Psychology Today Blogs - MetroPolar

Crazy Back

Greg Dillon — Thu, 15 May 2008 09:47:15 -0700

Justin Timberlake took "sexy back". Okay, fair enough. But where had it gone? And why did JT earn the right to get it back? Had sexy become a commodity, a style, trend, or fad? Was it demode, but now a la? I suppose if "sexy" gets stickily emeshed in a Tom Selleck mustache and snug slacks with just a hint of lycra, then sexy can come and go. But it is my understanding that sexy describes an ongoing, flexible dynamic, one that flows, shifts, changes between people, eras, and cultures.

Reading through a NYTimes piece on the "Mad Pride" movement, I started think about "crazy back." Mad pride is about debunking the stigma of mental illness. Like gay pride and race pride movements before it, it seems to be taking an in-your-face approach to confront and demistify. This approach is likely necessary to shock some people out of their ignorance and anxieties re: mental illness.

However, I hope that crazy back will eventually take a more integrative course. Some of the great biopsychosociially oriented theorists (that is to say psychological theorists who value the importance of biological and social interactions and development) like Erickson and Harry Stack Sullivan, as well as old school Freudians, have made it clear that mental illness can be understood on a spectrum. For example, extreme paranoia in a person with schizophrenia can be viewed as an extrapolation of suspicion in a person without diagnosed mental illness. While there is a huge caveat here (do not minimize severe symptoms of mental illness, their risks, or physiological underpinnings), we can use this spectrum to better understand, empathize, and relate to thought processes and feelings inherent in people with mental illness. Taking crazy back, hopefully, will not have to be solely the charge of the people with diagnosed psychiatric disorders, but the empathetic duty of all citizens to recognize and wrestle with traits in themselves that are on the spectrum from "normal" to "crazy".

During the Elliot Spitzer issue, a Washington Post reporter called me to comment on what would make a man with such power and reptutation risk everything for a paid fling. I explained that we all carry some yin and yang, and that the very doubts and insecurities that might drive a man to strive and achieve a certain success could, in another situation, drive him to embrace his shame and doubts and succomb to self sabotage (a little unconsious masochism, perhaps). We all have this capacity, nothing shocking. "I don't think my readers would like hearing that," sniped the reporter. "Well," I said, "your readers have some work to do." GD

Spring Cleaning

Greg Dillon — Tue, 01 Apr 2008 12:51:27 -0700

I have seven surfboards stashed in the back hall/ fire exit of our apartment. Somehow, I have convinced myself that I need all seven. A longboard for small days, a short board for the rare, epic summer days, a wider, floatier fish for summer mush, a mid-sied, hybrid, for medium days, or spring, when I'm too out of shape to paddle the short board. One short, fat, egg with blue flames that I call "Gordito", etc. These, and others, make up my "quiver", the boards I need, or think I need, to cover all situations. Ignore the fact that the metro-surf in and around Rockaway is merely serviceable, and it makes sense.

Last weekend, I spring cleaned, tackling closet and dresser as a first pass. The impulse to spring clean must be genetic, akin to molting, rebirth, phoenix from the wintery ashes, etc. But the angles on the process are multiple. Do we spring clean because we are wiser, and we realize the frivolity of harboring so much baggage (clothes, books, friends, etc.)? Is it because we are fickle, impressionable, and our moods, likes, dislikes, weights, styles, change with the seasons? Or are we impulsive, acting out our desires, angers, dreads, and fears in Hefty bagged bundles for points afar like the dumpster, Salvation Army, or to someone who might want them?

Many patients seem to want psychic spring cleaning as well. It is a time of change, and they get impatient to have their insides change to keep pace with the anticipated external changes. Patients ask me for deadlines. "When will I be done... ready...better, etc." Nothing wrong with motivation, drive, a kick in the ass, a jumpstart. But, slow down. Know your motives for spring cleaning. It is probably better to hold on to your baggage a little longer and try to really understand why you are willing to let it go... or keep it.

Seven surfboards is a lot. Maybe it's too many for New York City. Admittedly it's a rare year when each gets equal time on the water. But, I figure, as long as I continue to try to understand my reasons for holding on to each one, and continue to give each some play, or until the fire marshal busts me, they'll stay on my back stairs. GD

Virtual Betrayal

Greg Dillon — Fri, 21 Mar 2008 06:51:33 -0700

Occasionally, I get a truly insightful or provocative comment on one of my blog posts. Yesterday, in response to my piece Bear Stearns In Treatment, I received such a heartfelt and germane response, that I wanted to share it.

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When I first received the email notification that someone had logged a comment on my piece, I felt touched, warm, and hopeful. The idea of a cyber connection on an intellectual plane that mattered to me was really exciting. I must say that when I realized my good cyber friend "Tramadol" was merely hocking discount pharmaceuticals via a new platform, I admit I got a little testy.

We are all familiar with the late-night telemarketing call. The phone rings. Then, an uncomfortable pause, followed by an almost human " Hello! I understand that you may be interested in (x,y,z), Mr. or Mrs. ..." And, by now, spam is old news, the seemingly random littering of virtual leaflets. But there was something truly invasive and creepy about this new platform. As a writer, psychiatrist, and person, I had put myself out there, made myself vulnerable to comment criticism, engagement. As with all my posts, I was ready for a smack-down, argument, or even a pat on the back. But Tramadol's response felt more like a random, absurdist act of violence, as if I were a politician giving a stump speech and a couple of terrorists from Bizzaro-Ethereal-Madison-Avenue jumped me, dragged me into a back alley, tattooed a billboard for Coco Puffs on my bare back, and went on their cyber way. No point, no, message, no handshake, just a marketing mission well done.

The wheels of capitalism must turn. Everybody has to make a living. I get that. But doesn't the disrespect that these tactics show, not just for individual citizens, but for the process of human engagement as a whole, lower the bar for our hopes and expectations for meaningful interaction? If 50% of my email or phone interactions become carpet-bombings of marketing dreck, then why bother engaging at all? So many of my patients wrestle daily with troubled communications, hoping to better understand and relate to their friends, families, etc. This tidal wave of targeted, misrepresented betrayal, can only make that task more of a crap-wading struggle. GD

Bear Stearns In Treatment

Greg Dillon — Thu, 20 Mar 2008 15:19:02 -0700

On the elevator up to my office, a patient of mine asked me, "Can you believe this?! Can you believe what happened to Bear Sterns?!" I gave him the knowing, wow-it's-crazy smile/nod, until we got settled in my office for our session. The truth was, I could totally believe it. What goes up, must come down, live by the sword, etc. But he was really shaken. The idea that a presumably rock solid financial institution, the hub of prosperity and the American way of life could go down in a fire sale unsettled every bit of his psyche.

Crises, disasters are traumatic. While we often mount a heroic or even manic response, they shake us to the core. This is not about Bear Sterns or even the economy. Anyone who can delude themselves into thinking it is reasonable to expect an over-leveraged debacle like the recent sub-prime mess to yield all good all the time, must have some shred of dread that the house of cards will tumble down. The stress and anxiety that Bear Sterns generates goes to our child-like core. How could this happen? How could they do this to us? Who's going to fix it? Who can we trust? This is not fair!

Well, it's probably not fair to make several million a year off over extended/leveraged investments. Or to live in a $35 million apartment. But few pointed out that discrepancy when all was good. While the numbers and the victims of the situation may mitigate our empathy, it's important to see the psychological premise. This wasn't supposed to happen. And we weren't ready for it. My three year old daughter doesn't quite understand why she can't have three ice cream sandwiches for breakfast, but we're working on it.

The weird thing is that second runner up to Bear Sterns fears this week in therapy was In Treatment fantasies. More than five patients wanted to compare their sessions with me to the tight angled, intense TV sessions with Gabriel Byrne and co. on HBO. The link? In times of destabilization, regression is often close behind. And nothing begs for salvation like regression. "Why don't I feel like you care about me as much as Paul (Gabriel Byrne's character) cares about his patients?" I don't want to be her savior, but just to let her feel that there can be care. "We can work on that." GD

Placebo Abuse: The Hubris Effect

Greg Dillon — Thu, 06 Mar 2008 18:49:49 -0800

Had to chime in on Jay Dixit and Dan Ariely's recent thread on placebo effect. As a psychiatrist with a practice heavy in addiction, pain management, and detox/rehab, I've grown to cringe at the loaded implications of the placebo concept. Maybe it's helpful to first toss out some definitions and etymology:

pla•ce•bo (pl -s b )
n. pl. pla•ce•bos or pla•ce•boes
1.
a. A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well.
b. An inactive substance or preparation used as a control in an experiment or test to determine the effectiveness of a medicinal drug.
2. Something of no intrinsic remedial value that is used to appease or reassure another.

placebo
c.1225, name given to the rite of Vespers of the Office of the Dead, so called from the opening of the first antiphon, "I will please the Lord in the land of the living" (Psalm cxiv:9), from L. placebo "I shall please," future indic. of placere "to please" (see please). Medical sense is first recorded 1785, "a medicine given more to please than to benefit the patient."

In medicine, a clinical response to a placebo often carries the baggage or implication of ignorance, lack of insight, or self awareness. The idea that a patient would report a symptom response from "a substance containing no medication" unfortunately suggests the notion the he is easily duped, albeit unconsciously. A double extra unfortunate sequela is that many doctors prejudicially define placebo responders as not having a real disease. Many illnesses and symptom complexes (fibromyalgia, chronic fatigue syndrome, even migraines and seizure disorders) have suffered incredulity as a result.

I suggest that this is a function of the hubris of medicine. If it doesn't fit our categorical diagnosis, or if we can't explain it, it isn't a real disease. I am particularly sensitive to this for two reasons. First, in med school @ U Penn (a very crunchy, humanistic place at the time), they always drilled the difference between disease and illness into our heads. While a disease is a complex of signs and symptoms, often consistent across cases, an illness is the dialectic of that symptom complex and the person's reaction to it. Disease x Person's life/experience = illness. Using this math, we might say that: Medication x Person's life/experience = Treatment Respone (which includes a biochemically mediated effect as well as a cognitively/emotionally mediated effect, "placebo"). So, maybe the placebo effect is a complex level of endogenously mediated treatment that we just don't get quite yet.

My second annoyance with the fallout of placebo stigma is that placebo-responding patients and illnesses are often dumped onto psychiatrists. Don't get me wrong; I love the work. And now that psychiatry/neuroscience is more concretely mapping the physiological links between emotions, cognition, pain, and even the immune system with pretty pictures from functional MRI and others modalities, we have more to contribute than ever. But the dumping of these patients into a field that, sadly, still carries an it's-all-in-your-head stigma, can feel dismissive and devaluing to people who are suffering and need help and support. This leads to a plea for the integration of mind and body in medicine and psychiatry.

Lest I get too holier-than-thou, I have one final bee in my psychiatry bonnet. Placebo is the first person future tense of the latin placere, I will please. In dynamic psychiatry, the notion of pleasing or gratifying a patient's needs is often misperceived as a no-no. A placebo feeds into some unscientific, neurotic, and unconscious need. Unfortunately, bad psychiatry can miss opportunities here. The positive response to a placebo should not be read as irrational, pathological, or pejorative, but rather lead to an understanding of what brings that person or people in the aggregate relief.

The flip side of dismissing the placebo effect is using it for good. Dan Ariely and Jay Dixit both suggest the possibility of harnessing the power of placebo in treatment. Whether this is done by actively prescribing placebo medications or opting for economic, behavioral, or therapeutic structures that take advantage of psychologically mediated or ameliorated responses to treatment.

Sounds good to me with one phat caveat. Slow down. When Piaget first came to America to lecture on his studies on cognitive development in children, he was miffed to find that the big, American question was, "How can I use this to make my kid smarter faster?" His response was "Dude, back off!" There is a lot of turf between observational science and prescriptive medicine. And, just because a placebo is not an official FDA approved "medication", it can still do a lot of good or damage. GD

Let It Bleed

Greg Dillon — Tue, 04 Mar 2008 11:49:53 -0800

I am hearing a lot about blood and bleeding. "Doc, I'm bleeding here!" "What do I have to do, open a vein and bleed all over your rug?" And the occasional self-inflicted wound. Not real suicide attempts, just blood-letting.

I get that bleeding can be serious. Medically speaking, excessive bleeding can lead to bottomed out pressure, strokes, heart attacks. Anemia can lead to low oxygen carrying, tissue necrosis, organ failure. And, at least, it can be a harbinger of badness, injuries, ulcers, cancer. Aesthetically, it can be pretty shocking as well, spurting arterial bleeds, scarlett spatters on crisp white linens say horror like nothing else.

But I am finding that the invocation of bleeding doesn't draw me in like it used to. I flash back to my surgery days. Mostly, med students and surgical interns get to suck, clearing out oozing blood with a suction wand; so the higher ups have a clean view for cutting and sewing. You start to think of blood as an obstacle, a necessary nuisance or mess to be tidied; so you can get to the real work at hand.

I guess I could be desensitized or jaded from over-exposure. But, "Doc, I'm bleeding here" in my psych office doesn't say "Stat! Catastrophe!" as much as it says, " I'm coming apart at the seems, scared, angry, confused, and I don't know how to stop it." Psychiatry has its own suction. Diffusing the noise of panic, anxiety, rage, confusion in order to allow the heart of the problem some visibility. Like in surgery, this psychic bleeding can be overwhelming, flooding the field, and it needs attention. But often, it's symbolism is scarier than its meaning. I figure that when someone invokes bleeding, they are digging for the most visceral, deepest crimson metaphor they can to express core, unnamable feelings.

We all have our own reaction to red, red blood, often informed by culture, media, myths, but the evocation of this trump card means something different to and for each who plays it, consciously or unconsciously. Personally, blood in black and white, as seen in too many, neo-goth, Japanese horror movies, freaks me out the most. It says "dark vital life fluids are draining from this living soul like mythical humors of yore" much more than flashy red spatter with all it's diluted associations. GD

Free v. Cheap

Greg Dillon — Thu, 28 Feb 2008 10:58:14 -0800

“Free!” reads a big pink sticker on the cover of this month’s Wired, on my waiting room table. My heart leaps. I’m still programmed to read “free” as no cost to me the consumer, gratis, a perk. A weird reaction, given that most of my use of “free” with my patients is about liberation, lightening of baggage, guilt, etc. I grab the issue and read it on the subway home.

Chris Anderson’s cover story Free: Why $0.00 is the Future of Business makes for a diverting trip into the world of web/tech economics. The heart of his thesis is that the price of technology (transistors, storage, bandwith) shrinks asymptotically to zero over time, and the two party, buyer/seller economic model gives way to other possibilities. For example, the commodity of on-line time bought and sold for profit gradually gives way to free exchange of web time, which facilitates the growth of other exchange opportunities, advertising, viral marketing growth, generation of trends, wants, desires, etc. Anderson argues that “free” (stuff, exchange, whatever) psychologically triggers enthusiasm in a way that even “very cheap” cannot.

Don’t get me wrong, I find most economic models confusing and frustrating. But I couldn’t help but link this to trends in psychotherapy. So many patients are looking for a deal, a plan, a comprehensive package, a system. They see/feel something wrong, a relationship, job, situation, and they want a plan to fix it, preferably an affordable (financially and emotionally) and time-limited plan. Not surprisingly, this demand sparks a hefty supply of options, from self-help books (7 steps to a better this or that) to better studied an proven cognitive therapy modalities. These plans can be really effective tools in managing problems, even emotional or cognitive response patterns, but they seem to follow a two-party, buyer-seller system. If I pay (in money, energy, commitment), I will be paid off in results, problems solved.

I feel this most acutely when, at the end of a session, a patient asks me “What’s the plan? What do I do?” Sometimes there is a plan. Talk to your husband. Take a break from your mother. Don’t do that anymore. But, more often, the desire for a plan is about anxiety. And the offering up of a simple plan can be a reactionary bandaid for that anxiety. That reactionary offer (“Here. Do x, y, and z, and you’ll be fine”) risks shutting down mulling over other options, really understanding the patterns. Just like a business that thinks small, buyer-seller, and misses the opportunity to expand. “Free” comes in when you stop looking for a plan, a deal, a solution, but rather zoom out, and think about bigger questions. What do I like, how do I process, what slows me down? And, ultimately, how do I freely access all these and other questions? GD

Is Ryan Seacrest the Devil?

Greg Dillon — Tue, 26 Feb 2008 13:40:50 -0800

Film, television, literature, the Bible have all taught us that when the devil comes, he will be sneaky. At least a slithering, tempting snake, if not a more ethereal manifestation of our own baser traits. More lately, Sam Harris and the New Atheists (albums in stores now!) suggest that the true evil may be a function of our own passivity, laziness, and our willingness to give it all over to G*D.

So, is Ryan Seacrest the Devil? Probably, yes.

Here's how it works. We're on the red carpet before the Oscars, and by we I mean me, my wife (in our den), Ryan Seacrest, and untold millions of Americans. Jennifer Garner, who seems like a genuinely warm, likable woman, and Laura Linney, another apparently authentic and decent sort, are catching up. They seem excited to see each other, conspiratorial yet playful, like friends catching up at another's wedding. Then, Ryan Seacrest butts in. I can't begrudge him that. It is his job to get the story, or at least mingle and chat. His questions and discussion frame are so banal and self-satisfied, I can't recall them. He reads like an unfunny, lost-in-translation alien clone of an already not so funny frat-boy wannabe. I wonder if his abilities to dodge and avoid any trace of human connectivity are conscious, Machiavellian manipulations, if he's just that out of it, or if he really believes that this is how he should perform his job.

I keep thinking, if not for the media, manifest in Ryan's diabolic form, desperately attempting to hock glam and trite quips, we could have a chance to see colleagues celebrating, catching up, relating. Then, a real opportunity for a human scene and empathy stumbles in, in the form of Gary Busey. Busey is an icon. Not just uniquely authentic to himself in life and films like The Buddy Holly Story, Big Wednesday, and even Point Break, but clearly a character and person with complexity, history, etc. Busey yells something across to Seacrest like "I'll catch you later." A bit brash, but in character. Then Seacrest takes the opportunity to introduce Busey to an unprepared Jennifer Garner, a little awkward, but not catastrophic. Busey, a big guy, leans in and gives her a kiss, and she appears a little taken aback. Fair reaction. To that point, I feel like I am getting a glimpse of interpersonal reality in Hollywood. Decent people doing their best to relate in slightly awkward circumstances.

But Ryan Seacrest has to push it. He channels the regressed, narcissistic dad at Thanksgiving, who pits his fully grown sons in dinner conversation battle; so he can reclaim his lost paternal crown. Again, who knows what he said exactly, but along the lines of " Whoa! What happened there?! Did you see her reaction to Busey?! That was crazy!" It's the money-shot of every low-key satanic depiction, tittering while goading mere mortals into reactionary rallies.

Why the simplistic scape-goating of an accomplished and clearly complex actor and man? Is it what the people want, what the viewing public craves? I doubt it. I used to get off on the train-wreck aesthetic of failing stand-up comics and even the early montages of first-round American Idol, but it is just so toxic. In his book Anger , Buddhist monk and writer Thich Nhat Hanh points out the notion of poison in, poison out. Toxic food and bilious thoughts can only perpetuate bile. To that end, I think the viewer just gets queasier the more junk he ingests. So, is it that Ryan Seacrest has nothing else to offer, desperately pitching his gen-Y vaudeville banter? Doubtful. Everyone has more to offer, to communicate, to discover, if they take some chances and push it. I figure the diabolic link must have to do with idle hands and ingrained, maladaptive neurotic behaviors on a societal level. Exploitation of trite dynamic ruts works. People buy into scape-goating, under-bus-throwing, calling an awkward guy "crazy." It gratifies, gets the ball in the cup. But is that really the height of the bar?

Ok, Ryan Seacrest is probably not actually the Devil. But maybe the closest thing is epic passivity and sins of omission, lost opportunities and bad vibes at the hands of lowered expectations and cheap thrills. GD

Empathy Within Reach

Greg Dillon — Mon, 25 Feb 2008 10:45:10 -0800

Design Within Reach haunts me. Not in a scary way, more ruminations. Where did it come from, what does it all mean, and, more importantly, why do I find myself strangely attracted to it?

With brick and mortar representation gaining on Starbucks, some suggest that DWR is the new Pottery Barn. Clearly a different vibe, as PB seems to be about New England Farm/Nantuckett nesting, whereas DWR is all mid-century mod and Italian gloss, lending to anonymity and clean escapes. One argument for the shift could be that we are getting less comfortable nesting, easing into overstuffed feather couches with stuffy Brit names. Maybe the modern metropole wants hard, clean surfaces that won't hold a trace of his comings and goings.

What plagues me is: "Within Reach of what?" The initial go to would be within financial reach, affordability. But, unless you make seven figures and can blow $10K on a set of six dining chairs, that seems off. Within reach of easy delivery? Sure there are zillions of stores, three on my block alone, but, as everything requires four to eight weeks for delivery anyway, also not the point.

So what is Within Reach for me? I figure there are two levels. One is Within Reach of my aesthetic comprehension. It's like taking an introductory wine tasting class. I get it. Pinots are dark and complex and could go with rare meat. The DWR catalog or site gives me a gallery grad shot of the piece, a black and white head shot of the designer, and a MOMA-like write-up. I can contextualize and own that piece of history. That is pretty cool, but risks dying on the shelf. I own a Mies day bed...big freaking deal. However, level two is more dynamic, Within Reach of my engagement. If rather then just owning the frozen, lifeless commodity, Mies day bed, I engage in the intellectual history, an aesthetic understanding, a psychological attachment, and a sensual feeling for said Mies day bed, I am reveling in a dyad of me and Mies day bed, engaging in a multi-leveled relationship, both with day bed, and parts of me that Mies day bed, object and construct, awaken.

So, that's resonance. If a string is plucked on a Gibson dreadnought, it echoes in the resonator (the guitar box part), which then sends that frequency back to the string, causing it to continue vibrating at that wavelength or pitch, all in a glorious feedback loop. DWR picks a handful of pieces that are a stretch, but within reach of what I can relate to, understand, empathize with. That stretch or gap, unlike Pottery Barn's fluffy, nostalgic, comfort, gets me wired to engage in a process of engaging and understanding what such a piece of furniture could mean to be. That said, once the process stops, it's all just chairs and couches. GD

Sterile Drapes

Greg Dillon — Mon, 25 Feb 2008 10:42:00 -0800

When I was a resident, training to become a plastic/reconstructive surgeon, friends were often freaked. "Jesus! How can you cut into someone like that. That is crazy messed up!" And while it admittedly tweaked a nerve to cut into a recognizable and sensitive spot like a an eye lid or a child's cleft lip, I always answered them, "It's all about the drapes."

Surgical draping, the squaring off of the minimal exposure necessary for adequate access to the surgical field, defines the difference between cutting or carving into someone and performing surgery, a detached set of technical maneuvers. Once a field is draped out with bright blue paper and green sheets, and the skin painted a deep, faux-tan-bronze with betadine, the act of cutting is transformed into a circumscribed procedure. Rarely, I experienced the shock of actually cutting or sewing up a person's flesh, stitching hand lacerations from a punched out window in the ER, or excising a questionable mole with local anesthetic. But focus on the draped-out field mixed with the single-mindedness and heavily valued efficiency of the surgeon made it easy to bypass the messy humanity.

There's a longer story between, but now I am a psychiatrist in New York, and the messiness of drives, motivations, and fears should be much harder to manage than the surgical field. On my better days in my private practice or working at my affiliated hospital, I visualize myself rolling up my sleeves, even my pants, to get in waist deep. Diagnosis, at least by-the-book diagnosis has become fairly easy and simplistic, checklists of five out of nine symptoms earn you a name for what ails you. But I and most of my colleagues prefer to get into how individuals feel about what ails them, how they deal with it, ways to both manage and sit with their fears, how to listen and be understood.

Though I am still youngish and greenish in the field, I had started to fancy myself as flexible, balanced, even a bit Zen, able to shift sets, metaphors, models of the mind to keep pace with my patients, and, mostly, to empathize and remain fluid, present. But then Tarloff happened.

I realize I just said "Tarloff happened", as if it were 9/11 or Hiroshima, and in a way, for therapists, it was. Unfathomable. Unspeakable. Terrifying. On my way back from a blissful surf escape to Costa Rica, a friend and colleague e-mailed me. "We should talk about Tarloff." At first glance, I mistook this for the classic Tarasov case that premised a psychiatrist's "duty to warn" exception to confidentiality, should he/she suspect a risk of threat or violence. But, when I googled it at JFK, I got the gruesome facts. David Tarloff, a man with a possible diagnosis of bipolar disorder, but, more importantly a complex history of rage, impulsivity, frustration, and resentment, reportedly went to rob his psychiatrist, stalked him from the Dr's office basement, then brutally murdered a bystanding therapist, the elder Dr's colleague, and slashed the psychiatrist as that Dr. attempted to intervene following the murder. As a case, it is a horror story.

I remembered John Hersey's Hiroshima, and his description of a victim's flesh slipping off his hand like a glove as another attempts to rescue him. So horrifying, to a near mythic extent, that it becomes circumscribed, engendered as gore and myth, a little out of reach of the human experience. My first reaction to the Tarloff piece in the Times is similar. In the age of media-commodified tragedy, this is pure horror. "Did you hear the story about the brutally murdered therapist?"

But as I read the details, "East 79th Street", that's near my hospital and my old neighborhood, "psychiatrist in his 70's in private practice", he could have been one of my mentors or a colleague and friend, it works it's way under my skin. I share an office with colleagues. We all have patients with angers, fears, resentments, impulses. We all have off days. And we all impact our patients' thoughts and feelings, sometimes more than we realize.

One of the psychiatrist's best defenses is what I have been describing above as a sense of flexibility, self-knowledge, the impetus for a thorough analysis as requisite for a practicing analyst. The hedged defense at the other tail of the spectrum is "we can only do so much." These are both valid and often true, but they are also our surgical drapes. We try to get in deep, to not simply intellectually understand our patients and their lives, but to feel something of what they feel to understand on a deeper level. But we also have to block out a clean, safe space, maintain a toe-hold, save a little bit of our selves for the long haul. A situation like the Tarloff scenario rips off those sterile drapes, shatters a sense of safety and, leaves us uncertain, vulnerable, and afraid.

What to do with that? I find with most traumas that cut to my most vulnerable core, I hit a three-way cross-roads. React, withdraw, or just slow down. Mostly, if I can do the third, I feel like I am moving forward in understanding and empathizing, and the first two are not so necessary. GD