There was a long article in the NYT Magazine Sunday about whether psychopharmacologists do their patients a disservice because their med visits are short (20 minutes) and they focus on symptoms that can respond to drugs that those self-same doctors are able to prescribe.
And yet. The doctor describes the slow creep of doubt, of the growing belief that he does his patients a disservice in these short visits, that perhaps he’s not getting all of the picture because he doesn’t practice psychotherapy and get into the issues that also occur in his patients’ lives. You know– the things that make those chemicals in the brain get all wonky, because eggs don’t occur without chickens?
It was, in some ways– in many, I’ll take it that far– a good article. His critique of the constraints placed by insurance companies on medication visits was valid. In so short a time, it’s impossible to get at all of the things that go on in one patient’s head. And he acknowledged that he hadn’t gone far enough in knowing his patients– that as he dug further with one, he learned that there was more going on, and that he had in fact, either under or mis-diagnosed, and what the patient needed was a whole different cocktail of drugs, one that suited much better.
There were problems, however. The doctor acknowledged that he, as a prescriber, did not have time to provide therapy. Acknowledged, too, that therapy is often looked-down upon even as it can be marvelously, incredibly helpful. And yet, there was no indication that this particular doctor had ever reached out to his patient’s treating therapeutic providers. His assumption seemed to be that instead, he should be the one providing the therapy.
Ever heard of a phone call?
Email. That could work too.
And also, there’s such a thing as a detailed history, and learning to finagle the insurance company forms so the patient’s diagnosis is such that the extra time you spend with them on intake and the occasional longer med visit is justified and gets paid for, so you can ask the extra questions about situation stressors that are necessary to finding out how your patient is doing– to observing if your patient fidgets, is avoiding your questions, seems really distressed, all of that jive.
Now. I don’t know this doctor from Adam. And he teaches at a respectable medical school, has had respectable hospital affiliations, too. But there was a certain arrogance underlying his writing in presuming that hey, presto, it’s just time for him to reincorporate therapy into his practice when he hasn’t been doing it for what sounds like at least several years and he’s been almost entirely med-focused. Why not work collaboratively with the people who do it day in, day out? You know, like doctors and nurses do on a care team in a surgical ward? (Oh, wait. Did I say something shocking?)
I shared the article with my therapist. I’ll share it with my shrink when I see her next. She is one of the good ones– she collaborates with my therapist– and takes time during our med visits to ask those detailed questions, to ask after the stressors, to call me after hours if that’s what is needed to see how I’m doing. It’s clear that psychopharmacologists do need to change. I could give Mr. Carlat a reference, if he were interested.
I saw Noah Baumbach’s Greenberg yesterday. Or perhaps I should call it Ben Stiller’s Greenberg. Because for all of the beautiful shots, all the wonderful writing and casting, all the whole-ness and fractured-ness of it all, this is Ben Stiller’s movie. David Denby did a review of it in the New Yorker, and there was a separate profile of Stiller in a different New Yorker issue (subscriber access required) as well as a review in the NYT by A.O. Scott that was likewise full of praise.
I wavered a long time about seeing this movie. And yet I went to see it. The reviews tell you what it’s about– but here’s what I saw, and let me try to at least link it to the first part of this post and the last. (Themes, Erika, themes. We can haz them.) Here’s a man let out of a mental hospital, seriously fragile, adrift in his brother’s empty house, peeking out the curtains at neighbors who use the pool while his brother’s away. He’s taking the pills he’s been given and reaching out– grasping at straws– at people he hasn’t talked to in years. He also grasps at his brother’s PA, the young, lost, doesn’t yet know what she wants Florence, who’s lovely and despite her own lostness sees past Roger Greenberg’s damage to what lies beneath. (Roger doesn’t yet know it’s there.)
At no point does Roger see some kind of therapist. But he asks all kinds of therapy questions to all kinds of people unqualified to give him any answers that are going to do anything except hurt him some more and make him lash out– be angry– be hurtful and hateful and self-focused because, well, yeah, um, he’s still kind of crazy. (Everyone around him hates him for that. What they don’t see is– they’re also a little bit crazy too. All of us are. Roger’s just more crazy than most.) And Roger, because he sees something in Florence– oh, but she’s lovely and good– he hurts her a lot, even as he does some awfully nice things for her too. He grasps too hard at the bird in his hand, and it’s crushed and wounded and messy, flapping away one-winged and squawking. He should’ve had a therapist there, asking him questions that let him think about it when sessions are over in a way that let everyone feel a little less reeling.
There are lots of great cinematographic metaphors– him walking alone in LA in places where no one should walk, sound effects coincident with panic attacks, things that he sees on the outside that mark what’s going on his very, very still face (Stiller does something wonderful here with his expressions, he’s really got the blank face of someone on a lot of anti-anxiety meds or someone in such denial until the rage just comes pouring out, blasting past that self-preservationist wall) that just from a film student’s perspective, it’s a movie worth seeing.
But if you’ve ever been depressed, in denial, been someone trying SO FUCKING HARD to keep it under control, and then you just can’t, and you lose it, hurt people you don’t really want to and then fuck, what do you do, you still have to get out of bed the next morning, and the sun hurts, it’s too fucking bright, Ben Stiller does something amazing. He just totally nails it.
Seeing this movie hurt, yet there were some wonderful, wonderful moments that gave me such hope for the character, because given something constructive to do, outside the lull in his head, goddamnit, he did it. He made the doghouse, even if it took him a while. He took care of the dog. He took care of Florence when push came to shove, even if it was within the limits he still had to work in. He put up that picture on the wall, and that moment of care when with soft, tender fingers he measured off where the framed niece’s picture should go? And though it took too much booze, some coke and a joint to break through that wall of denial he’d built between himself and the denial of “I’m trying to do nothing” he kept telling everyone he was there in LA to do? He was finally honest. Painfully so, awkwardly so, and oh, with potentially great and unknown consequences, since the movie fades to black just as Florence gets to Roger’s voice mail confession of like-maybe-love with perhaps the greatest ending line I’ve heard in a movie in years.
“This is you,” Florence says, and Roger’s eyes dart away, because he can’t bear to look as she listens. We can only guess what happens next. But yes– that is Greenberg.
Last spring, I stopped working. I just couldn’t do it anymore. And I couldn’t tell anyone how depressed I was either. Not my therapist, not my husband, not the people at work, not one of my friends, online or in life. I felt helpless and hidden and awful and useless and while I didn’t actively contemplate suicide, I did wish there were days I wouldn’t wake up or I’d just not pay attention and get taken out by a bus. So I hid. And I wallowed. And then hid some more. There were lots of reasons why I couldn’t admit how depressed I felt, lots of old issues and new, some of which involve people whose feelings I won’t drag into this blog. But suffice it to say it was messy and awful and complex and I felt utterly, totally, lost.
I stopped taking my meds, stopped taking showers, avoided phone calls and emails, didn’t eat much, all sorts of things. And people knew something was wrong, but I wasn’t talking, and every so often I could put on a facade of half normal and go out to a family dinner– and it wasn’t like I was cutting or bursting into tears or doing something so obvious as drinking myself into a coma. Things occurred– like in Greenberg– that forced me into function– and those were helpful, because the focus on something besides myself got me moving. (And I was never so mean to other people as he.) There were weddings to attend, my mother-in-law’s apartment to clean, other outside things to get done, and my truly Better Half sat my ass down and said– “I don’t care what you do, but you need to get out of the house every day.”
Thus the bookstore.
I have gotten out of the house every day and smiled and sold memberships and looked up books for eight hours a day and been competent and slowly– so slowly– gotten back some of the sense of self-worth that I utterly, totally lost by giving up on my legal career and some kind of proof that I was smart and knew what I was doing despite all the feelings inside my head that tell me I’m stupid and worthless and not worthy of love, even when the medication is working.
To date, despite the fact that I see a very good therapist and keep up my visits with my excellent shrink, I have walled off those feelings and not thought about them and taken my meds and gotten out of bed every day and concentrated on doing my job really well– my stupid retail chain bookstore job, because that’s how most rich, “successful”, professional people think about people who work in bookstores, didn’t you know? I have made friends with kooky book people who love all my baking and think I am smart and amazing to recall all the names of those books and come to me to ask me what I think about X because some customer’s asking. I feel better because I have regular customers who come to me for book recommendations and think I have excellent taste. I feel better because my bosses tell me I’m awesome on a regular basis and I can tell that they mean it. I felt better because my shrink and my therapist ask me excellent questions, and even if I haven’t been entirely honest with them about how depressed I have been, they ask me excellent questions that make me think about things I don’t want to think about and yet, with the increasing effectiveness of the meds, I can’t help but do. I have been taking my meds.
But it’s spring, and spring is a bad time for me. So a few weeks ago, when it rained and rained and rained, I used my high-intensity-UV light a little too much to combat the horrible weepies I get, and after a few days I was washing dishes and could get the new-fangled dish soap IN THE CUCUMBER SCENT AND I HATE THE CUCUMBER SCENT AND JESUS FUCK WHY WON’T THIS OPEN WHAT THE FUCK IS WRONG WITH THIS FUCKING CONTAINER?
Yeah. Something was wrong. It’s just dish soap. So the Better Half came and opened the dish soap, retreated, and I went back to washing the dishes. When I was done, I took an ativan and realized I was probably manic and told the BH so.
Ativan is a wonderful thing, and we went to a family party for my nephew’s first birthday that night, and except for needing to go be off by myself for a little bit when there were a lot of people all laughing at his smearing the cake that I made him all over his head (nothing so satisfying as a baby loving your cake enough to smear it all over his hair)– and there’s a scene in Greenberg where Rhys Ifans comes in to ask Ben Stiller if he’s going to play Gatsby the whole way through the party that spoke to me oh, so very deeply– so I was mostly better by the next day and kept up with the ativan, except by the end of the next week I was spiraling deeply again and wishes of buses and not waking up and letting go of the steering wheel, while not yet manifesting, were edging toward consciousness again.
I called the doctor this time. And the therapist. And told my Better Half. And we’re working my way up through new meds. And I am feeling better. Still tired and weepy. Still prone to need time to myself. But I am seeing it’s time to break down that wall that I’ve had because I have to get out of bed every day and just get to work, because you know what? I have. And I also saw that I almost couldn’t, and yet I still did. I’m kind of proud of that bit.
So. I’m blogging and blathering again, and I’d suggest to Mr. Carlat and Mr. Baumbach and Mr. Stiller (especially Mr. Stiller, even though you’ll probably hate his character as much as you love him, and yet Roger Greenberg is now forever a hero of mine). Talk to your patients. Talk to your therapists. But most importantly? Talk to yourself.
I’ve been avoiding what Florence said in so very clear-eyed a way.
This is you.