Category Archives: change

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Integrated behavioral health

The buzzwords now in Family Medicine. Integrated behavioral health in primary care. I am finding it a bit annoying.

Integrated does not mean race in this context. It just means the clinic should have a behavioral health person.

I suppose that is a good idea maybe, or might seem like one. But what do they think I have been doing for thirty years? Ignoring behavioral health?

Really, primary care is half or more behavioral health, if a primary care doctor gives people time and pays attention. People have an average of 8 colds a year. Why do they come in for cold number 4 if it is no worse than all the others? Because the cold in not really why they are coming in. The cold is the excuse. Notice that the person is there, that they are not that sick, that they do not care that you are not going to prescribe antibiotics.

I have my hand reaching for the door when an older patient says, “May I ask you something?” She came in for something that she didn’t seem to care about, so I am not surprised. I turn back. “Yes.”

“I have friends, in another state. They had a baby. The baby is very disabled.”

I sit down. This is more than 15 years ago, so I do not remember what the baby had. Hydrocephalus. Cerebral palsy. Something that requires multiple doctors and physical therapy and the parents are grieving.

“What bothers me most is that they have to struggle so much for services. There is very little support and very little money set aside. One of the parents has quit their job. It is a full time job taking care of this child and they are frightened about the future. Is this really what it’s like?”

And that is the real reason for the visit. “Yes,” I say. “It can be very difficult to access services, you have to track down the best people in your area, some physicians won’t pay much attention and others are wonderful. And the same with physical therapists and everyone else. Tell them to find some of the other parents of these children. Get them to recommend people. And the parents have to be sure to take care of themselves and each other.”

She frowns. “It’s a nightmare. Their life completely changed from what they thought. First baby. And it is overwhelming.”

“I am sorry. You are welcome to come back and ask me questions or just talk.”

“Thank you. I might.”

“Do you need a counselor?”

“No, I’m fine. I am just worried about them and feel helpless.”

“It sounds like staying in touch is the best thing you can do.”

“Ok.”

The true reason for the visit is often something entirely different from what the schedule says. Sometimes people are there without even knowing why they came in. “Can I ask a question?” That is key. Saying to see people for one thing is criminal and terrible medicine and makes behavioral health worse. There is so much we can do in primary care just by listening for these questions and making time for them.

I have nothing against adding a behavioral health person to the clinic. They talked about “embedding” a behavioral health person in each group of soldiers back in 2010, when I worked at Madigan Army Hospital for three months. I always pictured digging a hole in my clinic floor, capturing a counselor, and then cementing them in the hole. I would have to feed them, though. I always thought that was sort of a barrier. One more mouth to feed. I found it more useful to contact counselors, ask what they wanted to work with, learn who knew addiction medicine, learn who was good with children or families or trauma. And ask patients to tell me who they liked and why. I integrated behavioral health in my community, not just in my clinic, because there is no one counselor who is right for everyone.

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The happiest day of his life

When I was a preteen, I got my first Spiderman comic book. I was enthralled. A hero who had powers, but had a grandmother, responsibilities, made mistakes, felt guilt and confusion. I wanted this, not the princess crap. I did not want a prince to ride in and carry me off. I did not and don’t trust princes. The wedding being the happiest day of a woman’s life: what the hell? Is it the happiest day of the man’s life? If not why not? It’s important to the woman to be married to her love but not the man?

And anyhow, the Disney movies were very consistent. There were no good Disney Queens. The good ones died in childbirth, or were absent, or their ship went down. The stepmothers were evil. The princess career ended with marriage. Pregnancy either kills you or turns you evil. Actually, sex turns you evil if you are a female. That was the very clear Disney message judging by the animated features. Virgin girls are pure princesses but there are no adult female role models for years and years and years. By my preteens I wanted to drive my own wagon: I was not going to be taken care of, controlled, or left poor and with small children through divorce. I would have a career and children.

What IS the happiest day of a man’s life? Do we have any map of that? When they are promoted? When they buy twitter? When they are elected President? When they get married? Why do we have a happiest day for women (and is it the marriage or the sex?) but not for men?

In the romance novels, the man is usually older, “experienced”, rich, and has a reputation for seducing women. The woman is often a virgin, or she has a child because there was an evil man who she thought loved her, or the older man got her pregnant and she never told him. She knows it is true love because she is pure and yet is overcome by lust, so it must be true love. Snort. I have always thought this is stupid and silly. So men in the novels are experienced, have sex with lots of women, and then are carried away by lust that turns out to be true love with this woman? What about all the others? Did they think it was true love too? Or were they “bad” women, who had lust without true love? Impure, not virgins, not a “good” girl. Seems pretty confusing to me. Often the virgin gets pregnant because, hey, she is carried away by uncontrollable love, so of course she would not think about birth control. What is the experienced man thinking? Hey, let’s get this one pregnant, I’d like to pay child support? Oh, he’s carried away by uncontrollable love, but really now, you’d think after all that experience that he would use birth control. Apparently the rich experienced older seducer males are all morons when struck in the heart by true love. These books should be burned, really.

Anyhow, I was suspicious of the princess story and I wanted my own horse and armor and sword and I’ll fight my own dragons, thank you! I was much more interested in the super hero story, even though the superheroines were still pretty lame and likely to get killed off. Oh, and girlfriends get killed off. Gwen dying from fear during a fall: give me a break. Yuk. Made me glad she was dead if she was that much of a weakling. At least she couldn’t reproduce. I liked Mary Jane a whole lot more: feisty.

I wanted to be a superhero and still human, not a princess.

So what is the happiest day of a man’s life?

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The cat is Boa, not Sol Duc. Boa died at age 17 right before Covid-19 started.

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Which?

For a long time I think I am a werewolf, but I am not controlled by the moon. But I can get angry. And then I remember this poem and think “Not a werewolf. An ogre.”

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Butterfly Girl Comes to Visit

She is so beautiful with her wings
multicolored many splendored lights caught and multiplied
as she flutters

I freeze
I am an ogre
Huge and clumsy
I know from past past many times
Not to touch you
My rough fingers have brushed the tiny feathers from your wings
You cry in pain and your flight becomes erratic
My kiss is just as bad
Rough lips
If I move the wind of my passing blows you against a window
You fall stunned

I hold and crush
the box of feelings that can hurt you
Sorrow, anger, fear, dismay
Even fatigue turns my aura red
And scorches your wings

I hate to cause you pain

Fly butterfly girl
My baby needs me, my pager rings
My ogre husband stirs
The effort of holding still plain on his face
I can’t hold still much longer

Butterfly girl
Fly on home

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defiance

I am listening to the Offspring today. Because I have a friend who is not behaving like a friend.

It is what people do that matters, not what they say. They can say they are my friend all they want, but if they treat me badly, I will walk.

The Offspring are fabulous for defiance. Though I need to change the genders on this one.

And not only that: they are fighting opioid overdoses and death:

Bravo, Offspring. Blessings and peace you.

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silence

You are silent.

I try a little more but I am tired. I am tired of drama, trauma drama. I dream and dream and dream. I dream that my ex touches a live bat. The bat changes in my dream, from a tiny brown nose bat to a huge fox bat with fur and stripes. It is unconscious.

“Don’t touch it! You touched it! Now we have to take it to the Health Department!” I am eyeing the bat and thinking of throwing something over it. A container. It’s huge.

My ex laughs. “No we don’t.”

“Yes we do! Rabies! It could have rabies! If we don’t take it in, you’ll need rabies shots!” Poor bat, I think, it will be killed to test for rabies.

My ex keeps laughing. “I’m not going to be tested, I won’t have shots, and the bat is fine!”

“WHAT!” I say, “No, you could die!”

I wake up. What was that dream about? Oh. It’s about you, refusing to test for Covid after being exposed. You said you would hike with me. “Not if you won’t test,” I say, “I can’t afford to get Covid again, I can’t be around you for 15 days if you won’t test.”

And you go silent.

And I try a little more and I let go. You will have to break the silence if you plan to keep your promises. Will you or won’t you? I am supposed to trust you. But people say trust me, and then sometimes they are drunk, and lying, and you can’t trust them. “I will never hurt you,” is a lie. Try this instead: “I will try not to hurt you and I will listen if you feel hurt.” And change, maybe?

Maybe.

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Dreams are funny. Fox bats ARE the largest bats in the world, but they do not have stripes: https://allthatsinteresting.com/giant-golden-crowned-flying-fox.

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Embodying a dream

I wrote about the two dreams I had one night, with seven people. Two babies, a boy and a girl. Two professionals, a woman physician and a male policeman. Two rebels, a woman and a man, the man lying or at least misleading the rebel woman. The rebel woman trying to do something that she suddenly realizes is not important and is, in fact, foolish and dangerous. And a quiet woman.

I have been thinking about the quiet woman ever since. My Meyers-Briggs type in medical school came out INTJ, but we are not one thing or another. We have preferences, but we all have to use all the skills. I can be extroverted. I had to work on feeling, that was the really difficult one for me after a frightening childhood. I can pay attention to facts though I sweep them into the intuition very quickly. Medical school is facts and facts and facts, except then there are parts that turn out to change as science changes.

The eighth person is a quiet man. He is not present in the dream. I am thinking about him. I wonder if I will have another dream when I am ready.

I am attending some workshops on line for treating trauma. It is quite fascinating. They talk about working with clients who have aspects like my dream: a small child with trauma. A “fake adult”, aka “adaptive child”, with the tools that the child develops to survive in their childhood. Helping the “fake adult” recognize that some of coping tools may not be helpful or necessary any longer. First, they thank the “fake adult”, for protecting the traumatized child and for surviving at all and for not giving up. I think this is so important, to acknowledge that we have to thank that part of ourselves that did what it had to, that did what it could, to survive. And this can include things that we are ashamed of or fear that others would hate us for if found out. We had a temporary doctor at the hospital who described being a boat person escaping Vietnam at age 8. They were picked up by pirates. “We were glad to see the pirates, because we had run out of water. If the pirates had not picked us up, we would have died.” So there is perspective: death by dehydration or pirates? And she went from a refugee camp and then through medical school and became a physician. Survival and success and I hope that she is thriving.

I like it when a dream has such recognizable symbols. My now retired Unitarian Universalist minister says that we can sit with dreams for a time. What do the symbols mean to me? What is the dream telling me? My dream is in part telling me that I do not need to have the rebel woman lead: she can rest and let the quiet woman take over. And that I am very tired of rebel men who mislead me or run away. I woke up and thought, oh, yes, I see! I am tired of that and ready for change.

Change and transformation can happen throughout our lives, at any age. I welcome it.

Blessings and peace you.

___________________

The photograph is Sol Duc and Elwha enjoying doll bunkbeds. And acting like siblings do sometimes. And then they curl up together.