drmargaret

I am a forensic clinical neuropsycholgist. What that means in English, is that after I completed a doctoral degree in clinical psychology, I went on to complete two training programs. My first was in forensic psychology. Forensic is misinterpreted (thanks to television) to mean either working with dead people or with the police as a crime scene investigator, but what it actually means is with the law. I write reports for people to have in court. I’ll get back to the types of evaluations I do in a minute and the types of reports I write. I generally do not go to crime scenes. I never conduct investigations of crimes with police. I went through an additional training program following my forensic training program. I learned how the brain functions and how it impacts behavior in a variety of ways. I learned how the brain works when it is damaged from accident and disease. My ability to study the brain through psychological tests in this manner makes me a neuropsychologist. When I apply this to legal matters, I’m a forensic neuropsychologist.

All in all it’s about 24 years of training. It’s a lot of school. Areas of law are quite vast. They involve knowing cases specific to the local, state or federal judicial system. It involves keeping up with rules of evidence and what will be admissible in court or not. The rules change over time with judicial rulings. My training started off with evaluating individuals who were admitted or convicted sex offenders as part of their ongoing treatment and presenting reports to the parole and probation departments.

I left clinical psychological training with the misinformation that I should like the people I was working with. My work with sex offenders changed that. My role was to evaluate their treatment and to ensure compliance with treatment. I was an extention of their court order. I needed to treat them with respect and dignity. It was fine if I did like them, but it wasn’t a requirement. The most violent of the offenders were brought into the office in chains with armed guards. I knew their offenses. They primarily offended against children. I could respect them; it would be hard to like some of them. It was surprising to me when I did like them. It was heartbreaking when they were not following their treatment, or were reoffending and were having to be sent back to jail or prison. Evaluation involved psychological testing with mental status questionniers, tests specific for sex offender populations, and showing slides or movies or listening to audiotapes of sex offenses and wating for arousal patterns on a penile plethismograph–think of it as a lie detector for a man’s penis. So if they were saying they were no longer aroused by children, I could actually show them pictures of children and tell. The men sat behind me in a small room with a door closed. I just watched the numbers on the dial and listened to dialogue on headsets or saw the slides or the movie as he did. There was a microphone attaching the man to my headset. Sometimes he would make comments to me. Almost always the comments were inappropriate. The comments would go into my report.

After that I worked on injury and accident cases for people claiming they were hurt emotionally or suffered head injuries. They called the emotional injuries damages to their “psyche.” It’s a very different population. The reports are for alleged, not determined, injuries. A judge, arbitrator or a jury would have to determine if the person was in fact injured and the monetary value of the injuries based on the reports.

There are different rules for people injured at work than for people injured elsewhere. I worked with this population as well. There are tables to determine the monetary value of parts of people and whole people in various levels of education and ages. In years past, the industry of Worker’s Compensation, especially in California, was rife with fraud. There were lots of clinics set up to process people with very questionable injuries. People were plucked out of unemployment lines to file for psychological injuries from their last employer for simply having been laid off. In some cases the people had legitimate injuries and simply didn’t know about the system. In other cases there were no injuries present and the person was just told it was a way to get money. In more recent years the laws have tightened. Fraud laws have been put in place and clarified. Most people have legitimate injuries but some still exaggerate the nature and extent of their difficulties trying to get more money.

Finally, I got called in to testify at court. The court cases have been of a wide variety. I testify in court based on how the attorney knows me. If the attorney knows me from my treating sex offenders I may get called in to testify on behalf of a sex offender. I do not like these cases and am no longer taking them. I don’t believe psychology has tools available to adequately treat offenders and I don’t believe we can differentiate who will offend from who will not offend. The most recent studies are showing that the treatment programs the prisoners are volunteering for are not doing anything for the offenders. For career sex offenders, I don’t think there is anything much we can do for them. There may be a few sex offenders who benefit from treatment. I have met them. They go on and live normal lives. These are people who are offending in their family and aren’t offending against stranges. Violence or coersion isn’t involved. People abusing substances during offenses may also benefit from treatment. Once the substance abuse is stopped, the offense may stop. The vast majority of sex offenders are adult men molesting young girls.

I do take cases where there are personal injuries with psychological damage or possible head injuries. I do evaluate people who have had injuries where the people may have had something wrong with them when they were injured to start with and the degree of injury is unclear. I have worked with criminals and police officers. I have given testimony in court on behalf of both in different cases. If a police officer does something wrong I will say so. If a criminal is injured wrongly I will say so. If a police officer is following the rules set down by the department I will say that too. If the criminal was injured prior to coming into contact with the police in a prior incident I will say that as well.

Some attorneys know me from my ability to testify about rules and regulations in health care. I did quality assurance. I know what health care agencies are supposed to do. This applies to doctors, their notes, their office procedures, the hospitals where they work, authorizations, managed care organizations, appeals and grievance procedures, pharmacies, labeling of pharmaceuticals, prescription writing, and handling of sample medications. So I can tell an attorney to hire a pharmacist specialist because the prescriptions and the process of prescription management is wrong in a case. Or I can tell an attorney that the chart notes are wrong and not standard and to hire a medical doctor to comment on that for that speciality. Or I can explain to the attorney that the hospital is governed by the JCAHO and to contact someone on the standards because the organization doesn’t seem to be in compliance and to pull the most recent report.

One of the things I worked on as a forensic psychologist was compliance with regulatory agencies for large organizations. This involved making sure that all aspects of an agency were in correct compliance with all local, state, national and federal regulations. It involves a lot of paper. There are tons of lists. I actually got called in to fix problems because the organization was not in compliance with some aspects. Usually there are timetables involved in fixing the problems. I did a couple of these “projects” and got noticed by some attorneys and testified in some cases at depositions and in court.

Another area of forensics is competency. The ability to understand things. I have done two areas of competency. The ability to understand the legal documents someone is signing and the ability to provide legal testimony in court and to understand the charges against the person and to aide in their defense. Competency to sign legal documents means having the ability to read and comprehend what is written adequately enough to make an informed decision about signing or not signing the document. In the case I worked on the person did not have the reading level for the document, was corersed into signing the document, and even had she read the single words individually she would not have understood them. In the case on competency to stand trial I was asked to evaluate the individual independently because the court had already found him competent and the individual wanted a second opinion. I was the second opinion. He was charged with a felony case and was facing possibly 10 years in prison. He had no recollection of the crime due to his use of drugs at the time of the offense. He completely understood the charge against him. He spoke English although it was not his first language. He was fully able to participate in his defense. He understood all the major participants in the court-the judge, the prosecutor, the jury, his attorney and what heir respective roles were. He was above average intellectually. I too would find him competent to stand trial. I told him so. And he said “but I don’t feel competent at all. I think I’m going to lose this case.” So I then explained that “competent” means to understand the legal process and “confident” means to think you might win the case. He might benefit from a dictionary during the trial. I don’t know how the case came out.

I love psychological testing. It’s the majority of my professional job and it’s what hooked me in graduate school. I spend 7 hours a day, five to six days a week doing psychological evaluations.

Lots of people dislike the process of being evaluated. I can sympathize with that. I’ve been evaluated. In order to perform the tests I have to take them. I like some of the tests better than others. I think some of them have clearer items. I think some of the items are more challenging. I think some of the items are too simple or not engaging enough. I think some are too hard to see. What people dislike about the process of being tested, especially for SSDI, is the lack of feedback. I can’t tell someone if they got an answer right or wrong. I can’t tell them if they are doing as well as most people. So there is a lot of ambiguity in the process. Ambiguity makes people feel anxious.

Psychological testing gives me lots of data. I start collecting data from the moment I see the person. I might see the person in the parking lot or elevator or in the waiting room. I might not see them until I get their initial paperwork and call them in to be evaluated. I have a four page intake form. It is mainly check off boxes with brief answers for some history. I review the form with the person. An average person with a high school education can complete the form in 15 minutes.

Most people don’t realize that from that limited interaction of seeing someone walk down a hallway and having them complete a form made up of check off boxes I already have an approximate IQ score. I have an idea about what is wrong with them and what they are applying for. I have some idea about their ability to remember basic information.

After that I get to talk with them. My questions are to confirm or reject the hypotheses I am attempting to develop. Psychological testing has gradiations on how I can score responses. Some responses can get a score of 0. The response isn’t close enough to the answer to merit a number. Some responses get a 1. It’s closer, but it isn’t quite it. The person knows what I’m talking about but hasn’t articulated it or put it together enough. Some responses get a 2. The person knows what it is and can articulate it. There isn’t a test I know of that asks someone to describe a banana. So I can use it freely to describe it as an item. A zero would be a yellow thing. You keep asking the person to go further and tell you more but they can’t go beyond yellow. As far as you can tell it’s a yellow beach ball. A one is something you eat or it has a peel or you cut it up for corn flakes. They clearly know what it is. A two goes beyond that to a classification to a fruit. They may go further to a tropical fruit. Tropical fruit tells me they are smarter than the person who just says fruit. Now there are debates about people who use common use versus abstraction. You have to get the person to abstract before you score the response and you get around the debate. The tropical fruit person is going to keep me longer on the test and we are going to go through more items.

There is also speed. People who work quickly get more points than people who work slowly. Speed on tasks stays fairly constant. If it declines over time then the decline is steady. So if someone finishes the forms in 15 minutes then I expect an average perfomance on all the timed tasks. If they suddenly slow down when the timing starts it gets kind of obvious. It’s like they say to themselves “Oh, she brought out her stopwatch, let me slow down by 80% now.”

Then there is memory. People have lots of misinformation about memory functioning. Memory involves lots of parts to it. It involves paying attention long enough to put information into memory storage. Concentration to hold information in memory. Storage in memory in the immediate memory range. Transfer from immediate memory to intermediate memory. Then eventual transfer into long term memory and ultimately retrieval of information from memory. People will tell me they have “no memory.” That almost never happens. In addition they tell me that after completing 4 pages of historical information. Concentration problems are what people usually mean when they report memory problems. Occasionally there are some people who can’t remember. Vascular problems are the most common causes of memory difficulties. Depression is the next cause and is reversible. Finally there are actual problems with the brain. Accidents and diseases impacting the cortex can cause memory problems. People try to fake memory problems about 2-10% of the time. There are tests to evaluate faking. It’s sad that people think they have to exaggerate their real problems or fabricate problems to try to get a check for benefits. It complicates the lives of the people who have problems. It makes a lot of work for all of us in the field.

When everything lines up correctly, psychological testing makes the evaluation process easy. The person comes in with complaints. The complaints match everything the peron says. The complaints match all the data. The complaints match all the history. The complaints match all the statements from all the treating providers. The complaints match the objective psychological test data. There is a report to that effect. The analyst for the person makes a decision which is then comparatively easy. The person either gets benefits or they don’t.

The worst thing someone can do is to try to fake data or exaggerate their illness or problems. When they do that then they are considered suspect. Then everything has to be looked at with suspicion. So the person comes in and says “I don’t know what a banana is I’ve never eaten one. I don’t eat fruit.” That’s not a 0. That’s a 2. But the person is being a jerk. They clearly know the thing is a fruit. If they do that throughout the testing the test will not be able to be scored. They can be classified as above average but problematic. Lot’s of people are problematic. They don’t like testing and are resistant. I end up describing the resistance. I classify them. Resistance doesn’t help them. It hurts their case.

I ask lots of questions.

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.

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.

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.

I might as well jump into the fray about the contention between Scientology and Psychiatry. Last week Tom Cruz went on the Today show to promote his movie The War of the Worlds and got into an argument with Matt Lauer about the use of psychotropic medications. Lots of news stations covered the argument. I saw it rebroadcast on CNN. I then saw a panel discussion on the Today show the next day with the strangest collection of “experts” about medication. These included a psychiatrist who is opposed to psychotropic medication, a psychologist, and Marie Osmond who had suffered from post partum depression. I’m not sure what anyone could reasonably get out of those “experts.”

There’s a long history of several hundred years of problems with psychiatry. Psychiatrists were making guesses at what was working and what wasn’t for very serious mental illness. These were the people who were confined in insane asylums. These were people with illnesses like dementia, serious organic disorders, the criminally insane, schizophrenia, and bipolar disorder. Occasionally a major depression would slip in, but that was rare. The big break through happened when someone noticed that some schizophrenics with high blood pressure got better on a blood pressure medication known as reserpine. (Schizophrenics see things, and hear things and have delusions and strange thinking, they don’t have split personalities.) So some researchers started looking at why people got better on reserpine and made the hypothesis that chemicals in the brain caused people to be psychotic. So a whole variety of chemicals were developed by drug companies to try to normalize these abnormal brains. If you take pictures of schizophrenics brains on MRI they look different than people with normal brains. They also look different on autopsy. The same is true with dementia also known as Alzheimer’s disease where the entire cortex of the brain shrinks. This starts after age 45 and no one knows why it happens in some people. It produces memory loss. Memory loss isn’t the only symptom but it’s the most obvious. Bipolar disorder used to be known as manic depressive illness. The name was changed a few years ago but the disease is the same. There are periods of grandiosity and severe sleep disturbance and possible delusions with a frank manic episode, and periods of depression. Every single one of these conditions can be improved with medication. In many cases, medication takes these people from institutional care to functional ability. If it is possible for any of these people to live independently without medication outside of an institution then they should absolutely make an attempt at that prior to attempting medication.

Medication is used as a last resort. Hospitalization is used as a last resort. Institutional care on a permanent basis is used when all methods of treatment fail and the person can not live safely in society. Right now people get psychiatrically hospitalized because they are either dangerous to themselves, dangerous to others or gravely disabled and not able to adequately care for themselves. Medications are used on an urgent basis to prevent hospitalization. With correct supervision sometimes they work and are life saving. Sometimes they are given out like candy with little supervision and little direction. They can be harmful when used in that fashion.

Medications are also used because they are faster. They can be problematic when used like this. A child is bouncing off the walls at home. The child isn’t sleeping at all for days on end. The family is staying awake in shifts to watch the child to try to prevent the child from injuring himself. They have relatives coming in to help. There is a family history of bipolar disorder. There are clear parenting issues. The child is getting injured and has been breaking things in the home and climbing on things like bookcases and pulling them over on himself. The kid is running the home. He’s not socialized, is becoming hyperactive, inattentive, isn’t listening, and is getting aggressive. He’s been kicked out of preschool. The place to start with this isn’t medication, but I see lots of these kids coming in for evaluation on very strong medications, some not even approved for use in children. This is a poor practice and is simply done to be faster. Medication alone won’t solve all the problems and may create new ones. Medication may not even be indicated.

In contrast is the case where a teen is showing some episodes of brief delusions. Occasionally he reports everyone is against him. Sometimes he thinks things have been crawling on him. It’s only happened a couple of times so it’s not a big deal and no one is prescribing any medication. He’s being monitored closely. There’s a family history of schizophrenia. There’s been a suicide and a homicide in the family so the stakes are high here. The family is working closely on parenting issues. He’s had normal teen conflicts. Every once in awhile something seems to go awry. The thinking process is disordered. So far he doesn’t need any medication. He functions at home, with peers and at school with just some unusual episodes. The family members all understand the stakes. He can stay the way he is and be a productive member of society. He may not need medication. With stress he may become paranoid and delusional but not need medication. Some members of the family have been able to do that. Others have gone on to develop the full paranoid schizophrenic syndrome and have not been functional even with medication requiring episodes of hospitalization or institutional care. Others have decided to discontinue medication after being released from institutions or hospitals and have either killed someone or killed themselves while in a delusional state.

Now I talk to people who aren’t taking medication, or who are struggling with violence frequently. I think that before someone decides that taking medication is so appalling as Tom Cruz suggests, that they need to recognize that for some the alternative is suicide, homicide–with the attendant prison term, or a life in unspeakable torment by internal demons rendering them unable to function in society.

I don’t think medication is a choice to be made in a flip or glib manner. I don’t think it’s to be made on the basis of what’s easier. I do think it should be the last option. I certainly wish the drug manufactures would test medications on children so we knew the effects. I wish parents were advised when drugs for their children were being provided off-label so they could have informed consent that we don’t have a clue what the medications are doing to their children. But I think psychiatric medications allow people to live full and productive lives outside of State run institutions. Psychotropic medications have saved lives.

In the past week or so, there were two earthquakes in Southern California, one in Northern California which triggered a tsunami warning, one in Alaska, and one in Japan. While most people at the office knew about the two in California they didn’t know about the others or many other smaller earthquakes that occur around the globe. I follow earthquakes as a hobby. The link provides a map to the US Geological Survey.

Now it's important to do some basic planning if you live in California for earthquakes. Having an earthquake kit in your car is a great idea. The old idea of standing in a doorway is a great way of getting your fingers smashed and the better idea is to stand in a hallway or to get under some sturdy furniture. Running out of a house is a bad thing and you get hit by debris. Most of the time you can just ride out the shaking and cover your head. When the shaking stops put on shoes and watch out for glass. Be careful when opening up cabinets because everything shifts. It may not be where you left it. The more you can plan the better things will be. The less you scurry around running around in circles the less likely you will get hurt. People up in Santa Clarita who took off after the Northridge earthquake in 1994 got hurt as freeways and roads were collapsing. Wait until everything stops shaking and there is some light if it is dark. Get a first aid kit and a manual. If you live in an area where there are some major disasters, have camping gear. Have a plan. You may not know when the next earthquake is coming even if your goldfish and puppy is acting weird and everyone around you is crazy, but you can certainly get everyone calm, have extra fish food and puppy food on hand and get everyone settled down while sanity resumes.

People report hallucinations as one of the most common reasons why they seek treatment by a psychologist or psychiatrist. Hallucinations can actually involve any of the senses. The most commonly reported hallucinations are auditory hallucinations and visual hallucinations. Medical conditions can cause hallucinations as can psychiatric/psychological disorders.

When people are trying to fake being disabled, hallucinations are frequently what they report are going on. The most commonly faked hallucinations are reports of seeing dead people or hearing dead people.

Real hallucinations may indeed involve seeing former family members, but hallucinations are accompanied by more symptoms than just hallucinations alone. What people miss when they attempt to fake the hallucination is the package of symptoms.

Visual hallucinations often involve seeing dream images when not dreaming. These are the result of impaired rapid eye movement stage of sleep. It takes place over a period of weeks to months, although in some cases can occur in as little as 5 to 10 days with a medication like an antibiotic. In fact, it’s often a side effect of a medication like an antibiotic. It goes away after the medication has been completed and is no longer in the system. People may often have periods during the hallucination where they can’t seem to move. They may have a falling sensation or a flying sensation. These hallucinations often occur just as sleep is starting or ending and the person is already in bed. They are a sleep disturbance.

Another type of visual disturbance misconstrued as a hallucination is a floater. This is a sediment from the aquious humor of the eye which has been dislodged and now floats. Although it’s behind and within the eye. The person sees it as outside themselves. It’s often described as spiders or roaches on the walls. It’s frequently a sequella of head injury.

Auditory hallucinations range from actual conversations between people to sounds in the environment. The most common one is someone’s name being called when no one is there. As an occasional event, it has little meaning. As it increases in frequency it may signal hearing difficulty, sleep disturbance, or psychiatric problems. Noises are the same. Buzzing noises, known as tinitis, can be extremely irritating. Some are due to hearing loss produced as side effects of medications which are toxic to the hair cells in the inner ear. They signal eventual hearing loss. Depending on age, other noises may represent other toxic body states such as kidney disorders or liver disorders and the body’s difficulty with filtering out the wastes in the system.

More unusual hallucinations come from illegal drug use. As brain cells are killed off, visual, auditory and, in some cases, tactile hallucinations develop. Even when the drugs are discontinued the chemical effects can last for some time which the brain heals. This is especially true with the designer drugs, with methamphetamine, and with some of the natural hallucinagenics which can be fatal. It’s not pleasant to watch someone attempting to rip their skin off because they think there are bugs or snakes burrowing under it. Tactile hallucinations do not appear to be pleasant in the least.

I’ve had visual, auditory, olfactory, and gustatory hallucinations. So I can discuss those experiences personally and know what those experiences are like. My family has some rare medical problems. If they are not correctly treated we develop severe sleep problems and depression. Medication for depression or psychotherapy will not fix the underlying medical condition which is a gastrointestinal disorder which disturbes the neurotransmitters in the brain. It causes vitamin deficiencies, oral lesions, skin lesions, and lots of changes throughout the body. It causes scary dream images, auditory command hallucinations, and hallucinations of my name being called. It causes depression and insomnia. Knowing the events weren’t real and were hallucinations didn’t make them any less frightening. There were times when the visual hallucinations were pleasant, bunnies hopping all over the walls, and the voice was positive not negative, but still vague in quality. There were other times when I could see shadows or could see things moving that were stationary. Knowing what these things are like helps me when someone comes in and tells me they are hallucinating. I know all about hallucinations. I come from an entire family that has them. It’s not like we don’t talk about it. We compare notes. I know the difference between my hallucinations and those of people who are depressed or schizophrenic. There are differences in the quality, and the substance of the hallucinations.

My olfactory and gustatory hallucinations are related. In 1985 I was assaulted when I came home one evening from work. A man hit me in the face breaking my glasses into my face and I fell backwards. He stole my purse. He got all of $10. In the process of breaking my glasses into my face my olfactory nerve was partially severed. The olfactory nerve controls your sense of smell. I have a significant loss of sense of smell. Smell is significantly connected to the sense of taste by 85%. When I lost my sense of smell I lost most of my sense of taste. What I got instead were hallucinations. In the presense of strong odors I have a smell. It isn’t the smell that’s there, it’s a different smell. It’s a hallucination. When I taste a strong taste, it’s not the taste that it’s supposed to be, it’s a different taste. It’s a hallucination. Now it’s been 20 years and I’m used to the changes, but my diet tends to be rather bland tasting foods as a result. The good news is that if someone hasn’t taken a shower in a couple of weeks and has been sleeping outside I really can’t get how bad it is, just a minute fraction. So there are some benefits.

People get prescribed medications for a variety of things. One of my neighbors was given an antibiotic and we were having a conversation about it. I was a pharmacy clerk for a couple of decades so I know a bit about medications.

Medications are labeled very specifically by the pharmacist in accordance with the prescription given to them by the doctor. The prescription has the name of the person to take the medication, the date the medication is filled by the pharmacist, the number of tablets in the container, how the medication is to be taken, the name of the doctor, and the phone number of the pharmacy, and the number of the prescription for reference. These things are all required by prescribing laws. The pharmacist isn’t allowed to pour medications back into old containers. Sometimes if there is a shortage of medications there can be an amendment made to the number of pills made in the container but that’s about it.

Now how people take medications is a completely different story. The person asking me about her antibiotic was asking me if the three times a day label was a suggestion or if she really should take it that much or if she felt worse to take more and if she felt better to take less. So for all of those people out there who are unsure let me answer this once and for all. Think of it as a commandment from God. You take it exactly as it says on the bottle. You don’t take too much. In the case of the antibiotic, if you take too much you will get the runs. You don’t take too little. In the case of the antibiotic, if you take too little the bacteria in your system ir was killing off will start to grow and multiply again. So you take it exactly as directed.

So the big question for a lot of people is what does three times a day mean. For some people you might want to ask your pharmacist. For most medications, three times a day means morning, afternoon and evening. For some medications it means every eight hours exactly, set your clock to wake you up if you need to.

This adherence to labeling is very important in using psychiatric medications. A lot of psychiatric medications take time to work. In many cases a couple of months before they start to become effective. Then they require a constant amount of medication to be in the blood stream to maintain that effectiveness. If someone only takes medications when they feel depressed, or anxious or psychotic then the medications will not work at all they will only produce side effects.

All medications have side effects. Side effects are things that are not the general intended effects of the medications. Not all side effects are bad, in fact some medications are specifically prescribed for their side effects!

It’s also important that you read all the stickers that come on the container that your medication comes in. They tell you important things about your medication. Some medications need to be taken with food. Some medications need to be taken on an empty stomach. Some make driving hazardous.

Make sure you tell the doctor who is writing the prescription about every single other medication you are taking. Make sure in the list of medications you include all the herbal medications and vitamins and over the counter remedies and all that stuff that you “borrow” from other people. If you are using illegal drugs, make sure your doctor knows about it.

Now for those of you that go “doctor shopping” to obtain illegal drugs, it’s not that hard for someone to figure it out. I’m frequently amazed how long it seems to take an MD or series of MDs to catch on. I’m not allowed to report stupid things people do to themselves. When someone comes into an evaluation with four bottles of medication and two of them have someone else’s name on them I get to ask about the other person for whom the medication was intended. When the medication is a narcotic I start getting suspicious. When I see four bottles of a narcotic for the same person filled within a week by four different physicians I’m not suspicious of anything except if the MDs know each other is filling the same medication for the same person. It’s bad practice. Ultimately it’s going to hurt someone.

At least once a week I see someone with long term effects of illegal drug use. Some of these are young people. Some of the effects contine long after the drugs stop. There’s a recent practice of mixing pharmaceutical medications with illegal drugs. Some of these combinations are fatal. There are tremendous spikes in blood pressure and the areas which regulate temperature and the the midbrain fail to work correctly and nothing can fix it. In some cases the heart goes into an arrythymia and beats wrong. It’s a mess.

Some medications interact with things like food. Sometimes you might see a label saying don’t take this medication with grapefruit juice or some other food. The food will either reduce the effectiveness of the medication or will make it too strong.

Finally there’s a book I want to mention. It’s called the Physician’s Desk Reference. It’s published every single year on all of the medications. It’s put out by the manufacturers of the medications. It tells what the medications do, the chemical properties they have and the side effects, their effective dose, and they have pictures of what common medications look like. It’s a collection of all those little pamphlets that come with the medications. The book is either red or blue in color and most libraries have a copy at their reference desk.

For professionals, there’s a book which is updated by researchers on medications. It’s called Facts and Comparisons. It’s available at Medical Libraries. It lists the research on the medications done by researchers, not just the research done by the drug companies. It compares the medications across classes. There are monthly supplements. Check with your local Medical Library to see if they have a copy.

I get told often that forensic psychology must be a very interesting field. People presume that I do crime scene investigation. I don’t. When “Quincy” was on television, people presumed I worked with dead bodies. I don’t.

Let me explain what the word “forensic” means for all you people who don’t want to look it up. It means simply “having to do with the law.” For those of you old enough to remember the television show, Quincy was a pathologist. A pathologist examines cells and tissues, and can determine illness. Therefore a forensic pathologist is someone who determines the causes of death for a court of law. Lots of people are involved in crime scenes. The stuff they show on television mixes up several types of professions for the purpose of making an interesting show. They are all investigating what happened. They are all doing it for law enforcement and ultimately for a court of law or for the police or district attorney. They are all therefore doing forensic work.

I’ve done several types of forensic work. I provided treatment to mentally disordered sex offenders as required by the courts. I provided testimony as an expert witness on several different types of cases in terms of how someone functions psychologically in different circumstances. I provided testimony in statements that were recorded legally as depositions on what the appropriate standards of care are in the regulatory community in terms of hospital treatment, note writing, standard of practice, and care for patients. Sometimes I talk to attorneys about medical cases that have an impact on cognitive functioning. Psychology is one of the professions that can test how the brain functions as it works to do tasks. We can measure how people think. There are lots of different ways to measure those thinking processes. Medical problems can cause some difficulties in thinking. Medical doctors can take pictures of the brain and can look at the structure and the the tissues and the chemistry and the blood flow. They can take MRIs and CT scans and PET studies and BEAM studies and lots of very pretty colored pictures. Psychologists, especially neuropsychologists, can tell people how their brains function. They can explain for the court the difference between normal brain functioning at the level of the thinking part of the brain, the cortex, and the abnormal brain at the same level. Forensic neuropsychologists do that for the courts.

Psychologists look at behavior. Forensic psychologists look at behavior as it applies to law. I saw a woman who had signed some papers. She couldn’t read well and was told to sign the papers by someone she liked and believed. The papers gave away the house she lived in. There was no question that she had signed the papers. There were photos of her at the bank signing the papers. There was a question of whether she understood what she had signed. She was not able to read the document in my presence. I gave her a reading test. She could read words at a fourth grade level. She could understand words at a fourth grade level. The document she signed was at an eighth grade level. It was not probable that she understood what she had signed.

Psychologists talk in probabilities. That comes from math. We use statistics to make decisions. If you flip a coin you have a 50% chance that it will come up heads and a 50% chance that it will come up tains if the coin is evenly weighted. You flip the coin 10 times and 9 times it comes up heads. The next time it is 50% likely to come up heads assuming it is evenly weighted. As you continue to flip the coin and continue to get heads you may start to doubt that the coin is evenly weighted. You may speculate that the coin is favoring to fall with the tail side down. Those speculations would prompt you to do research on the coin. You would be starting off to test your theory about the coin and your hypothesis that the coin wasn’t equally weighted. These kinds of data collection and hypothesis testing are what psychologists do. They do them on people, on situations, on animals, on lots of things. They make observations, they make hypotheses, they collect data, they do some research, they collect more data, they tell people what they find. Forensic psychologists tell people in law.

I do Social Security Disability Evaluations. It’s important work but nothing like crime scene investigation. People tell me what’s wrong with them. They have “allegations.” The allegations either make sense or they don’t. I’m limited to evaluating allegations in my field of psychology. Often people have allegations in other fields. They will tell me they have pain in their arms and legs. That’s going to be evaluated by someone else. I write down in my report what they tell me is wrong with them. That’s evidence. I do psychological testing. I determine a diagnosis. I write a little thing called a Medical Source Statement. I answer a few questions from the State of California on the person’s ability to do some specific tasks. Those answers are based on my test results and my opinion about how well they did in their effort. My report then goes either to their disability analyst to make a determination or to an Administrative Law Judge to make a determination. I don’t decide anything. I don’t treat anything. I don’t make any recommendations. So if someone tells me they graduated high school and they believe 1+1=6. I write that down in my report. I’ll check the allegations and the history to see if anything explains why they think 1+1=6. I’ll ask about treatment. I’ll ask a bunch of other questions. If they also tell me other stupid things, I might wonder if they realize I went to school for a very long time. I might suspect fraud. I don’t have all the history. The analyst or the Administrative Law judge can get more history. I might suggest they do that if I don’t have enough information in some areas.

I like the evaluation to be consistent. The tests usually are consistent across measures. People tell you what’s wrong with them. You find that. You write it up. Very simple. It’s not very complicated.

There’s stuff that’s complicated. Most of the tests are developed for people who can talk and hear and see and who speak English. When people come in who need translators or who can’t talk, or can’t see or can’t hear, there are adjustments that need to be made to insure that the testing is accurate and fair. I know a few words in a variety of languages so that helps quite a bit. The testing still should match the history and the allegations and the presentation. If it all comes together it’s all fine. When it doesn’t there’s lots of explanations needed.