AN OPEN LETTER TO THE AMERICAN PSYCHIATRIC ASSOCIATION

To whom it may concern:

I am writing to express my extreme displeasure (i.e. anger) at the system you have set up for the DSM-V. As far as I can tell, the publication of this volume is nothing but a money-making scheme.

I am an APA member and have been one since residency, a good 25 years now. You have received thousands of dollars of my money over the years. I purchased the DSM-V as soon as it came out (in paperback, as the hardcover version was prohibitively expensive). I now re-purchased it as an e-book, for the only reason of being able to copy and paste diagnostic criteria for inclusion in forensic evaluations. Yes, I am well aware of the limitations and cautions of using the DSM-V in a forensic setting. I am a board-certified (and re-certified - yet more $$$$) forensic psychiatrist.

So after I spent an additional $120 on the electronic version of this relatively uninformative and useless book, which bears minimal resemblance to daily life in the office of a working psychiatrist, I now find that I cannot copy/paste the criteria. I have to TYPE them out as if I were in typing class in seventh grade. I also note that the electronic version of the DSM-V is not even clickable, so in order to get to a certain section I have to scroll through hundreds of unrelated pages, and it is quite difficult to reach the page I want. I tried the "bookmark" feature but all my bookmarks disappeared when I closed the application. Perhaps I am technologically stunted. That's okay. I studied psychology, and then medicine, not computers. I also note that the time I spend typing is not really billable as expert time.

Meanwhile, your organization, of which I am a less-than-proud member (I do it only for the fact that the courts, in their infinite naïveté, expect membership in professional organizations) has done NOTHING to help psychiatry and psychiatrists. We have more mass murderers than ever before. Insurance companies don't cover medications. Patients don't want to take responsibility for their own treatment or recovery. Medicaid, now a big deal under Obamacare which you supported, pays a whopping $7 per outpatient visit. My 17-year-old earns more making food deliveries on his bike. We have to farm out psychotherapy to social workers to who tell our patients to "smell your food" and instruct girls to pretend-cut themselves with ice cubes instead of razor blades. These same social workers like to tell their patients that psychiatrists don't know how to do therapy and also tell them that all we are good for is writing prescriptions, so they should specifically ask for Wellbutrin (the only medication with its own rabbi) or Lexapro (the one that causes total post-synaptic burnout in five weeks). Do you guys even know that this is happening? We have a parody of parity, in which we are paid a fraction of what other specialists are paid to work much harder, to try to cram therapy and suicide prevention into 15-minute hours every three months. And I can't even include diagnostic criteria in my reports without spending an hour typing them over? You must be kidding me. The APA is a useless organization that has done nothing for its members let alone for the millions of mentally ill in this country.

Don't bother sending a fake response. Take this email to some committee. I invite any one of you people whose salaries I and my colleagues pay to come sit in with me for a day and see what life is like in the trenches. The APA and its love affair with big Pharma and the insurance industry disgusts me. Sadly, I will have to laugh when a psychotic psychiatrist comes to your office to act out his rage.

Sincerely,

The 90-word-per-minute typist psychiatrist

Goodreads | Homicidal Intent by Vivian Chern — Reviews, Discussion, Bookclubs, Lists

Please read my books! Both are available as paperbacks or as ebooks. These are just the warm-up books - both were written over ten years ago - but the next wave is coming soon!







Goodreads | Homicidal Intent by Vivian Chern — Reviews, Discussion, Bookclubs, Lists

Goodreads | Loosening of Associations by Vivian Chern Shnaidman — Reviews, Discussion, Bookclubs, Lists

Goodreads | Loosening of Associations by Vivian Chern Shnaidman — Reviews, Discussion, Bookclubs, Lists

Now for something completely different - a book review!

Jason Porter nailed it. Thank you. You just got into my bibliography of the (non-fiction) book I'm writing. I wish I did not understand this book so well but I do.
For people who don't understand, don't try to analyze. This is the story of a breakdown (in colloquial terms). It makes sense. It is moving. And it shows us how normal stuff is really not normal at all - and vice versa.
Jason is a good writer, he can use language, and he is funny while being sad. I don't generally read books like this one, since my everyday life is overflowing with these stories, only not told as poignantly, eloquently, or without self-pity. I guess that's why this book was so moving and impressed me - because most of the depressed people I see every day can't get off that pity pot.
Anyway, if you like books that are only about character - this is a great one. Me, I usually like books with plots, but I think the writing in this book is good enough to write a more complex story next time.
I do highly recommend this book for everyone, though. Maybe it will help people's eyes to open inward a little bit.

Going Postal?

It's been a while, friends, and now I am back to tell you - I can't accept Medicaid anymore. Or Cigna. Or a whole bunch of insurances which don't pay anything. And here's why.

Since I last wrote a blog post many things in my life have changed drastically. My forensic practice is still busy-ish - but I don't get five DYFS cases a week anymore. Partly because I'm "too expensive" (it takes me at least ten hours to do an evaluation properly) and partly because I'm a maverick - I say what I think, not what someone wants to hear. So if a referral CAN parent her children, and I say she can - that DYFS office (now known as the Division of Child Protection and Permanency, or DCP&P) might not be so interested in sending me more cases.

So I started accepting insurance. Lo and behold, I now have around 900 patients. In three years. I keep discharging people when they get better - or when they are non-compliant - but still my total, as per my EHR - hovers around 950, even as I mark patients "inactive" every day. And still there is not enough money to pay for the month. I am earning about what I earned as a fellow when I also moonlighted, almost twenty years ago. And I don't mean with inflation - I mean in actual dollars.

I see my own doctors, as a patient, too. I had knee surgery, I have weird allergy symptoms, I have stuff. I'm past the mid-point of my life and things start deteriorating. A few weeks ago I went to the gastroenterologist. She saw me for less than ten minutes and my insurance paid her over $300. She scheduled me for some invasive procedures (for which I have to take a day off from work, too) that will bring in a few thousand dollars more. That's fine. She's making a living, and she takes insurance.

Why can't I make a living by taking insurance? If I see someone for ten minutes (which is not possible in psychiatry no matter how bad a doctor you are) I would get about $45. Why exactly is gastroeneterology more important than psychiatry? I know people THINK that anyone can do psychiatry. Certainly all the family doctors, pediatricians, psychologists, social workers, internists, and for all I know, dentists and chiropractors, believe they can treat psychiatric disorders as well as I can. Just prescribe some medication that they saw on a TV commercial and everyone is good to go.

Let me tell you something. None of that is true. Even many PSYCHIATRISTS don't know much about psychiatry. We are no longer permitted to treat patients with psychotherapy, so our patients go to social workers who try to talk people out of their schizophrenia, or depression, or obsessive-compulsive disorder, for years before they end up in the right place. The insurance companies would love to skip the middleman and send patients directly to a pharmacy (for the cheapest drug, of course, not the best one) without ever stopping by a psychiatrist's office. But here's the thing: we psychiatrists are the ones who see, identify, and prevent, disasters. School shootings. Murder-suicides. Train shootings. Infanticide. Even elaborate Ponzi schemes by manic individuals who believe that what they are doing is okay because they have the power to re-earn all that money. We are the ones who can identify and treat these conditions, in these individuals, before disaster happens. Like the NSA and Mossad, we work behind the scenes to make sure that people don't get crazy enough to do those awful things that we keep hearing about.

The problem, of course, is that people don't always want to get help, and that even when they do, we can't force them to take medication or go to a hospital until they expressly say the words: "I have a PLAN to kill myself or somebody else." How stupid is that? A crazy guy brought a rabbit into my office. It could have been a gun, but that's another story. When someone starts to lose contact with reality (and this guy certainly had, and I'm not going to tell you how I know, because of course having a pet rabbit does not mean you are crazy, so if you want to know how I figured it out, go study psychiatry for four years after four years of med school after four years of college), it's time to get that person into a safe place where he can be medicated based upon what a reasonable person would want. This is the main problem with the way the law sees psychiatry and psychiatric patients. And when insurance reimbursement is so low that psychiatrists are reduced to spending ten minutes a month or every three months with their patients - how are we supposed to use all that training to identify who is totally nuts and potentially dangerous?

We are the ones who prevent the world's disasters - at least the small disasters - the small-time bombings (anyone remember the unabomber?) the school shootings, the murder-suicides, the infanticides. We are the ones who treat countless numbers of mentally ill people so hopefully they don't go flying off the roofs of "downtown parking structures." Yesterday, one of my young male patients missed his appointment. Around the same time, I saw online that the body of a young white male was found on a local street, an apparent suicide victim. My heart almost stopped, even though I kept telling myself that this patient was not even depressed, would never kill himself, and probably just mixed up his days. Thankfully, it was not my patient. But was this young man someone else's patient? Or had he been unable to ever even see a psychiatrist, because his insurance wouldn't pay or he could not find a doctor who would accept it, or because someone told him to "be a man" or "suck it up"? We may never know, but we do know that statistically, if nothing else, the horrible cases we see on the news are only a small fraction of the truly mentally ill people who are helped - who are SAVED - by psychiatrists.

I think that we psychiatrists should be paid fairly - the same as gastroenterologists or dermatologists or any other specialists - so that we can treat our patients fully, and help prevent further tragedies. We should be paid fairly so that all psychiatrists can afford to accept insurance, and still keep up with their continuing medical education. Hospitals should be allowed to hospitalized mentally ill people who are not imminently dangerous. People who have emotional problems should be permitted to get better in their own time, not forced to continue to work in a place that figures prominently in their delusions, until they get so angry that they end up "going postal." Imagine that, something that has occurred so frequently that it is an expression. And we can treat that! We can work with angry, delusional, psychotic, hostile, and paranoid people and make them better! But we also have to be able to pay our mortgages and feed our families. Plus why does my orthopedic surgeon, an antipathic and possibly sociopathic individual, deserve a better car/house/vacation/retirement fund than I do? I promise you I know more medicine than he does. He is a carpenter of bones. I am an artist, a master of neurobiology, someone who understands the complexities and clinical challenges of post-synaptic receptor down-regulation.

We fought for "parity" in congress and in our state legislatures. But some insurances won't pay for treatment of post-traumatic stress disorder because it is not "biological." Excuse me, nasty insurance company with a big lobby in Washington, but every time I type a word here, biological events of incredible complexity occur. Somehow, psychiatry has become a non-specialty, an unloved stepsibling to the rest of "real" medicine. For this reason, psychiatrists are doing silly things, like genetic testing to see which version of liver enzymes  their patients have, so they can pretend that they now know which medication the patient will respond to the best. In reality, these tests are expensive and useless. You can tell clinically if you need to increase someone's dosage - and that is the ONLY way you can tell. How quickly or slowly someone's liver metabolizes a medication tells you NOTHING about how that medication is going to work at the synapse (the space between the neurons in your brain). Insurance won't pay for those tests, but some patients will. Some patients believe that you get what you pay for, and so they go "out of network" to see overpriced quacks. I think that this "get-what-you-pay-for" mentality is what makes me the angriest out of all the things I've just mentioned. That my patients think they are getting worse care than people who are going to the no-insurance accepted doctors. Which is ironic, because I have plenty of patients who ended up with me after their no-insurance doctors could not help them (and I could, can, and do) and even a few patients who were referred to me by the no-insurance doctors who just could not get those few people better. (Hint: It's all about that downregulation of the post-synaptic receptors).

Here is my summary: Psychiatry is a medical specialty. A complicated specialty. To do it right requires a lot of time with each patient. And the lives we save are not just those of the patients who don't commit suicide, but the lives of untold innocent victims who survived because a psychiatrist managed to help a patient headed toward insane violence. One of these days someone will figure out how to study this concept, how to deduce how many school shootings did NOT occur because someone was psychiatrically treated appropriately. For now, you have to take my word for it. And please ask your congresspeople and insurance companies to pay us enough money to treat all patients appropriately, so I don't have to come back here and say I don't accept insurance anymore. Because that will be a sad day for a lot of good people.

Why I Accept Medicaid

Practice what you preach. Put your money where your mouth is. Do unto others as you would have others do unto you. Love thy neighbor as thyself. 

Any of these sayings sound familiar? I came up with them in about two seconds, but I’m sure there are many more of a similar sentiment. They are intended as rules to live by. As far as following the rules go, I have generally been pretty good with the ten biggies - one God, keep the sabbath separate, don’t kill, steal, covet, or commit adultery - and I’ve managed some of the other 603 also - my sons are circumcised, I give to charity according to my means, I did not intermarry with a gentile, especially not a Moabite or an Ammonite, I have not even castrated my dogs, and as a physician I try to use all means available to me to heal my patients. All of these are included in the 613 commandments in the Torah. And interestingly, I am not much of a biblical scholar. I looked up the list of the 613 to see which ones apply to me (as I am not a Cohen or a Levite or a Nazarite or a man), I found that of the ones that do apply to me, I’m doing a fairly decent job. And I think I do a fairly decent job because I happen to be a fairly decent person, and the Torah asks us to be just that: fairly decent people.

When we follow the commandments, what do we receive in return? Well, nothing really. We receive the benefit of having a good life in which we follow the rules, honor and respect ourselves, each other, and God, and know that we are doing our best to “guard diligently [our] soul[s].” (Yet another commandment). 

In recent years, I have been working doing many different types of evaluations for different types of courts: family court, immigration court, sex offender court, even municipal court on one occasion! All sorts of cases come my way, and I always tell the lawyers the same thing: “I will be happy to evaluate your client, but I may not see the case the same way that you do, and I may not be able to help your case.” Shakespeare recommended that we kill all the lawyers, and it may have not been a bad idea (with the exception of the thou-shalt-not-kill part), but in the morass of amorality out there, I have encountered quite a few attorneys who manage to practice ethically and sometimes even amazingly. So I continue to accept cases with the possibility that I might disagree with what the lawyer needs, and they must take that chance. Most are fine with the concept, and of course, some are not. That’s okay, because there are so many suffering humans out there that there will always be another case to evaluate for the court.

But here’s the thing: After years of making extremely specific recommendations for what people need in order to be better mothers, or less dangerous, or less depressed, stoned, or drunk, I have discovered that many times the recommendations get only as far as the court. They are used for some legal purpose, and once that purpose is achieved, the individual whom I’ve just evaluated gets none of the interventions or treatment that he or she needs in order to improve his or her life.

So a few months ago, or maybe even a year ago, I made a fairly drastic decision. I would accept for treatment only, or primarily, those patients who could never afford a doctor like me on their own. I would not build my treatment practice around the worried well who were convinced they had adult ADD and would pay through the nose for their monthly stimulant prescription, or pretend that I could cure grief with Prozac. Instead, I would see adolescents and young adults from a group home, and make sure they got not only the medications they needed but an ear to listen to them. I would see the abused children or battered women who had lost everything and who were being “treated” with nothing but mountains of pills. Occasionally I could see some patients for free, or get paid something out of someone’s grant, or accept a token $10 as payment. This treatment practice would be a sideline - something that I could do for the sheer pleasure of it, like having a third child. 

Eventually, I realized I had to start accepting Medicaid, because I had to at least pay my overhead for these cases, and that’s about what Medicaid covers. Should I be actually donating money as well as time to these patients - in other words, paying my assistant and my rent and everything else and getting nothing for it? Would that make me a better person? I don’t think so. These patients are lucky to have some kind of health insurance, and believe me, no clinic that has a nurse see eight psychiatric patients an hour and bills for a full psychiatric appointment with the psychiatrist who was not even there that day is worrying about not being considered “nice.”

Referrals poured in. Some very damaged and traumatized individuals came to my office. I did what I could for them, and they kept coming back. They got better. They got jobs and graduated school. And I admit it - I felt good. The way I understand the commandments, you are not supposed to do them so that you feel good for doing them - you are supposed to do them just because you are supposed to do them. But there is something about helping people who are less fortunate, really helping them, on an individual level, that just makes me feel good. Don’t get me wrong - I love to make money and I’m happy to get patients who can pay - but if they don’t have a real psychiatric problem, I won’t tranquilize or stimulate them and then lie on the insurance form. I prefer to make less money and know that I am making a difference. 

Is this false pride, or hubris - something that definitely is not part of the 613 commandments? Is it wrong to take pleasure in making somebody else feel good? I certainly know lots of people who take pleasure in making other people feel bad - after all, I am a forensic psychiatrist and I’ve been around psychopaths and sadists my whole career, on both sides of the security perimeter. But there is something about being able to actually treat the patients who need the help the most, and who are the least likely to get it, that is very satisfying for me as a psychiatrist. I wish more of my colleagues would do what I do. I hear too many stories about people who lost their jobs and insurance and can’t afford to pay the psychiatrist the $150 he wants so that the patient can fill his $4 prescription at Walmart. How can any doctor be so cold? I was already 21 before I ever heard the expression “What comes around goes around,” but I started teaching it to my children when they were born. I think that the creator of the 613 commandments understood this idea. Whether you believe that the Torah is the direct word of God or made up by people, those 613 rules have a logic to them that is inescapable. Treat the world as you would like it to treat you. There will always be bad guys. But ultimately, in some small way, what comes around will go around again. So if you’re a doctor, sign up for Medicaid, and do something for those people who cannot do for themselves. If you’re a lawyer, don’t steal your clients’ escrow money. If you are a vet, do what our vet did, and let the grieving family stay in the room and cry while you gently inject permanent sleep into the sick and dying dog. If you are a waitress, know that calling the customers “hon” goes a long way! Do what you can to make someone else’s day a little better, even if you are feeling horrible. You will feel better. And you will even sleep better at night. I do.

New Fiction: A Fairy Tale for Your Enjoyment

Once upon a time, in a very special treatment unit not so far away, ruled a very bad man. He was ugly and narcissistic, and possessed some evil magic which drew people to him and made them believe he was their friend - until it was too late.

Now this evil man loved to have an audience. He loved to expound for hours on his theories of the world, and to indoctrinate his listeners to his beliefs even when they were completely and provably false. He preferred young women in his entourage, or men who lacked self-confidence, or, if possible, that most important testosterone-producing set of organs which interferes with the smooth fit of trousers. Lacking much testosterone himself, the evil man found the way to be the king of the blind (or, more specifically, the king of the testosterone-challenged). In fact, he became so convinced of his might and his power, that he declared himself king of that very special little treatment unit. Behind the barbed wire fence, this little nebish king ruled with an iron fist and a ruthless sword.

What did he do? What didn’t he do? He was not a physician, but declared himself more knowledgeable than any physician. In the Land not so far away, the law had decreed that only a licensed physician could decide which evil prisoner-subjects could be released beyond the barbed wire, and which should remain there forever. King Evil, as we shall call him from here on, for the sake of clarify, decided that he did not like the law. He would bring his own disciples to make these decisions. They would not have to be physicians - they could be anyone. He picked several - a princess, some knights, some ladies-in-waiting - that he could rely upon to tell the grand inquisitors what he, King Evil, wanted to tell them. He wanted to have absolute power over who remained in his captivity and who was released, and he would not let such a small thing as the law interfere with his rule.

His anointed Princess, she of the long legs and long hair, was put in charge of all the knights and ladies. King Evil knew she would do his bidding, because his evil heart had already identified her area of weakness. Princess Rapunzel, we’ll call her in homage to her inappropriate workplace hairstyle, did not understand that bad guys hurt women because they are bad guys. Deep in her heart, she believed that bad guys hurt only women they found sexy and irresistible. King Evil, as a bad guy himself, knew perfectly well what motivates bad guys: the opportunity to hurt other people and show how much power and control they possess. But as part of his power and control trip, he deputized Rapunzel, gave her almost limitless power as long as she did what he wanted (he was able to make her think it was her idea) and then sat back to enjoy the show.

One day the inquisitor informed Evil and Rapunzel, and all the other lords, ladies, serfs (i.e. Psychiatrists), and the rest of the kingdom that one of the prisoner subjects had to go. He decreed that this Young Subject, after spending half his life in captivity, could be released into the community under close supervision by - gasp - soldiers from beyond the barbed wire fence! Quickly, King Evil devised a plan. He knew that Princess Rapunzel needed attention from every man she met, and recently she had been devastated when her long-term affair with one of the knights ended - the knight had been given an ultimatum by his wife and the mother of his two children that if he did not end the affair, the marriage was over. Because this knight recognized that Rapunzel was truly fucked up and not someone to leave your wife for, he accepted his wife’s ultimatum. Therefore, poor Rapunzel was feeling ugly and unloved (never mind her own handsome husband and her two children, her beautiful home and her successful private practice). King Evil could not have been certain of the outcome, but knowing her type, he did what every evil bit of pond scum would do. Rapunzel decreed herself not only the person who would decide whether this Young Subject was “cured,” but also the person who would “treat” him until a cure was achieved. King Evil, as the boss of the very special treatment unit, knew that this arrangement was completely unethical, contraindicated, non-therapeutic, and potentially dangerous. Yet in his role as the evil king, this type of situation made him ecstatic. He enthusiastically permitted Rapunzel to meet with Young Subject weekly, privately, and confidentially.

Rapunzel bloomed. On the scheduled therapy days, she would come to work in ever-shorter skirts and ever-higher heels. When they did not have appointments, she would find reasons to meet with Young Subject. Their therapy sessions became longer and longer, and Rapunzel would emerge from behind the closed doors flushed, with her long locks mussed and a dreamy expression on her face. All the knights and ladies, Prisoner-Subjects, serfs, and various and sundry other citizens figured out what was going on immediately. The buzz spread beyond the barbed wire fence and into the Land Beyond. All of the banished subjects, or the subjects who had escaped, heard about the shenanigans going on behind the gates. Only the grand inquisitor was apparently spared the news, for, upon hearing the glorious testimony of Rapunzel and how “cured” Young Subject had become, the grand inquisitor permitted Young to leave the special unit and go forth into the Land.

One beautiful summer day, one of the guards of the fortress had a rare day off. This being New Jersey - um, I mean, this being the Land - he chose to, as they say, go down the shore. Armed with nothing more lethal than his cell phone and a cooler, the guard was enjoying the beautiful summer weather when he spotted some familiar long locks. Looking closer, he almost urinated upon himself. Rapunzel! And Young Subject! In one of those tonsil-tickling lip-locks that people over thirty generally save for behind closed doors! Amazed, he remained paralyzed for exactly three-tenths of a second, when he recalled that his phone had not only a camera, but video capability as well.

Poor Rapunzel had to resign as princess. She is now in hiding, waiting to have her license to practice psychology revoked. Ironically, Young Subject had not placed all of his eggs in Rapunzel’s basket. Rapunzel was older and supposedly more mature, but any girl would do, really, so he found another former worker-subject from the evil kingdom/special unit. In fact, while he was courting Rapunzel, and while Rapunzel was deciding his fate, he was simultaneously courting this other worker-subject. This other young girl had actually committed a felony: she brought illegal drugs into the fortress and distributed them to the prisoner-subjects while she was a worker-subject. She had been engaged in a turbulent romance with a mentally retarded child molester, and she really wanted to please him. So she brought him drugs and called him from her cell phone a zillion times, and when she was caught, she was almost dead meat. But for some reason, King Evil took pity on her (or didn’t want to be bothered with all the paperwork) so he told her if she resigned, he would not pursue criminal charges (the cover-up being also a felony, but what’s a felony or two between friends?) She left, found a new job, and then rented a nice cozy apartment where she could wait for one of her sex offender-prisoner-subjects to join her.

Young Subject arranged everything. While he was screwing Rapunzel, he was planning to go live with - oh, we’ll call her Goldilocks, to stick with the theme. He left the evil fortress and moved in with Goldi, and then would continue to meet Rapunzel while Goldi was at work. Rapunzel should have been at work, too, but because she was the Princess her time was flexible.

After Rapunzel and Young Subject were spotted at the beach, and Rapunzel fled the evil fortress kingdom in anger (“I can’t take this bullshit!”) Young Subject was stopped by the police one night, while driving in the Land. His car was searched. But guess what - it was not his car - it was Goldilocks’s! And guess what was in that car? (Hint: what did she bring into the fortress?) Uh-huh!! Amazingly, Young Subject was not arrested for having drugs, since it was not his vehicle - but his parole was violated and he was returned to the very special unit to await the next decision of the grand inquisitor. He remains there to this very day.

What have we learned from this story? We have learned that King Evil is in fact, quite evil. We knew it before, and we have many more stories to illustrate his evilness, but I propose to identify a new condition: Sex offending by proxy. In this mental abnormality, the offender, too chicken to actually physically commit an offense, manipulates the people around him into acting out some of his vilest fantasies. As the ultimate supervisor of everyone in that fortress, his job was to know who was too screwed up to work there. Yet he took, and continues to take, great pleasure in identifying women whose lives he can ruin by placing them in proximity with Young Subjects and then letting nature take its course. Women who believe that rape is a crime of being pretty (i.e., women get raped because the men who rape them find them irresistible) should not be working in a sex offender facility. To gleefully observe while people’s lives are ruined is one of the worst acts of sadism I can think of. Yet King Evil continues to rule, hiring more and more vulnerable young women he can manipulate.

So, dear reader, our story must pause here, until the grapevine yields new information. Of course, this story is only a fairy tale, and any resemblance to any person living or dead is purely coincidental. But just imagine if it were true - just imagine if the place where sex offenders get locked up until they are “better” were really run by a sadistic evil psychopath whose father is a registered sex offender . . . Just imagine if dozens of impressionable young psychologists were taught that rape is an act of affection . . . Just imagine if you could bring drugs into the security perimeter without any consequences . . . Just imagine . . . 

To Friend or Not to Friend . . .

I have been marveling over the shrinking of the world for at least a few months now. The number of people on the planet is growing but somehow the size of the planet seems to be smaller all the time. People who had disappeared from my life for decades reappear in a second, as if they never left. Conversations that were interrupted twenty years ago can continue as if one of the participants just left for a few minutes to go to the ladies’ room. Photos that we took in our teens pop up on our computer screens like instant messages. And for the most part, it’s all good. Sometimes we exchange a few e-mails and call it a day. Sometimes we find that we really missed our old friends and we readmit them into our lives. Mostly, I think, we, or at least, I, feel connected to my whole life all at once, but interact with many of those old friends mainly out of nostalgia, and possibly a desire to feel young again.

But there is a flip side to all of this instant connecting. Recently I sent a friend request on Facebook to my first friend. This woman came to the states as a toddler; her parents arrived here around the same time that mine did, and I was born a few months later. I have pictures of the two of us in our pink party dresses at each other’s birthday parties, and with all sorts of unrecognizable adults lined up with their closed-mouthed, poor European dentition smiles. 

This girl, I’ll call her Gaby for convenience although it’s not her real name, grew up in my neighborhood, went to my elementary school and then my high school. We did not stay close after our parents stopped forcing us together, but, as far as I know, we never had any major conflicts or disagreements. Eventually she became the type of person I’d say hi to in the hallway - not a friend, but not an enemy. I haven't thought of her in years.

Enter the internet, and Facebook. Another childhood friend sent me a friend “suggestion” - that I add Gaby to my friend list. Wow, I thought, I haven’t heard of her or even thought of her in ages. I was curious to find out how her life had turned out. I sent her my friend request, with a little message. Nothing. She disappeared from my list. So, naively, I sent another request, assuming a system malfunction. Again, she apparently ignored me. 

I should have laughed off this incident, but instead, I got mad. I googled Gaby but the information was scant - more or less what my parents already knew from bumping into her parents every few years. I began to worry. Had I inadvertently offended Gaby? Had I done something back in high school which she never forgave? (not that I had any memory of such a thing). Did I have the proverbial cooties?

I’ll probably never know, but Freud did his own self-analysis and I’m going to do mine too. I did not do anything to offend my first friend - and while I have no clear memory of the birthday parties with the pink frilly dresses, I do have the photos, and I still treasure them because they are all I have of those early days - before I could speak English, before I had a sister, before I ever began my formal education and before the layers of school, society, friends, family, travel, work, and emotional challenges ever began to turn me into the person I am today. So I have decided that I actually feel a bit of pity for Gaby - pity that she has no connection to those early days, or any nostalgia for a time in her life that was not hers to control, but during which she - and I - were the darlings of a group of young immigrants. I have always felt a deep connection to my roots - not just to my parents and grandparents but to all the generations going back through Spain and Persia to ancient Israel and Egypt and back into the land of Ur. I love being part of a history, and trying to make a little mark that can live on. I am lucky enough to have three amazing sons who will pass on my legacy; I try to write and publish both fiction and non-fiction so that part of me will live on. Grandiose? Maybe, but I’m hardly alone in wishing for some sort of permanence, connection, and immortality. Gaby apparently is uninterested in either her roots or her immediate past. Too bad. In psychiatry to know a person’s history is to know a person. When people ask me how I can know so much about someone in a ninety-minute interview, I point them to the list entitled: “Sources of Information.” The interview is only a small part - it is the person’s history - his c.v., curriculum vita - which explains all of the details leading to the ninety-minute interview and resulting in my clinical impressions.

If Gaby changes her mind and decides to “friend” me, I hold no grudge. I am curious about the lives of other people - without this innate curiosity I could not do what I do for a living. If she chooses to remain distant, that is her prerogative. I certainly don’t need her in my life - but for someone like me, who does what I do for a living, the absence of information is sometimes more informative than any clinical interview could ever be.