Sigmund Freud wasn’t only a brilliant psychiatrist, he was a pioneer in canine assisted therapy as well. He had a Chow named Jofi, whom saw patients right along side him. Freud observed that she had a calming effect on patients. When Jofi was present patients seemed more open and candid. Freud also shared his office with his daughter, Anna, who had a wolfhound. Apparently the dogs had the run of the office and would bark when anyone new showed up.
A growing number of psychiatrists, psychologists and therapists have followed Freud, and are bringing their dogs to work where they interact with patients. Virginia Commonwealth University School of Medicine even offers courses in human-animal interaction for fourth-year students and psychiatry residents. Veterinary schools are now focusing on animal behavior more than ever before.
Dogs have a calming effect. They’re a source of distraction that can be valuable with worried or confused patients. Science has demonstrated that simply petting a dog can decrease blood pressure and decrease levels of the stress hormone cortisol. Interacting with a dog can produce a sense of security by increasing levels of oxytocin and prolactin. In other words, it’s chemical not magical. But, if you work with dogs as long enough as I have, you’ll see the magic.
Once I had a patient who only spoke Japanese. She came with a friend who served as our interpreter. My dogs transcended the language barrier instantly. In subsequent appointments, I could determine her level of improvement just by watching her interaction with the dogs. One of my dogs took a particular interest in an autistic man. Very often people with autism don’t like to be touched and are easily overstimulated. She seemed to know that and would sit by him just far enough away so that when he was comfortable he could easily reach out to pet her. He was the only patient she did that for.
I started bringing my dogs to the office about 8 years ago. Initially, I wasn’t thinking about how they would interact with patients. I was tired of unreliable people who often failed to show up to care for them when I was at work. Doggie day care was available, but I only trust a few with my precious buddies. I had recently moved my office to a dog-friendly building, so I figured I’d bring them to work. Little did I know what a profound impact they would have on everything.
When I was in my early forties, I wanted to get a dog. Grace was a Brittany/Labrador mix I rescued as a puppy. I saw an ad for free puppies, called, and it was love at first site. There was no hesitation; she was mine and I was hers. About six months later, I started thinking about a second dog and I knew someone who was planning a litter of Golden Retrievers. His female had nine cookie cutter puppies. It was a tough choice, but I noticed the one with the little purple collar followed me. I named her Abby. At this point, Grace was 10 months old and Abby was seven weeks. I really had my hands full, but it was a blast. Puppy school, and later obedience training, got us well bonded. I liked everything about taking care of them.
Abby and Grace
When they were about six and a half I started bringing them to the office. They were well trained, polite, and took an interest in every patient. After a while I noticed that Abby seemed to gravitate to patients who were anxious, depressed and worried, whereas Grace was attracted to people with addiction, PTSD and what you might call mercurial personalities. I make it a priority to help every patient feel safe, secure and comfortable; Abby and Grace reinforced that. Patients developed their own relationships with them. If one was at the groomer or the veterinarian for the day, patients quickly noticed one was missing and needed to know why.
Their presence had an effect on me as well. Within a short time, I noticed I was more focused. Before I brought them I might fritter away spare time if there was a hole in the schedule or if there was a cancellation. I don’t know what it was about having them around, but I felt more motivated. I got phone calls returned sooner; Progress notes got done, and I read more. My relationship with them got deeper, and we moved around like a little pack. Having them here was good for everyone.
In May of 2013 Grace passed away. She was thirteen and a half. It was very likely she had cancer, and I didn’t want to put her through any diagnostics or treatment. Five months later, Abby passed. She, too, very likely had cancer and was over thirteen. As a dog owner I have two primary responsibilities: to provide a safe, healthy and stimulating life, and a compassionate and humane exit. It’s my belief that all dogs belong to God, and we just get to borrow them for a while. I’m grateful for all the support that came my way from patients when they died.
Story and Kae
It was Christmas of 2013 and I had been in contact with a professional trainer who knew of a little yellow Lab that needed a home. Kae (pronounced Kay) was my Christmas gift that year. She was 16 months, well trained and ready to go to work. I was a bit worried that such a young dog might be too rambunctious, but she knew instantly what to do. My patients were really happy I got another dog. I really liked having two, and 18 months later, the same trainer who found Kae for me asked me if I would be interested in a little chocolate Lab. “She’s pocket sized,” she wrote. I drove out to get Story about two months ago. They instantly liked each other. The first day I had both at the office, a patient walked in and said, “He got second dog!” Abby and Grace were the first generation and I learned a great deal from them. Kae and Story are the next generation. I’m excited to see what will be revealed.
About 10 years ago, I was talking with an older man who was a recovering alcoholic. He had been sober a long time, in fact I believe he’s the only recovering alcoholic I’ll ever meet who has a 50 year chip; which is a remarkable achievement. During our conversation, he bestowed a meaningful nugget of advice: “Don’t Hurry, Don’t Worry, Don’t Resent, Don’t Judge.” He went on to say, “If you pay attention to these four things, 98% of your day will go just fine.” I liked the sound of it, but it took me a while to get my arms around it. All four are things most people (including me) do all the time, every day. We do it so often it feels like common sense. It’s automatic. Because of this, I decided I really liked his advice. If I could avoid those four things, I could sidestep anxiety and anger; two emotions I could do with less of. I’ll try to explain.
Let’s say you’re at work and someone drops a project on your desk that you weren’t expecting, and it needs to be done now. You already have plenty to do, and maybe you’re tired because you didn’t sleep well the night before. What’s the first thing you’re going to do? If it was me, I’d pick up the pace. I have more to do, so I need to work faster. I try to think faster. In other words, I hurry. Then what happens? When I hurry, my thinking becomes less clear, and I start making mistakes. The mistakes cause alarm, and I start to worry. I start telling myself, “I can’t do this.” Worry is a very uncomfortable emotion. It’s a feeling of being out of control, something bad is about to happen, and there’s nothing I can do about it.
There are good and bad ways to deal with worry. The good ways I’ll get to some other time. There’s one sure fire way to neutralize worry; it’s not a good one, but it works. Anger will neutralize worry instantly. It’s a common defense. It seems that for many, worry (fear) and anger can’t exist in our minds at the same time.
Resentment is the result of anger neutralizing worry. In this case, you start resenting the guy who dumped the project on your desk. It’s a more tolerable emotion than worry. At least when you resent someone, you have the feeling or illusion that you’re right. In worry, you’re not sure about anything. Many secretly like their resentments. They nurse them. Have you ever had an imaginary argument with someone you don’t like while driving home? That’s resentment in action. Resentment is unhealthy and robs us of our energy. It doesn’t help you solve the problem. It keeps you stuck in it. The best definition of resentment I’ve heard goes like this: “I’ll drink the poison and expect you to die.”
Judgment, you could say, is a resolution of resentment. It’s a final determination based on your feelings. Some guy dumps an unexpected project on your desk. You react by hurrying, but then you start making errors and get worried. In your mind you lash out at the guy who added to your burden and decide he’s an idiot. Moreover the whole company is at fault because they don’t know how to treat their employees and they certainly don’t appreciate your unique talents. There’s a certain satisfaction that comes from judging others. It doesn’t require that we understand anything about them, but it does keep us isolated from others.
What happens after hurrying, worrying, resenting and judging? Many head for the vending machine or Starbucks for a sugar fix. After work some will go for the alcohol or marijuana to wipe out their unpleasant feeling. Next time something unexpected comes along don’t hurry. Take your time. Don’t doubt your abilities. Ask for help if you need to. Don’t blame the guy who dumped on you. He probably got dumped on too. Avoid judging, it doesn’t help you understand anything.
Addiction is a terrible disease. I’m reminded of this on a daily basis. I’m witness to the devastation it causes in patients and their families. What is addiction? What causes it? Is it a disease or a character flaw? I’ll attempt to make some sense of it.
Whatever addiction is, it’s been around for a long time. Accounts of the pathetic drunkard living homeless and destitute go back centuries. Addiction is a condition of suffering where the affected individual has lost control. In the case of alcoholism, the individual has lost control over alcohol. They can’t stop. In the language of Alcoholics Anonymous, the sufferer is “powerless over alcohol.” A member of AA might say, “One drink is too many and the whole bottle is not enough.” Once the drinking begins, an “obsession” develops. The second drink is no longer a choice, it’s a compulsion.
The condition seems to hijack neurobiological mechanisms that regulate motivation, decision making and judgment. Our brains are designed to reward behaviors that ensure survival. For example, eating is necessary for survival. Food tastes good, therefore we’re motivated to eat it. Sex is necessary for survival of the species. For most, sex is pleasurable, so there’s motivation to have sex and produce more offspring. Dopamine is a neurotransmitter that has several functions, but it’s primary function is to promote motivation. Here’s where things get interesting. When the brain releases dopamine, it creates motivation or desire. Dopamine is released when we eat or have sex, but most of the dopamine is released BEFORE we eat or have sex. Just the thought of eating or having sex causes an increase in dopamine. The anticipation of how good that apple pie is going to taste is the function of dopamine. It motivates us to eat.
For alcoholics and drug addicts, dopamine is released in anticipation of drinking or using. That doesn’t happen in people who don’t have the condition of addiction. A social drinker might enjoy a glass of wine, but there’s little or no dopamine release in anticipation of having that glass of wine. For the addict, dopamine is released in excess before the next drink, causing the individual to compulsively drink to intoxication, passing out or blacking out. Addicts who understand their condition will say the first drink is the only one they choose; the rest seem to go in automatically with little if any consideration for the consequences. Hence the condition of addiction has hijacked the regulation of motivation, decision making and judgment.
The cause of addiction is unknown, but studies have repeatedly shown that it runs in families. That suggests genetics are involved, but as of yet no one has found a specific gene or set of genes that causes the condition. In my opinion, the cause is likely multi-factorial with genetic and environmental factors working in concert to cause the condition. Is addiction an disease or a flaw in character? So far in this blog post I’ve referred to addiction as a condition. In my opinion, it’s a disease. A real disease with devastating effects. I view addiction as a disease just as I consider diabetes, arthritis and cancer to be diseases. Here’s what they all have in common: they all have a predictable set of symptoms, a predictable course, a pathophysiology, a genetic component and they all cause suffering and disability.
Once I had a conversation with a patient of mine who is a recovering alcoholic and drug addict. We were discussing whether or not addiction is a disease. She said, “Who cares? What difference does it make? My life was a shambles because of it. I could have died. I needed to do something different because my way wasn’t working anymore.”
Depression is the most common mental illness, and the most common condition I see in my practice. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is a manual that lists the signs and symptoms of all recognized mental disorders. It characterizes depression as a condition where the patient experiences low mood, low energy, apathy, poor concentration, loss of pleasure, irritability, anxiety and sleep disturbance. These symptoms need to be present for a period of time and not just an isolated day or two. The DSM-5 criteria for depression are an attempt to differentiate depression from other conditions. They don’t, however, get to the essence of the illness.
Depression is an illness that has a longitudinal course that changes over time. Many cases of depression begin as diffuse anxiety. The individual feels ill at ease and may begin to worry. They may attach the worry to something specific like money, relationships, their job, or their health. Often early in depression there’s a slow, chronic and grinding unresolvable stress perceived by the patient. This period of anxiety may last weeks or months and may come and go. In my opinion, whenever a person doesn’t feel right they start looking for a reason and a solution. When no solution is found the anxiety may morph into irritability. When there’s no usable solution the anxiety may increase to fear.
Fear is a horrible state of mind and the mind tries to neutralize the fear with anger. Fear and anger are two emotions that co-exist in the mind, but anger is a more tolerable emotion than fear. With fear the individual doesn’t know what to do, and is helpless and powerless. Being angry motivates defenses of fighting or running away. In this stage, patients are snappy with others and poorly tolerate frustration. It is at this stage that they may first seek help from a psychiatrist.
In the irritable stage the possibility of fighting or running away is more acceptable than being engulfed with fear, but in today’s culture neither inflicting bodily harm or fleeing are acceptable solutions. They represent a more primitive defense that may be an evolutionary remnant. The irritable stage can lasts weeks or months. After a period of diffuse anxiety and a period of irritability comes the last stage of the illness – Depression.
At this point the individual has not felt well for weeks, months, or sometimes years. Anxiety and worry haven’t solved the problem and irritability hasn’t defeated it. In my opinion, it is at this point that a switch flips in the brain and the landscape of life becomes bleak and futile: there’s hopelessness, marked apathy and sometimes suicidal ideation. So far nothing has worked. There are no more options. Energy is depleted. In this stage patients may stay in bed, become reclusive and fail to take care of themselves.
You can take all the criteria for depression and throw them out the window as far as I’m concerned. The essence of depression is a complete failure to reassure yourself. We take for granted that we can reassure ourselves. We do it all the time. We know we will get up in the morning, get dressed and go to work. We know we’ll manage our families, coworkers, friends, minor conflicts, pay bills, make dinner and enjoy our leisure time. In depression, however, all that’s gone. The simplest of tasks are overwhelming. Carrying on a conversation feels burdensome and tiring. The only reasonable course of action is to retreat. This, in my opinion, is what most depressed patients experience.
When I began private practice 25 years ago an old seasoned physician told me, “If you want to succeed at this you have to be Affable, Affordable and Available.” The three As, as he called it. It was good advice and I followed it. Today, however, patients are seeking more than that. With the advent of the Internet patients are researching their symptoms. By the time some patients get to me they already have a sophisticated idea of their diagnosis. They’re also knowledgeable about treatment options. It’s my feeling that patients are seeking a certain expertise and approach that they can feel confident in. If I was to give a new psychiatrist advice about starting a practice I might tell them the three Cs, Competent, Compassionate and Comprehensive.
In clinical trials as well as in clinical practice, some psychiatrists consistently achieve better outcomes than others, regardless of the treatment approach used. There are over 50 forms of psychotherapy. Most are supported by studies that demonstrate their effectiveness. When compared across specific disorders, such as depression, the differences between treatments are negligible. There are too many medications. In the 21st century we have in the toolbox numerous medications that, in clinical trials, are effective for specific disorders. That said, when antidepressants are compared to each other in terms of effectiveness the differences between different medications is also negligible. If the form of psychotherapy and/or the medication make little difference in outcome, what are the qualities of effective psychiatric treatment?
The psychiatrist and the doctor-patient relationship is tremendously important in the outcome of any case. Effective treatment requires accurate diagnosis to be sure, but it also requires hope, understanding, interest, motivation, communication and collaboration. It has been my opinion for a long time that effective treatment is the result of a meaningful dialogue between a person in distress and another who wants to help.
A lot has changed since I started my residency training in 1983. At that time the biological movement was just gaining traction. Most practitioners of the time were psychoanalytically trained. Since I was interested in both the biological and the psychological it was a fascinating and sometimes frustrating time to get into the field. People, in general, don’t like change and psychiatrists are people too. As I got into my training I observed distinct camps forming around new and old ideas. There were those who used medication liberally and felt psychotherapy was largely useless. Some were open to using medication, but lacked expertise on how to use them. Still others disdained the idea of medication in any form and relied solely on psychotherapy alone to relieve patients of their symptoms.
Fast forward 25 years. The pharmaceutical industry has developed a number of effective and safe medications that relieve the symptoms and prevent recurrence of many psychiatric disorders. Young psychiatrists today are trained almost exclusively in diagnosis and medication management. I’ve said to many colleagues that our specialty is in crisis. Psychotherapy has been shifted to non-psychiatric providers. Some of whom are excellent, but the partitioning of care has, in my opinion, not been in the best interest of the patient.
Over the past 25 years there has been significant advancement in psychotherapy as well. Cognitive-behavioral therapies have been developed to successfully treat some depressive and anxiety disorders. Certain aspects of psychoanalytic and behavioral therapy have been refined to help many specific problems. Study after study has shown that integrating psychotherapy and good medication management leads to an outcome superior to either alone.
Lastly group therapies such as the 12 step approach first proposed by Alcoholics Anonymous have made addictions much more treatable and conquerable.
In the early years of the 21st century we are in possession of powerful weapons, both psychological and biological, that can ameliorate severe symptoms, prevent relapse, and help patients grow and lead full and productive lives. Life Gets Better.
The idea of having a website for my practice has felt foreign and, at times, intimidating. I suppose you could say I’m “Old School.” On July 1, 1990 I hung a shingle and started taking care of patients. New patients came when they were referred by another physician or therapist. Often my own patients were great referral sources. The last 25 years has been a great educational experience for me. I’ve learned a great deal from my patients. I’ve probably learned more from them than they have learned from me.
Advances in technology have changed how potential patients seek out medical care. Everyone has access to medical literature and many psychiatrists, myself included, talk with informed patients on a daily basis. Not all information on the web is accurate, but the fact that patients seek out information tells me that they’re interested and want an active role in their care.
With the help of a very energetic and enthusiastic web developer I’m being pulled in to the 21st century. My website has been live for a few months. I’ve tried to present to the potential patient a snapshot of me, what I do, and a bit about the office itself. I’m enthused about having a blog. As they say in writing school, “Write what you know.” I hope to write about various topics in psychiatry that I feel are relevant to any patient. Lastly I’ve had a few thoughts about what to call this blog. The jokester in me thought of calling it, “Free Associations With Dr. Les Moody,” but for now I think I’ll stick with something simpler and refer to it as, Dr. Bob’s Blog.
