drmargaret

People postpone discussions about death and dying until the last minute. The discussions are difficult. Who gets what? What do you want done with your remains? How do you want the accumulation of your property handled? How do you want children or pets managed? What kind of service do you want performed? Talking about these things is described as “morbid.” But to not handle them puts a great burden on loved ones who then are left to manage all the difficult decisions at a time of mourning without any guidelines about what you wanted to have happen.

For people in healthcare, the decision also involves handling the practice and telling the patients. I left formal practice several years ago. I have only 2 patients and each of them has other therapists. The people I see for SSDI, EDD and the State Department of Rehabilitation I only see once and I don’t treat. But I did have to have the “discussion” with the two patients I have in clinical practice.

I got asked how I cope with medical problems that can potentially be fatal. Evidently people seem to see me as coping well. Here is how I think about it. You take off on a plane ride. Things are smooth, then you hit turbulance and you get nervous. The pilot comes on and tells you you are in for a bumpy ride. You fasten your seatbelt. The bumpiness gets worse and worse and the pilot tells you the plane will crash. You then have a choice about how you spend your remaining time. You can lament that you took the flight. You can scream at the pilot. You can cry and be upset about all you failed to accomplish. You can appreciate all the precious moments you had in your life and realize that everyone is on a plane that is crashing and you have time left to reflect. It’s my third crashing flight, which also makes it easier. Been there, done that. So I’m reflecting. I’m also trying to get everything done.

Let me explain what all needs to be done and this may be a partial list for people. My funeral is planned and paid for in advance. My family will have some say in the service and can add on if they want to but the basic service is all handled. I have a durable power of attorney for health care which allows a family member to make decisions for me if I become not capable of making decisions. I am putting together a living trust which will help my family avoid probate. My insurance policies are all up to date, current, and the beneficiaries are all exactly who I want them to be. I have a will. I have directives to my physicians regarding my care. I have instructions regarding the remnants of my practice. I have disability insurance. In essence my affairs are settled. I’ve have my discussions with God.

This is all planning. It’s not morbid. It doesn’t mean I’m dying tomorrow. It does mean that I’ve thought about the fact that everyone dies. It does mean that I’m not in good health, although I think everyone should have all this regardless of their health status, but not being in good health does make it more pressing.

Ultimately, the only thing you take with you from the plane crash is the relationships you have with people. Make them special.

It’s hard sometimes to write about people in ways that aren’t identifiable to others, especially people who are violent. I’m going to try to be vague. I spent part of an hour last week talking with a famous violent man about his criminal career. His actions changed life in Los Angeles. His crime was considered quite heinous at the time. People were appalled by his actions, as they should have been. His actions were appalling. He shot several people. Since then he has been shot. He’s upset by that. There are supposed to be “rules” to these shootings. You only shoot rival gang members. You only shoot in designated gang shooting areas. You only shoot designated people to be shot. Unfortunately, the “rules” aren’t all that clear. Violence spreads to undesignated areas, to undesignated people, to non-gang members.

I was a violent child. So I’m interested in violence. Violence isn’t the same as anger. Anger is that emotion everyone has that say that when someone takes your toy you get mad. Violence is when they take your toy a small thermoneuclear explosion goes off inside you and you decide to club them to death and if someone doesn’t step in or if you don’t have some stop signal go off in your brain you make that happen. Violence is a decision that never feels like you decide.

I talk to people who are violent. Lots of people I talk to are on parole for being violent. Some of them have taken these classes in anger management. Some of them have reoffended after having taken those classes. The classes are for a year usually. They are usually held in a group. I used to run those type of classes. Mine weren’t being done by the courts. Mine were just for people who were serious about getting better and were worried about hurting people. The big push for anger management hadn’t started yet. There wasn’t any research on what to do to treat violence. But these people scared people and themselves. They needed treatment. So I and a couple of psychological assistants started working on developing treatment for them.

I have some ideas about who decides to become violent. Violent behavior gets trained out of children between ages 2 and 4 when children get socialized. Kids throw temper tantrums. They learn how to manage big emotions like rage. They watch adults to see what is acceptable behavior. Various families use different strategies to manage anger and rage. Some people have the kid sit until they are quiet. Some parents hit their children and tell them to be quiet. Some parents lose control. Some parents talk to their children. Some put the child in an area and have the child calm down. Some are inconsistent. Some get frightened of the child.

I don’t know what the best method of parenting a 2-4 year old kid living in poverty is. I do know that being consistent is better than being inconsistent. I do know that clear rules for acceptable behavior are better than no rules. I do know that children can’t be in charge of the house. I do know that violence needs to have a no tolerance policy everywhere–at home, at school, at daycare, at church, at the baby-sitter. I do know it’s better to train appropriate ways to behave than to try to fix problem behavior. I know it’s easier to fix when it starts than waiting until the kid has a million episodes and is 18. But that’s all easier said than done.

There are some basic things that I do when I work with someone who is violent. I start off by trying to put in stop signals. I work backwards from violent events. I de-weaponize people. People are not allowed to carry weapons or things used as weapons during treatment. Most people who are violent are of the belief that they are under attack. They scan the environment to confirm that belief. They almost always carry weapons. Weapons are car keys, a nail file, a letter opener, a pen knife, a bottle opener, etc. They wear armor. Yeah, I know I wear a vest. In some cases I get the person to disarm in session and I’ll take the vest off as well. Then we work on the wrist bands, the outfits in black, the gang attire, the movements, the gestures, all of it. I get to wear a vest, I’m not being violent and I deal with people who are who haven’t agreed to stop. I also get to watch violent TV shows and movies if I want to. They don’t while they are in treatment. No violent TV, no violent cartoons, no violent games, no contact sports, no violent video games, these are all rehearsal strategies. There may be more. It may include music–rap, heavy metal, punk, some R&B.

Finally after all the disarmament and putting in behaviors that change violence, there is treatment to learn new skills. Social skills, negotiation, conflict resolution, communication skills. It’s a lot of treatment. Lots of people drop out of treatment. A few stay. Research on outcomes shows the ones that stay improve and don’t offend in a year. Given that the research was done on people who indicated intent to harm, that’s a significant outcome. The people report less ideas about hurting others. The drawback is that it’s self-report data on thinking. The good news was that it was one of the first studies on treatment of violence. I did the research back in the early 1990’s. It still holds. I haven’t seen the behavioral component replicated, just the talk therapy component. That’s fine. There’s also now medication to augment treatment. Medication is a last resort but it works very well and can be used at low dose and can even be used intermittantly on an as needed basis depending on the person. For some people who need to be kept out of a prison or an institution setting medication is a Godsend.

There was a recent violent act in the last couple of weeks in which a man used his toddler daughter as a shield while he engaged in a gunfight with the police. He has a long and violent criminal career as an illegal alien. His actions were heinous. There were not met by the type of outrage by the community that they should have. Some people protested the shooting of the toddler by police. The toddler’s mother suggested psychologists or negotiators should have been used to avoid the shootout. There has been some actions by the police where there has been excessive use of force. There have been excessive violent actions in the community against people and the police. Drug use, criminal behavior and gang membership contribute to a general air of unsafety in South Central Los Angeles. Sometimes the churches get involved and try to help get things calmed down. Other times like with the riots of 1968 or 1992 the area explodes into violence. Most of the time the warfare is small and is between rival gangs. It’s considered so commonplace as to not receive much news coverage. It’s an occasional footnote. It’s a sad part of reality.

It’s easy to treat violence when children are young. It’s treated as part of parenting. If your child is starting to hit, bite, kick, pinch, punch, or talk seriously about hurting others, go get treatment. It’s easier to get treatment sooner than later.

How do you know the right things to do? This is something someone comes to a psychologist for, a minister, a priest, a rabbi, or even a psychic. Psychologists decide for themselves by following a system of ethics. Ethics are a set of rules of behavior set out by the American Psychological Association and agreed to by it’s membership. If I have a professional question about something I can call the association or write emails and ask other members what they think and get their ideas. Most of the time the members have the same ideas on what is right and wrong.

In addition to ethics, there are the laws of society. There are local, state and national laws. There are the common laws of civility. These are the laws of civilization. These are the laws of etiquitte and class. People know them when they see them violated. They make refined people cringe. They cause social problems, often unspoken.

Finally there are religious laws and family laws. Most people have heard of the 10 commandments as part of religious laws. But there are others. These include dietary regiments, prayer rituals. Family laws are more complex and include which pan to use for what, and what side to put the spoon on in relation to the plate and what plate to use when Aunt Sophie comes over.

I’ve been lobbying to get “inadequately socialized” as a diagnostic label for children in psychology. These are children who haven’t quite gotten the rules down. I’m not blaming anyone here. I evaluate people for an hour or so, which doesn’t give me any idea about what someone will do in treatment.

I do understand socialization. When I started in psychology I didn’t start working with people. I started with cats, then moved to autistic children and adults, then I moved to criminals, then to violent people, then I taught parenting and became a psychologist. So working with both animals and people that do not fit in well with society was what I worked with long before I became a psychologist. So what is socialization? It’s how you get someone to live in a family and follow the rules. If the cat hides out behind the washing machine all day and doesn’t interact with any family members it’s not socialized. If the child stays in his room spinning the car wheels and makes no eye contact he’s not socialized. If the girl bites as a greeting she’s not socialized.

In some cases with children there is some big problem like autism causing the problem with socialization. But in other cases there isn’t anything other than parenting in question. How does a parent say no to a screaming 18 month old? Quite firmly. Unfortunately, some parents find this difficult and don’t do it. They say so. They tell me they just can’t deny their child anything the child wants. So I see children who interrupt their parents, children who hit, kick, bite, scratch and pinch, children who use bad language toward their parents and toward adults. There are children who are not able to stay seated in a chair, not able to stay seated, not able to come when called, not able to stay with their parents in a public place, and can’t pick up their toys. My hyperactive dalmation can do these things. Don’t blame hyperactivity. Most of these children are much smarter than my dog. Don’t blame retardation.

What bothers me about this isn’t just that these children aren’t socialized, but that the parents are so unclear about what any of the rules should be. Psychologists try not to interfere in the belief systems of others. It’s one of our ethical ideals. But that means that the people we work with should have a belief system. Without one, then the ideals of society get imposed. In the United States we live in a Judeo-Christian system. The laws came from the Common Laws of England and from the Religious laws of the 10 commandments. So I’ve got some basic ideas about how most people work in society here. Every once in awhile there will be some family with a different religious system, like Muslim or Wiccan and I can adapt. But when a family comes in with no system then I wonder what the family is using for a framework. Often they are using nothing and it shows. So I can explain that they have no structure, no rules, no framework, no behavior plan, and no idea about how to socialize that child for their family.

So how does a family socialize a child? The do it yourself model is difficult. You create the same types of rules religion has created. You come up with a list of things that are right and wrong. These are absolutes. A family can create these themself but it’s easier to find a religion that fits with their beliefs and save themselves some work. Then there are rules for conduct in society. These are the rules about how to behave. Are you quiet in public places or noisy? Do you yell for service? Do you yell when displeased? Do you converse socially to hired help or are social conversations limited to people of the same station? Do you ask for extra things if they are promotional or take only one. These are class rules. There are rules for dressing, eating, toileting, speaking, manners, greeting, and behavior in public related to class. Remember “My Fair lady and Pretty Woman” these were about changes in class standing and the rules about class. Then there are the rules about family. There needs to be structure and consistency to provide safety and security. The family rules need to be clear. The clearer the rules are the easier the rest of life will be.

The dogs and I returned from our Las Vegas outting. They had a good time guarding the house. There was a lot of fireworks noise all weekend. They had a lot to guard.

We did go on a long walk around the neighborhood. We went early in the morning before the heat got up to 107. It’s mainly a dog neighborhood which is a good thing. There were a few errant cats which Cinnamon considers snack food. There was also one aquarium turtle on the front lawn. Neither Cinnamon nor Baxter have ever seen a turtle before. They left it alone and got busy with smelling things in the new neighborhood and searching for errant cats.

Cinnamon did get almost within 2 feet of a cat lying on the sidewalk. Eventually the cat decided it wasn’t a friendly dog and took off. I hadn’t seen it, it was the same color as the sidewalk. Cinnamon hadn’t seen it either, otherwise I would have been dragged sooner. Baxter actually lived with cats in his former life, but he has assisted in helping purge the backyard of cats with Cinnamon so he has changed his ways and now is less than hospitable.

The big problem happened a couple of miles froom the house in Santa Clarita. We were driving along and had gotten to surface streets. Some guys in a pick-up truck decided to introduce their shepard and Jack Russell terrier to Baxter and Cinnamon at a stop light. To say the dogs didn’t like each other was an understatement. It was all barking and nashing of teeth on both sides of the closed windows. Lots of noise. Very upset dogs. So unless you have some idea how dogs are going to relate to other dogs in cars don’t attempt to introduce them.

I’ve been through this before. Cinnamon hates most dogs and gets territorial. She likes dalmations. If she sees a dalmation she’s alright. Baxter likes some dogs like Australian shepards but doesn’t like small dogs like terriers or poodles. I saw the shepard but not the Jack Russell in the truck. The shepard started barking immediately then the Jack Russell popped up and Cinnamon went nuts. Baxter started whinning at the Shepard wanting to play but started barking at the terrier when he saw it. Very not good. If I was on the street I would have crossed to the other side of the street and distracted the dogs.

I have rude dogs with poor dog manners. I know that because I read The Secret Life of Dogs. I also had a great dog trainer and had Cinnamon in the puppy socialization class for 5 weeks. She’s still a punk scardy dog even though she’s almost 75 pounds! She does a nice puppy bow at greeting, but then she sniffs too much and she humps bigger dogs. She has no dog etiquitte. Baxter is the epitomy of rude dog. He does cat moves. Cat moves are the biggest insult you can do to another dog. One dog was so insulted that he jumped over a fence to bite Baxter in the face. I keep trying to show Baxter that rolling on the grass in front of a dog is just the wrong thing. You are supposed to bow to another dog then approach to the side and politely sniff. But he always moves from bow to full stomach slide. It’s how a cat says “up yours” to a dog. Very not good. It’s not as horrible as giving the neck, which is dog for flipping them other dog off. Cinnamon does that. But she does that behind the gate. She usually hurls herself at the gate barking then gives the dog in front of the house the neck. Whoever is walking their dog has no idea why their dog then goes crazy. But they go crazy. People seem to have lots of problems controlling their dogs in front of my house when Cinnamon is outside. It has improved the sale of Halti collars in the neighborhood though.

The dogs did love the trip. Not as many people were waving at them this trip. They slept most of the way there and back. Now that they have been there it’s not as exciting. The big deal will be the fireworks tonight. They will stay inside to lessen the noise. There are three places in the community that set off fireworks near the house. Almost every year one of the places sets one of the hills on fire. I wanted to be home just in case something got too close. So I get to spend the 4th at the big house with the big dogs watching the big fireworks display. Have a Happy 4th everyone.

I met a woman who postponed getting that lump in her breast examined for 3 years and watched as it got bigger. It was class 3 cancer when she got it removed. She was fortunate she survived her procrastination.

I get tested for cancer every year. The tests came back negative this year again. The testing allows me to make informed decisions. It’s part of a complete physical. People in psychology sometimes don’t take a full physical history when they do an intake on their new patients. That can be a mistake. A lot of physical conditions can contribute to emotional problems. Things like anemia and thyroid disorders are frequent causes of depression in women. Infection causes fatigue and can easily be mistaken for depression. If you don’t get a physical you miss the opportunity to get an early jump on treatment when it can be most effective, when the conditions are minor and easy to treat.

People who are living in poverty not only eat poorly, but have worse outcomes for physical health and mental health as well. Treatment is postponed until it is late. It takes longer to treat and longer to recover.

It’s not just diseases like cancer. It’s heart disease, thyroid disorders, gastrointestinal disorders, anemia, respiratory disorders, and orthopedic disorders. The longer you wait for diagnosis and treatment the worse they are.

The same is true with psychological disorders. It’s much easier to treat minor depression, anxiety, or thinking problems than to wait until they are serious. If you’ve had the same symptom for a couple of months it’s time to get a complete physical and then see someone for treatment of psychological symptoms.

A basic set of lab tests include a CBC or a complete blood count and a urinanalysis. These tests tell a physician basic information about how the internal workings of the body are in addition to some other measurements like height, weight, vision, blood pressure, pulse, respiration, and temperature.

Psychologists do testing as well. A basic set of testing will include a mental status examination. Some of us can do this subtly. I have family members complain that I want the person who is having the appointment completing the initial paperwork. Families want to help. But I get lots of information from the initial four pages of paperwork. I get vocabulary, spelling, reading level, punctuation, motor skills and motor speed. I get an understanding of what the person I’m seeing thinks is wrong with them. I review all the paperwork and I often have a lot of history anyway. I compare what is written to what is said. There shouldn’t be too much of a difference. If there’s a difference I have to explain the difference. It might be a learning disorder, or someone doing poorly. I saw someone who had very poor motor skills. He was intoxicated. He’d had 1/5 of a gallon of alcohol to drink the day before. It takes awhile for that amount of alcohol to get through the system.

All the information works together to provide a cohesive picture of how a person is functioning both physically and mentally. The paperwork, the physical history, the psychological history, the lab tests, the psychological tests, all work in concert to describe someone. It helps to provide the best picture to allow for the best decision making.

If you aren’t being seen regularly by your doctor and getting regular check-ups then you are doing yourself a disservice. You owe it to yourself and to the people who care about you to find out what’s going on. You can always choose not to treat your condition. If you choose not to know you loose the option to get early and efffective treatment for many disorders.