Wednesday, May 14, 2008

Just a first post

I have been wanting to get this started for some time. I have been waiting and waiting for the proper way to introduce talking about what it is like to work as a forensic psychologist, but I just can't seem to get myself together. So, in true blog-style, I am just going to jump on in and tell you about my day today.

Not all about it, because that would be long and boring and repetitious. But I will talk about a relapse prevention plan and why I think I am weird sometimes.

I am working with a young man who has persistent symptoms of a mental illness. They are mild, but can slip into moderate if he is not careful. We have been talking a lot about relapse prevention -- the idea that you can be minding your own business, living your life, and then you can have a flare up of symptoms of your mental illness.

I work with people with severe mental illness -- schizophrenia, schizoaffective disorder, bipolar disorder ... those types of things. I will explain more later, I think. But when a person has a severe mental illness, it is helpful to have them put together a plan for how they will cope with it if they start to get sick.

Because the really awful, pernicious, lousy thing about mental illness is that when you are sick, often it feels just like reality. The line is not clear cut for some people. I was talking to a guy the other day, and he said that when he was "going through my changes" (i.e. being psychotic), he did not talk about it, just as we weren't talking about the table in front of us ... because it just is.

So, when a person is sick, what they feel is very real. So, you have to catch the symptoms when they are manageable and small enough to contain. My patient and I have noticed that he is pretty much always struggling with mild symptoms of his illness -- some paranoia, mostly. For him, he will have a thought that will trigger feelings of anxiety and then he will go down this spiral of negative thinking that can lead to depression. He has been getting better and better at recognizing the thoughts when they were small and using some tools that we have identified to combat the thought.

The whole idea is to see what thoughts are hot buttons for him, and he has done well, generally speaking, to isolate a triggering thought. But last week, he got all bunched up in a really scary thought. He was not buying anything that I was saying and was insisting that his paranoid thoughts were real -- not just that they felt real, but that because he felt them so strongly, they were reality.

So, today we talked about what was happening last week, what his thoughts and feelings were and how we could stop those thoughts before they got out of control and became full-fledged paranoia. He said that he could recognize that he will have a disturbing thought, and then the thought would lead to a feeling and the feeling would lead to a mood. In a depressed, paranoid, hopeless mood, he literally cannot think his way out of the situation -- the emotions are just overwhelming.

So, I was saying that we would generate a series of steps to rein in the early, more manageable aspects of the thoughts -- so when he had one, he could try the strategies out, one by one, and see what works the best, but that he had to have a number of ideas at his fingertips for such occasions.

We were standing in the hall of the mental hospital where I work, him leaning on the wall, and me standing out in the hallway a little. We both have our arms crossed, but not in a defensive posture -- is it just comfortable. I notice how we are mirroring each other little. This man is often in motion, jiggling from foot to foot, shifting restlessly -- anxious, but now, he is slouched comfortably. No one else is walking down the hallway, which makes it easier to work. I should take him into a treatment room, but I am afraid that we will miss count, and that would be a drag. I don't want the situation where other staff members are running around looking for us, so we are in plain sight of the nurse's station.

So, I was saying that he needed to know his mild symptoms really well, and have some tools to manage them. The idea is that if those strategies don't work, and the symptoms persist or get worse, he needs to know that there is a specific moment when he will ask for help. Because without that, mild may turn into moderate without him really being aware of it. And moderate symptoms will interfere with his functioning in a significant way, and will make help even more difficult to ask for or accept if it is offered. Moderate symptoms are likely to feel so real that he will not listen to anyone when they try to help. He needs to know when other people may be better able to see the situation and the solution, and to be able to accept it.

I said to him that it is like The Cat in the Hat Comes Back, when the Cat realizes ... I notice that he is looking at me quizzically. "You have read The Cat in the Hat Comes Back, haven't you?"He shakes his head at me, eyebrows lifted interrogatively.

So, I have to give a brief synopsis of the story, how the Cat left a pink ring in the bathtub that they tried to clean it up with Mother's new dress and how it got splashed all over the house and then it got outside and all over the snow, turning it pink. I am aware of my patient's amusement and the fact that he is politely waiting for the point of the whole story. I could tell him about Dad's ten dollar shoes ... and the fact that the dress has dots ... and the Cat was eating cake in the tub ... but I refrain.

It would have been easier if he had just known the dratted story.

So I explain that the snow is all pink and that there is no way to get pink out of the snow, because ... well ... it is just hard to get pink out of snow. And the Cat in the Hat realizes that it is just too much for him to do alone, so he lifts his hat to reveal ... Little Cat A. And Little Cat A realizes that the job is too big for him and reveals Little Cat B, and then C and so on and so on until Little Cat Z.

My patient is looking at me, listening, and I can see the point where he starts to get it, because he says "Ohhhh".

I tell him that Little Cat Z does not have another cat in his hat, but he has VOOM and that is the thing that really works to get the pink out of the snow.

He is laughing a little at me, and I say to him ... I want you to be like the Cat in the Hat who knew when the job was too much for him and tried each Little Cat and went all the way to Little Cat Z, who uses VOOM to clean up the snow. I want you to have Plan A and then Plan B and then Plan L, M, and N. And I want you to know that there is a place when you cannot take care of it any more, when you have to turn to the Cat with the VOOM!

My patient is shaking his head at me, but not in an exasperated way, but in a kind way, I think. He is used to my odd conceptualizations ... I can't help it that I know more about Dr. Seuss than Dr. Freud. He gets what I mean, that sometimes your symptoms get the better of you, and you need a whole hat full of little cats. Because when you have done everything that you can think of, maybe it is up to someone else to help, because even the Cat had to have a little faith ...

"Voom is so hard to get,
You never saw anything
Like it, I bet.
Why, Voom cleans up anything
Clean as can be!"

Then he yelled,
"Take your hat off now,
Little Cat Z!
Take the Voom off your head!
Make it clean up the snow!
Hurry! You Little Cat!
One! Two! Three! GO!"

Then the Voom...
It went VOOM!
And, oh boy! What a VOOM!

Now, don't ask me what Voom is.
I never will know.
But, boy! Let me tell you
It DOES clean up snow!"


rowan said...

Dr Bob! I have never thought of "The Cat in the Hat Comes Back" as therapeutic. What an original and helpful lifeline the analogy brings, not just to the man in question, but to all of us.

My mother was wary of Dr Zeuss. The undercurrent of discord seemed endless, and the escalation was boundless. And the drawings seemed slightly malevolent. I came to him late in life, and did feel the ambivalence of the meddlesome feline a little disturbing. However...he does offer metaphors for life. You are right. Life is like that. Not expecting the unexpected. Trying to contain Thing 1 and Thing 2. They scared me. But yes - I see how Dr Zeuss offers solutions to the disruptions he unleashes. And they are empowering. Thanks! I don't need to feel and identify with the angst of the fish in the pot. I can access my inner cat Zee.

rowan said...

I know the mother leaving the kids in the house for a whole day on their own is a structural device. If she wasn't seriously into bingo/Milano Blahnik/Starbux, there would be no interloping cat, and no story. Still...I have always found it all a mite disturbing, and am intrigued to process your interpretation of the anthropomorphic feline and his antics. I am going to see if it works for managing my eating: isolating strategies into an organised and systematic hierarchy. Still, as someone always on the lookout for shortcuts,I want one of those big stripy hats.

Yep...sometimes life looks like pink snow. But you have the wherewithall under your hat to clean it up.

"How neat is that?" said the Scot, at this thought.

A mom in the 'burbs said...

I am totally going to have to go back and read that story--I have forgotten all about the cats in the hat. :)

Thank you for putting your work into words--you have stories that need to be told!

Dr. Bob said...

Glad to see you two!!