Cognitive behavioral therapy

Dr. Aaron Beck, father of cognitive behavioral therapy, died this week, November 2021, at age 100.

Oddly enough, the best explanations of cognitive behavioral therapy that I’ve read is on a writing website. It talks about writing down all of the horrible thoughts and then going back and writing counter thoughts. Psychologists have been talking at me at medical conferences for years about cognitive behavioral therapy, but they never explained it. They said we could do it in clinic. I thought cynically that maybe I could if I knew what the hell it was.

And the explanation by the author is oddly similar to what I think of as the angel and devil on my shoulders. It turns out that I do do it in clinic.

When I react to some event, I let the devil out first. It has a fit about whatever is happening, writes poems, is reactive, paranoid and full of anger and grief. It often imagines over the top terrible things happening to the person or people that did whatever it is. Then the angel wakes up and says, wait. What are you saying? What you are imagining and cursing that person with is WAY worse then what they did. The angel writes the poems of forgiveness.

So I have been doing a homemade form of cognitive behavioral therapy.

However, I would say that it can be overused. We need to listen to patients carefully. If they are in an abusive relationship, it should not be papered over with cognitive behavioral therapy. A friend and I have been comparing terrible childhoods. His involved being beaten without reason.

I said recently that what people hit with in my family is words. They make grief and fear into stories, funny stories, that make people laugh. Shame and humiliation and reliving the feelings. I said that I am reactive and pay close attention to words. But I have reason, back to age 2. I said that books are my refuge because the words are not about me, they don’t shame me, they do not humiliate me, and if I read a book twice, it has the same words. Home, love and safe.

In my maternal family, if I said that I was not comfortable with a comment, I was told that I took things too seriously, that I have no sense of humor, that I can’t take a joke. Gaslight and then dismiss any objection. That is how one side of my family loves. I do not like it. Unsurprisingly, they do not love me, or at least I do not feel loved.

And my friend said, your family, your childhood, was worse than mine.

One of my talents in clinic is that I can listen to insane family stories. I can listen because my family is insane. They are cruel. At least, it feels like cruelty and horror to me. I didn’t ever try to find out if a family story is true. I listen and then say, yes. I think it is appropriate for you to feel angry/sad/horrified/appalled/scared/hurt/whatever.

Somehow that listening and validation is huge. I have people come in and say, “I NEED AN ANTIDEPRESSANT.” They want to supress the feelings. So I had time in my clinic: why do you need an antidepressant? Tell me the story. Fill me in. What are you feeling and why?

And more than half the time after the story, after validation, I ask, “Do you need an antidepressant?”

The person thinks. “No. I don’t think so. Let me think about it. I feel better.”

“Ok. Do you want to schedule a follow up?”

Half do. Half say: “No, let me wait and see. I will if I need it.”

Mostly they don’t need it. They have emptied out the awful feelings in the exam room and they aren’t so awful after all. I say that it sounds like a pretty normal response and I would feel that way too. Because I would. Once the feelings, the monstrous feelings, are in the light of day, they relax and evaporate, dissipate like mist, fly home to the Beloved. Goodbye, dark feelings. You are appropriate and you are loved.

Blessings, Dr. Beck, and thank you.

guns in the house

During wellness visits I used to ask, “Do you have guns in the house?” in the safety/accident prevention part of the visit. Along with helmets, seat belts, smoke alarms and not driving under the influence.

As a Family Practice Board Certified Physician, I counsel patients. Family Practice is a specialty, just as internal medicine and general surgeon are specialties. A three year residency training after medical school and I retake the Boards every 10 years. I counsel patients in “annual exams” or “medicare wellness” visits.

A patient reported me to the state board because of that question. I then got a letter from the state board saying that I was being investigated but not why. Later I got a letter saying that the patient had complained that I had asked about guns. The state replied that in fact, I am supposed to counsel patients about gun safety.

I changed my counseling. Now I say: “If you have guns in the house, I am to counsel you to keep them locked up with the ammunition locked up separately.”

I get three responses:

1. “My guns are in a gun safe, locked at all times, with the ammunition locked.”

2. “I don’t have any guns!”

3. Silence.

It is the silent ones that worry me.

I did not change my counseling because I was reported to the state and the state did not tell me to change it. I changed it in hope that someone who keeps their guns unlocked and loaded, in the bedside table, under their pillow, up in a closet, or where ever, will think about it. The question “Do you have guns in the house?” is too loaded for those people.

I met a woman with an impressive star shaped radiating scar on her chest. Her boyfriend kept a loaded gun under his pillow. One night she was returning from the bathroom. He shot her in the chest.

They are not together any more.

When my son went to preschool, over 20 years ago, I counseled him. “If another child says they can show you a gun or they have a gun, say that you have to go to the bathroom. Go and tell an adult right away. People can get killed.”

He reported an overheard conversation in preschool between two other boys. One said that he knew where his parents kept a gun. The two boys were planning to leave the school to go look at the gun. I called the preschool. They already knew about it and had talked to both boys’ parents. I don’t know if the parents locked the guns up.

In Portland one of my neighbors chased his upstairs neighbor into the street one day during rush hour, stark naked, trying to hit the upstairs neighber with a 5 iron. Yes, a golf club. I am very glad the downstairs neighbor did not have a gun right then, because he would have used it. Any of us could have been killed. And later the SWAT team was called to deal with him: he did have a gun that time. He threatened to shoot himself in the head. Then he did: well, except he only creased himself. He went to involuntary psychiatry, supposedly for six months. He was back in three months. The neighborhood was very very nervous. The house next door was sold and he disappeared and we were all relieved. He was strong, completely illogical and terrifying. We discussed how to deal with him but mostly we hid.

When he chased the neighbor into the street, I had already called 911 because I heard screaming next door. My voice shook. The dispatcher said, “Yes, we know the address, we’ve had three calls and they are on their way.” The traffic stopped dead at the sight of a nude man chasing another man with a 5 iron. I unbolted my door and stuck my head out. “(C—-)! Up here!” The upstairs neighbor ran up my steps and into my house. I slammed the door and bolted it and crouched by the front window with a baseball bat, ready to hit the downstairs neighbor as hard as I could if he came through my front window.

He didn’t. The police arrived. The whole thing was over the upstairs neighbor “playing music too loud” and “not turning it down enough”. The downstairs neighbor had broken down the upstairs neighbor’s door with the five iron. The upstairs neighbor had tried to defend himself with a butter knife and then ran. The police explained to the downstairs neighbor as he was arrested that if someone breaks your door down, it is not assault to defend yourself with a butter knife.

We discussed which illegal drugs we thought he was on. This was in the 1990s, so we thought it was crack. There was a big article soon after that about a crack house. We said, whew, glad we aren’t those neighbors and then realized that it was within two blocks of our house. Great.

Drugs and alcohol and guns and anger and grief….. it is a toxic mix.

Please, lock your guns.