Thursday, May 21, 2020

Doing it in the Displacement

It begins with the Guinea Pigs:

What are we talking about when we are talking? In therapy when you talk about one thing but you are really talking about something deeper we call it "doing it in the displacement." Today we dealt with life and death by talking about my patient's guinea pigs.  50 year old white woman, from a privileged background, with a history of eating disorders, body dysmorphia, borderline, suicidality, and bipolar with depressive features.  When I meet someone like this their prescriber hands them off to me with a sigh--they take medication to smoothe out some of the rough patches but often they have a lifetime of multiple hospitalizations for delusional thinking or suicidality and the twenty minutes they get with their doctor or psychiatric nurse is the most therapy that they are getting--and often the most enduring relationship that they have in a lifetime of explosive or failed relationships, stressed family members, sad losses.

As a social worker, and an ex anthropologist, I tend to come at therapy from a strengths based perspective--what can this person do, not what can't they do.  More integral to my approach is that I tend to focus on joy, creativity, expansion rather than contraction, on the idea that most of my patients are already taking care of themselves pretty well they just need more encouragement to recognize what they are doing as valuable and skillful.  Also, because of my interest in Trauma work, I tend to draw on a model of the person which is multiplex--all of us have at least five nameable parts to our responses to stress: Fighter, Flier, Freezer, Fawner, Follower.  Most of my patients rotate through these five responses to stress, or to me, or to therapy, or to family so fast that I can get fired several times in one session by a fighter, or someone who is experienced in freezing may collapse and seemingly go catatonic in session.  Princess Sparkle Pony once mimicked freezing so successfully that she got hospitalized right out of my session room when none of us could rouse her although once she got to the ER she sat up and said "Aimai was wrong" quite normally and furiously.

We started session with [Brenda] telling me that she had nearly had a panic attack trying to take her guinea pig to the veterinarian (immediate problem) which I addressed practically.  We ended it talking about death--about her fear of death and her experience, as a child, of her mother's near death and multi-month hospitalization, of her mother's depression, and of her own desire to shrink, starve, and vanish.  To blow her brains out through a pillow. "I think I've always been afraid of death" she said dreamily, as she packed up pumpkin to go to the vets.

Thursday, May 7, 2020

The Truth, and Nothing But the Truth, and Apparently The Whole Truth Too.

Anxious patient "What's going to happen?"
Anxious therapist "We are heading for a deep depression in which millions will be out of work, people will become homeless, and people will starve. After a while, if we don't apply Keynsian principles, the federal government will move to reinstitution slavery."
Anxious patient "Oh."

Tuesday, April 28, 2020


I've been working from home since late March--I actually self furloughed the week before my managers realized they needed to move as many of us home as they could.  The situation became untenable as I could not, in good conscience, ask my patients--many of whom have chronic physical health problems on top of their mental illness--to come to the office.  For the last week before I came home I was madly engaging in sanitation theater by wiping down the chairs and the door between patients.  But I was becoming increasingly anxious myself on public transportation and as I realized that even in a Medical Health Provider Organization my bosses were sleepwalking forward without thinking at all about our health and safety as workers.

A few days after I came home they figured it out--and to do them credit a lot had to be put in place in a short space of time. I work in a 500+ organization that provides health care and mental health services, runs group homes for the developmentally delayed, mentally ill, and addicted and which runs three clinics one of which (mine) is devoted primarily to persons living with psychotic disorders.  Now the clinics are closed and the prescribers (psychiatric nurses and doctors) and the clinicians (clinical social workers) are all working from home. We are not yet licensed to give tele therapy by Zoom so no face to face work but we are permitted to access our medical records and call our patients.

I'm busier than ever and its terrible and wonderful at the same time.  For me being able to work through this pandemic has been a saving grace, I can't imagine what I would be doing if I were just sheltering in place with no work demands.  And the work itself is very rewarding still--ridiculous, touching, powerful.  But there is no respite--not even five minutes to walk down the hall and chat with the secretaries, or as in the bad old days walk down the hall, out through the swinging doors, around to another corridor, unlock the door to our disgusting bathroom, and run back to the next patient. Instead I sit down at my desk at 8:30, review charts and make notes about who I'm going to call and the order that they are expecting the call, check email and respond to whatever crisis or hospitalization or plea for support from another provider, and then I start calling at 9:00 and finish at 5:00.  Now I take an hour break for lunch, where before I ate at my desk for 20 minutes.  That's because I'm working from home with four other people all of whom would like to be able to scamper around the first floor and eat lunch in more time than I had been giving them. I grab my lunch and retreat to my bedroom and eat in solitude while they emerge from their rooms/desks and eat lunch together.

I sometimes speak to eight or nine patients in a single day. One new intake a week.  The work feels qualitatively different because when people come to your office in a sense they have self selected for functionality.   They have chosen to come in to see me, they have gotten dressed and made it on public transportation or arranged The Ride (subsidized transportation for elderly/disabled), and they are quite triumphant and organized when they get to me.  Calling people at home is like throwing a lifeline to a drowning person--they may fight, they may be confused, they may pull you in.  I've had several sessions with people who are cowering under the blankets--I have even asked people to get into bed and pull the covers up if they sound like they are having a panic attack--It feels like a high wire act, like juggling bombs, choose your metaphor.  Absurdly, its a bit like calling my daughters when they were in college--its quite a familiar experience to have to parent at a distance and hold someone's hand over the phone.

Its fine, its all good, but the tension involved in having to switch gears so rapidly is overwhelming.  I have hard of hearing patients with trauma histories and delusional thinking (VPN communication), I have trans patients who are depressed/anxious and schizophrenic living in shelter, hiding their identity from the other shelter patients,  I have Princess Sparkle Poney who is alternately suicidal and in a rage with me and hand making me gifts;  I have patients who are depressed and delusional CEOs of failed companies, I have a guy I call Chance the Gardener who never launched but did rouse himself enough to stab a relative with a fork and throw himself in front of a train, I have Lady Job whose life history reads like outtakes from a Dennis Lehane novel, I have little Mouse woman schizophrenic woman who usually comes to my office and chooses a rock from a bowl and takes it away, I have a patient for whom I have cast out demons and prayed to Jesus.  I have about 35 patients at the moment, and one more every week, and I speak to about 26 + of them every week or otherwise touch base about the rest of them via email or conversation with other prescribers/caregivers.

I have patients who don't know what day it is and others who sit waiting for my call. Such is the uncertainty of the situation that being four minutes late for a call caused one patient to spin out and begin worrying that I had died or that the clinic had closed without informing him. I have had patients tell me not to bother calling who then call a week later asking to be put back on the schedule.  I've been fired twice by the same patient and then when I call the next week she resumes with me as though nothing happened.  I have basically taciturn, non communicative patients ask for the teletherapy session and then be floored when I point out that we need to be talking or its not much use.  One thing that I do now that is entirely new: I send cards to a lot of my patients. Just cheery notes so they have something to hang on to between sessions.  The borderline patients often have both separation anxiety and lack object permanence so they love it.  The paranoid ones love it too but they scold me, fondly, for "putting too much information into it" since they believe that their housemates are creeping into their rooms at night and reading things left out.  "But its ok" one told me, "I keep it in my pocketbook so no one else can see it, but you should really know better." [The letter had said "I look forward to our next session on ___ date."

OK, got to run, the day begins!

Friday, March 6, 2020


How time flies!** I've been at this for more than a year now and I don't come over to my own blog much. I'm taking a mental health day today and spending time in a cafe with Mr. Aimai and I suddenly really wanted to share some of the work with you all. (Victor, if you are reading, and Yaz, thank you so much for keeping an eye out for me! I think of you both all the time and look for you on the net).

Life at work continues to be enormously satisfying. There is something about passing that one year mark. I feel now like I've seen almost everything at least once.  On one memorable day I had to handle the possible new patients--multiple people who show up and just ask to be seen and have to be evaluated--and also a walk in guy who just wanted to have his hand held. This meant rocketing from an elderly clubfooted gentleman who was sent to us by his priest for too much sinning (Aimai: Is it a Cardinal or  Venal sin? Man: Its a MORTAL sin!" to a sad eyed elfin girl who insisted on speaking for the whole meeting through a large stuffed hippopotamus and who was working at a vegan cupcake store because of course she was. There was the elderly barfly from the wrong side of the white tracks who thinks Matt Damon stole his life story ("That was me working in MIT, I'm a genius, I've had my identity and my work stolen many times, I also wrote Fast and Furious--the God's Eye episode." ) There was the super paranoid schizophrenic who thinks he is "Just depressed" and thinks he has been treated for depression for 20 years instead of for schizophrenia. He is sure that an international conspiracy has robbed him of his life ("They are against me, that is why I'm not married." Aimai "An international conspiracy, if they are so powerful why aren't you dead yet?" Man: "Oh, well, maybe they are going easy on me." ) He is very snotty with me "No offense but I would rather work with a Psychiatrist or a Psychologist or someone with a Ph.D." Aimai "Well, I do have a Ph.D but not the kind you are looking for no, doubt.  However you will just have to make do with me as the Psychiatrists and Psychologists are too expensive to give you therapy, and you seem to need therapy." Him "OK, well, can you tell me in the five minutes we have left how to reduce my paranoia?" Aimai: "No. Not in five minutes. Come back regularly and we'll see what we can do."(Reader: he didn't.)

I have been fired quite a few times by patients who don't like to work with me but I've also had the enormously satisfying experience of having patients come back a few months later and tell my manager "I want to come back to work with Aimai, it feels like a boxing match but I know that something is happening, I can feel the change. My new therapist was a guy and he never said anything. What was the point?"   I found out that this guy--middle aged white ethnic guy--was coming back to me on the same day that I had another revelatory moment which I bundle into the observation that for some white ethnic guys, from an ethnicity which will not be named, shouting "shut the fuck up" turns out to be very soothing. They literally don't feel seen by women or therapists if you don't match the intensity of their emotional level.  I had a very wonderful, miserable, collapsed, chaotic, patient--the kind of guy who has a permanent black cloud hanging over their head and who always makes the wrong choice every time increasing his misery and his poverty and stress, limp in on a cane, back against the wall, struggling to manage his status and housing, to discuss his depression. He had injured himself having unsafe sex with a drug addicted homeless woman ("Really embracing sex and death at the same time, eh?" I said unsympathetically "Come on, Doc, that's harsh!")  Me: "Look, I've got to call it like I see it.  I get it but this is risky for you and her, we need to get ahead of this because you are at risk of losing your housing and you are distracting yourself with primal shit." He: argues, pouts, complains. "With all due respect, Doc you gotta let me make my point."  We were on a short time line and we had paperwork and other stuff to do to save his housing and I ended up cutting him off with the therapeutic adjuration "STFU for a minute" and  he gave an enormous sigh and got up to go and said, with a look of complete bliss "I feel better, I really do. I was so depressed when I got here and now, somehow, I feel better." I was telling this story to my coworkers in team , arguing that you have to co-regulate with your clients by meeting them at the intensity that they are at and then bringing them down to functionality. If someone says "I'VE GOT A PROBLEM" you have to agree at that level YES YOU DO AND I'M LISTENING or they just don't know that you are listening.  One of the others, who had handled this guy for a year before me, said suddenly "Oh my god, no wonder I never got along with him, I'm half Canadian."

**All patient information has been anonymized and changed so that no real patients are described. Descriptions are composites and not true to age, sex, gender, race, or diagnosis.