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Tuesday, November 24, 2015

Pre-Thanksgiving Snapshots


Once in a while you'll see a sign on a tree, Have you seen Fluffy

Somebody in my neighborhood keeps losing his iguana and posts pictures in the summer. I always wonder, if I found him, what would I do?

But this isn't about that.

Therapists hear many pet stories. People are crazy about their animals, marvel at their better qualities, worry when they are ill, and grieve their loss. When a favorite pet moves onto the next world, it is as if a person in the family has died.

Because pets are family. They live with us, we feed them; they reciprocate with unconditional love. It is a fair deal.

My brother and I have the same memory. You tell me how this happens. He tells the story exactly the same way:
One chilly autumn morning, the dog scratched at the back door to go out to the yard. About to leave for school, I saw an accident on the kitchen floor, wiped it up quickly, then let him out. He'd been sick for months, but he was a very old dog.
My father walked in, saw me watching the dog from the window.
He looked at me, I looked at him. "We should. . ." 
We both said it at the same time. . . put an end to this. Then we carried the dog into the car and took him downtown to the Anti-cruelty Society.
Maybe both of us were there, my brother and I. Or maybe one of us told the story and the other snagged it. But that we each own it tells me we both wanted to be there.

You want to have every last minute with your pet, especially if it is a dog. Because no one else will wag a their tail at you, not like a dog, and you can't buy that loving gaze, the nonjudgemental innocence. (Well you can if you buy a dog).  We count on our dogs, we count on all of our pets, for venting, to comfort and hear our woes, listen, without interrupting.
Still a puppy, thankfully
We could learn from them.


Like a good pet, there are people who are always there, assuming we have cultivated friendship, not an easy thing. When the family is far away, or the thought of being with family has lost its glitter, the alternative is Friendsgiving.

If you get an invitation for one of these dinner parties, just go. The food will be amazing, everyone can cook these days, and there will likely be a break in the conversation for guests to toast the hosts and one another. Maybe you'll go around the table. The praise and thanks will be about the importance of being there for one another, providing consistency, support, help when it is most needed. Some will be singled out as endless givers in relationships.

On other days our egos are in the way. We are too busy wondering why nobody has done anything for us lately. So it is good to get outside of that, thank our friends for what they do.

The whole business, however, can get stressful, especially for the hosts. The problem is the association between hosting and physiological arousal, and two little discussed DSM 5 disorders, specifiers of generalized anxiety disorder, related to performance and anticipatory anxiety.

(1) There Will Not Be Enough Food Disorder,  and
(2) The Food Will Either Burn or Be Undercooked Disorder.

Luckily, other bloggers have addressed this problem and many other problems, so I defer to Emily Fleischaker, the food editor on BuzzFeed (the post is clean, nary a 4-letter word):
17 Rules of Friendsgiving
The best, for sure, is number 17, Don't Tell Mom if You Like It Better than Regular Thanksgiving.


Spoiler: She zaps the turkey because her mother worries it might be undercooked.

Everyone is afraid to tell everyone else that they watch SUPERGIRL. But they do. Test this theory this Thanksgiving, or Friendsgiving, whatever. Nobody will mention SUPERGIRL outright when the conversation turns to TV talk. But when you bring it up, just wait and see. You are not alone.

Maybe we don't want to appear too geeky. Liking a show that is campy, soppy relationship-wise, female-centric, has special effects and a drag down, knock 'em dead, but don't necessarily kill the bad guy scene in every show, plus throw-back costumes out of a comic book, maybe isn't cool. Who reads comic books?


Geeks know that fantasizing, and watching or playing fantasy games, can be a healthy coping strategy. (Until it isn't).

But assuming you're not the addictive type, if you can't wait for the new  Star Wars movie, catch an episode of SUPERGIRL on CBS. The first minute of each show will fill you in on the backstory.
DC comics Supergirl
As if you didn't already know it.


The news, unfortunately, is hardly ever good and it is often sad. Therapists warn against too much of it, too many headlines.

We didn't need Paris to know that terrorism is bad news, and that it is closer than we think, a real international threat.

Years ago, after one of the college massacres here in the US, some of us blogged about the way that Israelis handle security. They have had more than their share of suicide bombings on busses, in malls, pizza shops downtown. For years no one has walked into a school, an auditorium, stadium, shopping center, even coffee shop in Israel without first having their bags checked and bodies scanned with a wand.  If you live there you don't complain about these measures, not at the airport, not anywhere else. Soldiers are usually posted everywhere, and they are awake and armed with rifles, anywhere people might congregate.

Do we need that? Yes, we do.

I think that it will be hard to be happy this Thanksgiving.  I think we will all be wondering when and where the next ISIL attack will be, how many will be killed. Will we know a victim? The moment will pass, of course, the discussion will be over, and we'll get back to dinner and talking about shopping, movies, and of course, TV.

In Israel the war on terror is becoming more personal, more challenging. The Palestinians, despite grabbing attention for not having a country, live there, in Israel proper, not just in Gaza. And now anyone can be a terrorist, no professional training or expensive equipment is necessary. All you need is a car and a knife. Not even a car. Just a knife. Everyone has knives, our most primitive tools.

Ezra Schwartz, stabbed by a terrorist in Israel
Ezra Schwartz, a United States citizen from Boston studying in a yeshiva, was stabbed to death last Thursday. He was  delivering food to Israeli soldiers. Young Ezra is describe with
boundless energy,” capable of “making friends with anyone.” From mentoring his siblings to spending quality time with his grandparents,Schwartz was remembered for earning the respect and love of all kinds of people — “kids with little quirks and idiosyncrasies were his specialty,” according to Schwartz’s grandfather.
He was eighteen.

Hadar Buchris, stabbed by a terrorist in Israel

Yesterday Hadar Buchris, a female Israeli seminary student, also a child, 21, suffered multiple stab wounds to her head and chest while at a junction in the West Bank. She died in Shaare Tzedek hospital, a victim of this new knife intifada.
"She was a very talented theater student and a successful comic who always created positive vibes around her friends, . .. She was also a kind of 'psychologist' who would lend a sympathetic ear to whoever needed it.
This has been going on for a few months. It started with Palestinian drivers ramming cars into crowds of people at bus stops, or in train stations, hoping to kill pedestrians. They are succeeding. The drill works like this. After the car hits the targeted group of innocent civilians, the driver gets out, grabs his knife from the front seat and runs off, stabbing and slashing as many people as he can on his way to escape. Attackers are usually shot by soldiers or police, so it is really a variation of a suicide-homicide attack on Jewish citizens.

There used to be rules about war. You didn't go after civilians, the elderly. Children.

The Israel Defense Force posted on November 18:
A year ago today, terrorists entered a Jerusalem synagogue during morning prayers. Armed with axes, meat cleavers and a gun, the terrorists murdered 5 worshippers and a policeman.
That happened again, as men left afternoon prayers in Tel Aviv last week, praying for an end to sickness and war. 

Lital Shemesh (below, or watch her video on FaceBook) tells us:
In just two months: 7 shootings attacks in Israel, 51 stabbing attacks, 13 car ramming attacks, 51 rock throwing attacks. It's time to speak up against terror.
Nobody knows what to do with this kind of terrorist, the one that appears out of nowhere, sometimes a he, sometimes a she. The hatred is the same hatred that drives young men in Brussels to step out of taxis in Paris with loaded guns wearing suicide vests. It is the same kind of hate.

Meanwhile, the FBI reports that the majority of the hate crimes in the United States are against Jews.

How can we stay happy? Should anyone be happy when there is so much anger and hatred in the world?

Of course we should! We have to try. I went to a funeral today for a Holocaust survivor. People in the camps tried to stay happy and they were literally starving. We are most alive, you know, when we are happy.

Happy Thanksgiving friends. Try not to let it get you down. Don't let the news ruin your holidays. Don't cancel your plans to visit Israel, if you have them, for there is much to learn there. Don't let them terrorize you, not here, not there, not in the USA or England, France, Turkey, Argentina, Canada, Japan, Malaysia, or wherever you are. It really is what they want.

Escape it with the likes of SUPERGIRL. Or quality time with the people you love. Take the dog for a long walk, good for you, good for him. Or sit down and write to your congress-person about more security. We're going to need funding for guards in public places.


Friday, November 13, 2015

Hoarding, Mess, and Barry Yourgrau

I want to think that everyone has a closetful of plastic bags.
Barry Yourgrau's MESS, required hoarder reading

The city of Evanston banned plastic grocery bags, the ones we see caught in the branches of trees, if we look up. The good news is that we can now choose between a bag made out of tougher paper (they still break) or new sturdy, shiny plastic bags that talk.

We're supposed to bring them back to the store to use them next time.

This never happens. They remain in the trunks of our cars because who can remember to shlep something out of the trunk of the car to shop? But the thought of reusing things is nice.

Chinese gift bags

The cynic in me thinks of an Iranian relative somewhere on the family tree who made his fortune many years ago in the shopping bag business. Smart guy.

On a recent vacation, I found the shopping bags in China so crisp, new, and easy on the eye that throwing them away proved challenging. I paused before giving gifts to relatives. A voice inside whispering,  
Keep the bag.
It shouldn't hurt to throw things away, but the illustrated panda and the fortune-cookie script in Chinese-- priceless. Such things keep memories fresh, like photographs, but not being much of a pack rat, seeing the bag is wrinkled, it is history.

Similarly, had there been two panda bags, only one would have made it to  the closet with the good bags in the first place. (closet not shown).

Let's get serious and take a look at the features of Hoarding Disorder to determine what is pathological, what is not. Because lately, a lot of people are nagging other people to get rid of perfectly good stuff. 

Hoarding Disorder (F42) DSM 5 (not word for word but close, page 247)

A) Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B) The difficulty is due  to a perceived need to save the items and to distress associated with discarding them. 
C) The difficulty discarding possessions results in an accumulation that congests and clutters living areas and substantially compromises their intended use. 
D) The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment).
E) The hoarding is not caused by another medical condition, such as a brain injury, or cerebrovascular disease)
F) The hoarding is not better explained by the symptoms of another mental disorder.
We're to specify if there is excessive acquisition, and if insight into the condition is either good, fair, poor, or delusional. 80-90 percent of this clinical population fit excessive, most with hoarding spending habits. But many of us hoard freebies, like gift bags. Few steal. 

The word persistent refers to a life long condition, not having acquired an inheritance (a garage full of incredible stuff). Most hoarders believe in the value of their possessions. Many are simply sentimental fools. There are combinations.

Also a feature of Obsessive Compulsive Disorder, holding onto possessions is a way to defend against intense contagion fear. Keeping something serves to protect others from the perceived biological contagious quality of the item. Hence there might be rancid, putrid, moldy things among the possessions of those worst afflicted.

Animal hoarders probably fit in there with obsessive compulsive personalities.

Someone with this disorder might feel defective, incomplete. Surrounded by things fills us up.

It is also a familial disorder, fifty percent see it in other family members. That said, a traumatic event might precipitate safety in hoarding.

It is not an easy problem, not for the person who has it, not for family members.

We think that because the thought of discarding acquisitions causes distress, that hoarding behavior is intentional, even when it is dysfunctional to the degree that there is no room to move, a narrow snake path left, maybe, for a visitor to find the bathroom (although visitors tend not to be welcome). Piles of newspapers or National Geographics decorate beds, take the place of mattresses. This would be where back issues of Psychology Today, the ones we'll never get around to reading, might go. A hoarder will frequently sleep in a chair rather than chuck items on the bed.

It could be because as humans we're members of the animal kingdom. Take hamsters. Once while house-sitting the dog and a family hamster, the hamster escaped! He had been planning it for weeks, for sure, but when we found him, had an excellent stash of candy and dog hair that he couldn't possibly have acquired on such a short vacation. He had priors.

This nest could have meaning, could be what hoarders are up to.

Barry Yourgrau, in his beautiful memoir, MESS, describes his struggle to get rid of his clutter. The fear of losing the love of his life, who insists he make her dinner in his apartment, motivates him to change.

Forget that the writing is so strong, which it is, and that you will learn new words, like flaneur. In an effort to clean up his act, Mr. Yourgrau tries different methodologies,a multivariate approach. Family therapists don't believe in any one size fits all cures to life's obstacles, and because people with hoarding disorder in particular tend to be indecisive, trying everything is the way to go.

Barry's scientific approach:

(1) He studies up on famous hoarders and visits them to learn more about himself, You don't have to be a journalist or hunt any of these people down, it is all in his book, makes for an interesting who-done-it. People with this diagnosis can be exceedingly private.

(2) He attends Clutterers Anonymous meetings, reinforcing the therapy adage that we are only as sick as our secrets. Hearing what other people are doing, feeling, hating about themselves is the great normalizer. Plus the stories are compelling and true.

(3) He hires professional declutterers to help him get rid of things, a very brave and painful process. But love is a great motivator, and losing the love of your life, a person who will take you to far away places to buy shiny new things and an endless buffet of bags, is not something you want to do. Lose your clutter, find yourself.

(4) Which is the process of therapy, too. Barry goes through a few therapists before finding the right one. Finding a therapist is like finding a 12-Step meeting you like; try six before you give up. He shares the experience, the ah ha moments, only briefly touching upon being a twin. Being a twin, imho, can account for much of the psychodynamics of the disorder.
Maybe Barry Yourgrau was blue. MESS

Twins tell me that they are particularly cautious, even zealous about their belongings. They are forced, even in utero, to share! The competition for resources never really stops, either. Whatever the other has, even as an adult, can seem better than what you have. And nobody talks about it because it is like talking trash (no hoarding pun intended) about yourself. Even arguing with one's twin can be like arguing with oneself. What you do get is a color, and you are glad for that. You are the one in the orange.

So the author has that going for him, along with the fact that he moved so much during childhood, and moving is associated with hoarding, so much interruption, so much down-sizing. A person wants to hang onto their things, especially if they seem ephemeral, which goes along with never throwing anything away, even when you can replace them at will, as an adult.

The excuse, one of the many, is that everything might be useful one day. We have our comfort stashes, old medications,paint cans with an inch of paint or less. Add your example here.

Well maybe not all of us. The spouse of a Marine, a career service guy, once told me that she couldn't bring home a new blouse unless she gave away an old one. A Marine might have a watch collection, however.

What is the difference then, between a hoarder and a collector? If Mr. Yourgrau acquired only specific things and organized them systematically, even if there were a lot of them, he would be a collector. So there is that out.

But if your basement is really one big train set, you might reconsider the whole idea, make room for a ping pong table, just to stretch your identity.

And if the plastic bags are everywhere, just toss them.


Thursday, November 05, 2015

A little more about that dirtyword: Blame

Should I sue the hotel?
Not saying there's anything new, here. But is is a practical application, something to keep in mind when someone is busy blaming you for God knows what. 
When we think back later, we say, What a silly argument!
This morning FD left without his keys. He returned right away and knocked on the door. It took me awhile to open up and he was angry--at me-- for taking so long, making him late. The best possible spin on this is to assume that sharing emotions is a good thing, better out than in. Permission to let off steam is what healthy couples do.

So why does it feel so bad?

A few months ago, after stubbing my toe on the metal frame of a hotel bed, I cried out. Maybe I even cursed the hotel. It hurt a lot, warranted expletives, facial grimaces. The object of the anger, unclear. A person can't exactly rant at a bed frame, it is inanimate, doesn't care. Hotel management might care, but it is inconvenient to go to the front desk, ask for the manager, complain about a bed frame. So I let it go. Somehow we survive such things.

The mystery is when something happens and someone could be blameworthy, just a little, but still. Perhaps a child leaves a tricycle on the walk and someone trips. Or, looking around to answer a Where Question, we bang our shin on a coffee table. Or a document is missing, a bill, a check. If a housekeeper has been around in recent history, she's the first scapegoat. If not, anyone will do.

What could have been bad luck, clumsiness, or simple short-sightedness, becomes a gotcha' moment when someone's around. We assign blame. The front desk is in the room.

I've thought of a few reasons that people lose it, act either as little children or very scary adults when something goes wrong. We've all got at least of few of these working for and against us.

(1) Social Needs

We're born social  animals, and as infants can't get very far in life unless somebody takes us there, cleans us up, too, feeds us, etc. That first social experience, a mixture of biological and learned dependency, is never erased entirely. Our memories packs primitive, but powerful social expectations, Someone else should protect us, anticipate our needs, prevent us from harm, The best parenting, the most charmed childhood, won't erase the imprint. But it might make us less reactive to the thought of abandonment, more independent.

That primitive memory, our infant ego, unfortunately, is fed with wedding vows. (Not that you shouldn't get married, but it is a good thing to discuss).

(2) Generalization

Spouses or intimate partners become our mothers, fathers, sisters, brothers, aunts and uncles, friends and lovers, all in one. They represent any and all of our people in the here and now and the past, too. Those who have systematically disappointed or hurt us get top billing. We might not have been able to punch back as kids, but maybe we acted out. As adults, the force is with us--displacing anger on a loved ones just feels right.

(3) Stress

Stress, perhaps from hunger or lack of sleep (new parents are particularly susceptible), often makes us testy. Add to that testiness a sense of hopeless over life's inevitable dilemmas and one more potch (rhymes with watch, means slap in Yiddish) becomes the proverbial straw that breaks the camel's back. A decent crisis, post-potch, even over something that will seem silly later, evokes a  rise in adrenaline. Then the fight or flight relief response kicks in.

Except there's no place to go, because the problem, the crisis, has to be solved, the key found, the broken glass swept up. So flight isn't an option.

But fight is.
You're going to say, but not everyone does this, displaces anger, goes on the offensive when things go wrong. Some of us prefer to mutter to ourselves, shake our heads back and forth, occasionally pound a pillow, even when someone is home to take the blame.
So maybe something else is at work, perhaps annihilation anxiety is the answer. That might explain both the aggression for some people, and self-control for others.
(4) Annihilation anxiety.

If you have ever held an infant, you might be familiar with what is called the startle response, a noticeable shiver that disappears as an infant develops. But some of us know it is still there. We feel it when we're afraid. When we are small we are afraid quite often, everything feels dangerous, a bee buzzing around us, a parent with a frown. This feeling has been described as fear of annihilation, which might sound extreme, but if you're little you just don't know, especially if you've been subjected to child abuse,

Abused kids get negative messages about who they are. They are told that they are deficient, blameworthy, to explain frequent punishments, displacement of a parent's negative emotions about God knows what.

So when things go wrong, an abused person, to avoid more abuse, might jump to apologizing even if they have nothing to do with anything. This averts a crisis, owning responsibility,and functions to avoid annihilation. If they don't apologize, they keep it quiet, have learned that passivity is better than saying more, getting into more trouble.

Alternatively, abused kids identify with the aggressor, learn that the best defense is a good offense.

But not only abused kids learn that. It is a social response to stress that just works. Anger puts everyone off. So use it to your advantage, is the thinking.

The rest of us learn variations of the above, probably much less extreme.

So in the end there are no easy answers, no one size fits all.
But at least I know, when I stub my toe, that I have only myself to blame. And FD? Just a guy with too little sleep, maybe not enough food, and too much stress. That's all.


Tuesday, October 13, 2015

Why the Baseball Playoffs Drive Us to Distraction

Not always a good thing, a baseball addiction
Hearing the title of this post, "Why We Love Baseball," FD told me that it has been done before.
So I changed the title.
What is it with baseball? Twitter, Instagram, Facebook, you might have noticed, are flush with exuberant Go Cubs Go adulations. FANDOM

Cubs hoodie-to own it

Kris Bryant- Go Cubs
But really, it makes no sense, and I don't understand it myself. Why all the excitement? It is just baseball. Just a sport. Why should anybody really care? .

My friends asked me to dinner last night. Could I get free? 

"No I'm really sorry, uh…"

They compassionately text back before I finish: 

Oh, right you've been working all day, and your back will hurt if you sit a minute longer. Right? It's okay, another time. We get it.

But I can't let it go with a lie, even if it might be true, sometimes.

"Don't be ridiculous! To go out with you, for the opportunity to catch up, I would take drugs! (Advil, we're talking). For sure. But it's the Cubs playoffs, see, and like, I really, really, love the Cubs."

You can feel them shrug and shake their heads side to side as they text back, simultaneously, OK

Then we all feel bad, me especially, because friendship should trump watching baseball. Maybe.

It's not as if I don't record the game. It is something one can watch later. But it's just much better live, in vivo, as it is unfolds in real time. Fans want their games immediately, like addicts with drugs. It's been said before, sports is addictive and one never wants to get in too deep. But once you're there. What to do? Is there a 12-Step program?

For a therapist to justify giving into the compulsion, she has to have real reasons, should probably get to the etiology, the possible causes, sift through them and chew on the relevance,

We could say that it starts young, during early childhood, in my case, maybe in 1966. As a free-reign kids (it was safer back then), riding the Skokie Swift for the first time with my older brother, taking it down to the Howard Street EL, and from there to Wrigley Field, the stop on Addison. Paying the five bucks for a ticket. That felt empowering, cheering on baseball greats, Lou Brock (yes, he was a Cub first), Ernie Banks (number 14), Ron Santo, and Billy Williams.

Or maybe it begins playing baseball, again, as a little kid. If you have brothers, your chances of learning to throw and catch increase exponentially (probably). You see yourself as a big league hitter, too, even if you are a girl. It is how the brain works, or should, gender-blind until life spoils that lovely judgement-free assumption of unlimited possibilities.

That would be considered a very strong neurological connection, attachmentas we say in psychological parlance, established as a pre-adolescent child with baseball players, particular teams. We don't break those well-traveled neurological paths that form connections easily.

Obviously people say that it is all about the competition, rivalry. But what drives that? Some say that we want to hate someone, or some symbolic thing, want to beat, overwhelm, displace our rage because we all have some anger dying to spurt. The opposing team, the one playing against us, serves nicely. Our team becomes an extension of ourselves. Frankly, this is much better than coming home from work and taking grief out on the dog.

This projection of self, unconscious merging with a baseball team, explains why we own the win, or the loss, whichever. When the player we love, our player, our self, hits it out of the park, that vicarious identity confusion comes out as a community shout: WE did it! 

It is as if we were the ones playing, making those winning runs, fielding those plays that rob the opposing team of what could have been a game changer. 

Not everyone takes it this seriously. Certainly for millions, spectator sports is merely a social exercise, sitting around with friends and watching the game, maybe having a beer or three together. But we don't all drink, and for some of us, there are no friends who like baseball or any sport for that matter. I have FD, thank God, but he's a Cardinals fan, which makes things uncomfortable sometimes.

But staying with that social bonding theme, Yesterday, while watching the Cubs-Cards playoff game, I thought. . .  I must call my brother! And or just text him, How about those Cubs? But then Starlin Castro hit a homerun and I forgot. Definitely not a social thing for all of us.

Baseball might be a vehicle for showing off a knack for remembering statistics, a numbers acumen, letting them roll off the tongue at appropriate moments: batting averages, rankings, runs batted in. Numbers people don't always get the respect they deserve any other way.

The obvious answer, certainly, is that we all need escapism, want to forget for just a little while about the next crisis, the next shoe to drop. Why not live in the moment for a few hours, lose one's self in a spectacular display of athleticism. Athletes are performance artists, and it is something to behold, men throwing pitches at 100 mph, more incredible still when somebody hits one of those rockets. 

Not bad, right, as a theoretical exercise, finding the variables, the reasons we're so distracted by baseball games. But why do some of us go crazy and others don't? They might be interested, they might watch, but they don't get high off of baseball wins, or upset about losses. 

It might even be the norm, actually, for baseball fans, for the entire population of sports fans, during playoff games, or the World Series, World Cup, Stanley Cup, etc. to feel a little better than usual if their team is playing well. Maybe most fans, even the stoic ones, are able to leave their prozac behind when this happens. It can be that good.

That would point to a biological explanationthat games contribute to sustained surges of serotonin or dopamine, and we get naturally high, even with the anticipation of winning. Surely, too, some of us are just more biologically excitable than others, our brains more easily aroused by fast movement, drama. We thrive on anticipation, the possibilities of good things happening. Baseball is a slow game, but when it comes to being a Cub fan, we're patient sorts.

FD tells me to prepare for the fall, in any case, because the Cardinals, his Cardinals, have been known to rise to the occasion, to come from behind to win the pennant, take it away. They're behind the Cubs 2-1 at this writing. 

I told him, naturally, Wishful thinking on your part dear. Not to let anyone burst my bubble.


Saturday, October 10, 2015


Therapists often talk about quitting, going into some other field. Some normal field, where they aren't flooded with the emotions of others for five to eight hours a day; what I call empathy overload. Most people, even those who aren't therapists, become overwhelmed when friends and family have tsorris (Yiddish, rhymes with floor-dis, means troubles), all that feels unfair.

When the Holocaust is mentioned in a therapy session, it is empathy overload for the victims, even for the survivors, that brings the patient (and sometimes the therapist) to tears. Someone has to change the subject.

The rub is that even if we did change jobs we would find ourselves still feeling the pain, that of the people, the very world around us. Just like you do.

So at the gate, waiting for the plane, I’m looking around, not at the books so much, usually there isn’t time for that (barring a flight delay), but am scanning my fellow travelers, the most interesting species in the zoo, my attention mostly to women, sometimes men. People lose their social persona, that put-on thing, seated at the gate, outside their usual milieu. It is hard not to watch.

At some point I stop. Because there she is.

She’s not making eye contact with anyone, rather focused on a computer, never her phone. She may be wearing make-up, but often goes bare, a touch of lipstick, eyeliner. She may be wearing jeans with a nice blouse, or slacks and a blazer. She’s generally not got much, if any jewelry, maybe a pendant, an antique ring. She isn’t smiling. Her lips are pursed, shoulders back, head held high in that line to board. Standoffish. concentration within, gazing at nothing.

And I wonder, is she thinking about someone she’s about to visit? Her mom, her sister? Is she running from a boyfriend or grieving a break-up? Did she just lose her job? Is she a writer? A middle-manager? Why is she aloof, and is she this way with friends, too? Is she usually sad, or is this just how she seems, beaten? I feel she is, and want to know her story.

It is not such a mystery, this emotional draw to others, random lives at the gate. The brain likes new things, wants to unravel the puzzle of human beings, especially if this is what it is trained to do.

Even if we wanted to leave our empathy sensors behind while on vacation, leave the whole idea of other people and their problems in the taxi, we can't. It is a part of our packaging, noticing the emotional state of anything with a pulse, any living thing. (You certainly don't have to be a therapist to be equipped like this, but it is a vocational plus if you are.) Empathy is a trait, but curiosity an appetite, nourished young. In third grade, there's a girl sitting in the desk on the left, upset about something more than her C-minus. You're dying to know what.

Here, with a random stranger, it is just that, empathy sparking curiosity, but there's no authentic caring. If she were to run to get a last minute coffee and missed the flight, it wouldn't matter to us. Our curiosity doesn't work that hard.

But if our sister or brother   took off for a sandwich and didn't return, didn't make that plane, we would care.  Second to parents, siblings are among the first objects of attachment. We bond with them, are in forced-habitation with them during those early, formative years.

Parents contribute, reinforce those first ties, even orchestrate close sibling alliances, by (1) staying out of the middle; (2) showing favoritism to all, not no favoritism; and (3) forming a loving executive committee that makes decisions. The last is a tight communicative unit that allows input from the peanut gallery, but still makes the rules. Or (4) parents can influence a sibling alliance off-handed, unconsciously, behaving in completely dysfunctional ways, their children close because of the dysfunction. When the sibship is unhappy, people say: Family breaks your heart.

But back to hanging out at the airport.

So when I’m looking around, it looks as if there is at least one person whose heart, whose very identity, has suffered a fracture or two. Not that the hunch is necessarily right; this is just a feeling, an intuition. Maybe misguided empathy. There will likely be no conversation as a validity test. 

But if I wanted to delve, if I wanted to ask about someone's life while waiting for a plane, or anywhere, for that matter, it would be the life story of Mary Anna King.

Lucky for us, she kindly wrote Bastards  and shared. The memoir could be considered bibliotherapy, and like Mess (the September book pic), is extraordinarily well-written. Bastards reads like a mystery. Not what will happen next, but how will these messed up people ultimately turn out? Dead on drugs or as medical professionals, perhaps, in a uniform? How will they pass?

Ms. King won’t talk to you at the gate, for sure not. But to read her story about losing four sisters (!!) to adoptions, losing herself to an adoption,  is to feel unimaginable separation anxiety.

We know what it is like to lose someone to death, to disease. We know what it is like to lose someone to an abusive relationship, watch that someone lose self, personality, to domination. We know what it is like to lose money, to lose a home, possessions, even to lose a loved one to terrorist executions, assassination, airplane and car crashes, to alcohol, to drug overdose, even old age. School shootings. Adoptees rarely tell their stories. Everyone assumes it has to have been the best choice, in the best interest of the child.  
In this memoir we learn, maybe it is, maybe it isn't. Feeling what it feels like to lose siblings, either as the one who is taken away from the others, chosen by an adoptive family, or as the one left behind, isn't feeling so good.

Bastards is about what family, what having brothers and sisters, should mean to us.

And as I'm reading it, cover on, I keep flipping to Mary Anna King's picture, just like I do while working, jotting notes, looking up, repeat, or even at the airport, when someone just looks interesting.

So, Ms. King. If you see someone glancing one too many times in your direction at the gate, don't get paranoid. Maybe offer to sign my copy of your book. I could mail it to you with a SASE*.  


* a SASE is a self-addressed, stamped envelope.

Bastards is published by Norton, a company that is really putting out wonderful psychological treatments on difficult subjects. 

Sunday, September 20, 2015

ICD-10-CM and the Panic that Numbers Ensue

For those of you who do not know the meaning of ICD-10-CM, it is the International Classification of Diseases, a lengthy clinical catalog system conjured up by the World Health Organization (WHO) to designate medical codes. Physicians and clinicians everywhere are bound by them, use theses codes for billing and diagnostic purposes. The ICD-10-CM replaces ICD-9 on October 1, 2015.

To bill, we need to code, and start with procedures. Your primary care doctor perfunctorily codes hundreds of procedures, ranging from removing a dot on your skin, to listening to lungs, heart beats, peeking down throats and wiggling toes. General check-ups might be called wellness visits, now, because things just have to keep changing.

Mental health professionals have only a few procedure codes, a handful, really. Is this an initial evaluation? Group or family therapy? A 15, 30, 45, or maybe a 52 minute-hour? There are a few more.

Then come the codes for diagnoses, naturally. Here's where mental health professionals choose from a considerably wide menu. In the diagram below you'll find some thirty new diagnoses per page, 21 pages in all beginning on page 839 of the appendix in the back of the DSM 5. Therapists tend to keep it simple, stick to basics, anorexia, ADHD, substance abuse and dependency, psychosis, depression, anxiety, autism, and the many variants of common constellations of complaints. But we shouldn't, there is so much more. Go up and down the alphabet, you name it, there is a code for something you never thought that much about before.
ICD-10 DSM-5 codes translated

And there might be a specifier. Is the disorder recurrent? Is it severe? Does it have an organic cause, or a severely anxious component? Are there hallucinations?

Etc. Rock on.

I owe my suite-mate mountains of gratitude, because for years she has provided me time to kvetch between patients. She gives me advice and empathy, and seduces me with candy to keep me awake on the job. But for six months, at least, she's been making meaningful eye contact as her patients slip into her office and I await mine. She'll look serious, and with a raise of both shoulders a slow shake of her head. She inhales deeply, then sighs before booming:
How are we going to prepare for the ICD-10?  It is coming soon!!!! 
I look heavenward, eyebrows frozen in an arch. Nod.

Thinking me not taking this seriously enough, she rants on.
If we don't code properly they will reject our claims. And some codes will be paid at a higher fee schedule, some lower. We have to know!!! I'm getting emails about this from every insurance company under the sun! And I'm making a wedding! I have NO time for this!!!!
Send me the links, all I can offer, mustering an ounce, no more, of compassion.

See friends, it can't be that hard. It really can't, and it isn't. It is far harder for medical providers who have to code that it is the left shoulder, not the right, the right kidney, not the left.

But we will have to  learn all new codes, all of us. The old ones are defunct as of October 1; why, no one knows. And, from what my buddy tells me, procedure codes will pack more meaning.

So because I do have the time, I take twenty minutes and log onto a workshop from Optum, a United Behavioral Health (United Health Care) insurance product that I don't accept, but once did, many years ago when getting on the lists of behavioral and mental health managed care products seemed like a good idea. (Just try to get off. It will take you years, but do it. Don't work twice as hard, twice as long, for even less money.)

Here's what the good people at Optum don't say. They don't tell you what codes to use to get paid more, naturally, because a managed care company is not interested in you making more money. If anything, when you call a managed care Provider Relations Specialist, you might be counseled to code down. That way you, the person seeing the vulnerable patient, will be paid less. The managed care company keeps the money. Hello.
Note: no Aspergers in DSM-5

The mellifluous, compassionate presenter makes the whole experience go down easy, puts the care into managed care. As if you need that. Here's what she does say, notes from the slides.

1.         Coding the diagnoses: Read your DSM 5!

All of the new codes are right there, in a white rectangular box with the old codes. Below the words, Autism Spectrum Disorder, in the picture above, you'll find 299.00, the old ICD-9 diagnosis. And next to that, F84.0, the ICD-10 dx.

For patient visits on or after October 1, 2015, code with the ICD 10, in this case, use F84.0. Not before.  For visits in September, or for back visits in 2015, use ICD-9 codes. 

Never use both codes. 

Oh!  And there are even newer codes, code changes since the publication of the DSM 5. Go to Psychiatry.org/dsm5   and scroll down to Updated Disorders.  

We will still need to code for medical, psychosocial, and functional levels and prognosis.

In case you haven't really read your DSM 5, you can just skip to page 839, the appendix mentioned above, for a quick and dirty translation of codes from ICD 9 to ICD 10. Except for the changes we just mentioned above.

2.         There is something new to be concerned about on claim forms.

Whether you code by paper or online, electronically, you'll have to indicate if it is an ICD 9 or 10 diagnosis/procedure. 

For paper claims, in box 21, at the top of the box, all the way to the right is a space. Your billing program is already filling that with a '9,' probably.  You want to make sure, for visits on or after October 1, 2015, that it changes that '9' to a '0.' White it out and change it if your program fails you.

Electronic billing will offer choices with radio button, a lot more fun.

To add to the fun, there is an industry standard with electronic claims (form 837). For ICD-9 it looked like this: BK= ICD-9.  Now it will look like this: ABK = ICD 10  No one seems to have any idea what this is all about. Before Kugle? After Baking Kugle? No one knows.

3.         Authorizations, eligibility and benefits

The drill is the same. If you're paid as a managed care provider you will be calling for authorizations, etc., when you see new patients. You don't have to call to reauthorize care for patients who have already been authorized. Remember, however, that I sat through an Optum workshop, and other managed care groups may differ. Best, in my humble opinion, is to get out of network and not have to care. But we all start somewhere.

4.       Specifiers
I indicated above that you will have to specify specifiers, but I'm still not quite sure how. In the DSM-5, however, there are particular codes that you will be adding to your codes, just to keep it all simple. For example, if a patient has been depressed for ten days, not two weeks, check, other specified. If he's been down for two-weeks, then specified.  So clear.

5.      Autism/Aspergers
Aspergers is no longer a diagnosis. It will be considered High functioning autism. All those tee shirts, gone to waste. 

6.      HIPAA 5010

Since 2012, if you're good with HIPAA, you're probably still good. As for me, it is time for another workshop. BCBS, I'm told, has a really good one.

7.  Wrap Up

The Optum workshop kindly provided another link for more information, which we all will surely need, the APA Understanding ICD-10-CM and DSM-5-A Quick Guide.  In straight, easy English, it is a delight, worth a read. 

Remember. . . Time's running out.

But don't panic. You can do this. Even if you are planning a wedding.


Friday, September 04, 2015

Snapshots: Mostly Jewish

We're not likely to get that short
(1)    Looking up  

The other day we were standing in stocking feet and I asked FD, “Am I getting shorter?  And what happens when do you get shorter? Do you lose weight?”

He faced me and said, with certainty, his head inches from mine,
“Yes, you are getting shorter. We all get shorter.” 
He didn’t respond to the weight question.

And I noticed, as he said this, that he had lost some height, and that my chin didn’t point up as high as usual as we spoke, and our eyes weren’t level, but they were almost level.

It was alarmingly intimate.

(2)   Holidays and guilt  
FD waking me up with the shofar

It has happened many times. I’ll be listening to a patient who will suddenly look directly at me, across that perfectly calculated space between us, and declare:
“It’s Catholic guilt. The problem is Catholic guilt.”
There will be a pregnant pause, then a bold continuation:
“You Jews have it too, I think. The guilt.” 
And I confirm this. It is true, for many of us. Guilt is a code that we live by.*(1)

About this time of year I print up a little piece of paper and hand it out at the end of visits.

Here's a list of dates for Jewish holidays coming up. I won't be working or returning calls on these days,*(2) but will get back to you asap. Understand it could be a few days before you get a return call..
Think of this as a yoga retreat for me, out in a desert, far away, but intermittently hopping on a plane, a proverbially late plane, and coming home to work between asanas.
Use the emergency contact if necessary.
Okay, I left out the line about the yoga retreat and the asanas.
Just some of the Jewish holidays

The retreat for Jews, those who sign up, begins in the first Hebrew month of the lunar year, Tishre (rhymes with wish-day). Rosh Hashana. The holiday will be here with the setting of the sun on September 13, a two-day affair, cuz we're Jews.

Then, ten days later, it will be Yom Kippur (the Day of Atonement/Judgement), then Succot (why not build a new home in the backyard) four days after that, culminating with a wild celebration (for the most part alcohol free) Hoshana RabaSimchat Torah, not shown on the calendar above. It goes on and on, or certainly feels that way, and can be quite serious, sobering, which is why many observant Jewish doctors are nowhere to be found on the holidays, except for FD. They seem to find him. 

Even as he's being paged, we're like kids on Christmas, on our best behavior, worried about the King's decisions for our future, no idea how it will all turn out.

What's interesting to me is that there's real anticipatory anxiety going on. Heavenward attention (fear) starts well before Tishre, the month of judgement. Even in the last month of the year, the one we're finishing up just now, Elul, we think that God is listening, a little closer, like at weddings (She attends! Go ahead, ask for it!). The sound of the shofar, the ram's horn, is heard at daily morning services in Elul, loud, insistent, sometimes whiney--plaintive, a plea for mercy. Or a plea for return. Or both.

Some people begin to get nervous mid-July, even before Elul, in the month of Av. As soon as the summer heats up they start examining how they are living their lives and what they should be doing better, differently. It can put a damper on your summer, honestly, examining your deficits.

Emotions are a roller coaster until court is adjourned late in the evening on Yom Kippur, ten days after Rosh Hashana (although the gates remain open, really, until the end of Simchas Torah, and naturally, we're judged every day, in the moment, not for the past so much, as a general rule). But on Yom Kippur the future of every city, tree, insect, person, animal, turtle, lizard, flower, giraffe, and fish is determined. The fast greases a positive verdict.

We'll say, if someone dies just before the new year,
God of mercy, the Old Mighty gave her the whole year
Or when something tragic happens, any time of the year
 It was decided on Yom Kippur
This is an answer, see, to the big question of Jewish guilt, and even the big Why questions. The answer might come down to (1) not praying hard enough, (2) withholding charity, and (3) not making it happen, that promise the year before to very specifically change our behavior, or worse, having no intention to do so. Everybody has to chip in, the stakes for the entire world ride on it.

So you get it, Jewish guilt.  I have no idea what subscribers to other religions have to complain about.*(2)

(3)     Yahrtzeit  

Holidays aren't the only annual interventions. 

When the anniversary of a death is anticipated, families have different ways of handling what can be a healing, if emotional experience.

Some make calls, check out feelings of sadness, empathize and commiserate. There are plans to meet at the cemetery, drop off a flower, or share memories on WhatsApp or a private Facebook group page (others are very public about it). Or there's a picnic. I had a photo shrine pic ready for a previous draft of this post but took it down because FD said Internet stalkers might bother my mother in Heaven. My cousin has pictures of her mom all over her apartment. Sometimes I wonder if our fathers are jealous.

We go to the effort of socializing on or around an anniversary, because we remember, or maybe we forget, but want to connect with other people who remember. Or maybe we just like being with others who care, who still grieve a little, that time of year.*(3)

And it has been said in many a doctor's office, a therapist-type doctor, while tracing emotional cycling, that the anniversaries of deaths are associated with a spike in negative emotion, sadness especially, maybe even depression. The change might begin months before the anniversary. I told one friend who gave me plenty of notice about a dinner invitation that I'd need a rain-check, wouldn't be in the mood. Too close to the yahrtzeit.

The yahrtzeit, for Jews, marks the day a parent, child, or sibling died. We might keep a yahrtzeit for grandparents or aunts and uncles, or other special people, too, but it isn't technically ours. Again, the date of the anniversary is as it lands on the lunar calendar, which varies year to year on the Gregorian calendar (the one most of us keep, January, Feb, etc.) It can be confusing because even Jewish types don't use the lunar calendar much, except to check on the proper time to light the Sabbath and holiday candles.

So we're never really sure when the yahrtzeit will be unless we check that or use a phone app. Or we can wait for a postcard from the synagogue,
Remember so and so, whose yahrtzeit is on such and such a day 
 Most are not so crass to ask for the check, but it might be implied. It is also an invitation, really, to stop by to say kaddish, the special remembrance prayer.

But for many of us, knowing when it will be is too important to wait for the shul's notice. When one of us figures out the date we'll inform the rest of the family.
September 3 is Mom's yahrtzeit; let's do dinner that week.
Or maybe we'll get more specific,
This year, mom's yahrtzeit, the 19th of Elul, will be on Thursday, September 3
Figuring out when will it be can trigger strong emotion, that's the beginning of the anticipatory anxiety I'm talking about. Maybe our brains are reenacting the stressful times attached to the death itself, or the anticipation of the death itself. I randomly remembered, two days after a yahrtzeit, when someone mentioned going to the ER at St. Francis, how I threw myself on my mother, as the paramedics hauled her in on a gurney at the beginning of what was to be the end and said, in answer to her question, "You're not going to die."

So the yahrtzeit is grief work, reliving a trauma, and the experience feels a little like acute stress disorder.

It all makes sense when we're in the moment, when someone is dying, when a death is imminent, inevitable, and comes to pass. Elisabeth Kubler Ross famously noted five stages of grieving: denial, anger, bargaining, depression, and acceptance. For that emotional resolution to continue annually, however, years after someone's passing, tells us everything about how we're made. *(4)
We might forget where we put our keys, may have no idea what we're looking for when we walk into a room, cannot remember who we saw yesterday, but we're wired to remember the important things.*(5)

*(1) If you are too young to know the Crosby Stills and Nash song, Teach Your Children Well, here's a link.

*(2)  Probably all religious codes are the same, capitalize on fear, assuming that within that code is tucked the concept of divine retribution. That tickles our most primal fear, the fear of annihilation.

Which Darwinists believe is burned into our DNA, and mental health professionals insist is a product of parental behavior (the rod), instruction (talks at night before bed, rewarded with hot milk and cookies), and institutional hypnosis (Hebrew school).

Jung's concept of a collective memory explains why all of us, at certain times of the year, are programmed to feel certain ways. Americans just feel like lighting up the barbecue on July 4th to make fireworks with that lighter fluid, consciously or subconsciously looking skyward for the rockets red glare, ala 1776. Groups remember even ancient history, like the Jews remember God holding a mountain over our heads, making us an offer (the Torah) that we can't refuse. Memories are passed on in some still inexplicable way. Gotta love Jung for this one.

Therapists might say that the emotional programming of the Jewish high holidays is necessary because most of the year we're sleepwalking.

And there's this comforting feeling, too, when the season fades away,when everyone anticipates getting back to work without interruption the second week in October this year. We turn, not only to friends and family, but to our Maker, and say,
Same time next year 
 We hope in Jerusalem, if at all possible.

*(3) The crazy thing, should you do this, pass along the memories with one another, discuss feelings about the relationship you had with a person long gone, is that it affords an opportunity to work out some guilt, or neurotic misgivings, legitimate regrets, too, even anger. My brother, at dinner on Sunday, told me that he felt guilty for one thing only, not taking Mom out to dinner more often. And I told him, that after two years, I'm working through some of mine for not confiding more, not telling her the things that might have made us closer, and not listening to her often enough, because I knew she always craved more intimacy with me. If you don't do this, don't have the dinner, don't do anything that brings a loved one to life once again, it is your own loss, imho, and experience.

*(4) I'm told it improves as the years roll on, the intensity of grief work. That's what I tell people.

*(5) The important things, unfortunately, would include traumas, and for that, everyone needs therapy. For the things parents teach us, the things that stick, no matter how many days pass, we might need therapy, too.