Chest Pain

by Robert Lanz LCSW

 

What do chest pain, gambling, Mexican food, jail and social work have in common? I’m about to explain, so pay attention.

I did family therapy in juvenile hall as my first straight job out of grad school-unless you consider breakfast cook, dishwasher and baker at a ski resort straight jobs. As a family therapist, I was given 10 weeks to try to fix some seriously dysfunctional family dynamics with my what we call in social work the “identified patient”, the delinquent kids in jail. I learned quickly which families were motivated and which weren’t and which kid was fixable and which wasn’t. And I learned my most valuable lesson early on. Everybody didn’t grow up like I did in a basic middle-class, educated household with everyone trying to do the right thing most of the time. If there was a problem at my house we fixed it ourselves or sought out the right resources to help fix it. Of course, I knew everyone didn’t grow up like me and my family, but that didn’t mean that everyone else shouldn’t do the best they could to improve their family dynamics. It was just a matter of using the available resources. That was me. The available resource. I took my job seriously and had a good relationship with my wards: Potheads, burglars, gangsters, and all other types of delinquents assigned to me. I was supposed to make them better.

Right off, I made sure they always knew the rules as well as the consequences for breaking them. For most of them, that kind of consistency was the first they’d experienced in their lives and I pushed hard on that issue with the kids over whom I had almost total control. The problem was, I only had access to their families for an hour a week. Pretty hard to get the control I needed from the family in an hour, especially when they thought their kid was the whole problem. This would limit, and of course, guide my interventions.

There was one young man I really liked, probably because he responded so well to the limits I set on him. In any case, away from the gang he was a good guy, not nearly as tough as he pretended to be and not nearly as mean as he wanted the other kids to think. When we were alone in my office talking about his life I could actually make him cry pretty easily which, of course, I did often. His parents didn’t speak much English and communication was an integral part of the therapeutic process, so my rudimentary Spanish, lacking nuance, was not very useful. After two sessions I recognized that Jorge’s parents were good people from another culture who didn’t get the whole East Los Angeles gang thing. They thought that Jorge should’ve just stayed home and done his homework. Of course they were right. And if he had, he wouldn’t have ended up in juvenile hall.

But when he went to school he would get his butt kicked every day if he showed too much interest in his schoolwork. He had to flow with the culture that was available to him at the time and that culture offered a lot of gang activity. If he was seen as a wimpy kid in a macho culture, it would be pretty tough on him and the consequences could even be fatal. This was hardly a conflict you could expect a 15-year-old to be able to resolve. It was hardly a conflict you’d expect his unsophisticated parents to be able to resolve. The dad’s response was to lecture his son, giving him the right information but in the wrong style. Jorge got defensive when he tried to explain his rock-and-a-hard-place dilemma to his parents. What can you expect a 15-year-old to do when he feels he is under attack?

Stay with me here, the story has a point. I wanted to change the whole family dynamic in a couple of months of one-hour-per-week therapy, and given that restraint, there was no way to use conventional family therapy. I would have to try something different. Something creative. Something simple. Something I had more or less learned in grad school: Start where the client is.

Jorge loved his parents but he wasn’t sure they loved him. I could tell that his parents did love him, an important factor, but not as important as Jorge realizing it himself. Their style of communication would need some serious tweaking and that would come from me, the middle-class white guy/probation officer/surfer.

The parents were rural, marginally educated conservative folks from Mexico and Jorge was sort of caught in middle of that first generation American culture clash. The city guy stuck in a high school gang culture that would crush all but the toughest and most independent kids. So what did we all share in this equation? How could we all start in the same place and be at peace together for an hour a week? What would we all have in common? Love of Mexican food would be a good guess.
At the next family session, I began by asking Jorge if his mother was a good cook. Before he could answer, his father announced proudly that she was an excellent cook. Jorge confirmed it.

“Look,” I said, “I have to change my schedule around for a couple of months and I wondered if you could come in at six instead of seven. From now on you can bring dinner for Jorge.”

His mom said she would bring dinner for all of us if that was permitted. Great idea. Why didn’t I think of that? So for the next two months we didn’t do any family therapy; we just sat and talked and enjoyed great Mexican food together, eating, laughing and telling stories like, well, a real family.

At the end of our last session I wanted to wrap things up. Jorge had done well in our individual sessions and had become the model prisoner, more or less. His teachers reported he had taken more interest in school and in group therapy he had become one of the leaders, showing real insight. After our weekly dinner, I asked Jorge’s dad if he thought Jorge knew he loved him.

“Of course he knows I love him. He is my son. I’m just afraid for him.”

“So you’re not angry when you raise your voice, you’re afraid?”

“He’s my son I don’t want anything bad to happen to him”.

“Jorge” I asked, “Did you know your father was afraid?”

“No. My dad is tough. He’s not afraid of anything.”

“He’s afraid to tell you that he loves you.”

That brought the room to a standstill for a moment. Had I pushed the wrong button this time?

Then Jorge’s dad got tearful. He rose up out of his chair, looked over at Jorge’s mother, touched her lightly on the shoulder then embraced Jorge, tears running down his weathered cheeks.

“Jorge, you’re my son,” he said. “and I will always love you”.

Jorge told his dad, “I thought you thought I was stupid and you were mad at me.”

“I was never angry, Jorge, I was afraid.”

Jorge embraced his father vigorously and said, “I’m sorry Dad. I didn’t mean to scare you.”

End of story. Confusing the way love and fear and anger are expressed is a common problem addressed in therapy. You just saw one solution.

Fast forward 20 years and there’s a woman down in the cardiac room, fifty-six years old with chest pains. Her EKG is okay but her pulse oximeter is just barely okay and we wanted it to be great. She’s a smoker, so a marginal pulse-ox is to be expected. To add to that, it turns out she’s been in a smoke-filled room for 24 hours straight. That would be the smoke-filled room down at the local card gambling palace in Gardena where she often spent her evenings. Luckily for me I read the newspaper every morning and that very day there had been a major article about the growing poker club business in Los Angeles. Because I read the whole thing, I knew more than the average person about playing poker in card clubs.

While we were waiting for the woman’s  test results I went to the waiting area to talk to her husband and adult children. They were really worried about the patient’s health and as they told the story about her endless nights in the poker parlors, I could see tonight their fears had been compounded by her ER visit. When I asked what they had done about it, they told me that they were all so angry all they could do was make demands and threats. They didn’t get any traction out of that approach, although they kept trying.

Now Mom was in the cardiac room hooked up to a couple of monitoring devices, short of breath and with significant chest pain requiring a full cardiac workup. No surprises here. So far the machines hadn’t recorded any bothersome findings except for the pulse oximeter showing that her ability to uptake oxygen was compromised, same as with any heavy smoker.

When the family and I went back to the room to talk to the patient, all those angry emotions were churning in the air to the point where I could see the changes on her cardiac monitor as soon as we arrived. The social worker who doesn’t glance up at the monitor from time to time and pay attention is missing out on a valuable biofeedback device.

“You know,” I said, “I read this great article about poker clubs today.”

It probably seemed to them that I was just socializing, but I was the guy who had ten minutes or so, not ten weeks, to get everyone to a neutral space and try to gain a little traction myself. My approach was kind of like a Mexican family dinner. A good place to start. The monitor started showing more normal readings and soon we were all laughing and telling poker stories. The adult son even told me a couple of ways to cheat at poker that I hadn’t seen in the newspaper story. It was kind of fun. I liked them and I could see they all loved each other. By then all the tests were back and the docs were done. But I wasn’t. You can probably guess what I said and how it worked. The basic stuff, confusing love and fear and anger is a pretty common problem and we had arrived at a simple solution.

 

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Totally Legal

Prayer hands

by Robert Lanz, LCSW

In the sixties, like a lot of guys my age I did some things just to prove I wasn’t part of the establishment. Hardly shocking I guess. One of those things was to gleefully follow the Reverend Kirby Hensley into the Universal Life Church. This wasn’t actually a church in the physical sense but it did meet the newly changed requirements for an established religion and virtually anyone, due to that new found freedom of religion, could sign up to be a reverend in the church. All you had to do was send a donation of twenty bucks up to Modesto and in a couple of weeks you would receive a certificate attesting that you had met the legal requirements to be a minister in the Universal Life Church and as such you could do all the things that any legally ordained minister could do.

You could have your own church or charity. You could perform weddings, give last rites, provide spiritual counseling and get involved in any number of religious chores. It was kind of a goof really and most of us never gave any thought to actually doing any of those things. Oh, I did perform a wedding in a bar at a ski resort in Utah in 1979. Totally legal.

I got found out one night in the ER when a father died and his two daughters were there at the moment of death and they decided to dig back into their youth and pull forward some religion in their moment of crisis. With no connection to any church they expected we could call the local parish and a good hearted priest who had never heard of them would gladly bound out of a nice warm rectory into a very cold night, break out his good book and help transport another soul to the other side. Yeah, sure. Pardon my cynicism but believe it or not, priests are human too and some of them actually feel no moral obligation to a person outside their parish or someone they don’t know or maybe they don’t even have a connection with the night shift staff that would nudge them into coming over on that cold and rainy night just because a social worker was calling for help.

That situation was so common it wasn’t even shocking any more to have to tell a family member that a priest was not available at three in the morning. That’s when they both broke into tears. Deep guilty bottom of the soul tears. Not the gentle weeping usually coming with the death of a loved one, but the deep wailing that comes with heavy unfinished business.

Up until then, no one in the ER knew I had bought my way into the ministry for $20. But tears have always been my weakness and the survivors were my patients now. The dead guy belonged to the doctors. The live family belonged to me and it was my responsibility to take care of them in whatever way I could. A good social worker should have a full compliment of resources, an emotional tool kit if you will, of fixes, temporary or permanent. I had studied hypnotherapy and sometimes used it. I’d studied martial arts and sometimes used my skills to protect myself or a patient. Speaking Spanish was a real plus on a regular basis. Being a licensed marriage counselor was handy a few times. Understanding story structure and documentary film making even helped  once or twice. Life is full of opportunities to observe and then bring those observations to the ER where they might come in handy some time too. Tonight was the night I would reach into my bag of tricks and pull out that Universal Life Church certificate and use it with all the sincerity I could muster.

“I’m a minister myself and if you think it would help I could say a few words for your father.”

“Oh yes. Please.”

When a priest does show up he has his black suit and white collar and magic beads for props and a book of ceremonial words and passages. Everyone gets the same send off and if you are a devoted church person and deeply rooted in the ritual of religion I guess there is comfort in that.

Consistency of ritual is probably something that no one would ever say about me. More than likely it would be along the lines of “What’s he doing this time?” And they’d be right. Because most of the time I depend on something internal to guide me, something sincere, maybe even bordering on spiritual some people might say. But it’s doubtful anyone watching me do anything would be thinking “This is so ritualistic”.

My approach was totally open. With the family standing right there I would put my hand on the lifeless chest of their loved one, channeling I guess, whatever that person’s spirit directed me to say. It worried me every time I did it and was something I never looked forward to. No one hired me for ministerial duty. They hired me for social work tasks. I just happen to have had a piece of parchment saying, totally legal, I could do whatever a minister of any religion could do. A new entry on the Everything Else list.

I never talked about it much except when the nurses and docs asked what happened with that family asking for last rites. I had to tell them so they could document it in the patient’s chart and note that the family had passed through the initial stages of grief without difficulty. Thanks to Reverend Robert.

The word never got upstairs to my bosses or maybe it did and they were OK with it. I doubt if the pediatric charge nurse knew about it when she called down to the ER at one in the morning to try to get me to find a priest or a minister to come out on another cold and rainy night and do last rites on a dying child. The parents had gone home and expected to return in the morning to find the child had received last rites, something they had been unable to arrange themselves. But they deserved it and they expected it. It was my job to make it happen. It was on the Everything Else list.

No one answered at the Catholic church. The Presbyterian minister was sick and couldn’t come out. The Episcopalians only came for their own parish. And that’s how it went until three a.m. when I gave up and decided to do it myself. I was opening a can of worms with a lot of inherent problems, least of which was a whole new group of nurses knowing about the addition to the Everything Else list. I went up to talk to the charge nurse, a woman I knew well from a four month rotation I once did with her. We always got along well and she knew me as a respectful and truthful guy.

“Laurie, it’s three in the morning and no religious person is coming out tonight. Maybe the daytime social worker will have more luck but I struck out.”

“This kid could die at any time Bob. It’s a weird diagnosis. Everyone will be reading this chart and the parents will freak out if the kid doesn’t get last rites.”

Desperate times. Desperate measures.

“Laurie, bring me a fresh charting form, put a time stamp on it. I’m a minister in the Universal Life Church and I can do last rites. And I will. Then I’ll come back here and document that I did it. My documentation will be the only writing on that page. If the kid dies before his parents get here with a real minister from their real church leave the page in the chart. If a real minister comes in and does last rites with the family take my page out and toss it. Are you OK with that?”

“Is that legal?”

“Totally legal.”

I went home and wondered for a few days what happened then like a lot of these things it just slipped away. Laurie never told me what happened and I never asked. The only important thing was that the child got to go to Heaven because someone gave him last rites. That’s all that mattered.

Dividing line

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Grief Group

grief group doves

By Robert Lanz, LCSW

My boss, a sensitive woman, thought I might get quickly burned-out witnessing the amount of death and loss that I did at the busy ER where we worked. Too much crying. Too much hopelessness. Too much uncertainty about what happened next. She thought I needed help processing some of this stuff.

I’ve explained my philosophy on ER interventions: People get 100% of me when I am there, but not much of me when I’m not – worrying about our patients after they leave our care would be wasted energy.

Emotional energy, I think, works better in-person and has minimal value once the patient — or I — have gone home. My style allowed me to give my all during face-time, while saving my ‘me’ time for me. But, my boss was my boss. So I soon found myself a co-leader of the hospital’s structured grief group, with the other leader being a very competent and experienced social worker.

The literature seemed to indicate that the grief-group experience is most effective if it is brief and focused. The issues of focus and brevity were ones I was familiar with, so eight weeks of focus for ninety-minutes for each weekly session seemed reasonable to me. I didn’t decline the ‘invitation.’

I was a little nervous the first night, but covered it well enough — well enough that the eight women and one man in the group didn’t jump up and bolt out of the room. I mention ‘bolting’ because the only other guy present was not particularly adept at hiding his body language: he had that ‘ready-to-bolt’ look about him.  No one was surprised he never showed up again.

Since I was the only guy in the social work department most of the time, I utilized my feeling that men and women think differently or act differently, even when they feel the same way. (Twenty years after my grief group experience there is ample data, thanks to better technological devices like CT and PET scans to show there actually is a difference, in general, between female and male brains.) Nowhere is that difference more obvious than in the expression of emotions. Women will tend toward the open expression of emotions as an effective way to work through them. For the most part, men prefer the opposite. Generalities at best, but in the eight weeks of my grief group experience, these generalities became very specific.

Women are obviously more involved in the processes of their emotions. They prefer to get them out, roll them around, take them apart, tweak them with friends and put them back together in a workable form. Men, I have observed, are the same. But they just prefer to do the ‘taking apart and tweaking’ on their cars or boats or motorcycles. There’s a lesson here, but I’ll get to that later.

The initial meeting of the structured grief group went like this: We all sat in a circle and the group leader started around the circle asking each woman to talk briefly about the circumstances that led them to join the group. Each woman got out no more than a sentence or two before breaking into tears. Each of the other women, close to crying too, immediately offered sympathy tears, and I’ll admit right off it was hard for me not to puddle up myself. I looked over at the other group leader and she was also puddling up, so we were all on the same page. At the end of the first session everyone was exhausted. I was, too. I could hardly wait to get back to the chaos of the ER to relax.

The group co-leader asked afterwards what I thought.

“Pretty cool.” (I didn’t feel the need for overstatement.)

The next week was pretty much the same. Everyone was refreshingly open, with tears flowing freely. Both social workers puddled up again. By the end of this session participants were already emotionally close and they made plans for the following session. Food plans. Comfort food plans. Liquid refreshment plans. Crying a lot seemed to have the desired effect and the group was already showing strong signs of cohesion. After the second group meeting, the leader asked me again what I thought.

“Really cool.” (I was starting to feel more comfortable.)

By the fourth group meeting everyone was openly friendly and trusting. No one appeared to have any issues about the male intrusion (me), but that could have been because I hadn’t said much. The female group leader hadn’t said much either. She didn’t have to, because the women had become so focused. (Oh — I did have to step up and be the official ‘guy’ when one of the women had a question about why her husband had acted one way or another. I gave as honest an answer as I could based on my own experiences and on research data.)

There was one time (sort of a guy epiphany moment) when a young widow in the group opened the session with, “Can we talk about loneliness and sex tonight? — There are no guys here, just Bob.”

And that’s the way the rest of the group sessions went,’ just Bob.’ Not Bob the guy, just Bob the person. Of all the insight I learned from the group, that was the best of it: These women weren’t objects and neither was I. The group was a real success for all of the women and I considered it a success for me. I’ll admit I was a little envious of the women who were so, well, feminine and caring and loving. I thought a group of guys would never do or say the things that these women had. But I didn’t want to make a lame assumption, so I went upstairs to talk to the other male social worker in our department. He also ran a kind of grief group: a support group for spouses of terminal cancer patients. I asked him what his experiences were with the guys in his group.

“Guys are more content focused. When their spouse dies, the content of that relationship is over and they grieve in a different way, most likely home alone. If you want to work with them, you need to get to them while the project is still ongoing. Afterwards, it’s almost impossible to get a bunch of men in a group to talk about their feelings.”

He was right, of course. Guys generally don’t do that. It would be like going shopping with another guy and asking him, “Do these Levis make my butt look big?” Not going to happen.

Maybe a better therapist than I could put together a group of grieving men: Round-up a bunch of widowers and take them to a widow’s run-down house and get them to fix it up. I think that could work. A project.

But I’m not the guy to do it. I’m the guy who will go back to the ER and do the ER work that has always been in my comfort zone, unusual as that is.

In the end, I realized that my boss was right: I did need to go and see that people do get past, grief, one way or the other.

Dividing line

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Those Girls

Those girls

by Robert Lanz, LCSW

If it had only happened once or twice maybe I wouldn’t have noticed it. I never saw any research in the social work or medical literature about it and never heard my colleagues mention it. But I’ve always had a decent eye for coincidence and combining that with what Malcolm Gladwell calls “thin-slicing,” the ability to find patterns in narrow windows of experience, which gave me a handle on this particular problem. Sometimes, I was able to pass that handle on to our patients as well.

A basic premise in mental health is that you can’t always tell much about people by the way they act in public. (Maybe “act” is the operative word here.) Having grown up in Hollywood, I knew a lot about show business people who were famously cool in the movies but infamously uncool at home: great actor; bad parent. Not a fresh concept where I lived, but there wasn’t a lot of research on the subject either. So the stuff I’ll be talking about here is purely anecdotal. As for that movie persona, there is a term for letting our heroes get away with bad behavior: Suspension of morality.

I’ve often thought – and my experience bears this out – that more often than not it is bad mental health that propels some people upward, in the same way that it can make people do bad things.  I’m talking about heads of movie studios who like to be tied up and peed on; famous stars who want their spouses to have sex with other people while they watch;  macho action figures who want to be spanked and put in diapers. Of course, I didn’t see many of these people in the ER where I worked. But let’s just say that in my neighborhood, this behavior is part of the social fabric that is weirdly woven together and something the neighbors usually don’t get too worked up about. They just accept it as normal. For the most part, the rest of us don’t pass judgment, but we don’t invite these people over for barbeques, either.

The patients I am talking about may have been at a barbeque with me or they may have sat next to me at the dog park carrying on a conversation about the entertainment business, reveling in their successes. In retrospect after meeting several of these types of women in the ER, I began to wonder how many of them I had unknowingly met, possibly in a yoga class, or sharing a ski lift while engaged in a brief but pleasant conversation. I may even have admired one as she walked past my beach chair one sunny afternoon while I was reading a book down at the Venice Beach pier.

In the ER I saw them at their worst and they seemed to have several things in common: they were professionals, and physically attractive. They had the kind of drive and focus that can make others jealous, pursuing and achieving their goals through a pure force of will.

On the outside are the apparent signs of success. But on the inside, is pain beyond imagination. Pain so terrible, that the only way they can tame it is to deny its existence, and always focus outward. Through their successes, they set out to prove that they are powerful women, covering their fears through achievements much the same way an insecure man might: believing he would feel better about himself if only he had a bigger house or a cooler car or a prettier wife or more money. Always more, more, more – never realizing that more wasn’t the answer, yet believing it even after they had achieved the honor of having a building named after them or an airport or some such thing.

What both the men and women in this group have in common is the false belief that their internal pain can be cured by the external trappings of accomplishment. The men I knew in this group often showed up drunk and behaved stupidly: less a shock to me being a man, and also because I have been surrounded by over-achievers most of my life. I believe I am able to see through this behavior.

The women, however, were a surprise. Most of them averaged about twenty years worth of incredible drive and accomplishment and admiration by friends and colleagues. Then one day (more likely one night) when they reached a point where their bodies and minds could no longer keep up the charade, they ended up in the ER as a result of a drunken car crash, or an intentional overdose of prescription medicine no one knew they were taking. For most of them, the self-destructive act came out of nowhere. But the ‘nowhere’ they all had in common was something that happened thirty or so years earlier, when they were molested by a family member or trusted family friend. What happened to each of them was a violation of trust so profound that their sense of self and safety was redefined, setting them on a irresponsible journey of avoidance and denial. And on a night when the strength needed to cover it up is somehow diminished, the woman finds herself back where she started, vulnerable and alone, without even the fantasy of holding it all back by overcompensating. The fortress built by over achievement can no longer keep the pain in check. Death might seem a better alternative than another moment of intolerable fear and vulnerability.

In my experience, patients like these would not willingly admit they had been sexually abused as children. Usually, once they awoke from a near-death experience, they would reinforce their defenses enough to look at us and lie: to me, the nurse, the doctor, their friends and their family. The lie did work on me a couple of times before I caught on to the sexual abuse connection. In the middle of whatever manipulative story they were trying to put over on me, I began to ask, “Were you molested as a child?”  It only took a couple of seconds before their tears and sobs informed me that I had guessed right. After thirty years of overcompensating, everything fell away with one simple question. The beginning of the hell of getting better.

This guessing is one of those skills you develop, yet are never proud of: the ability to light lives on fire, knowing that – like with a burn victim – recovery is a long and painful journey, for those willing to take it.

The ones who chose not to take it might end up in another ER, disintegrating further into a life of drugs, sex, violence or other attempt to escape their pain.

But there is no easy way around this pain. Like s a swamp, you must slog through it to make it out the other side.

Dividing line

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From the Past

by Robert Lanz, LCSW

Improv wisdom

Sometimes they show up again and bring something so unexpected that the pain and pleasure begin to intertwine in a way that defies description. The simplest request brings on the heaviest flashback. There’s a mom down in Room Fourteen who needs admission and she’s worried about her kids at day care and who will pick them up. The social worker’s job doesn’t get any more basic than that. Make a few calls. Make a few arrangements. Done deal. Five minutes max.

Any of our social workers could do the same. Just walk into the room, introduce yourself and make the calls. Pretty simple.

I walk into the room and I see the attractive 30-year-old mom under the covers. She peeks out, makes eye contact, says, “Oh Bob, it’s you,” and starts crying. I draw the curtain around the bed to give her a little privacy and to give myself a minute to try and connect with who she is. She obviously knows me and I don’t have a clue about her. She obviously has very strong memories of me but I have none of her. This is a common problem that all of the staff, at one point or another, are confronted with in the ER. In their whole lives, the patients may interact with only one of us and that might be on their worst day. Their worst day is just another day in our lives. It has to be that way to protect us from emotional overload. But these encounters don’t just go away, they get tucked away in some emotional hot zone in our brains, waiting for a memory stimulus to bring them back.

Still crying, she asked “Do you remember me, Bob?”

“I remember your face but it seems like it was a while ago.”  A safe statement to make.

“I was here 18 years ago and I remember you. You were so kind and I felt safe.”

What’s been going on since then?” I asked her.

“I got married and have three great kids a good husband. All that other stuff is behind me but I always remember you.”

“Wow, that’s great and I’m utterly flattered that you remembered me so long.”

“I was a scared little girl and you protected me. I wasn’t scared anymore. I told the police everything.”

“And everything is okay now?”

She wiped her eyes and smiled big.

“Everything is okay now, Bob.”

“How can I help you today?”

It was easy to call a friend and contact the day care and reassure the docs that everything was okay.

But I wasn’t okay. I have no idea who she was other than to assume that eighteen years ago, a scared twelve-year-old was most likely the victim of some sexual molestation, possibly incest, and didn’t know who to trust. Something I said or did got her through all that, whatever it was, and I was embarrassed that I didn’t remember it. I was also a little embarrassed to be remembered so fondly. Part of the job, I guess. Part of the job that doesn’t happen very often. But it happened that day and one thing I will never forget is how that made me feel.

Dividing line

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Suicidal Tendencies

Suicide

by Robert Lanz, LCSW

“There is a fine line between self-directed violence and an ambivalence for life.”   — Robert Bossarte, V.A. suicide expert

Most people who come to the emergency room exhibiting  suicidal behavior don’t want to be dead.  If they wanted to be dead, they would already be dead, and they wouldn’t have made it to the ER.  They would have chosen a method that virtually guarantees death, such as a gun, which has an efficiency rating of about 99.9 percent.  Jumping off a high place is almost always successful.  Standing in front of a train, even a slow-moving train is just about sure to result in death (and for reasons unclear to me, is a favorite of depressed Viet Nam vets.)  Setting yourself on fire and stabbing yourself generally are effective as are jumping into deep water if you can’t swim.  Gassing yourself with carbon monoxide from your car’s exhaust works pretty well, too.  Cutting wrists and taking an overdose of medication almost never work, yet minor wrist slashings and overdoses are the most common presentations of ‘suicidal behavior’ we see in the emergency room.  The reason for this is that they are not very lethal, available to everyone and relatively painless.

Wrist cutting and overdosing are mostly seen as suicidal gestures rather than suicidal attempts, and these patients almost always return home unless there is a medical reason for them to be admitted to the hospital.  Most of these ‘gesturers’ demonstrate the ‘cry for help’ that is so often quoted in the literature.  The majority of them have no intention of dying, and if for some reason they actually did die, it would come as a surprise to them.  Those who use these non-lethal methods may think they really want to die, but with enough time and gentle questioning, it becomes clear that they really just want to stop their emotional pain, and have come to a point in their lives where they don’t see any other way to do it.  They fit into the classification of feeling ‘hopeless and helpless,’ one of the diagnostic criteria for clinical depression.

Another category of  patients showing ‘suicidal behavior’ are those manipulators that have absolutely no intention of dying and are trying to get someone’s attention.  Usually, it is someone specific, but a desperate person will perform desperate acts, and may settle for the attention of almost anyone, including the staff in the emergency room.  There are those who believe that if they came to the emergency department and said, “I’m really depressed, pay attention to me,” that no one would take them seriously.  Instead, they take fifteen aspirins or scratch their wrists and are ‘discovered’ by friends, family or neighbors who call the paramedics.  Then, they’re brought to the emergency room where, of course, nobody takes their behavior seriously.  We take their feelings seriously, but it is hard to take their behavior seriously when there is a bottle of fifty aspirins and only twelve are missing or when the patient tries to slash his wrists with a plastic razor that couldn’t cut deep enough to require stitches even in the hands of the most overzealous of surgeons.

I have no idea how many successful suicides there are in any given week, because if they are successful they don’t make it to the ER.  I can say there are a few who shoot themselves and live long enough to show up, but not much longer.  The same goes for jumpers and hangers.  What I do know for sure is that men are three times as likely as women to be successful at suicide.  Men are more aggressive.  They kiss oncoming trains, put guns to their heads or in their mouths and jump from very high places.  Women try three times as often as men but are less successful because they almost always use overdoses or wrist slashing.  Even in deep depression there is a sexual difference that can be noted.  I won’t try to explain it but it would be a mistake to not mention it.

Most patients displaying suicidal behavior, especially if they are adults, have displayed suicidal behavior in the past.  Many will do so again.  Our job is to try and help the patient get connected to someone who will help him or her find another way to express their feelings that is more direct and not as self destructive.

About five to ten percent of wrist slashings are serious enough to require stitches.  But most don’t, and besides, it is almost impossible to kill yourself by cutting your wrists.  Almost.  If someone really wanted to do it, he could.  It hurts a lot, and usually only highly intoxicated or psychotic people are able to withstand the degree of pain that results from a cut deep enough to cause death from loss of blood.  One of the many wonders of blood is that it is able to clot even in large arteries, and bleeding stops on its own.

The vast majority of ‘slashers’ have no intention of dying, and are really going for dramatic effect, needing some acute form of attention.  There’s nothing like a lot of blood to get everyone worked up, which is, of course, the intended purpose of the slashing.  In that sense, it is highly effective behavior, and because it works, it is likely to be repeated.  This will present a dilemma for the clinician who attempts to work with the patient and his/her family.

Most ingestions are the behavioral equivalent of wrist slashing, although they are much more common.  Ingestions don’t hurt, and many of them, depending on the substance ingested, feel pretty good.  People who have low tolerance for emotional pain also seem to have low tolerance for physical pain, and it’s just a lot easier to swallow a few pills than it is to actually cut a wrist.  I’m not sure I understand why that is.  I’m not sure I need to.

With all ingestions, our goal in the ER is to clear the stomach of the substance, give charcoal to filter out what is left, observe the patient’s vital signs and intervene if necessary.  Finally, we test the blood and urine to determine exactly what and how much of anything the patient has taken.  If we know what the patient has ingested, there are some immediate remedies we can take.  If the patient has overdosed on some opiate like heroin or codeine, we can give them an antagonist drug like Narcane and immediately reverse the effects of the opiate.  If they have taken an OD of benzodiazipines like Valium we can give them an antagonist that reverses the effect of that drug within a few minutes.  Not as dramatic as Narcane, but benzodiazipines aren’t as fatal as opiates so the reversal doesn’t need to be dramatic.

The most common course of events for the overdosed patient includes what’s called a gastric lavage, commonly referred to as pumping the stomach.  It is a very uncomfortable procedure, and the patient has to be close to unconsciousness or highly motivated to be able to do it without problems.  A large tube is greased and put up the patients nose and guided down the esophagus into the stomach.  A five-liter bag of liquid, called normal saline, is attached to the tube, gravity-fed into the stomach and then pumped out again.  This is done over and over until the contents come back clear.  Then the patient is given six ounces of charcoal slurry down the tube, chased with a bottle of magnesium citrate that speeds it through the stomach and intestines, where it absorbs whatever was not extracted by the lavage.  Most patients find the experience very unpleasant, and it is not uncommon for that singular event to change the patient’s mind about ever taking an overdose again.  As in many cases in the ER, some physical sensation will have a lot more of an impact on a patient’s consciousness and subsequent behavior than anything a doctor or social worker might say.

If I do think a patient is truly suicidal, then it is my job to figure out what to do with him.  Due to the ever-changing face of health care since the nineties, this can get more and more difficult.  If a patient has insurance and wants to go into a psychiatric facility, then there is the nightmare of getting approval from his insurance carrier.  If the patient has insurance, doesn’t want to go into a facility and is a danger to himself, as in still feeling suicidal or threatening to hurt himself further, the patient can be locked in a facility against his will for three days while being evaluated.  If, at the end of the three days, the patient is still a danger to himself, he can be held for two weeks.  After that it takes a court order to keep him confined.  Court orders are rare, especially if the patient has no insurance.

If there is no insurance, I can try calling the police, and they can transport the patient down to the county hospital for a psychiatric evaluation.  This is a nightmare of another sort, as the county hospital is almost always full, but they cannot refuse to evaluate the patient.  They know they will have to evaluate several patients on any given night, so they are reluctant to give up any of their beds.  As a result, a patient without insurance who exhibits a certain set of behaviors and feelings might get released from a county facility while a patient with those exact same behaviors and feelings would not be released from a private hospital where his insurance company is paying six or seven hundred dollars a day.  This is a classic example of the two tiered system.  It would be a real tragedy, except for the fact that most of the people who are being evaluated and treated didn’t really want to die in the first place.  If they had, they would have killed themselves instead of showing up at the emergency room with a non-lethal OD or some minimal wrist cuts, saying they wanted to do die.

Having to evaluate a suicidal patient, or rather a patient with suicidal behavior, is an almost nightly occurrence in the ER.  I’ve done about two thousand of them, and to my knowledge, no one I have sent home has ever killed himself or herself.  To my knowledge, only one whom I have ever sent to a hospital and was subsequently released from that facility has ever committed suicide.  I guess that is why a successful suicide always makes the news, because it is really rare.

Jimmy O. came to the ER for multiple lacerations and abrasions, road rash he sustained while riding his bicycle down the street in front of his parents home.  He was intoxicated, going at a high rate of speed and went through two stop signs before his big time crash.  Because of his intoxication and confusion from the head injury, I was not able to interview Jimmy, even though his history was suspicious.  He knew the area; he had ridden his bike there for years, yet he was going too fast to have had control over the bike even if he had been sober in broad daylight.  He was thirty-three years old, probably an alcoholic and living at home with his parents.  Just before he crashed, I was to learn from his friends, Jimmy had had another argument with is parents.  He went out and got drunk then Kamikazied past their house just before he crashed.

This seemed like really self-destructive behavior to me, so I brought it up with his friends.  They denied ever seeing him do other self-destructive things.  They denied ever hearing about any plans to hurt himself.  I knew that they were lying.  We generally feel in the ER that the odds are against catching somebody the first time they make these big time errors in life.  It’s the same with the cops.  When they catch a bad guy, they never think they caught him the first time he did something illegal.  More likely, this is merely the first time he was caught doing something illegal.

Jimmy O.’s friends did tell the truth about Jimmy’s wild streak, but downplayed it or misinterpreted it.  No one thought he was suicidal but me.  His family didn’t.  The doctors didn’t.  The friends didn’t.  Jimmy entered the hospital for medical treatment of his concussion and despite my observations, no mental health person saw him for suicidal tendencies while he was in the hospital.  He denied having a drinking problem, and that was about as far as our mental health interventions got.  When I found that out, I went up to his room myself and confronted him.

Possessing the average amount of insight of a typical alcoholic, he denied having suicidal thoughts or plans or any problems at all.  He thought I was just a spoilsport for trying to get him to pay attention to the pattern of his drinking.  He was released from the hospital in a few days, and everyone thought it would be business as usual when he left.  I didn’t think so, but there was nothing I could do about it.  I had brought it up with his friends and confronted Jimmy openly.  No specific suicidal attempt, no specific suicidal plan, no strong suicidal ideation.  No criteria for involuntary hold.  I knew he would be back.

A week after his duscharge, Jimmy found a pistol, an old thirty-eight that his father kept around to protect his home.  One day, Jimmy got drunk, put the pistol under his chin and pulled the trigger.  The bullet tore through his jaw, took out most of his teeth, blasted away half his sinus cavity, traveled between his eyes and through his frontal lobe, the part of the brain where personality is located.  Jimmy didn’t die from the hot lead that seared his brain, but his personality did.  At least the depressed and alcoholic part of it did.  In that sense I guess Jimmy was a good shot.  He managed to blast away all the pain, the need to drink and a lot of his adult memories and cognitive processes.  In effect he knocked himself back to a happier place in life, the mental age and temperament of a ten year old with no problems.  He went home and lived in peace with his parents, the child they had always wanted.

Some time later, one of his friends ran into me in the hall outside the ER.  He remembered me from the first night, the night of the bike crash.  He said he was feeling guilty because he didn’t tell me about how depressed Jimmy had been and how he often talked about being better off dead.  And then Jimmy shot himself, just like I told him he would.  He  tried to apologize.

“Save it,” I said: “Jimmy got what he wanted and he didn’t have to die for it.  He just killed the part he didn’t like.”

Most people who think they are suicidal would probably settle for that.

Note-this is an old story and the treatment for overdoses has changed significantly with activated charcoal replacing the dreaded gastric lavage most of the time.

Dividing line

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Movie Makers

Shooter

by Robert Lanz, LCSW

“Think how to fit disparate things together.” Jonah Berger, Marketing Professor, Wharton School of Business

I hate to be the guy who would stereotype anyone. That said, generally speaking, most gunshot victims are black or brown, and most of the guys that shot them were black or brown also. The occasional white guy or Asian guy who comes into the trauma center for being shot is most often shot by a black guy or a brown guy who was robbing them. Hey, don’t even start in on me about this, I’m only the messenger.

Anyway two young black guys came in as trauma codes because they had been shot in a neighborhood where black on black target practice was a frequent pastime. Many of those victims act as if having been shot is not that big of a deal and they remain passive or even hostile while in the ER.  Either of these might be considered normal reactions in some areas where frequent shootings take place. But these two young black victims weren’t covered with tattoos. They were cooperating with the police and it was pretty obvious they were terrified. It was pretty obvious also that they hadn’t come from a neighborhood where this was normal behavior. And other than being African-American they most likely
had little in common with the guys who shot them. They were essentially middle-class white kids in black skin, and just like a terrified white kid who had been shot, were prime candidates for post-traumatic stress disorder or the shorter lasting Acute Stress Disorder. The common symptoms of these disorders generally occur after exposure to some extreme event likely to cause death or serious injury and for some people merely witnessing such an event can bring on these disorders.

The emotional symptoms include intense fear, re-experiencing the event when triggered by thoughts, sights or sounds or smells associated with the event. War, natural disasters and un-natural disasters, near death experiences from almost anything all qualify for “out of the normal experience.”  Drive-by shootings you are not accustomed to as part of your neighborhood experience fits right in there also.

All that  other racial/historical data at the beginning of this story has a point. To a lot of guys, death in the street is so commonplace and so not out of the ordinary that they don’t consider such death as an exposure to an extreme dramatic event and they seem to be defended psychologically (some might even say numbed) to the point that unlike the rest of us, they would not be at high risk for developing PTSD or Acute Stress Disorder. But as I said, my guys weren’t from that place of indifference so the fear of impending death, especially their own, made them prime candidates for psychological problems downstream.

Unless of course they had a few elements on their side. Those elements would include that they had  an intact and supportive family. Their wounds were not life-threatening. They seemed to have adequate coping skills and openly talked about how frightened they were. Also it helped that the chief trauma surgeon was an old personal friend as well as professional associate of the social worker who didn’t mind me butting in with his patients once they were medically stable. One of the most helpful things in treating a traumatized patient is to get them out of the emotional moment and move them over to a more thoughtful cognitive view of the events as soon as possible. That move is called reframing,
and every therapist knows to use that when necessary. When the event is reframed to a different issue, it looses some of its emotional power, hopefully enough that the road to PTSD is blocked to the point that the patient has an easier recovery.  Reframing can be as much an artful move as a technical one.

In any assessment, start where the client is. That can be done with a simple question as in “Can you tell me what happened?” or by making an observation like “that sounds like a scary situation,”  to get the patient talking about the event. Basic stuff.

Fortunately, during the medical interventions, I had time to spend with the boys’ parents standing in the hallway. Bright, educated, focused. They had given me some background about their sons, who had done well in school, had no police problems and were currently in college studying screenwriting and filmmaking and looking forward to a career in show business. Jeez, they could have grown up in my neighborhood, East Hollywood, where half my neighbors were in show business. I had written a couple of screenplays myself.

Reach deep down in that bag of social work tricks, Bob. Help these guys. They have a future and PTSD doesn’t have to be one of the issues in it. I approached the most injured of the boys and introduced myself to quickly define my job.

“Mike, your surgeon says he wants to admit you for the night. Just being careful. But part of being careful is giving you an extra layer of protection and to do that I’m going to give you a false name. An a.k.a. so only people you want to visit and find out where you are and, your parents of course, will be able to  get to your room. That protects you. That protects us. I don’t want some banger coming in here to finish you off and take out a couple of us, too. I see you’re studying filmmaking so I want you to be able to use this shooting like a scene from a movie. I’m going to admit you as part of the movie. From now on when you get upstairs you will have a new name:  ‘Johnny Chicago.’”

Before he could even respond, and this was a positive sign when his friend, the other trauma — who wasn’t injured enough to be admitted –  yelled out from the next bed, “Hey what about me? What’s my a.k.a.? Dude can you give me one too?”

I looked at this chart and he was still listed as John Doe 1937. We usually don’t assign fake names unless the patient is getting admitted because, in the computer, its easier just to roll over the Doe into the patient’s real name. Unless, for some reason, the patient requested anonymity. “Oh Dude, can you give me one too?” was close enough for me as it fit in to my clinical plan. I checked with the supervisor in admitting who had learned a long time ago if I made a special request, I would always have a good reason and more importantly, I would take the hit if they got any heat from leaving the hospital protocol.

“Jimmy New. That’s  your a.k.a. As long as you’re down here anyone asking for you won’t find your name in the computer. You get a new name now. Jimmy New.”

Johnny Chicago, and Jimmy New had just been given an opportunity to reframe tonight’s events. So had their parents. I overheard them talking about it when I left to see another patient. Now these were movie guys, like my neighbors. Now they have a different movie with different characters, characters, who they can control, one of the essential elements to avoiding post-traumatic stress disorder.

Dividing line

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