hasty in taking off the snow tires. This is the biggest April snowstorm I can remember since the "April Fool's Day Storm" of 1997. Two hours to get to Green Acres this morning... absurd...

Wednesday, April 04, 2007

What I Learned In School Today:

... How to light an (illicit) cigarette using only a battery and a pencil.

Tuesday, April 03, 2007

Must've Been A More Frequent Dilemma In The Hippie Days

If a suicidal person is admitted to our acute, locked psychiatric ward, we generally take away any potentially dangerous objects (long ropes, scissors, pens, lighters, shards of glass, nunchuks, etc.) and hold on to the items until discharge. Then we give them back. This plan doesn’t work so well, though, for people with very long tresses, who might (have) tried to strangle themselves with their own hair (sometimes while attached to their heads, sometimes not.) It doesn’t really meet with people’s approval to say, “Welcome to Green Acres—we’re just going to shave your head now. Oh, don’t worry, you’ll get all the hair back when you’re discharged.”

It is a conundrum.

Monday, April 02, 2007

The F*#&ing Moon

It’s that time of the month again (the full moon). The weekend was a blitzkrieg of chaos: People leaping into the nursing station and drinking hand-sanitizer. People breaking into the kitchen and chug-a-lugging a half-gallon of coffee (not decaf.) People ripping fire extinguishers off the walls. People throwing chairs, cafeteria trays, fire extinguishers. Pounding on doors, pounding on windows, kicking the television. Boy patients trying to get into girl patients’ pants. Patients complaining of chest pain and bringing back narcotics from the Emergency Room. People masturbating in the bathroom sinks. Urinating in milk cartons and hiding them under the bed. Tearing up pillowcases. Ripping chunks of hair out of their heads. I don’t know where to start today.

It’s not always like this. But it seems to be so roughly every 28 days.

I just did a quick calculation, of the sort I like to do. Over in the Bay of Fundy, the moon throws around, four times a day, a mass of water equal to roughly 25 million Humvees. And that’s just a smallish corner of ocean. To think that we are immune to lunar forces may be truly naïve.

Anyway, I have to do some serious career decision-making in the next couple days. I’m not sure I can be objective, the way things are going here.