A Gift From My Son

I have been contemplating writing this post for 3 weeks now. I don't know why I want to write this, nor do I understand why I don't. For the most part, I have tried to keep this blog about my ups and downs in the residency and have used my children only as examples in posts, as needed. At least that is what I have tried. You be the judge.

Yet, my absence here since January is, for the most part is due to my children, specifically my son. As a working mother, I have many things that make my life rich and expand my horizons beyond my home and family. That being said, I have never been more aware of my guilt and sorrow than in the last 3 months. I have had days when I have ached to not work and to be available to him. I can't say that he feels the same way because he is almost 8 years old, and this is all he knows: me working. There is no other reality for him. His mom is a physician and she works. I, however, have access to an alternate reality. My daughter, who is 10 years old now, knew me as a stay-at-home mom for the first 2 years of her life, and although I had a very rough start with her, as a new mother, I tend to romanticize the era more than I should. Funny that I am aware of that, yet in these last 3 months, I have had bouts of nostalgia and longings for what-ifs, for my son.

For the most part, what I do for a living brings me joy and makes me feel good about myself. I can't remember many days when I felt miserable. Annoyed, frustrated, and tired, for sure, but never miserable. It's safe to assume that I have been fairly happy with what I do, and still am. But now I wish that I had the leeway of being at his school for more than 30 minutes in the mornings, when it's my turn to drop them or had the freedom to go to be in the classroom, when I felt like it. I am not sure if that would make a difference for the challenges that he faces daily with learning, or if I had never worked, would he have developed dyslexia? The rational, scientific side of me knows that he would have because that is the reality of dyslexia, but the emotional part of me feels the sorrow. Kind of sorrow, only a mother can feel, when she feels inadequate.

I always felt a natural pull towards the mothers under my care, who struggled with special needs children. There was this connection with them, and I had to be very mindful of it, so that the treatment wouldn't be compromised by confusion about their feelings vs mine.  Maybe because I related to a mother's frustration, when her daughter couldn't read despite extra help at school and home, because after the clinic was over, I was that mother. Or maybe I felt bad for the mother, who didn't know why her son couldn't sit still and had to constantly move, and questioned whether he had ADHD, because I knew what that felt like. I also knew that there were no easy answers, I could give them or to myself. Until I found out last month that there indeed was an answer. Having a child with dyslexia and sensory sensitivity, even though unbeknownst to me until now, has given me a different perspective on things. The simple logistics of how much work it takes to navigate the school system are mind-boggling. I have a new appreciation for the word "overwhelmed."

But I have learned that I don't know much about learning disabilities, even being a psychiatrist, I don't. I have started reading more, and I have started asking simple questions to my patients. When I see a struggling patient, or when patients tell me about how awful their school was, because they were stupid, and couldn't read or write, I try to get more information from them, which I wouldn't have thought to do before. While I am aware that I am not diagnosing people with learning disabilities after the fact, nor am I trained to do so, I am now interested in knowing their strengths and weaknesses, to think more broadly about them.

Having a son with dyslexia has opened my mind to the struggles many of my patients talked about previously, and I didn't know how to navigate those. Necessity is the mother of invention, and my need to help my own son has pushed me to invent means to educate myself, which in turn, tunes me more keenly into my patient's childhood and even adult struggles.

I can't stop working because that is not the answer, nor will it help my son, but I do know that the only way to live with this is - to walk behind him and not in front of him. He has shown me how I am enough the way I am, by taking his diagnosis in stride, by sitting through relentless testing, and always coming out shining at the other end. He has touched so many people who evaluated him, with his tenacity and his teachers with how willing he is to work hard. If he has given me one gift from our struggle over the last many years and journey over the last 5 months, it's the gift of knowledge.

What I do for a living is not stagnant, nor does it exist in a bubble outside of my life. What happens in my life directly affects my work. My wish to work, my fantasy to not work, and my willingness to live somewhere in between, because isn't that the elusive balance, we as women always talk about?

So here is to embracing my motherhood guilt, with my son's affirmation that I am enough the way I am and letting him be the best he can be, with what he is. If he can love me with all of my work and for all the times that I feel like I wasn't enough, then I need to do the same for myself because there is no greater gift than to be loved and accepted the way you are.

   

A Good Enough Therapist

“Real isn't how you are made,' said the Skin Horse. 'It's a thing that happens to you. When a child loves you for a long, long time, not just to play with, but REALLY loves you, then you become Real.'

'Does it hurt?' asked the Rabbit. 

'Sometimes,' said the Skin Horse, for he was always truthful. 'When you are Real you don't mind being hurt.' 

― Margery Williams, The Velveteen Rabbit

Our weekly psychoanalytical seminar ended today with this reading from the famous children's book, The Velveteen Rabbit.  We are into our second pod and going through object relations.  We have read about Melanie Klein, Fairbairn, Bion, Ogden and now are reading Winnicott,  The famous British pediatrician who later took on psychoanalysis and was trained by Melanie Klein herself, is best known for his concepts of "good enough mother", "transitional objects" and was an avid advocate for mothers.  He introduces ideas such as "Ordinary mother and her ordinary love for her child" and talks about never interfering and undermining an able mother's ability to intuitively know how to take care of her child.  He boldly challenges the long held concepts of infant's aggression viewed in classical drive theory models and the original Klein object relation that focuses on the infant's fantasy.  He looks at aggression from a rather unique point of view of something vital to help transition from "object relation to object use." (Winnicott, 1969)  

The idea of a transitional space (Winnicott 1969) between the mother and child where play and creativity comes in play is the containing space for this aggression.  It helps the baby to be able to relate to the mother in his own time and manner.  For example a baby may bite his or her mother while feeding or even playing with her (those of us who have breastfed our babies can relate to this).  The biting is not simply an act of aggression related to his fantasy about the good breast or the bad breast, when you are in Winnicott's world.  It's rather necessary.  The baby is testing the limits of the mother's tolerance.  Of course the mother will react and will be in pain but it's what she does afterwards that matter.  If she can understand that the act doesn't mean that the baby is intentionally hurting her because he/she considers her bad, she will be able to experience the pain, show the pain and take the baby in her arms and feed him again.  The time old expression of children telling their parents, mothers that they hate them, is another example of a child's anger and rage towards the parent/mother in the context of whatever evoked that anger and the words came out.  What is a mother to do when the child does that?  I can tell you what she is NOT to do.  She has to allow the child to say this without shaming the child and not taking it personal because as hard as it is to hear that, the child is allowed to say that.  It will take a good enough mother to tell the child that she understand that he is angry and probably also hates her at that time for whatever it is that happened but she also wants to tell him/her that she still loves him/her and they can talk later.  

With time baby will learn that it hurts the mother when he/she bites but the mother still loves him/her and will continue to offer the breast.  The child will learn that it is okay to hate parts of his mother at some point but that doesn't mean that it ends the relationship.  The mother's ability to accept the child's true feelings without making it all about herself, promotes a true self that is nourished by acceptance and deep love.  Mothers who have not experienced the holding environment themselves, remain trapped in the inadequate transitional space with their own mothers; and are not be able to provide that safety to their own babies.  When they receive pain or harsh words from their children, they can't help but be threatened, defensive and enraged.  

A mother's ability to let the baby show aggression and experience that they may have hurt the mother without scolding, retaliating or shaming the baby, takes the baby beautifully into the object use phase.  This simply means that the baby learns to know the limits and powers of his/her part in a relationship and is able to hold on to trust and belief in the love of his mother.  That she can handle his/her personality and that he/she doesn't need to hide the true self in order to win and keep her love.  Baby is good enough for the mother as their true self and there is no need for the false self to appear.  

Children who grow up with narcissistic mothers or caregivers, turn into adults who don't have any idea of their "SELF".  Self is the basis of our existence.  

I will give you a simple example.  My supervisor explained the concept with this example today and as simple as this example sounds, it is the concept that matters.  Think about a baby who is playing by himself and is busy in his own world.  Now imagine a mother or caregiver who wants to interact with the baby at that very moment.  They baby keeps playing and ignores the advances because he is really interested in what he was doing.  The intrusion continues and continues to get intense, until the baby finally responds by looking at the mother or caregiver, or smiles and laughs in response to the whatever was going on.  Harmless, right?  Well not quite.  Of course once in a while, all of us have done this sort of thing with our own children or children in our families.  Now imagine this scenario many times a day for many days, weeks and months.  Repeated intrusions of the child's space, until the child gives up their activity to please the mother or caregiver.

Of course I do not mean that we should never initiate interactive play with the baby but rather that we be tuned into baby's need and give him space to be by himself, if he/she doesn't seem interested.  Now also imagine a child who can't be upset around his mother because the mother can't not take it personal and shames the baby into an apology or a child who is neglected and ignored because the mother's emotional needs overshadow baby's emotion needs.  Such children learn to hide their emotions and feelings to be the "good girl or boy" so the mother is able to tolerate them, love them and doesn't turn away.  Such adults never feel comfortable in who they truly are because they never had a chance to be themselves.  How could they?  They always had to hide their true self to be in tune with the mother.      

Think about the first scenarios and think about who is the real benefactor there?  If you said the child, I urge you to think again.  Are you thinking about it from the child's perspective?  May be you are looking at how the adult really wants to be with the child?  And you know what? You are right, the adult really really wants to be with the child and that is precisely what is wrong with this picture.  

The baby has to tend to the adult's need and give up their activity because the adult is relentless and needy until the baby gives in.  He can't be his true self, who wants nothing more than to play alone and be with himself at this point.  But rather has to respond to an external force and make up a false self to please the adult.  

This translates into therapy when the therapist provides the transitional space and allows the patient to be the true self, while he/she contains the rage, tears, loves, sadness and despair, without freaking out and shutting down.  When the therapist can push his/her needs aside and tune into the patient as a good enough mother may tune into her child, the patient learns that he/she can be their true self and that won't mean annihilation of the love object (in this case the therapist and the mother in transference) and a calamity of the childhood i.e. the loss of love of the object doesn't have to be reenacted.  Learning that there is an alternative to the calamity, may seem easy but that is the most intense part of the relationship with the therapist.  

Many adults and children who come to us to seek treatment and therapy, are still trying to find their real selves because growing up, they never had a chance to have a love as true and pure as the little boy who had the Scarlet Fever had for his fluffy soft toy rabbit.  The magic fairy of the nursery never came when tears rolled down.  For these patients the fairy can't arrive, until they can relive the nursery in their therapist's chair or laying on the couch; and feel that they matter more than they ever mattered to anyone before.  And that even when the Scarlet fever hits, they won't be cast aside and blamed for the misery.  The real test lies in being patient and present because the fairy will take it's time before she materializes.  I believe that the good enough therapist is the fairy indeed.  There is no magic dust but only the reality of what happens in the therapeutic alliance and transitional space that mends a broken heart.  Once that happens, people become real and unafraid.         

Because after all, as the Skin Horse said to the rabbit:

'Does it happen all at once, like being wound up,' he asked, 'or bit by bit?' 

'It doesn't happen all at once,' said the Skin Horse. 'You become. It takes a long time."

"Generally, by the time you are real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don't matter at all, because once you are Real you can't be ugly, except to people who don't understand.”

― Margery Williams, The Velveteen Rabbit

The Green Me

Today is the last time I will post the end of year musing as a resident.  Next year this time I will be 6 months into my new job.  Not a resident anymore.  This is like growing up all over again and it is exciting and scary.  Last two months of my absence have been pretty eventful.  I finally achieved Nirvana and by that I mean that my 4th year has set into lower gear and cruise control.  Of course PRITE is over forever and from this despair that started this blog, to this less desperate slightly happier mention of scores, to a complete absence of any update on scores this year, things have certainly changed for the better.  In honor of my original post, let me just say that, I did really well this year.  I have moved from the lower ranks to top 5 scores in the program.  I think that is enough said about the dearly departed.

I can finally read, have time to see patients as often as I need to and have taken more therapy cases.  It's actually really fun to be a 4th year.  I completely agree with myself about what I said here regarding transition pattern in my posts.  Clearly I know myself, Yippee!!!

This gives me perspective about my anxiety with change.  When I get anxious and feel pressed for space and time, it means I will eventually get over it and on top of it.  This shall pass too, never sounded more relevant than in the past 3.5 years.  I look at the new interns and nostalgically remember my green, struggling self as an intern.  It seemed like it will never end but it did.  I remember the weekend calls and pager beeping, inpatient grind and off campus rotations with early am rounding with coffee in hand.  Part of me misses that intern because of how protected I really was and never realized it, until after the fact.

Then came second year and being the chief.  Again another green year because I was the "chosen one", the one with the invisible cloak etc., etc., etc.  I had to grow up faster than others and at times had to do it alone.  Being the oldest in my family, it just felt natural to me; until I wasn't the chief anymore this year and actually got to have less responsibility.  It is nice.  Part of me misses that green chief as well because of how she reshaped the more pedantic parts of herself/me and I never realized it, again until after the fact.

My 3rd year came and yet I was green once again, out patient!!  "I got this." I told myself when I started 3rd year, even though I had no idea what I was doing.  I knew I loved therapy and boy did I push myself.  At one point, I had 15 regular therapy patients and I was pressed for time in supervision to get consultation on all of them.  The best part of having a heavy therapy load was the decision to have my own therapy done.  I went through ups and downs of 3rd year, hanging on to my soft place to land namely, my therapy and my supervision plus my own office because let's just face it, frame matters.  I sat through sessions, my own and my patient's.  My emotions ranging from confusion to clarity, annoyance to enjoyment, sadness to happiness, anger to delight, scared to bold and then there were times when there used to be nothing.  At times, I miss that brand new 3rd year resident trying to be a therapist, because of how she pushed herself despite her doubts and stuck with it.  I just didn't realize it, until she wasn't there anymore.

So here I am, only 6 months left to graduate and knowing what I will be doing after graduation.  As I look back at years in my training, at every point, I see a part of me that had doubts, frustrations, anxiety, joys and changes, yet I was unaware of those at the time.  Sometimes things seemed impossible and sometimes it felt like an uphill battle that wouldn't let up.  But now I know that underneath it all, there always was a soft warmth of assurance and a sense of belief in what I did everyday; otherwise residency can be quite a jading experience.  Those of us who can hang on to that warmth and belief in our capacity to go beyond just "what is needed", tend to come out of this experience changed for the good.

We enter as interns but in order for us to be able to be on our own, grow up and do the job we signed up for; we have to accept the residency as a privilege and not a right.  Rights make people entitled, privileges make us humble.  Rights can be taken forgranted, privileges keep us on our toes.  Those of us who can admire that privilege in it's entirety, eventually come out better on the other side and that is my firm belief.

So as I say good bye to 2015 and wave in 2016, I hope to remember to be kind to my next green self in 6 months and take lessons from every past green part of me through these years.  I always come out better on the other side as long as I can keep my feet on the ground and head in the job.

So I will close with this,

“Drink from the well of yourself and begin again” — Charles Bukowski, (Author)

Happy new year everyone!!!

What Doesn't Meet the Eye

I am slowly waking up from my post PRITE coma and starting to feel somewhat excited about this year.  I have 3 weeks left between finishing my child rotation and starting elective months.  Here comes the planning for job search and graduation leading into board exam.  I have an elaborate plan in my mind about how I want to spend these last 8.5 months of my residency.  We shall see if I can execute the plan.

I am in the 2nd month of our year long psychoanalytical course that is offered through our local psychoanalytical society and is mandatory for our 4th year residents.  The course consists of organized schedule that takes one through the history and progression of theories in psychoanalysis, from Freud to modern day, along with clinical case presentations which by far, are the richest part of this course.

During today's class we discussed Sophocles's Oedipus Rex and then came the Sphinx and the riddle part.  Somewhere in between listening to the story and trying to stay with it, my mind wandered to the Netflix episode of The Adventure of Puss in Boots.  Odd and a little off the charts, don't you think?  Clearly it is a little too soon for me to be back on my normal schedule after PRITE.  But there is a very good explanation.

You see, the episode I thought about; depicts the Sphinx, the riddle and the Puss in Boots, who has to answer the riddle to get the hour glass or all of the town's children would die.  My kids laugh uncontrollably every time the Sphinx spits out a riddle in her valley girl accent and the Puss in Boots truly has no business being there because he can't guess worth a dime to save his own life, let alone save the town.  But how did I miss it?  The sphinx, the riddle, the cat.  This seemingly funny and witty sphinx is not a story book character for children but Sophocles's Sphinx from Oedipus Rex.  But what would that makes the Puss then?  I am sure there is something there, I just don't know what.  It was in this class today that I realized the connection between the animated TV and the old play that remains the major source of debate, inspiration, opinions, theories and clinical work to this day.

In his book Bruno Bettelheim talks about how most of Freud's work has been misunderstood and lost in translation when his German work is translated in English particularly and goes to great lengths to debunk the strongly held beliefs about Freud and his theories and particularly Oedipal Complex.  Though Bettelheim has a fair share of his critics and has been portrayed pretty harshly by his critics about his work and his views, but above and beyond all those; I think he makes the seemingly hard to digest Oedipal conflict very natural and human to all of us when he explains it's applications to the psychotherapy and our own personal growth.

His explanations of fairy tales like Cinderella and Beauty and the Beast or The Little Red Riding Hood are an interesting way of looking at the world of enchantment given that he was a child psychologist.  His explanation of Cinderella in the context of sibling rivalry and a child's natural desperation in the face of one of the biggest calamities of childhood "loss of love" i.e. birth of another sibling or presence of another sibling means having to share the object of love mother/father (according to Freud's Calamities of childhood) makes it clear why we from very young age tend to be fascinated by the stories of witches and princesses and knights in shining armors.  Because these fairy tales serve as a safe and benign way of satisfying our unacceptable (to self or others) feelings, wishes and fantasies.

His description of Little Red Riding hood and the Big Bad Wolf is not very well received but anyone who has seen the play or the movie Into the Woods knows that the Big Bad Wolf doesn't want to simply eat the Little Red Riding Hood.  The children storybooks are merely a more tolerable container for what we can't contain in ourselves when we are younger or don't want to face in it's raw, volatile reality when we grow older and become parents ourselves.

Ever since I started reading more and opening my mind to the ideas of psychoanalysis and psychodynamic theories, I have been fascinated by how children actually really do exhibit what Freud had described so many years ago.  If I have ever seen a young child go through the Freud's phases, it has to be my own son (he is my only window into a little boy's mind; who is growing up in what I hope is a healthy environment).  He has gone through an age of being totally dependent on me and his dad for everything as an infant to being a 2.5-3 year old who used to scream at the mere sight of his dad when he was crying for me and I was on call away from home.  He then developed into a 4-5 year old, who clearly was in direct competition with his dad for my attention and in his own boyish way would protest and show his anguish, if he disapproved of his dad sitting a little too close to me for his liking.  He gradually started to give his dad more attention at around 5.5 to 6 years of age and then grew out of his competition with his dad.  He went from telling me that he will be marrying me when he grows up to saying that he will find a girl like me and marry her.  He has attained developmentally appropriate resolution of conflicts necessary for a 7 year old per Freud.  It has led to him eventually accepting that his mother and father are separate entities than him and he cannot compete with his father, nor his father is in direct competition with him.  All of this has happened because he has been provided with a consistent and developmentally appropriate hierarchy in the family unit and hasn't been pathologically triangulated in neglect or overindulgence that leads to pathology due to conflict in Freudian stages.

Of interest is the sibling rivalry that I have seen among my children and has been verbalized by my daughter, who was merely 2.5 when her brother was born.  A child who you may think won't remember much but is somehow able to tell her brother that if they had another sibling; he would feel how she felt when he came along and took "mom's love" from her, and then he would know what she felt like.   Amazing that a child this young remembers 8 years after her brother was born, what she was going through and holds him accountable for her distress.  Her aggression towards him as a rival probably serves a function of feeling powerful over him as an older sibling and a way to be determined to never feel what she felt when he was born.  She very well may have guilt for feeling the rage, she probably isn't even aware of it and the mind doesn't want to acknowledge it either, since you are supposed to love your family.  She is able to process these feelings without feeling threatened by them because she has learned that she is allowed to have those feelings, along with caring and loving feelings her brother and that she won't be told by her mother or father that she shouldn't have those feelings towards her brother.

More on guilt and shame in a future post when I will talk about Alice Miller's work.

We all hope to raise children who will pass through all the stages of their psyche with appropriate conflict or at least minimal unresolved conflict.  We can be sure that as long as mothers and fathers we don't impose our own unresolved conflicts onto our children and allow children to be their true selves with their emotions and feelings, we will end up raising intact human beings.  We can be the containers we are meant to be for our children and not the other way around because it is not their job to contain us.

Because fairy tales are not fairy tales if there are no happy endings.  There is always more than what meets the eye and what doesn't meet the eye can make a difference between a nightmare and a dream for a child.   

Tales From the Other Side

Seems like I tend to zone out for a few months when I transition.  As always I have a perfectly good reason.  I got busy and guess what it's September, yet AGAIN!!  Now I don't need to remind you what this means, do I?  I am sure my PRITE post from last September can help.  Yes it's here again.  I am clearly in panic as this year so far I haven't had any chance to study at all.  Serves me right.  I mean what was I thinking procrastinating until July and hoping that being a PGY-4 will somehow make me invincible and give me unlimited amount of time to study right from July.  Being a PGY-4 is challenging and so far mostly a constant whirlwind.  Running from one place to another and not having an office anymore basically is the life right now.  It's busy and at times quite draining when it leaves no time to actually sit down and study or read.  I do have a light at the end of this tunnel in about two months when I can start my elective months and have more flexibility in my schedule but until then it's the hamster wheel, only much more bigger and my feet get stuck almost every day.

This is my last transition while in residency and change is always hard.  Being in my own office for a whole year was something I got used to and used to look forward to.  It was a feeling of being at a home base which is gone now and in so many ways may be is appropriate because I need to move on in about 9 more months so I can't get too comfortable.  May be that is the natural course of things.  I will probably feel much better as I get to the month of starting my electives and take a breather.

I have looked over my posts from last few years ever since I started writing here and see that every transition brings feelings of being overwhelmed, annoyed and at times pure frustration but it also helped me see that eventually I start feeling like I have grip on things finally.  I am hoping it will happen soon.  In the mean while I have to study for my in service exam so I can move on to bigger and better things like studying for the boards, which sounds oh so pleasant, NOT!!

I would like to come up here and write some about a few great books I have read over the last 2 months of absence but I need to be in a zen mind set to review these books.  I think my zen will come after my in service which is in time with the end of my child rotation which starts in 2 days.
I will peek back in next month to see if I can produce something worth reading but for those of you who read this blog (and it amazes me that so many people read this from all over the world) I will say this much; first rule of being a psychiatrist, be in touch with your inner self and take care of yourself before anything else, (at least for me).  So my absence here is not out of a memory lapse but only out of the survival mode I am right now.

Until the storm calms down a little, hang in there with me because the other side is kicking my behind so to speak and it is going to take a while to start thinking more clearly.  

Final Chapter

I just completed the seemingly mundane task of updating my signature for my work email on my iPhone.  For many this may be an unnecessary task or a head scratcher as in "what?" or "you have a signature in your email?"  For me however, it's not.  My email always has a proper intro and a formal ending with of course what else but my always up to date signature.

Today is the last day of my 3rd year of residency training.  End of so far the fastest year of my residency.  I am slightly shocked by how fast this year has gone by and now as of tomorrow I am a PGY-4.  Next year on this day I will finally be done with my training.  So many emotions go through my head when I think of where this year is headed.  I think I don't want to think about it for a few months.

My signature update included changing my PGY-3 designation to PGY-4 and most importantly removing the "Psychiatry Chief Resident" title from the body.  It was a mix of nostalgia, sadness and slight sense of relief.  I am not the chief anymore.

I won't be getting dozens of emails about millions of different little things that I used to do from schedules (until I did them) to class schedules, to putting out little fires here and there, to big things that happen in every group that has 20 different adults of various ages and personalities, to many emails that I had to write to ask for this or that to be done.  I am not doing the orientation this year nor am I responsible for anything else chief residents have to do.  I mean there is no set job description as is and yup still no magic wand.  While I feel like I will miss the daily churn and the feeling of being needed that came with the job, it is probably going to be pretty nice to have a relaxing final year of training and being back in the middle of the group in the meetings rather than at the front of the room.

It is going to be a big adjustment because at this point I have more time as a chief in the program than just being a resident.  I am fully aware of this transition and that it will be a bit of struggle for me because I have a tendency to try to handle things when they present or take upon myself projects to handle things I think need handling.  My title gave me enough autonomy to do so while I was in the role, like figuring out patient hand off between incoming and out going residents or taking on updating our website or changing the ER rotation structure when I felt like it needed changing.  That is a place from where I have to mindfully step back and let the newbies get their feet wet and make their own mistakes and take up their own projects.

If I had a chance to do it all over again, I would probably do it despite of the frustrations and stresses and extra work it gave me.  These past two years also gave me a lot of experience to look back on and learn from my mistakes.  I am sure because of these two years I really want to think about what do I want from my life after this year is over.

I am finally ready to let the responsibility go and enjoy what is left of my residency training.  In the end as I edited my signature today to take my place back in the middle of the group, I realized that sometimes the seemingly little or mundane acts like hitting the backspace and delete keys are all it takes to take a load off and put up your feet.  Of course, it helps that now I am officially allowed to do so.
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As some one once said "Don't close the book, just turn the page."  so here I am and I think the final chapter is going to be the most exciting.  

Tis' the season to be Jolly!

Here it is again.  It seems just like yesterday when presents were given and parties were thrown, families got together and emotions were mixed.  Time sure flies when you are having fun.
Sounds like Christmas and for the graduates from all walks of life, it might as well be.  The diplomas that are handed to these graduates all over the U.S. are like the Christmas present you get from your grandparents and you know what is in it because you told them a thousand times what you wanted but now you aren't sure you picked the right present or worst would you be able to use the present as intended?

I have come to love the graduation season almost as much as Christmas because well really what's not to love?  It's not cold and there are flowers (unless you have allergies and then it sucks), sunshine, Facebook feed with a slew of gleaming pictures with grads and their proud families; and best of all Target and Home Goods have stellar sales for the grads.  I mean come on now, who doesn't like a good sale any time of the year?

Just like other academic settings this is also the time of the year when medical students, senior residents and fellows are graduating and other residents are moving up the PGY ladder.  What a great time!  I am going to be a 4th year in about 3 weeks.  When I started writing this blog I was in the middle of my 2nd year of training and here I am now finishing my 3rd year and being the senior most upper level resident.

I am graduating from PGY-3 to 4.  There is a virtual party in my head 24/7.  Well in the background at least.  It also is the last year of my training and I find myself getting sad at times thinking about losing the comfort cushion my program has provided me.

I call my program "The mothership" when I am on an away rotation and all of us have pretty much adopted that term.  Just like a mother, it provokes loving and secure feelings in us; while at the same time we have conflicting feelings towards it, making it what the Kleinians refer to as the bad object.  I have another year left at the mothership before it ejects me in the outer space to navigate on my own.  Talk about anxiety.

There is also the transition of the patients I have seen for a whole year and have formed relationships with.  It has been a hard transition for many reasons.  Some patients I wish I could keep but I am capped and some patients I have struggled with myself.  To find a new resident, that I feel may fit them or vice versa; has been a challenge.  Hand offs in residencies are not well organized for the most part and with mental health patients it can be even more sensitive and chaotic esp. for the patients.

This is also the year I will step down from my position as a Chief Resident for the past two years.  This has been one of the most challenging roles I have played during the residency and I say this with a five year supervisory role prior to starting residency.  Being a chief in a residency program is nothing like being a supervisor.  This is a position of a certain perceived power where depending on your PGY ladder position in the program; you may have peers, juniors and seniors to manage and think about.  I have learned of my weaknesses and strengths and I have made mistakes and done good things for us as a group and hopefully for the program.  The best lesson I have actually reaffirmed for myself is that as long as you do the right thing, and as long as you are willing to step back to look at yourself and your peers critically; you will do okay.

People are generally reasonable if you are fair and honest and by that I mean that you can sleep at night knowing that there is no nagging little voice tugging away at you from somewhere deep inside.  Because your only job at all times, whether you are a chief or not; is to take note of that little voice that we like to call the superego.

So here I am in the last stretch of my chief time and PGY-3, passing the hat on to the next chiefs; and passing a lot of patients to incoming PGY-3.

Next year it will be my time to graduate as we bid farewell to our current PGY 4s next week.

As the lyrics go:

As we go on
We remember
All the times we
Had together
And as our lives change
Come whatever
We will still be
Friends Forever

So if we get the big jobs
And we make the big money
When we look back now
Will our jokes still be funny?
Will we still remember everything we learned in school?
Still be trying to break every single rule
Will little brainy Bobby be the stockbroker man?
Can Heather find a job that won't interfere with her tan?
I keep, keep thinking that it's not goodbye
Keep on thinking it's a time to fly and this is how it feels.      

"Graduation by Vit C."

A Word Less Spoken - Grief !

C.S. Lewis said "No one ever told me that grief felt so like fear."

I see patients every day who are sad, anxious or angry but hardly anyone ever mentions grief, fear, being scared or being afraid.  I don't seem to get those emotions out easily from them, hence many of them remain unaware of their grief and the fear that comes with it.

Grief is tricky, grief is sneaky and grief is scary.  I say it is tricky and sneaky because we generally don't think of grief when we see people for therapy.  The most common feelings we hear are sad or anxious.  I tend to think there is always grief that lurks in the corners of their minds, sometimes obvious, mostly not.  Rage and anger to me are directly proportional to the grief people carry around.

Children need security of consistency, affection, love and care to thrive and become self sufficient, adequately attached adults.  No matter what your inclination is theory wise, an overwhelming majority of professionals do believe in importance of the early year bonds we as humans need.  When these bonds are dysfunctional or absent a perfect storm simmers.  How unfortunate it would be to come to this world and question the reason for being here not because of pure existential concerns but because no one ever made a big deal about you being here?  I wonder how many of us can relate to this feeling conveyed by any number of patients?  

My guess; probably most.  

I always wonder about the people growing up with feeling unwanted, unloved, uncared for or all of the above.  How it shapes them and their relationships?  What is it like to live in a perpetual state of being irrelevant?  It makes people angry, sad, enraged, anxious, worried, doubtful and so on and so forth.  But come to think of it, would all of these feelings not be linked to the feeling of grief?  

Grief for not having what seems so natural and right for us to have when we are born.  It's the sort of grief that lies so deep and is so intense that it almost demands to be acknowledged yet is so intolerable that it's almost always ignored because how can you grieve something you never had.  

But why can't you grieve not having something at all?  Wouldn't deprivation lead to indulgence but without gratification?  Adults with early attachment challenges mostly keep looking for what they never got.  Sometimes in form of one after another dysfunctional relationship, sometimes in substance use and many times in both ways.  The early age deprivations drive people to indulge in relationships with people and/or drugs in such self destructive ways but seldom result in gratification of what they need.  A bottomless pit of despair that always seem to be wanting more.  

I wonder if the grief of deprivation is so immense and scary that people can't seem to face it?  It must be very scary to never know what is it like to trust that one is worth anything.  It must be terrifying to ever think that your being in this world would ever matter to someone else.  May be it's the fear that realizing one's grief would mean staring the deepest darkest moments of despair in their face while at the same time acknowledging the hard work that it will take to own it and learn to live with it.  Grief isn't like sadness because sadness fades away but grief never leaves.  It etches permanently and it always have fear close by.  

To live with grief is to live with fear but to not respect and acknowledge grief; is to live in a constant storm that always simmer, is consuming and unpredictable because the more it is denied, the stronger and scarier it becomes.  

As C.S. Lewis says it's a process not a state, 


“I thought I could describe a state; make a map of sorrow. Sorrow, however, turns out to be not a state but a process.” 

The Couch Reversed

After a long absence I am back.  I have a few thoughts about what made it possible for me to come back today.  Last few months have been a whirlwind for me to concentrate on this blog and muse much.  I don't think there are enough hours in the day to contain what goes in my life on any given day.  I am nearing the end of my 3rd year and it is only 3 months away.  Hard to believe I started here midway through second year.  I have bad days and I have good days.

I worry about my impending cord severing in 17 months to be on my own and it scares me to think I will be on my own.  One would think moonlighting is a good practice to run solo but I still have options to consult, mainly because I am probably quite lucky to have that option.  I am losing one of the best times of my life at the end of these 17 months and I feel like I want to grieve at times.  I am sure, I am starting to.

One of the best things I have done for myself over the last 2 months is exactly what the title of this post says.

Have you figured it out yet?

And if you thought of therapy; you are the winner.  You are pretty awesome at this guessing game.  

So after 8 months of monkeying around this idea of getting in therapy for myself, I finally gave in.  The proverbial couch is literally reversed.  It is quite a transformation and one that I never knew would make me think so much.  

For many psychiatry residents, esp. if they are like me and see or want to see a lot more therapy patients, it is something that just has to be done.  I hope all programs provide supervisors for therapy cases, as they should but I also hope that many psychiatry residents do not end up ignoring the need for their own work to be done.  If you have a supervisor that is open to working simultaneously with you and on you, that is great.  My supervisor on other hand never had a choice and mainly because of me.  I am used to taking charge and in my mind, I had this one hr a week for case consultation, so I would walk in and use every minute of that hour for my patients.  He got to get glimpses in my personality but by the time I brought up the question of my own work with him, I already had a mindset that this is an hour paid by my program and I shouldn't use it for myself.  Not to mention I had 8 cases for therapy and at times 10-15, so I needed this hour more than ever.  

I started noticing my anxiety as a therapist get louder, the more intense therapy with my patients got.  The emotions and reactions in me were what forced me to be very honest with myself about what did I want myself to be able to do when I take on people for therapy.  

I started reading more this year.  Yalom, Bowlby, Beck, Wachtel, Gabbard, Robert Karen and numerous articles here and there.  None of these people that I admire so much and learn so much from, got so good at what they do without having their own work done.  

I want to be half as good as any of them.  That is what I want.  So I can't ignore the need to be the patient in order to be an effective therapist.  

I finally gave in and asked my supervisor to be my therapist.  That in itself was an intense experience from having to process my need to have the safe path to therapy with a known person than to open to a totally new therapist, finding a new supervisor and then realizing I lost my supervisor relationship with my now therapist.  It was something that came so unexpected yet proved to be a great stepping stone into the new relationship.  

Now 5 weeks into it, I have started to understand why my patients, who come sit across from me in my office; keep coming every week.  I understand that they are the ones doing the work and when they ask me questions about what to do, they are not meaning to put me on spot, neither are they looking for a magic formula; but rather exactly the opposite.  They already know what they are asking me, I just help crack the code.  Sitting across from my therapist when I share things that make me question my own abilities, limitations and that frustration that I feel with myself many times; I hear myself say things I only think about but am too scared to admit to myself.  It's like I believe, as if I am superhuman or should be superhuman.  I have started to understand my worries and anxieties in ways I probably already knew.  It is so odd how actually saying them out loud is akin to giving life to something many of us like to keep buried.  Reversing the role makes me see how without this step, I was never going to be able to fully understand the person who sits across from me every week without doubting the process every step of the way; because I never had the experience from the other side.  

Dealing with my own life and facing my own limitations, I have to do it; to do what I want to do.  The proof is in this post.  Took me 2 months from my pledge to write here to actually write this.  The only thing that has changed is that now once a week I get to be the patient.  I get to be able to let it go and face myself without reservations.  Something so hard to do but has a profoundly liberating effect.  Most probably one of the reasons I am back here writing again.  

So if you are a therapist, psychiatry residents or aspiring to be either one of those, keep your work on yourself in your mind; not as an option but as a necessity.  Not because it is cliche; but because it is anything but.  

As Irvin Yalom says, 

"Self exploration should continue throughout life, including entering therapy at various stages of life."

    

New Year, New Resolution - 2015 is here!

Oh dear !! I feel like a broken record.  This was a long break but so needed.  PRITE is done and over with.  Last year it was my disgust with it that started this blog with PRITE scores are in post.  This year I am not as disgusted.  I think it was the last part of my post that kept me going and ah money of course.  What do you know, as a fully licensed resident I do get to moonlight now and my in-service performance makes or breaks my bank.  Talk about motivation.  It worked.

I think my resolution this year is going to be to give myself time to think and actually write here.  It has been a great release writing my thoughts here and I feel that it does good things for my processing of events and emotions.  Six more months till I move on to a 4th year.  It is going to be intense.  Things I want to write about are match/interview do's and don'ts from two years of being through this process, looking back at my chief role for two years, moving on to last year of residency and the new experience of moonlighting and of course I am reading more and more, so may be a few posts about some insight from readings.

So with this post I commit to thee, my musings.  Happy writing to me.