Friday, November 8, 2013

Smoking cigarettes as a means to do away with others and self

A man in his early Fifties who lives an isolated personal life, though gregarious when he goes to local stores or is siting in doctor's' office lounge or in other public places, treats his two cats as his family, reported that since he quit smoking he is having visual images of killing himself.

So the smoking was preventing his suicidal thoughts to emerge in his consciousness. For an impulse to turn into action it must first makes it way to consciousness - there are of course exceptions - and this was being blocked by lighting up of the cigarette. The pleasure that ensued from filling his lungs with warm smoke blanketed out the dysphoric destructive thoughts.

But before we go some more into the metapsychology of this defense, let us examine a little of his life history.
The patient's parents were old fashioned 'Church of Christ' followers from the South, who had migrated to Detroit when he was 9. The family culture was to quote the Bible frequently and to punish readily if  the children deviated from the straight and narrow. This made the core of his heart God-fearing. Though in his late teens and early twenties he lived recklessly and indulged head over heels in wine, women and songs with nary a thought of the afterlife.
He had a stormy Oedipal Phase, emerging out of it with typical death wishes towards the parents, stronger towards the father than the mother, consistent with Positive Oedipus Complex.  These death wishes were further accentuated during the Latency Period, because he faulted his parents for giving him his slight built - he is otherwise a good looking man - and his Southern manners, both of which invoked bullying from kids in school.

When he first began driving he had a horrible car accident which killed one of his buddies and left  another paralyzed from waist downwards. There were four teenagers in the car. His girl friend and he were in the back seat. A friend of his was visiting them from the South and was on the front passenger side. As a joke this Southern boy started making racial comments  to a Black man who was driving alongside. The man pulled out a gun and came after them, causing them to take off at a dangerous speed. While trying to escape through a dirt road, the car careened out of control, flipping multiple times, leaving the visitor from the South dead and the driver paralyzed. The patient and his girl friend escaped with minor injuries. 

His sense of guilt was markedly accentuated by this event and his death wishes had worsened. There also was now a tremendous need to repeat the trauma of the accident. It was a typical "Repetition Compulsion" to a devastating Traumatic Neurosis.

These death wishes and the guilt that followed  now shaped all his conduct. His life mostly became the game of getting into aggressive stances with people on the slightest provocation and then profusely apologizing to them for not behaving like a 'Christian'. He became a massive people-pleaser to cover up his death wishes towards everybody he came across. In his dreams, he was forever doing away with people, even committing mass murders, and in brutal fashion, recreating the bloody scene of the car accident, sometimes directly sometimes in displacement. His people-pleasing ways of praising whoever he came across, being kind and helpful to one and all, were of course every now and then punctuated by threatening to fight with them. He was very sensitive to being taken for granted, slighted or mistaken for a sissy when he was trying to appease people.

His adolescence and early twenties was marked by the emergence of a remarkable talent in singing. He formed his own band, which was highly successful, and for a while it looked like he would be a rock star. He had a big following, slept with innumerable women, and lived as if there was no tomorrow. 

During this music phase of his life he took a break for 2 years to join the Navy. He was shipped out to Middle East and was assigned for most of his stay there in the war torn Lebanon. Here he witnessed more turmoil and bloodshed, which, while stressful, also satisfied his urge to re-witness and abreact the trauma of the auto-accident.

His career, however, in the army did not last long. For he always felt restless in it, with an urge to be doing something else and finally checked himself out of it feeling like a failure.

He returned and formed another band. And once again just as he began to get successful with his music, disbanded it, cheated upon his wife which destroyed his marriage, and became a loner.

These failures, which were unconsciously engineered by him, and were as a punishment for his death wishes, caused him tremendous unconscious rage at the unfairness of it all. And this rage found an outlet in excruciating headaches. His whole life now centered around nursing his headaches, imbibing narcotics, alcohol and marijuana for its cure, and getting into oppositional defiant attitude towards authorities.

And he smoked all the time.

Analysis revealed that his smoking too primarily was an outlet for his death wishes. Whenever the death wish emerged  to get even with his parents for his Oedipal grudge, and all others who were the new editions of those original enemies, he would light up a cigarette. And then the warm smoke and the irritation that were generated in his lungs gave him the satisfaction of their burning; as if he was roasting them in hell-fire. Since the warm smoke also destroyed his body there was also the element of his burning with them which served as a self-punishment for the wish.

When he quit smoking these death wishes were no longer finding satisfaction in bodily self-destruction and could emerge undisguised and as plain visual images of killing himself.

He would see himself running in to one of his swords - he had more than 30 of them, along with all other quaint weapons of destruction - or taking a long needle and sticking it through the rib cage straight into the heart. A method of suicide that would puncture his heart and cause instantaneous death and spare him from pain. He declared only the fear of going to hell - for God forbids suicide - and the fear as to who will take care of his cats prevented him from doing the deed. 

When the interpretation was made that these imagery of suicide were punishment for death wishes against his parents, the patient pooh-poohed it on grounds that his father was already dead, and he loves and respects his mother more than anybody else in the world, so for him to harbor such a thought towards her was ridiculous.

But then immediately proceeded to confirm the correctness of the interpretation by recalling that the other day somebody in the grocery store knocked his mother with the cart, and he was so furious at that person's callousness that he went up to him and demanded that he apologize to his mother otherwise we are both going to jail. He could not directly see his own destructive impulses towards his mother but could see it in the action of others. 
I even suspect that when people light up a cigarette, it is because some frustration has occurred in the present, or memory of some frustration in the past has been stirred up in the present, and the need to burn the person or the circumstance that is causing the frustration, impels one to do so. The blowing out of the smoke is in a way blowing away the person who has caused one pain in to oblivion. This blowing away is not unlike how one clears one's throat or indulges in a hacking cough to mentally get rid of somebody of whom one wants no part of.

Cigarette smoking is amply suited to do away with one's enemies. It is quick, it does not cause any immediate pain, the warmth of the smoke gives one pleasure that overrides the pain of the memory, and the action of blowing away the hated person is visible as the emerging smoke, and it makes one feel masculine and in control.

The tendency in some cultures  - which strongly prohibit aggression against others - to indulge in self-immolation when they cannot destroy their enemy appears to be governed by the same mental mechanism.  While burning themselves they are also burning the hated enemy with whom they identify. The psychology of anorexia nervosa is also identical. The girl does not eat - as a reaction to the feeling that she was inadequately nourished by her mother - and sees the fat in herself as a symbol of her mother, and destroys herself and the hated mother (through identification with her) by getting rid of every piece of fat and then every other piece of herself by not eating.

Another patient of mine, who incidentally is the childhood friend of the person whose case history we are using to illustrate here the motive behind smoking, and was his "roadie" during their glory days, after reading this blog, remarked that the psychology of bulimia can be explained on same line. Here the ambivalently loved person is eaten to incorporate into oneself and then spit out as a mark of its rejection.

I remarked to him that perhaps the phrase to chew them alive and spit them out expresses this concept in its visual concrete form. 

Wednesday, October 30, 2013

A recurrent dream of castration

A man in his mid thirties, who suffers from paranoid illness, is single, still lives with his mother, her only child, reported that for the last two weeks he is troubled with a dream that won't leave him alone.

I feel there is a baby on my back, like a backpack. I feel responsible for it and have to worry about its safety. I want to do things but cannot because of the burden.  My dreams which use to be full of adventures now are cut short because I have to worry about the baby coming to harm. 
When I wake out of the dream I find my head hard pressed against the pillow. 
Initially the only association the patient could come up with was that the backpack reminds him of going to school.  But that association led to no where. And soon we drifted into his usual paranoid complaints about neighbors keeping a watch on him and how he cannot get away with any transgression no matter how minute.
"Every time I have sex with a woman I get in to trouble. It is not like I am having sex with married women. But neighbors look at me as if I am trying to have sex with their wives. If I just wear a different style of cloth they start wondering if I am up to something. Recently I was hired by a lady to drive with her to New York to help her load some mattresses for her business, and while I was eating at the White Castle she was watching me as if I was wolfing down my food.  If I exercise in my backyard my neighbors come to their windows and stare at me. Even my mother doubts my abilities. She tells me that I am a dreamer. But so was Martin Luther King. My mother accuses me of doing nothing that has any practical value and for earning no money. But hardly out of school I became a connoisseur of classic cars and flipped a couple at a profit. I have a collection of old comic books which one day will fetch me a neat sum."

By expressing to me all these persecutory thoughts and feelings, which his mind is constantly conjuring and no doubt to keep a lid (inhibition) upon his taking chances with the world - even his ability to free associate -  undid the repression partially, and the patient now could come up with the following association, "I read, or perhaps saw on TV, that if you see a child in a dream it is yourself."

This immediately solved the riddle of who the child represented. And I asked him, "Behind the facade of protecting the child is it yourself that you are protecting?"

"That makes sense. But why I am protecting myself through creating a double of me as that child instead of protecting myself directly?"

"Because when the fear of harm coming to oneself is overbearing, the mind plays a trick to lessen its impact. It starts worrying about somebody else who if harmed will cause one even greater pain. This way one's fear for one's safety is lessened. The focus shifts to somebody else getting harmed instead of oneself. This reduces the autonomic and other physiological responses that are triggered if one is anticipating danger. For the harm coming to somebody else, even if to somebody very close to oneself like one's child, still does not pose as much terror as harm happening to oneself. Or at least does not mobilize body's physiological responses to the same degree. The body does not have to activate the cascade of stress factors to protect oneself, because the injury is going to happen to somebody else. It is a very important defense: shifting worry from one's own person to worry for one's child's, or a spouse, or a favorite nephew or the federal deficit or the future of mankind or the disappearing rain forests, or the global warming.

"Since in real life you do not have a child, in fact you do not have anybody close to you who you really care for, you are working out your fear of some harm happening to you by creating an imaginary child who you must protect. And since you deny your fears in daytime, and in fact do not feel much emotions when you feel threatened by your neighbors, for that matter the world in general, for you experience the world as a hostile place, these fears emerge in the night when you are sleeping and you try to work them out of your system in your dreams.

"But why did this dream start just two weeks ago?"

"Because for the last two weeks I am struggling with a bad crook in my neck?" the patient replied

"Crook in your neck? What in the world is that?"

"I don't know what you call it. But us black people call it crook in the neck when we sleep badly and wake up with our neck stiff and hurting. Generally it clears up in a day or two. But this one has been a bugger and has persisted for two weeks."

This explained the immediate cause of the dream. The pain in the neck was disturbing the sleep and the patient who is always anticipating grave harm because of his paranoia had raised its significance to that of a mortal danger. This was consistent with how he experiences the world: a dangerous place. The need to do something about "this impending catastrophe - the crook in the neck" would have woken him out of sleep. But to protect the sleep - for him to continue sleeping - the brain mechanisms responsible for dreaming generated the dream. And the dream, by showing that the mortal danger was not coming to him but to his dream child, lessened the overbearing emotion of fear which otherwise would have woken him out of sleep.

"Why is your head getting buried into the pillow?"

Patient countered it by stating that the dream was in color. Now we know that if the dream is  vivid, feels very real, is in color, it symbolizes intensity and it is reflection of the intensity of the wishes/desires that are invoking the dream. Many scenarios of wish fulfillment have been condensed in to one. Not unlike how in some movies the director starts in black and white to portray the emptiness of the lives of the characters, and then, as circumstances change, and the characters meet new people and new sources of pleasure, their lives become multidimensional and full of happenings and the director shifts gears and ratchets it up from black and white to color.

The patient then gave some more associations which hinted that his burying his head in the pillow was trying to retreat from these intense wishes. For intense wishes are often accompanied with heightening of danger. Striving for things invites competition, threats and actual aggression upon one's person. In digging himself into the pillow he was actually retreating from the dangerous world and seeking to hide in its crevices - it was a variation of the fantasy to return to the womb. It was this intense fear too that was perhaps causing him to keep his muscles defensively tight while sleeping, causing "the crook" of his neck.

The correctness of this view was further confirmed when patient said that his dreams are full of adventures, or rather a wish to embark on adventures, which are cut short because "I cannot be involved with dangers and cannot accept daring challenges because I have this burden, this responsibility for the baby."

When asked to give specific examples of adventures which are cut short by the fear of harm coming to the child the patient said, "Like climbing up a mountain or some other steep structure. Or to get out of a tense situation, like being in a small space with so many people around me."

Now we know that climbing symbolizes sexual intercourse. In fact in Hindi the vulgar term for sexual intercourse is a man climbing on a woman akin to mounting in English. Being in a tight spot with so many other people around perhaps symbolized competition with siblings and father over exclusive possession of mother's genital passage. And considering that a little child often symbolizes penis I made the following construction.

"Is it possible that the adventures are symbolic of sexual adventures and the danger is of castration, with the little child being your penis which will come to harm because of it?"

Little child symbolizing penis is a well known psychoanalytic fact - people often refer to their genitals as their little one -  and this kind of conjecture could be made with this particular patient for he has been seeing me for many years and is quite familiar with the concepts of Oedipus Complex, castration, and dream symbols.

To my great surprise patient said, "It is interesting you say that because the child who I am saving always is naked, he has an erect penis, despite his being a baby, and I may as well add that it is over my left shoulder that I look at the child."

This association strengthened  the view that the dream was an attempt on part of the patient to avert castration for forbidden sexual wishes.

I asked the patient why the child had erect penis and he recalled:
"When I was 11 I developed torsion of the testicles. My mother took me to the Children's Hospital. But they did not treat me right away, and sent us home and told us to come another time for there were so many children who had to be treated before me. And my problem could wait. But then a few days later the problem suddenly worsened. I was rushed to the hospital and they did the surgery right away. The White doctor who operated upon me said that the condition had gone so bad that he was about to cut them [testicles] off. He added that the left one looked worse than the right. The White doctor had a serious look on his face as if he really meant what he said. I did not want to lose my manhood. For I knew one could not have kids without the testicles. After that I had dreams of that white doctor cutting of my testicles for quite some time. I also thought that they would have operated upon me when I first went there if I was a white kid. And for them to operate upon me so quickly when we went the second time, I must have bumped off some white kid who was scheduled for surgery that day."

The patient at this point added another element of the dream.

"The child on my back is whiteI was pretty white when I was born. Just like my grandmother."

So the patient's genetically determined excessive castration fear was further worsened by this unfortunate episode when the possibility of castration in hands of a White man almost became a reality. And to defend against it he had taken refuge in the belief that he was not black but white just like his grandmother. If he could turn white then the likelihood of getting castrated would disappear. And so in the dream he was defending himself from the fear of castration by making a double of himself as a white child. And a child who was not just white but who had an erect penis all the time - denial of castration through impudent defiance.

In his next session, a month later, he brought the following dream.

 I am a few streets away from my house playing basketball with my friends, two brothers, who I grew up with and who were nice to me and treated me with respect. Then another kid, a  neighbor of theirs, and I start fighting with each other. It is a martial art fight. The kid's uncle comes out who is blind. He has a white cane with red tip. We stop fighting and apologize to him for fighting like that and I explain to him that I live on Anna street. Then I return home and find that the boy with whom I was fighting had done a break-in and entry in to my mother's house. I call the police and grab hold of the boy. I see the boy wrapped around my hand as a backpack. I feel as if the burden of the boy who was always on my back as a back pack has disappeared for he is now wrapped around my hand.

We will not go in to analysis of the whole dream but only the parts that deal with the baby on the back.

The patient spontaneously associated that the boy who he is fighting with his own self. It is the part of him which he wants to [reject, project out, and] fight with. It is that part of him which if one follows the dream has failed to resolve the Oedipal conflict and is still seeking to find libidinal satisfaction through his mother - the boy with whom I was fighting had done a break in and entry in to my mother's house -and which was at the root of his illness.

Patient claimed that once he had this dream the  recurrent baby-on-the-back stopped. The patient and I agreed that the baby now instead of being a monkey on his back had shifted to getting wrapped around his wrist. So instead of the fear of castration completely controlling his life- sitting like a monkey on his back - it was now wrapped around his hand and thus under greater control.   

Wednesday, October 9, 2013

The humbug of Induction phase in Suboxone (Buprenorphine) Therapy

A shameful chapter of American medicine is the way the doctors authorized to prescribe Suboxone (buprenorphine)  have abused this privilege to financially exploit narcotic addicts. The latter are no match for the doctors. Not only because the balance is so much in favor of the doctor with the prescription pad in his hands, which the addict knows has the power to immediately end  withdrawal symptoms, but years of drug seeking life style leaves them emotionally and cognitively scarred, and they often feel like a thief, unworthy of asking anything of anybody. Finally when you are feeling physically sick from withdrawal you are incapable of negotiating with the doctor on his fees. 
Addicts are one group of patients whom the doctors should not charge more than what they charge their other patients for equivalent amounts of time.
It therefore comes as a surprise that while for their regular patients - who actually may require more medical skill, time, attention, and coordination with other medical personnel - doctors charge anywhere from 35 to 120 dollars, with Suboxone patients they want to charge 400 dollars for the first visit, and anywhere from 100 to 200 dollars for subsequent visits.
At least these were the rates when Suboxone first came to the market. The rates have gone down some since DEA now allows 100 instead of 30 Suboxone patients in one's practice, but, still,  most Suboxone-doctors nevertheless want at least 200 dollars for the first visit, and anywhere from 65 to 150 for return visits.
Also it is not uncommon for Suboxone-doctors to ask for additional monies besides what the insurance pays, which really is illegal.
Why they do it? And what has enabled them to indulge in this kind of highway robbery?
To prescribe Suboxone,  DEA requires special training - it can hardly be called special for it requires all of 8 hours of listening to lectures on a single day - and submission of the proof of having done so. DEA then issues a special unique identification number and voila the Suboxone doctor is born. Does that much of effort deserves charging 400 dollars to the patient and then hundreds more on subsequent visits?
Anyway, without this identification number, which is really the doctor's DEA number with letter X in front of it, the pharmacy does not honor the doctor's order for Suboxone.
It is this number which since only few doctors go through the special training empowers them to charge exorbitantly.
How difficult is that special training?
The training requires eight hours of passive listening to lectures in a one-day conference, delivered usually by two Suboxone specialists, majority of whom I have found to be just the kind who will gouge 400 dollars from some down-and-out kid who does not have a dime to his name, having blown all his money on drugs, and whose medical fees in all likelihood is being paid by a struggling spouse or a beleaguered parent.
Why more doctors don't take this training?
Because doctors like the rest of us are neophobic. If their practice is going good they don't want to get out of their comfort zone and acquire a new skill. But more so because of the prejudice we harbor towards drug addicts as trouble makers. And this contempt and fear of narcotic addicts has some merit. Addicts can be very difficult population to deal with when they are not as much interested in giving up their addiction but in procuring Suboxone to actually support their habit through selling it on the street and using the money to buy their drug of choice.
Yet charging these sick people - yes, some of whom who do indulge in crime, including prostitution, to support their habit, are often liars par excellence and on rare occasions can be hostile and outright assaultive to the doctor when he refuses to give them as much medications as they would like - such high medical fees is unethical.
Why did the DEA place this special training hurdle?
The need for special training to prescribe Suboxone arose because the way Methadone Clinics had degenerated into turning narcotic dependency - from the mildest to the severest - into a life long affair of going to those Clinics.  Anybody who came to them instead of being put on appropriate dose of Methadone which would have been equivalent to what they were abusing were actually put on way higher doses of Methadone than were necessary to prevent withdrawal and then instead of tapering down, believe it or not, the dosages were  ratcheted upwards to make their habit worse. This was the standard modus operandi of these Methadone Clinics and its logic was to make whoever came to the Clinic its permanent client. It may not be too out of the way to add here that many of the Pain Management Clinics also are nothing more than fronts to hook people on narcotics, spinal steroid shots, and other medical shenanigans for life.
So it was to prevent Suboxone treatment turning into another Methadone Clinic fiasco that the DEA, with good intentions, made it compulsory for doctors to get that 8-hour special training before they could prescribe Suboxone, and to restrict the doctor from not having more than 30 Suboxone patient at a time in his practice. The latter of course was placed there for the doctor to not give up his medical practice and become a Suboxone pill mill.
Alas DEA did not succeed! It may not be wrong to mention here that quite a few of these specially trained doctors are doing with Suboxone what the Methadone Clinic entrepreneurs did and still do. They often start patients on three Suboxone a day, 90 tablets at a time, and tell them that they should be at such a high dose for a whole year, before they will be ready for tapering, and thus hook them on Suboxone, which by the way is as addicting as any other opiate.
And finally, after this long introduction we come to the issue of the need for special induction phase in initiating Suboxone treatment.
Much of the mystique of prescribing Suboxone lies in its complex induction phase. Many doctors even after getting that special training and identification number will not take the first step of seeing opiate addicts because they find the induction phase of treatment too complex, confusing and impractical. They are too scared that they will mess up the treatment of the patient by not following the induction phase protocol and thus get in to trouble. And this reasoning is not entirely baseless. Not the fear that they will somehow harm the patient but that they will not be able to adhere to the protocol.
If one reads the drug company's information package insert, one is not supposed to just prescribe Suboxone and tell the patient to not take the first dose of it till the withdrawal symptoms become unbearable, but to have the patient come and sit in your office till you decide that  his withdrawal symptoms have become unbearable and then personally give him the first dose.
And there are further hurdles. The first dose is supposed to be not that of Suboxone - which is a combination of Buprenorphine and Naloxone - but of Subutex - which is Buprenorphine without Naloxone. The rationale is that Naloxone which is an opiate antagonist will worsen the opiate withdrawal. This is a bunch of nonsense. If you instruct the patient to not take the first dose of Suboxone till the withdrawal symptoms become unbearable the Naloxone in the Suboxone hardly has a worsening effect upon the withdrawal.
The guidelines also want the doctor to write the first prescription for just two or three Sabutex tablets and ask the patient to go and get them from the pharmacist. Then the doctor is supposed to assess him hourly or bihourly with a special rating scale called COWS - Clinical Opiate Withdrawal Scale - and only when the rating scale tells the doctor that the patient is in sufficient withdrawal the doctor is supposed to give him the first dose of Subutex. And then the patient is supposed to wait further for the doctor to keep doing the rating scale periodically and decide if he requires more than one Subutex tablet or not. And this assessment shenanigans is supposed to be carried on for the next few days.The guidelines require the patient to come multiple times in the first week for doctor to assess him daily with the rating scale to further fine tune what is the most appropriate dose of Subutex/Suboxone for him - one, two or three. And since it is illegal for the doctor to hold medication in the office that is prescribed for a specific patient, the latter is supposed to go every day to the pharmacist to get his daily supply of two or three Subutex.
 If one wants to avoid sending the patient to the drug store repeatedly, the guideline also gives the doctor the wonderful option to keep a supply of Subutex in the office. An option that given the penchant for American Justice to trap and turn one and all into the category of criminals to expand their business, can land the doctor, if he is not dotting every i and crossing every t in his bookkeeping, in serious trouble.
Does any doctor really follows these guidelines or more importantly is it really possible to follow all these commands in private practice? Are drug addicts capable of complying with this kind of quackery? Do they have the money, resources, gas in their car, if they have a car to begin with, to go daily to the pharmacy and get a fresh round of Subutex? Does their insurance - most of them have Medicaid or are uninsured - covers these Subutex prescriptions? Is it really practical for withdrawing opiate addicts to sit in your waiting room with your regular patients for hours at a stretch without scaring them? Does the mumbo-jumbo of COWS, for that matter any rating scale, really superior to clinical assessment of the patient through observation and common sense questioning by the doctor? Is any drug addict really capable of  coming to your office, get the prescription of Sabutex, take it to the pharmacy, wait there for it to be filled, return to your office, sit there for hours for assessments and then go home, only to repeat the routine the next day? And finally after giving the first dose of Sabutex and making the patient sit in your waiting room and periodically assessing him really tells you much whether the patient requires one, two, or three Suboxone a day?
The answer to all the above questions is a resounding no.
No doctor really follows these guidelines? They do some half-ass going through the motions of them, enough to convince themselves that their charging 400 dollars for the first visit is justified.
Yet these top-down guidelines exist, and turn away many doctors from treating narcotic addiction which has become such a large problem across the nation.
I have been prescribing Suboxone for eight years and must have treated hundreds of narcotic addicts with good results and without practicing any of these complicated rules of Induction Phase of therapy.
All I do is to make a careful clinical assessment of how much opiate the patient was abusing, how severe is his withdrawal, how honest and sincere he is in giving up his habit, and if he is not there to get some Suboxone as a temporary fix because he has run out of money and wants to stave off the withdrawal till he can go back to his drug of choice.
The first visit lasts for 45 minutes if he pays me 110 dollars, or for 30 minutes if he can afford no more than 70 dollars. And through this assessment, which is not corrupted with stupid rating scales - which are made for subnormal doctors who cannot think of medicine in qualitative terms but must turn everything into numbers - I can almost always make out whether the patient requires one, one and one-and-a-half, or two 8-mg. Suboxone tablets a day. Almost 90 percent of the patients fall in to these three categories. Very rare ones require three tablets a day. Patients who are switching from Methadone to Suboxone almost always require three tablets - incidentally of Subutex instead of Suboxone - because they have a very bumpy withdrawal.
I give the patients 7 or 11 or 14, and for very few 21 tablets, for the first week and ask them to come back when that period elapses. I emphasize to them to not take their first dose of Suboxone till their withdrawal becomes unbearable. Most of the patients are not Suboxone naïve, having already taken  Suboxone here and there, obtained from friends or bought on the street, and they know very well how not to take it till the withdrawal symptoms are intense. Their knowledge of their withdrawal symptoms is first hand and much superior to any assessment done by the doctor directly or through his rating scale.
In a week when they return, I reassess their Suboxone need and titrate the dosage up or down. It is rarely that I have to titrate upwards. In my practice there is always a constant pressure to keep ratcheting down the Suboxone, for it is as addicting as any other opiate.
I have never had any failure with this simple approach. It is also not a huge deal if some patient was given 14 tablets for first week when 11 or 7 would have sufficed. Also it is a rare patient who has gotten 7 tablets when 11 or 14 would have been more appropriate. And such a patient always has the option to come a couple of days earlier if he runs out of his Suboxone before the 7 days.
Why if initiation of treatment with Suboxone is so simple have the DEA, the doctors, and other interested parties have made it into such a rocket science?
Because there is always a tendency in humans to make their profession look more complicated - which justifies them charging more money and makes them feel more important than they are - than it is. Also it increases the scope of employment. There is a huge industry to treat narcotic addiction. The government regulators if they can make medical business more complicated and time consuming then their power increases and their department size increases.
Finally this kind of bullshit masquerading as evidence-based science is a significant component of  medicine. The art or science or quackery of medicine is heavily laced with many such useless protocols and  unnecessary regulations. The reason for this is because the payment for much of medical activity is made by third parties. So there is a built in mechanism to make medical treatment as dilatory and nonsensical as one can get away with. When one analyzes these protocols carefully most of the steps present there are useless, if not outright counterproductive, often harming than helping patients.
I remember in 1976, when I started my residency in psychiatry to admit a mental patient through ER would take all of 30 minutes. There was no money in keeping them in the ER. Now on average it takes 17 hours. For everybody and his mother, aunt, and brother are having a go at the patient in the ER in the name of triage and multi-disciplinary approach.  Are these multiple assessments by the clerk, nurse, social worker, ER doctor in the ER have any real meaning in improving patient's psychiatric condition. All they achieve is to exhaust the patient, and his relatives who have to sit through this period of ordeal in the waiting area, without doing any good to him.  But all this has become necessary to generate a stackful of medical notes so they can bill thousands of dollars to the government and private insurances and have documentation to prove it.

Sunday, September 15, 2013

Snake dreams and the phallic competition with the father

A highly gifted artist who draws cartoons as good as any Disney animator but never made commercial  use of his talents because of a fear of failure and has spent his life - he is now in his mid fifties - in a low clerical position because of the job security it offered brought to therapy the following recurrent dream that he claimed has periodically occurred to him all through his life.

Before telling the dream he added that it makes no sense for him to repeatedly dream of an animal that he detests and dreads when he is awake.

There are two snakes one of which is a diamond headed rattle snake the other one is black.

When asked if in all his dreams there are two snakes he said no: sometimes two, sometimes one, sometimes many. The latest dream had two snakes.

Now a long time back I had read in Karl Abraham's writings that snake in the dreams  often symbolize "phallic competition with the father". I had also once analyzed an Indian man's dream of being chased by a five-headed cobra (shesh naag) which on analysis had shown to be a dread of castration in hands of the father - for daring to compete with him and wish for his death - and the five headedness of the cobra was denial of castration - multiplication of the threatened object, so if one is lost there still will be some in reserve.

So my interest in the dream was piqued to see if this one too will prove to be some form of competition with the father.

"Why it is a diamond headed snake?"

"It may have to do with the triangular shape of the snake's head. Also the scales on its body were full of triangles."

Whether the triangles stood for female genitals could not be confirmed. This avenue was explored because of the theoretical consideration that coming across the female genitals during the Oedipal period in the little boy produces the horror of castration for he immediately concludes that it must be the result of punishment meted out for playing with the genitals (masturbating).

"Why is the other snake black?"

"There was actually a black snake that I once saw crossing across our house. I think it is taken from there."

"Is the diamond headed snake your mother and the black snake your father?"

The patient said it could be but gave no further associations that could confirm or reject the construction.

The patient then stated that recently his paranoid illness has taken an upswing. He feels unmarked black cars, with federal agents inside them, are following him whenever he is on the road. 

Now this patient has had bouts of paranoid breakdowns since the age of 34. These paranoid episodes
always begin with unmarked black cars following him. They quickly escalate into auditory hallucinations in which he is berated for being a pervert who indulges in all kinds of bad sexual practices including child molestation. These accusations have little to do with his manifest sexual behavior for his whole sexual expression is limited to masturbation and even this he does not indulge in more than twice a month. A limit which when exceeded results in paranoid constructions where he is constantly watched by federal agents, security guards, spy cameras, and condemnatory voices, all of which occur, along with a rise in the affect of guilt, to prevent him from indulging in masturbation and the associated [incestuous] fantasies.

His first episode of auditory hallucination began when he was dating a girl at the age of 34. He had only dated once before, a decade earlier, which had ended unsuccessfully because he would repeatedly tell the girl that wouldn't she be better off with somebody else. With this second woman the relationship had almost come to the point of getting engaged but then while having lunch with her in a restaurant in company of his brother with whom he is inseparable he had heard the man on the next table say that he (the patient) was fake and incompetent and should tell the girl he was hoping to marry to go and find somebody better than him. Later that evening the three had gone to the movie and the girl had abruptly left the two of them in the theater and had called off the relationship no doubt sensing his pathological sense of inferiority. Patient had concluded that she had walked out of his life to find somebody who had more money than him. Interestingly he is a millionaire despite his humble job because of a shrewd investment in stock market that he had made in the Eighties. The money though does not have any influence upon his daily living where he is frugal and wears very modest raggedly old clothes.

Few months after the breakup, he had a major paranoid breakdown.

The patient recalled in the session that fateful lunch, that first instance of auditory hallucination, the subsequent full blown paranoid schizophrenia, and then returning to the present told me as to how a woman who works with him, and who was acting quite interested in him had asked for a sum of money and on obtaining had become indifferent again.

"Was the dream sparked by this latest rejection?"

"Yes. Since she gave me hope and then disappeared, a repetition of what has happened to me before, I have been having suspicions that my bedroom is bugged, that there are spy cameras throughout the house, that my television can read my intentions, and the security guards from the campus where I work are standing outside my windows."

This had to be interpreted as due to an escalation of his hostility towards the world because of the latest rejection. He was trying to discharge his anger towards women - his mother was very domineering and had always held him back from taking interest in girls -  through sadomasochistic masturbatory fantasies and which were being controlled out of respect for his parents, for the fantasies were primarily directed against them, through creating paranoid structures of being watched by spy cameras, security guards and black cars. 

Patient at this point recalled that the dreams of snakes almost always occur a day or two before going to the confession. He goes there once a month and mostly to get absolved from the guilt of indulging in masturbation.

Patient was then asked if there were any more details to the dream. All he could think of was that the snakes were under his bed and he was deathly afraid of them.

"What exactly were you afraid the snake would do?"

"They will bite me on my penis," the patient replied.

So the snakes symbolized the father who would castrate him. Though the castration was shown not at the phallic level of psychosexual organization. Instead the great fear had caused a massive regression  all the way to the oral phase, where instead of his penis getting cut off by a human father he was quivering with fear over getting bitten by the snakes (the father substitutes). 

Here one recalls how in Little Han's case the castration fear was being worked through by dreading getting bitten by horses and in Wolf Man's case the castration anxiety had shifted to the fear of getting eaten by wolves.


Friday, September 6, 2013

A dream of getting bitten by a snake twice

A woman in her mid-thirties, twice divorced from two abusive marriages, and who despite a great need for love now lives a lonely existence dreamt the following:

Someone is drawing blood from my arm. A black snake with yellow underbelly hanging down from the ceiling bites me on my finger twice. The bites were sharply painful.

Since the patient is very shy and laconic in her descriptions, I knew there was more to the dream than what she was reporting, and if enough encouragement was given would bring up more details and on being coaxed recalled that:

She was sitting in a chair like one does in a clinical lab. Her arm was raised instead of being placed on the hand board, which is peculiar because arm is not kept in that position for blood drawing. The woman who was drawing the blood had short brown hair coming down to the neck.

The dream had occurred 3 weeks ago and the day's residues that had sparked the dream were not readily available. But, eventually, when it was suggested that the woman who was drawing the blood was perhaps she herself - for she has short brown hair which come down to the neck - she countered with, "No those hair are my aunt's. She, my mom and my grandmother came to visit me three weeks ago and the same night I had the dream. My aunt has short brown hair like that."

When asked as to why her aunt is drawing blood, the patient began talking about her grandmother. She declared that the grandmother is quite like her. She too has agoraphobia and like her (the patient) rarely leaves the house. In fact the patient was surprised that she had mustered the courage to ride along with her two daughters and come to the patient's house. She wondered whether behind the façade of aunt it was not her grandmother who was drawing the blood. 

"Why would it be so?"

"Because I look up to my grandmother. She is a feisty one, full of energy and wisdom. So if the blood drawing is happening to cure me, it would be my grandmother who I would want to be my healer."

"And what it is that she is curing you of?"

"You know I work in a dog boarding place. A big Labrador injured me quite badly on my shin. It is painful and has not been healing. Surprising no blood oozed out of the wound when it happened. If it had perhaps the wound would have healed faster. So I must have made my grandmother, behind the figure of my aunt, draw the blood to heal me. "

"Was it your shin pain that was being experienced as the snake bite?"

"Must be. The pain was throbbing in quality and the snake bite occurred in quick succession twice."

"But why did the experience of pain from the shin shifted on to the finger, and as a snake bite?"

"Because my grandmother must complain about everything and find reasons to be paranoid wherever she is. The minute she entered my house she started looking at my backyard where there is overgrown vegetation and started worrying about there being a snake on those lush creepers. So it was my grandmother's bringing up her fear of snakes that sparked the dream."

"Why the snake is black?"

"There is actually a snake that lives in that foliage. Though I have not seen it this year. In fact the foliage at my backyard is so lush and wild because I have stopped going out in to my yard out of fear of running in to that snake. I hate snakes. They give me the creeps. Though they eat bugs and critters which is good. For I hate those creepy things too. The snake in my backyard is black and identical to the dream snake. It does not have yellow underbelly though."

"Why the yellow underbelly?"

"Yellow underbelly means it is a poisonous snake."

"Why would you want to be bitten by a poisonous snake?"

"To be cured of the other pain. My life is full of pain, fibromyalgia, fatigue; in short I never feel good. So I must me introducing one poison in to my system to get rid of another. Kind of homeopathy doctrine. That must me the reason too for my hand being in that awkward position. Instead of getting my poison drawn out by my grandmother through the needle and syringe, I am opting for a cure through getting bitten by snake."

"Why twice?"

"Because I was married twice. Both were snakes. They both were abusive, made my life hell and gave me agoraphobia. They were good riddance, but I still crave for love. So when the pain from the shin injury was about to wake me up I must have started dreaming of finding a cure for it by finding a man, a wish that must have been counteracted by the memory as to how the cure would tantamount to being bitten by a snake."

We still did not quite make out as to why the dream chose her aunt and the figure of her mother and grandmother behind it to draw the blood. This conjecture was not confirmed but the three women are  the only people she relates with and avoids all others. So when the dog injury was disturbing her sleep, the dream was generated in order to find a cure for the pain and the injury. First her mind harked to the familiar figures of the three relatives and a composite  of the three was drawing her blood. But then the libidinal wish, finding the three women as inadequate objects for what she really needed, began contemplating relationship with a man [that would take away the pain]. However the traumatic experiences with the two ex-husband nixed that outlet as well - the cure would have been worse than the malady."

Monday, August 26, 2013

An unconscious conspiracy by the pharmacists, physicians and drug companies to overmedicate patients

When a doctor writes a prescription for medications that should be taken only when the need arises he puts the abbreviation p.r.n. It is an acronym for Pro Re Nata which is Latin and therefore Greek for 99% of the doctors. Nevertheless it does not prevent them for using its Latin origin to make their profession look more mysterious and prescriptions unfathomable, justifying charging patients more than their labor warrants.
My problem with p.r.n. is not that it should not be ordered, and that many medicines should not be taken only when needed. For example instead of taking Tylenol routinely it is better to take it only when pain or fever arises. My problem is the way pharmacies label the p.r.n. orders.
If I write:
Xanax 1 mg. tid p.r.n. [t.i.d is another Latin obfuscation]
which means that 1 tablet of 1 mg Xanax can be taken up to three times a day but only if there is a need for it, the pharmacy will write on the label: take three a day as needed.  
Writing it this way gives the impression to the patient that he should take three tablets of Xanax a day as [it is] needed.
It is a very subtle way of encouraging patients to take more medications than they should. This is especially true with anti-anxiety agents and narcotic pills where there is a tendency to take more medications than prescribed to begin with. As needed is interpreted tendentiously that they should take the maximum allowable dose.
Wouldn't it be better if the instruction reads: take up to three a day if needed.
If needed is much better than as needed when labeling prn orders.
Perhaps the ideal way would be: take up to three a day but only if needed.

Tuesday, July 16, 2013

A Problem Solving Dream

A man in his late fifties, happily married, presented the following dream, which he had dreamt the night before the therapy session:

In the dream, my wife and I were in some kind of workplace together. We both worked at the same place and for the same manager. I suddenly found I was working on a phone modem. The modem was in the form of a metallic bag, kind of like potato chip bag made out of the foil, wrinkled and a silver/black color. As I sat at a desk trying to flatten this bag out, the person I understood to be our manager said, "I can't get through on this phone line." To which I commented "That's because I am working on the modem for that line. I'm just about done and you can use it in a moment. It will be faster because I've adjusted the settings."

The desks of my wife and I were close to one another in the first row of the office. Suddenly, the outside wall of the office where our desks sat and the ceiling were gone. An open, grassy field appeared next to our desks. Walking into the field right next to our desks was a musical band of about 10 Caucasian men and women.  They formed the shape of 'L' and started playing instruments which was loud. Some of he women in the band started dancing by lifting their legs to their right side but I noticed they were not in sync with each other. I thought at the time that it would be almost impossible to work with that much noise (from the band) in our office. My wife was on the phone at the time looking at the band and laughing about the circumstances.

The patient had written out the dream but when asked to narrate it anyway, made one addition. His wife and he were facing the East.

Associations to the elements of the dream were not readily available. As to why he was facing the East he could just say that he is generally aware of the directions as to which way is North or South while dreaming. This peculiar feature of his dreams had been subjected to analysis previously and it had to do with his great need to be moored to reality even while indulging in dreaming (fantasy life). His parents had got divorced when he was 10 and this had had a cataclysmic influence upon his psyche and for a while he had felt as he had no direction to his life.  He did not know which parent he should live with, whether to live or not live at all, and whether he will be able to face the future without the joint protection of his parents. He had emerged out of this great turmoil quite well but with a scar. He had a tendency to go into states of mild depersonalization. He would suddenly go in to brief periods in which he would feel as if he was there and yet not there. To counter these attacks of derealization in all his other affairs he had become hypercathected to reality and even in his dreams he could not abandon the necessity to know as to which way was North, South, East etc.

When asked where did the dancing band came from he said that next week he is going to Key West where there is a bar called Sloppy Joe, where Hemingway use to hang out. Every year they have a Hemingway-look-alike contest around this time. His wife and he are going to it. The patient does have quite a resemblance to Papa Hemingway - flowing white beard, generous body girth and a benevolent facial expression, and he is hoping to score big in the contest.

He expressed some misgivings about being there and not just because it is crazy to go to Key West in July - he hates the heat and humidity of Florida in summer - but because he and his wife are very religious and conservative and the bar represents for them dancing, singing, partying and other kinds of "debauchery".

When asked if the singing and dancing band in the dream were representing the fear of giving in to the   temptation the patient said, "I'll be damned if that is not what it means. For those people in Key West area are a lascivious lot while I and my wife are just the opposite, and I have mixed feelings about getting into that revelry."

Once established that the singing band had come into the dream to represent the much anticipated visit to  Key West which was to take place the next week, we had to find from where was the actual visual imagery  taken from. And here the patient told me that the night before he ordered on pay-per-view a movie called "After Shock" where a bunch of young Americans go to Chile and while living a licentious life are struck by an earthquake of the magnitude of 9.5  which causes a cataclysmic upheaval; disasters of every kind are unleashed with criminals escaping out of prison, looting and raping women.

So the singing band was imagery of crime and punishment. Indulging in sin and suffering its consequences.

On being asked if anything else happened on the day before the dream he recalled that all evening his wife was complaining about her problems at work. She is a nurse who works as a case manager in a hospital where she has to make a judgment call whether the patients admitted to the ICU meet the insurance company's criteria for inpatient care or not. It is a difficult and thankless job where there is constant confrontation with irate doctors and insurance company representatives. That particular day her immediate supervisor was not present in the hospital and she had to go to the manager of the entire department to resolve an impasse with a doctor. She had been unable to reach the manager on phone. 

The patient who is retired is the sounding board for his wife. All her frustrations at work she relates to him when she comes home, and he sits with her, and tries to find solutions for her and sometimes feels as if he works along with her. It was from here that the visual picture of their sitting together at the workplace was composed. We could not decipher as to why they were on the first row. It was perhaps related to the fact that before retirement he was head of security in a Multinational Corporation where he always felt cut above the rest and he was bringing that same attitude and skill in helping his wife.

So when his wife lamented to him about how difficult it was for her to reach her manager and how frustrated she felt about it, his mind at once began to work upon resolving the issue and the problem-solving continued into his sleep, emerging in the dream as trying to fix the modem.

As to why the modem was shaped like a potato chip bag with wrinkles the only association that came and which to some extent was suggested by me was that the women  with whom his wife works are all getting up in years and are kind of old bags with wrinkles. The manager who she tried to reach unsuccessfully is a younger woman who really does not know what she is doing and is not a nurse but a social worker, a political appointee, and who per his wife lacks proper training to have the correct feel for medical complexities of the ICU, even a correct understanding of medical terminologies. His wife therefore dislikes calling her. In the dream the patient was reversing the situation and displacing the frustration of his wife trying to reach the manager in to its opposite. It was now the manager trying to reach out on phone and unable to do so and the patient was in the position of power and only through his efforts could the manager use the phone line. So the dream though it had to do with his wife's frustrations at work was showing him as the central character. Dreams truly are totally egoistical.

As to why the modem was black and white the patient said that the case managers who are about 10 in number are distributed in two sections of the hospital. Some of them are in the new wing and have a better work venue while others are in cramped quarters and have to share desks and computers with doctors of the ICU and they are constantly being interrupted by the patients and their relatives. This was given a pictorial representation in the dream:  I thought at the time that it would be almost impossible to work with that much noise (from the band) in our office .

Per patient the silver/black of the modem was taken from the silver and black stethoscopes of the doctors which often lie around in the area which they share with the case managers.

He added that the case managers in the old section of the hospital dislike the lack of space and having to share the desks and computers with doctors with whom they are often at odds. I wondered to the patient if the lack of coordination between the case managers with the doctors was reflected in the out of sync dancing of the musical band.

The patient said that the whole situation there is out of sync. They have a difficult job with constant wrangling over who should stay, who should be discharged and who should be sent to the observation unit. She is often worked up over what happens in that hospital but sometimes we have a good laugh at what takes place there. In the dream this laughing at her co-workers was shown as laughing at the performing band.

"Why did the walls and the ceiling suddenly disappear and you were transported to the open grassy field?"

Patient claimed it was the wish to get out of her stifling work environment and be on vacation.

"Why were the dancing band 10 in number?"

 "It has to do with The Ten Commandments. Whenever I think of number 10 I think of the Ten Commandments. You know how religious I am. Whenever in doubt I think of how God would have handled the situation. We went to sleep talking about my wife's problems and then this worry was in back of my mind how to deal with those wild people in Florida. So I must have been thinking of God and The Ten Commandments as guidance to deal with the two situations."

I wondered if the L shape of the dancing band was not taken from the epithet 'lascivious' but I did not communicate this to the patient and it could not be confirmed. I asked him instead, "Why were you facing the East?"

"Whenever I think of the Holy Land I think of the East. So I am looking to the East as if God resides there,  like how the Muslims pray to Mecca."

"Why are all the band members Caucasian?"

"This has to do with Zimmerman case. Yesterday I was watching his trial. That must have activated the issue of black and white in my mind and and you know how I scapegoat Blacks when anything goes wrong politically. I blame Obama for everything that is wrong in the country. So when my wife was complaining about the manager and the work I must have been thinking that she is Black and therefore she was not to be found on the phone. But she is white and so are all other case managers and her supervisor. And that may  the reason why my dream is making my wife laugh at that unsynchronized dancing as if to say that you all may be Caucasian to the boot but still haven't got your act together."

The modern scientific research on sleep and dreams makes a big deal of how during sleep and especially during dreams we become smarter than we are normally. And this kind of praise of our abilities gets a lot of media coverage and we lionize the researchers who come up with some corny experiments to show those who sleep or dream show astonishing improvement in their memory and creativity. And they all quote the historical example of how the structure of benzene ring came to the mind of that great scientist in a dream. Hundreds of millions of dollars worth of research money goes into showing how wonderful our mind becomes when it is oblivious to the world and snoring. All this belief that in dreams we become super smart  is bunch of baloney. There is often intense problem solving activity shown in dreams and it is often  accompanied by strong emotions as if one is really trying to do some intensely important work. But careful examination shows that the problem solving was all a facade. Behind it was just some wish or another trying to get fulfillment. In this dream too, the dreamer was doing some intense problem solving - full of sound and fury - on a modem. But on closer examination that problem solving was being done on a potato chip bag with wrinkles. And it was all for enabling someone to make a phone call through repairing the blinking lights of a modem! Something which even a child will see through as problem solving worthy of three stooges. 

Sunday, June 23, 2013

A dream confirming Zombies are our own evil impulses projected upon others

A high spirited woman, in her early thirties, mother of two, 12-year-old boy and  a 2-year-old girl, living with latter's father, whom she must incessantly criticize, because of a constant need to not feel inferior to men, brought in the following dream:

[Though even before telling the dream she broke into laughter as to how silly it was and declared, embarrassingly, that the dream could not possibly mean anything. In fact she wanted reassurance that every dream - and every single detail of a dream, I interpolated - has a meaning and there will be some normal thoughts behind her dream before she would proceed further.]

I am in a car with my friends - not my family members now - going to a mall. I am passenger [not driver]. Though they are my friends, only one of them I know, or at least can remember well enough now. She has been my best friend since childhood. Though recently we had a falling out.
In the mall - it is a big mall - we find out that it has been taken over by zombies.
[The girl could not restrain herself from laughing at this point.] They are not mindless zombie who don't know what they are doing but intelligent zombies. They bite my friends who turn into zombies as well. It is not a violent bite. Not like how zombies devour and tear you in to pieces. But a gentle bite. Finally seeing everybody turning into zombie I let my friend bite my hand and I turn in to a zombie too. [she laughed again at such a girlie conclusion of the dream and added that I am surprised I agreed to it so readily. For my nature is to kick ass and not give into anything so easily].

The girl's correction that she was not with her family members but her friends gave the clue that the friends were 'replacing' the family in the dream for the purpose of repression. When two thoughts like that follow each other then one can immediately assume an internal connection between the two and in her case the disclaimer confirmed that the process of repression was trying to make it doubly sure that she tell us that the two thoughts have nothing to do with each other. In reality she was using her friends as a substitute to work out her conflicts with her family [through the medium of dream].

This construction was immediately rejected by the patient, but only to tell me in the next breath that the  friend whose identity she can still recall is as good as family, almost a sister. They grew up together and she is like an alterego. "Her father and my father were alcoholics and both died young. She is 4 days older than me. We did drugs together as teenagers. We always got into trouble and together. But there were differences. While, her parents would ground her for a month for each transgression my parents within hours would forget what punishment they had given me, and I would be free to do whatever I wanted to by the next day.

"One would have thought she would have turned better than me with all the discipline she got. But it happened just the reverse. Though both of us did drugs, and no doubt to escape from the horrible conditions that existed in the house, especially the death of our fathers, she went downhill far more than me, and became far more boy-crazy than me. In fact she had no self esteem and would sleep with anyone who praised her slightly. She lost her kids to protective services because she was so far gone into drugs. I think the discipline did not work because her parents did not practice what they preached. My father was alcoholic too, but he did not hold me to higher standards than what he could practice. Her parents were druggies as well, but punished her severely for doing the same thing they were doing. It made her a chameleon. While I take punishment on the chin. She escapes them. As long as she can lie her way out of it she will do drugs and other creepy things. Not me."

"Why are you two going to the Mall?"

"We both are adventurous; Libra. We liked doing things spontaneously. However, there is a difference. I like to go against the grain, but she is a girlie sort. She likes to gossip. I think we are going to the Mall for different purposes. She is going there for buying soft stuff. Catty stuff. To make herself look vulnerable. I am going there to meet someone to kick his ass."

I have always found that Malls in dreams symbolize meeting place. Like a fair where one will meet someone for adventure, romance and life partnership. Agoraphobia arises from the same complex. A dread of coming out a loser in such an encounter provokes anxiety attack. One ceases to go to marketplace/mall out of fear that on not getting what one wants one may lose control and do something drastic.

"Where are the zombies taken from?"

"I don't know; they come all the time in my dreams. But usually they are mindless and aggressive, killing and devouring people, and I am afraid of them. But this time I find them half way decent, feel a little sorry for them, and they are even not mindless."

Recent work in therapy sessions had softened her attitude towards her boyfriend who she always criticized as mindless. So the criticism of Zombie was criticism of men. "They are dickheads and mindless, as good as zombies," was her frequent attitude towards men. Underneath, of course was her fear of them. Her father's aggressive and alcoholic ways had made her fearful of men. But she had also strongly identified with his aggression and had rejected her femininity. She took great pride in being adventurous. She had declared in other context her dislike for knitting, gossiping, wearing high heels, buying frilly things, and eating chocolate and hanging around in shopping plaza for hours."

"Why are they biting your friends and turning them into zombies?"

The girl insisted that the zombies were girls and boys. By getting bitten they were becoming ordinary people who go along with the program. "I on the other hand will never go with the flow. I refuse to be like all these girls, who will suck up to men."

"Why are you putting your hand out to be bitten then?"

"I guess, I am tired of sticking up for my rights and denying my feminine side. Remember the dream where I go to the Mall and shop around and buy high heel shoes with my mother and you interpreted that deep down I have a very strong feminine side which wants to find expression. It perhaps is making its comeback again in this dream. For now I remember the last part of the dream, which just came back to me.

We come out of the Mall and I don't know where I should sit. Like I lose my perspective. Everything looks different.

I guess it means I am ready to look at the world from a woman's point of view, even if I feel I am lost and cannot find my bearings. I went to the Mall as a passenger in the car. I think I am ready to let other women, chiefly this friend of mine, who acts so girlie, to show me how to be more like a woman."

There was element of the dream that had not yet been explained. Why were the zombies quick and full of vitality instead of moving stiffly, mindlessly tottering and barely able to stand up straight as would happen in her previous dreams?

The patient and I could only come up with the following explanation:

During the period when she was very competitive and hateful towards men she was full of evil impulses towards them. These impulses emerged as constant criticism of males during the day but in  night, in sleep and dreams, they were shorn of their verbiage and appeared as pure visual images. The visual images and behavior of zombies gave the best  representation to these evil impulses.  What she wanted to do to those mindless/dickhead men now appeared through the defense mechanism of projection as zombies attacking and devouring her.

As to why the dreams did not show evil men attacking her directly we could only conclude that in dreams while the brain is not completely asleep still parts of it are resting and whatever action and behaviors have to be done they have to be undertaken with limited abilities. So zombies have to attack people but with a lack of proper muscle tone - in dreams we actually have motor paralysis - which makes them totter and move as if a ton of weight is on their shoulders and their feet are shackled. All their motor actions lack smoothness and their brain seems to function like a lobectomy has been done to it. But that is how the brain does function during dreams where verbal, conceptual and abstract forms of thinking are resting/sleeping and the unsatisfied wishes and their satisfaction have to be given expression through visual imagery alone. So the dreams find it easier to give representation to one's ambivalence about attacking others - the patient wanted to attack men out of jealousy but also saw that giving expression to such evil impulses was wrong and part of her mind did not want to do so - by making use of the limited activity of the brain during dreaming and showing the evil being carried out by idiotic semi-humans - the zombies. While the zombies do not carry their evil intentions smoothly because of the ambivalence they never die but keep coming on and on because the evil in us despite our best intention to extinguish, or at least to give no expression to it, persists on and on and can never be completely eliminated.

In this particular dream the zombies were not acting like morons with cerebral palsy because her attitude towards men was changing and it was with love she was approaching them and hence the zombies were biting her back too with love and with absence of ambivalence there was no need for the zombies to groan, lurch, totter and fall all over the place.

One cannot leave the subject of zombies without making a remark upon the frequency with which psychiatric patients complain that the medications you are prescribing them has turned them into zombies. Now our evil impulses which remain in check during the day because we are conscious and alert and under pressure from people around us, during the night, in dreams, can emerge as zombies because parts of the brain are asleep. Is it possible that psychiatric medications do the same: put parts of our brain in to sleep mode and so we feel  we are in a dream state and are more "living-dead" than truly alive? It also raises the question whether the  modus operandi of psychotropic medications is not to put aspects of our brain to sleep so other aspects can  find expression without inhibitions.  

Saturday, June 22, 2013

Fear of needles and fear of going to the dentist.

I recently came across a gentleman, who is now in his early Sixties, who boasted that he has no fear of dentists. "Others chicken out at the very thought of going to the dentist but I can face without fear their prying in to my mouth, their giving injections in to my gum, and their putting in of those frightening instruments to keep my mouth open."
Now fear of the dentist arises from the castration complex. Teeth serve as an excellent symbol of the penis and any thought of harm coming to them provokes castration anxiety and a desire to run from the dentist's venue in a hurry.
What lay behind this nonchalance and absolute lack of fear?
Later in the session - it was his first session with me - when I suggested that he get some blood tests done for he had not seen an internist for a long time, he declared that that is out of question. He dreads needles and has avoided going to a doctor for God knows how long because the very thought of needle makes him faint. He bitterly complained that it is just not needles but the idea of  blood coming out of his arm in to the test tubes that makes him queasy and he falls to the ground when he witnesses it. He went on to declare that the medical profession should do the blood drawing while a person is lying down so he does not pass out, fall  and hurt himself.
Now the phobia of needles also arises from the castration complex. So this man's extraordinary castration anxiety found an outlet in the fear of needles with medical professions but as if by reaction formation he developed a completely opposite attitude towards the dentists.
The psychology of daredevils and those who climb the highest peaks and do bungee jumping etc. appear to be operating under the influence of the same reaction formation; a defensive maneuver designed to overcome their exquisite sensitivity to and fear of danger. 

Thursday, June 20, 2013

A dream of revenge getting discharged upon the wrong person

A young man, recently divorced, had two dreams on the same night, back to back. He claimed the first dream was premonitory.

The First Dream:

I receive a text from K -the girl he had broken off a few weeks ago after dating her for couple of months- that she wants to meet, and not because she wants to get back together but for the sake of children [they have a child each from previous marriages who had begun to get used to each other].  I message back: absolutely not.

He added that surprisingly a few days later he did receive a text making the exact same request but so far he has not replied to it.

The Second Dream:

I am back in the house where I grew up. It is Christmas. My ex-wife is taking down ornaments from the Christmas tree. But it is not she who is doing it. A pair of sneaky hands just emerge and take away the ornaments.  It is difficult for me to explain how, but the best I can describe is that the hands belong to nobody, they just emerge out of nowhere and are taking off the decorations from the tree. I am watching all this through a camera that is monitoring the entire proceeding. I want so much to hug her. My love for her, which I no longer feel when I am awake because she cheated on me, returns in the dream. Then slowly the realization comes that we are divorced and I feel great sadness. I wake up missing her terribly.  

Patient initially was only interested in talking about how the first dream predicted what was to take place a few days later. There was an element of pride in his premonitory power and a desire for me to be impressed by it.

Since I hear all kinds of premonitory dreams especially from my obsessive patients who cannot dream enough the death of others and therefore once in a while their dream does turn premonitory, I was not very impressed by it and we quickly proceeded to analyse rather than appreciate this psychic gift of his.

But the task was not that easy. Why would he dream of receiving that text before it actually arrived? It is not that he needed some extra time to think over it before the reply. In fact in real life he had just sat upon it unable to make up his mind to accept this veil invitation to rekindle the relationship. If he was psychic and could foresee the future, even if only in dreams, couldn't his psychic abilities have done a better job and shown him dreaming of something more important than a mundane instant message text. Perhaps the clue to decipher the dream lay in his reply: absolutely not. He had ruthlessly rejected her.

Why did he reject the offer from K, who possibly really loves him, to get back together, and then immediately proceeded on to another dream where he is craving to hug and love his ex-wife, who had cheated on him and had broken his heart?

Now we know all the dreams on the same night arise from the same circle of ideas; same dream-thoughts. So unable to make head ways with the first dream, it was but natural to abandon it and go on with the second one in the hope of finding the common dream thoughts behind the two dreams.

To figure out the wish which had motivated the second dream was not rocket science. It was a desire to hug and love his ex-wife again.

But why on Christmas day, why was there a Christmas tree and what could be the meaning of those sneaky hands taking down the ornaments from it?

"Why was it Christmas day?" I asked him.

"That is when everything came to a head - on the Christmas day year and a half ago.  For weeks we had been arguing on how the Christmas day should be spent between the two families. I was exhausted by the bickering as to whose parents' house we will go for what, and for how long, yet I was looking forward to the Christmas day hoping that somehow the spirit of the holidays will straighten things out between us. Then came the shock. She disappeared, leaving me and my son waiting for her all day, not returning till the next morning. I had no choice left but to do some detective work, which, in this day and age with electronic trail everywhere is not hard, and found that she was having an affair. So I guess in the dream I was going back to that Christmas day, a time when I was still not aware that she was cheating on me and when my love for her was still untainted."

"Why was the dream taking place in the house you grew up instead of the house where you lived with your ex-wife?"

"My fight with my ex-wife at least partly arises from my anger at my mother. She was addicted to prescription medications for many years and could not take care of us the way she should have. She was either depressed or busy partying and drinking with a bunch of card players in a bar not too far from home. And I think my anger at her for this neglect has become generalized to all women and it emerges as a need to control them. I drove my ex-wife away because of my subliminal anger at her and my need to reform her. I could not control my mother from her self-destructive behavior because she was my mother and I had little power over her, but that impulse found an outlet with my wife. And I think she could not handle my controlling nature and finally copped out of the marriage by having the affair."

"Whose hands were removing the ornaments?"

"They are my wife's. Perhaps my mother's. Perhaps the snake who broke our marriage. He was my close friend, he grew up with me, I trusted him, and he stabbed me in the back by having an affair with my wife. The hands are doing the job sneakily because the destructive influence upon the marriage of the three was not visible. They were all working behind my back, or at least out of my consciousness, to pull the plug on my marriage. I think the dismantling of my marriage is being symbolized by the ornaments being pulled off the Christmas tree.

"But also by making those sneaky hands do that dastardly deed I was protecting my ex-wife from blame. If I could convince myself that she cannot be faulted for cheating on me then I could love her again. My pride cannot  forgive her. Without forgiving her I cannot love her again.  But in the dream I found the way to love her by making the blame as much as my mother's and my friend's as her's.

"The camera monitoring the dream field itself is a reflection of my need to control everybody. I drive my mother crazy too by trying to control every aspect of her life which comes in guise of stopping her from smoking and taking all the medications that doctors prescribe her which I think have worsened her in the long run than helped her. And I think I drove my wife away by trying to improve her beyond her ability to improve and micromanaging our marriage."

After getting the associations to the second dream [which have been condensed and put as a monologue here for easy reading] from the patient it was not hard to decipher the first one.

The condition for his loving his ex-wife was for him to absolve her from the guilt of having cheated on him. One way to do was to reject that aspect of his ex-wife which had cheated and only remember the part that he had loved till that Christmas day. And this rejection was being practiced against the girl K from whom he had recently separated from. In the dream he was making K, the innocent one ,as the culprit, who had done nothing wrong to him, in order to salvage his love for his ex-wife.

Patient told me that he meets his ex-wife many times a week to pick up or drop off their son and though he still finds her extremely beautiful, he no longer feels any love for her.  But, he added, in the dream it is another matter. Perhaps his pride goes to sleep allowing him to forgive her and to love her with all his heart the way he had done once upon a time.

Sunday, May 12, 2013

Paranoid Illness changing into Bipolar Disorder

A woman in her early forties came to her monthly session, primarily to get her medications for she does not like to talk about herself or her illness, and complained that she is once again in her down mood.

"It started a week ago and it is so bad that my son - the only one who still lives at home - left the house. To add insult to injury I flipped my finger at him as he was leaving, which is insane. For the poor boy had done nothing wrong.  All week long I had been on his case. It is good he left on his own because last night given my nasty mood I could have physically kicked his ass out. When I am in that down mood I want nobody around. My son called me this morning to ask if it was safe to return. Thank God he is not upset because he knew it was my mood and not me which was making me behave like that. What lies behind such nastiness of mood?"

Patient denied that anything triggers it. With no leads to go upon as to why she went nasty the session shifted into talking the next thing that was bothering her. It was her anger at her mother. Patient could not be more angry, "She has chest pain but refuses to go to a doctor, treating herself with cold water and aspirin. I am afraid she will die just like my father did."

It too had started a week ago. What came first her worrying about the mother and getting angry over it or her nasty mood.

Patient first claimed that they had started simultaneously but then after being forced to carefully examine had to admit that mother's chest pain had begun a few days earlier. She also recalled that when her anger towards mother could not be contained it was only then some of it had escaped control and despite her best intentions to not do so had begun to get displaced upon her son.

"Why did you think that she will die just like your father?"

"Yes, that is my fear. All I can think of is that she is going to die like my father did. It was traumatic seeing my father die in 2009. He had clogged arteries, just like my mother has."

"Did your mood swings start when your father died?"

"No. His illness and death did not affect me quite that way. I did not get upset. I did not care for him that much. He was not around. For that matter my mother was not around either."

"Then what started the bad moods?"

"The death of my grandmother in 2010. But in the beginning they were not bad moods. It began as a slowly emerging conviction the house in which she had lived and died was haunted. I missed my grandmother very much. She was my real mother. My father and my mother were never really available to me. After her death I started hearing her voice and could feel her presence. I was admitted to the hospital and diagnosed as paranoid schizophrenic because of those voices. They put me on a lot of Seroquel which was the only thing that could block out the hallucinations and allow me to sleep. Even now I am afraid to go off the Seroquel despite your warning that it is making me fat and may cause me diabetes, because I am afraid of the return of the voices.  When I came back from hospital I moved out of my grandmother's house. But her presence followed me to the new house."

"When did the mood swings start?"

"They came gradually. As my fear of my grandmother's presence hovering over me decreased the mood swings started. They are always accompanied by anger towards my mother."

"You became sick after your grandmother's death, but your anger is always directed towards your mother, why is that?"

"Because I think I have a big time grudge against my mother. I loved my grandmother but hated my mother."

"Why you hated your mother?"

"Because she favored my brother over me. He was my half-brother. She preferred him over me, because his father was not around, while mine was,  and she felt he deserved special treatment because of that."

This patient's illness which started as paranoid schizophrenia shows no trace of it now. She is quite warm and social in her interactions when she is not in her down mood. This transformation occurred when she could allow her rage to emerge against her mother. This happened after the death of her grandmother. Prior to that her loving relationship with her grandmother kept her rage bound. Once her grandmother died her rage emerged unchecked and could only be contained through developing a paranoid projection . She started hearing voices that kept her rage from being acted out.  

Once the rage could be expressed against others - the latest being her son - it did not have to be projected and come against her in forms of voices. However since she could not be permanently in a state of rage her psyche developed bipolarity. A time was allotted to be in rage and a time to be nice and good to other people.

Thursday, May 2, 2013

A transference dream

A patient of mine who has been with me for more than two decades and treats me with great familiarity and friendliness, came for his biweekly session and said I had this hilarious dream from which I woke up laughing, because it is something that could never happen in real life.

The dream is about you. I come to the office at our usual time. But the location of your office has changed. It is not this old ranch building - not that anything is wrong with it, I love your place -  but  a magnificent high rise, all glass and beautiful. The staff has changed too. They are young, spiffy and professionally dressed, not like how your staff dresses so casually.  But what is funny is that they are not one bit friendly.  In fact they are nasty and hostile. They ask me who I was, and do I really have an appointment. I tell them what are you talking. I have been seeing Dr. Kelwala for 22 years, and you all should know I come here every other Friday at 11 or 11.30 am. 

I at once knew that it was an expression of hostility towards me that was being "projected" into my being hostile towards him though I was being represented by my staff.

When I told the patient that perhaps behind accusing my staff as being nasty and hostile it is me who he is accusing of being nasty and hostile, he said that that is impossible for he respects me too much. Then he suddenly remembered another section of the dream which confirmed that the interpretation was in the ballpark.  

"A part of the dream that I had forgotten now comes back to me. While I am being blown off by your staff you come out of your office and say that my appointment is at 8.30 pm. And I woke up laughing aloud as to how you could be so ridiculous, for you never see patients that late in the evening. 

"That I don't even know as to what time I see my patients, is it an expression of contempt ?" I asked him.

The patient protested that in no way he can be contemptuous towards me for he respects me too much but then immediately confirmed the accuracy of the interpretation by stating that recently he has been talking big-time in his sleep, and waking out out of his dreams laughing. For example the other day "I woke out of a dream laughing because I was calling my Dad you son-of-a-bitch, you crazy man. Which is  surprising for I never ever said anything like that to him when he was alive."

"Calling your father son-of-a-bitch and telling me that I don't even know the timing of my own office hours appear to have the same origin: contempt for authority/father figures. Where is the contempt coming from?"

"I dreamt the dream this morning, a few hours before coming for the therapy session. Around 8.30 a.m to be exact for I looked at the clock on waking out of the dream. I had run out of my Suboxone and Xanax couple of days ago, because I had been taking them more than the prescribed dosage. I was withdrawing and feeling nasty and could not wait for 11.30 to arrive when I could see you and get new prescriptions. Then I dozed off and had the dream. Now you know how you get mad when I take too much of these medicines and have at times refused to refill them or told your staff to not call them in if I have demanded them on phone if they are not due. So I always have this fear when I take too much of these medications that you will not refill the prescriptions or the appointment will get cancelled or you will fill them but not right away."

So his fear of that I may not refill his prescriptions which will prolong his withdrawal symptoms was making him think of all kinds of insulting thoughts towards me.

"Why the building was tall and magnificent?"

"It was eight stories high too!" the patient added

"Why eight?"

"It has to do with the 8 mg. of Suboxone tablets. I was craving for them and if only I could have gotten the 2 mg. tablet [Suboxone comes in two strengths 2 and 8 mg.] it would have eased the suffering. But 8 mg. would have been ideal. So I was granting you an eight stories high office building instead of this modest ranch of yours if you would prescribe me that dosage right away."

The magnificent office and professional looking neatly dressed staff were expressing two other concepts which were diametrically opposite to each other. On one hand it was an attempt to exalt my position. If only I would fill his prescription without any problem he would value me as a real upper class doctor whose office    was in a magnificent high rise building with professionally dressed staff instead of the humble office in which I see patients and the unpretentious staff who work for me. On the other hand it was an expression of contempt that given your humble office and even humbler staff and the fact that you don't even know your own hours of practice you better not make me wait for my prescriptions. And the dream was expressing this contempt by showing the offices of the more magnificent doctors with their sparkling glass offices.