Loco Locums

Three exams left. Counting my boards, which I plan to take either in late May or early June. Two finals and then that really big one. I have some study materials lined up, and I can purchase some computerized study aids too. It feels close, picked up my cap and gown, tassel and hood yesterday. Yes, hood, when you are bestowed with a masters, you wear a hood. The get-up is even stranger for the doctoral graduates.

Job quest rolls on. My plan to work for the specialized facility fell through. They said although I was the best person for the job, the locums tenen doctor (the term means "temp" for a practitioner) backed out at the last minute. This was to fill the gap until I was fully credentialed in late June. So their home office required them to fill the position now with an NP already licensed. I was disappointed, they were very nice about it, but what a time sink that was. I met with them three times, did research on their business and population, interview prep, etc. But the nice part is I'm actually feeling pretty happy about my other option now - it's working in a private practice with a local psychiatrist in central Austin. The only disadvantage is the initial lack of income - this is not a salaried position as the other one was. It will take time to build my clientele. But the team there (the doc and two other NPs) is a great bunch and it will be a great place to learn. The variety of patients will be good too - all ages, all different diagnoses. And I can walk to Kerbey Lane Cafe for lunch every day. Yes, the best revenge is happiness (I actually said that to a client today, when he was talking about recovering from a bad breakup). That's a bit of overstatement for me - no revenge intended here. It's all OK. Really.

Kitten season is coming at the Austin Animal Center. If you're thinking about adding to your family, please come by in the next month or so. We will be overrun soon.

I ran across an article at school that completely articulates my philosophy about mental health. Here's a link to it if you're interested. The cool thing is that this practice that I hope to join is completely on board with this. It's so much more than a pill pushing place. I really think I'll be able to put this into action.
Lifestyle and Mental Health

Ken and I go pick up Dani in NYC in late May. We are only staying 3 days, just lots to do and Nile is here, still in school. When Dani gets back, we will be going to yoga together. She's turned into this total flaming yogini freak, which I'm totally jazzed about. You know, it had to happen, I mean she does have half my genetic material. I got this terrific Groupon for us to take classes at a Lakeway studio together all summer long. Then, here's the cool part: in the Fall, she moves into an apartment that is quite close to where I hope to work and there's a yoga place within walking distance. Hopefully we can meet there after work while I wait for the traffic to die down. Mother/daughter bonding experience and get-healthy time, all wrapped up.

OK, so guess where I'm headed? Yep. Yoga. Aaaaahhhhhhh.

Wicked & Divine

Unique ceramic works.

Last night was Art Erotica, AIDS Services of Austin's big fund-raiser for the Paul Kirby emergency fund. Such a good cause, but man such a good time! It was noticeably toned down this year -- kind of wondering why. Here's the scene as we entered: dark, throbbing beats, art along the perimeter. Lots of gorgeous young gay men serving drinks in just their bikini briefs. There's a stage for fun later, and an area set up for three artists to paint/draw with live models with a circle of chairs for spectators. Lots of super sexy party-goers, yes, ass-less chaps and Marilyn Monroe-esque drag queens. Free drinks too, but I noticed that I've never seen someone stumbly-drunk there, never seen out of control behavior. It's just that nice Austin, tolerant chill weirdness.

This is the one we bought.

So some of the highlights: really cool trapeze performers using hoops and lengths of silk, a mini-Mardi Gras parade at one point, a male and female balancing act using just their bodies (I'd like to be that strong), oh and watching artists create from a tableau of 3 models. That was way cool. Two women and a man, the women had these interesting trompe l'oeil paintings on their bodies (pic below). I simply couldn't believe how fast the artists could work - of course, maybe that was the idea. But the finished works looked pretty good. We did end up buying a painting - its got that mystical Southwestern dreamy thing going on that we like.

So that was fun and well worth a night that I could be studying. School is fine, I'm very busy mostly because I spend two full days a week with Dr. Smith and I have 4 therapy clients now. I'm interviewing at two places for a job, and they are both quite different. One I mentioned in my last post, a local psychiatrist but I'm also talking with a small private center. In the interests of privacy, I won't be specific about the place but it serves a niche market of a specific disorder. They are interested in creating a brand-new position, so it is pretty different from most NP jobs, but one that fits well with my previous experience and my interests. Of course, I'd see patients too -- that's essential to me. Can you tell which way I'm leaning now? Ha. There's many different ways to work as an NP - we can be salaried employees, hourly employees, independent contractors that pay a monthly fee for supervision and office support, or pay a cut of our billings. It's a lot to analyze.

My New Year's resolution was to start adding a little running to my activities and I've been succeeding with that, but I started having knee pain. I suspected that I needed a different kind of shoes, so I went to this local running store in Lakeway, Capital City Running (http://capitalcityrunning.com), and they have a treadmill and videocam to analyze your gait, and I was impressed. I needed stability shoes but also turns out my shoes were way too small. A full size too small, maybe that's a female thing, we don't want to have big feet. I bought the shoes and yes, big difference. I love the running, want the knees to stop hurting though. And of course, I did too much too fast. Duh.

I'd love to say more....especially about interesting things I've learned. But I have a big paper to work on and some group members are counting on me. And the gym is calling too.

Three-Letter Acronym

School is zipping along and I'm liking that. In six weeks I'll be done! Of course, there's a final exam and then my board exams, but let's not count those. Just not having the massive reading (but often it's quite informative) and the papers (which are nothing compared to learning how to quickly document every patient visit) will be a relief. This is Spring Break, but I'm pretty busy. I did get to leave Dr. Smith's office early today because she had a meeting at her kid's school. Yes, working moms, we are everywhere. I have a list of 5 things to get done this week: 4 papers and a presentation, and 3 items are done. The presentation is on Alternative Diets for ADHD. I'll save you the trouble of sitting through it - special diets don't work in more than 90% of children. Kids with ADHD need meds. That doesn't mean that diet isn't important - kids with ADHD need good, healthy food (don't all kids?) and in many cases they need extra calories of high-quality nutrition. But it won't take away their symptoms. One of my last tasks is quite daunting - it's a group project to design an IOP (intensive outpatient program) for veterans with PTSD and chronic/serious mental illness. One of the three group members is a veteran herself so we have the inside track to make a truly realistic proposal. It's a lot of work but good learning.

I think I now could do a psych eval (new patient) in my sleep. I can cover your entire life in 40 minutes. Even if you're a talker. That's going to be painful, I'm going to be redirecting you a lot and it will absolutely exhaust me, but I can do it. I've been doing it. And I now have little lists in my head of what meds to pull out for what disorder, and how to tailor them to specific presentations. Are you depressed, sleepless and losing weight? You need Remeron and Celexa! Are you Bipolar II, don't want to gain weight and your manic periods weren't excessive? You need Lamictal! Are you only anxious and it's not too bad? You need Buspar and yoga! The other disorders (schizophrenia, ADHD, OCD, PTSD, etc.) are not as frequent so I don't have those right on the top of my mind. And yes, I know so many acronyms it's kind of ridiculous. You should hear Dr. Smith on the phone with other providers. It's just an exchange of 3 or 4-letter abbreviations.

Reassuringly enough, just in the past week I've started to feel that I could effectively handle most patients that we've seen if they were coming to see just me. But we had a doozy the other day that left me feeling like I was totally out of my league. I'm going to modify details to preserve privacy, but this was a teenager that had a long history of untreated mental illness, two specific disorders that are often co-morbid (meaning they occur together), and now finally, after flunking out of first semester of college, it's time for treatment. Never mind the fact that having one of these disorders untreated has likely resulted in brain damage according to the neurology report. I had to wonder - who was advising these parents? How did they feel about that now? The parents were very into alternative treatments, very against any medication at all, which is something we see frequently in Austin. The problem is that the alternative arena has a wide variety - yes, some things are new and work, but others are downright harmful. They are unregulated. And if you put all your chips on an alternative treatment, that's a big gamble. We didn't have time to cover everything, and we went 20 minutes over anyway. After this complex, difficult patient, I was pretty shaken. I thought to myself, if this teen came to me for help, I honestly would not know what to do. Dr. Smith said that when you're unsure on a complex case, don't make any decisions in the first meeting. Maybe you need another hour with the patient, and that's OK. She said tell them that you need to consult and do research - and that's OK. Call all the other providers that the kid has seen - previous psychiatrists, neurologists, therapists, psychologists, primary care. She said that usually by the end of that, you'll know what you want to do. But if not, call your mentor(s). She said there are a couple of guys that she trained under in town, and she still calls them once in while. I felt oh-so-much better after that.

I have a job interview this week. It's for a psychiatrist in town that works with three NPs in his office. I talked to two of them and both said great things about working for him - he's very available to consult and he enjoys teaching, he encourages work flexibility in terms of hours. Oh, and here's THE most important thing-- there is a yoga studio within walking distance. Can you say noon-time OM? I just want to see if it could be a good fit for me. He does see kids, so  the fact that my license allows me to see them as well (not all Psych NPs see kids) is a plus. I knew all that time on the kids unit at Austin State Hospital wasn't a waste.

My friend Kathy is moving to Colorado. We had lunch and talked about old times working together at the psych hospital here. I will miss her a lot, and I learned a great deal from her. She's one of the best at establishing rapport with very, very ill psychotic patients. Here we are, having lunch together at Hyde Park Grill (a great classic Austin place).

Cover May Not Be Indicative of Contents

This is an interesting, exhausting time. I'm spending two days a week with my precepting psychiatrist (I'll call her Dr. Smith), in class two days and seeing therapy clients the fifth day. I think the exhausting part is the clinical work. But it's so fun. Oh my goodness, if I ever had a doubt that I was meant to do this, it's gone. I read my textbooks for fun. Stahl's Essential Psychopharmacology? Love it. The chapter on depression is brilliant. And my doc is the best -- I mean, I selected her carefully, it wasn't an accident. It just feels so good that it's coming together for me. I have many avenues for work, the hard part will be choosing.

I knew this already, but I feel that it bears repeating -- people are so darn different, unique and surprising. I can't be specific about patients but I've heard such incredible things over this month. Someone really professional, polite, relaxed sits down, you close the door, and they dissolve in front of you as they talk about growing up with an alcoholic father that beat them, their resulting serious drug problems, their failed relationships, and the depression that's hounded them. It's quite something to pull out that little pad and offer relief. But it doesn't end there, of course. One of the reasons I respect Dr. Smith so much is that she pretty much insists patients see an individual therapist. The meds lift the fog so that you can sleep, function, and face your work in therapy. Therapy helps you make changes that last. Do all patients thrill me? No. I particularly don't like it when I sense someone isn't truthful (which happens a lot....sigh). The range of people's responses are so wide. I've heard from a patient, my Dad's friends sexually abused me but I'm in therapy and I'm coping (true) and then another patient will say, I've had such a terrible year, you absolutely wouldn't believe it. What's so bad? Job stress and elderly uncle died. Hmmmm.

The prescribing is starting to come. I did so much on my own today while the doc watched -- three psych evals (new patient intake -1 hour) and three follow-ups. She asked which meds I'd choose for each, and (yay) I was right most of the time. One I missed was recommending Viibryd, it's very expensive. We went with Effexor because cost mattered to the patient. Another big learning is how common sleep problems are. If you have a mental health concern, you probably have sleep troubles. I got to give a sleep hygiene lesson twice today.

Another thing I'm learning is how to confront or "go public" with my internal dialogue to patients. If your story doesn't add up, I say that, "This just doesn't make sense to me, explain why you refuse therapy, won't take your meds, and keep coming to me. How can you move forward?" luckily that conversation doesn't happen often. But it works even with little things - you say you're fine with your marriage but we've spent most of our time talking about your wife's failings.

There's a bill in Texas that loosens some of the restrictions on Nurse Practitioners' relationships with their delegating physician and it looks good to pass. It's very good news because Texas is terribly short on healthcare providers in most locations (especially mental health, that's actually the worst), so now NPs will be able to do more. And we are cheaper. I'm starting to look around and figure out who I want for "my" doc, and this really matters.

I spent 3 days with an NP at nursing homes, seeing demented patients. I like older people, and after working in NJ on a medical unit, I'm used to dealing with ill elders, but this was not my cup of tea. It was the same feeling I had when I worked in ICU -- so many patients can't really communicate with you, it just takes all the fun out of it for me. And it's just plain hard trying to figure out how to treat dementia (short answer: you can't. You end up medicating to control negative behaviors).

So I have often talked about how much people's weird behavior at the gym bugs me (yes, I know, I spend too much time there). But listen to this. At one of the yoga classes I go to regularly, a woman comes in late. She's older than me and very thin, wearing tight little short shorts. She has a strange double-wide mat, which she proceeds to lay out front and center (strike one - if you're late, stay in the back). She brings big hand weights with her, I'm wondering why. She's now way too close to another woman's mat, who looks irritated. We do our first down dog and I purposely don't look at her ass, knowing those shorts are not covering it. Strike two. Things seem OK, until we get to the abdominal work song, then she starts doing strange things with her weights and they are noisy. Guess that's strike three, because her neighbor picks up her mat and moves to another spot. I had never seen someone do that before. (I sure have wanted to.) I thought to myself, wow, lady, you have no no idea how much you're wearing your obsession. Stick-thin, inappropriate clothes, ridiculous efforts to ramp up the ab work, you might as well post a sign saying "Eating Disorder". Future patients, they are everywhere.

The pic is from the Austin Animal Center. Someone must've donated the cat bed. This little fella sure liked it.

I never said FAT crazy bitch

I have the flu. I spent the most god-awful day at work, periodically dashing to the bathroom to vomit as I vainly tried to have a heart-felt therapeutic interaction with a young woman the morning after her failed suicide attempt. It was beyond ridiculous. I walked in to work, sat down for report and waves of nausea washed over me. The day went downhill from there. I was so chilled, I had on 3 layers. I finally got to leave early -- at 4pm instead of 7. Yeah baby. (and yes, of course I got a flu shot.)

From the couch, I got to watch Lance talk to Oprah. I'm aware that I defended him in one of my previous posts -- I always liked the guy, guess I bought into the myth he created and of course there's LiveStrong (which I still salute him for). Can you hear the "but" coming? I was intensely turned off by his act on Oprah.  Yes, it seemed an act to me. He's a fame whore and a narcissist. And I'm mad at Oprah too. He bizarrely said about a teammate's wife that testified he was doping, "I called her a crazy bitch but I never said FAT crazy bitch.". She gave him an awfully strange look but she should have said WHAT IS WRONG WITH YOU?

Last semester has commenced. Things seem good, but it's early. And the job hunt is on too. I have a meeting next week to start some discussions with a potential employer. It's nice to be a nurse, even nicer to be an NP.

I had a terribly interesting therapy experience recently -- and it was actually both terrible and interesting. It was my first session with a client, and I had this feeling of repugnance afterwards. At first it felt like anger, but then I figured out that I was convinced he was lying to me, and I mean big, juicy lies. Critical information left out, bizarre answers to questions (no, he wasn't psychotic, believe me, I know psychosis). But since I'm new at this, it was good - I learned a lot. And I certainly will handle things differently next time. For one thing, I've been practicing this: "I think you're leaving something out." But I keep thinking about this: why would you pay someone to listen to your lies? Guess that's a topic for my next supervision session.

I enjoyed working so much over the break. Found I could still give emergency injections with flair. I realized that because I've worked in an acute psych hospital this long, I've seen a lot. I mean, reading in a chart that a patient killed his brother and just got out of prison is not eyebrow-raising. Some of my patients on almost every shift either came from jail or recently got out, or have that in their history. The worst is when you read about someone in the paper, show up to work, and there he is. Another thing that I've noticed is how pissed off the nurses get at these young women that try to kill themselves over some loser boyfriend that either left them or is cheating. It's an almost uniform reaction, I've noticed, and I try to remind myself to keep my own reactions to myself. Many patients are really good at driving others away. Let me give an example. I was assigned a patient with long-standing borderline personality disorder. I bring her morning meds to her with breakfast and she immediately complains that I'm rushing her. She apparently needs extra time to swallow her pills, which actually is fine with me, I am not aware that I'm rushing. I sit across from her and ask how she slept, how she feels (might as well collect some data), but instead of replying she notes what an ugly color my nails are. Later, she comes to the desk, says she can't remember my name ("it was something weird") and then harangues me because my badge is clipped to my waist and she can't see it right then. OK. I feel my reaction but I don't display it. At lunch, I bring her another pill and then she gushes about what a great nurse I am and wants to talk like old girlfriends. Really? What's sad is that she's done this exact sequence to the close people in her life and driven them away. Now she's old and alone, in poor health and suicidal. Yet a characteristic of borderlines is they don't want to change. I'm attending a workshop in late February on working with them, boy do I need it.

One of the standard frustrations at work is dealing with the prescription narcotic addicts, which is an epidemic in the United States. Did you know more people die from prescription drug overdose than from illegal drugs? Addicts are skilled at feigning both pain and psychiatric illness to obtain more drugs. Where it gets squirrely is when someone starts with legitimate pain but has become an addict. How can we help them? They need a detox, treatment facility and we're not that. But they don't want that. Most of them are so deeply self-deceived, it is comic. One of the docs told me that the United States writes 95 percent of the world's narcotic prescriptions. And we are only 7 percent of the world population. So why don't other advanced societies do this? Like Europe, Scandinavia? Ah, because of socialized medicine. The public isn't willing to pay for it. I haven't fact-checked these stats by the way. Something to think about.

Bullwhip

Ah, not feeling guilty because I'm not studying. Best feeling in the world. Even if I'm sick. Yes, I worked two days last week and everyone on the unit was sick. Seems to be just a cold, and I haven't missed any workouts yet.

Got another job offer, one of the docs at work. I'm starting to realize that I won't have any problems finding work. I knew that intellectually, but it's another thing when six months before you're available, offers come in. What I don't want to do is just take what's offered, I want to find the best fit possible for me. The day before Xmas was really awful on the unit - we even had a "code purple" in the admit area right at shift change (of course at shift change). That's when people are getting aggressively out of hand and we need extra staff to either restrain them or just a show of force. Our PICU (Psych ICU) has 10 beds, and the types of patients that are in those beds is very important in terms of what kind of day it will be. We had three young antisocial men, which is absolutely terrible. One is bad, two is awful... We ended up moving the "best" one over to the open side because the three of them just created an untenable situation. Too much hitting and threats and tempers flaring, which makes the nurses get in the med room and sharpen the needles. And a few of the other patients on there, not young men, were intensely psychotic. It was a rough day, and I wasn't even assigned to the PICU. Just the overflow of dealing with all that affected every single staff member. And this disturbs me - about half of my patients simply weren't improving, in spite of being on antipsychotic meds for at least two weeks, some more than a month. They seemed fine until you questioned them closely -- then the delusions came out, "Well, since I'm a doctor, they said that I can write my own prescriptions..." This came from a patient that was decidedly not a physician, and was in fact on court-ordered medication. Meaning we will hold you down and apply it via an injection if you don't swallow this pill. Not that physicians can't have mental health disorders - one of the saddest cases I ever saw in New Jersey was a psychiatrist that was hospitalized with major depressive disorder after his wife had committed suicide. I watched him waste away over a period of months.He blamed himself for her death.

I had a really odd dream. It was after the doc made me that job offer, I dreamed that I was at work as a Nurse Prac, and it was my first day. And get this, I had a venomous snake with me that I used to bite the patients to provide their meds. All the docs had their own snake, but since I was new, my snake was very badly behaved. He kept trying to bite the other docs and slither across the table as we were in treatment team meetings. I would grab him back and apologize. Talk about weird.

So moving the young anti-social man over to the open side turned out to be a really bad idea, he ended up calling 911. Now that has happened before (obviously) but since this guy is antisocial, he is as slick as, well, a snake, and super skilled at gaming people. The EMS team that responded was two newbies, so they were quickly sucked into Mr. Gamer's web. We spent at least two hours on that. Finally, the medical director insisted that the patient not be transported to the emergency department. His little game was foiled after all, but all of us were stressed and angry. What a waste of resources. Why doesn't someone so clever put their skills towards good instead of just jacking everyone up? The eternal question with the antisocial. And honestly, I would say that he's more borderline personality disorder than anything else, but I've noticed that there seems to be a gender bias when it comes to those two diagnoses. Men are classified as antisocial, women as borderline. He was a yawning black hole of attention-seeking behaviors all day long. For example, when I gave him his meds, he comments on how cool my nails look. I say thank you in a brusque way, I've already pulled on my no-nonsense schoolmarm persona, which I find works best with these types of patients. He moves on to initiate a conversation about his anxiety (right, he's sooooo anxious) -- he's appealing to my expertise and desire to offer therapeutic communication. I don't take the bait. The next time I see him, he's got a strange marking on his face that he applied with a magic marker. I don't even remark on it. Each interaction, he rachets up the "look at me" stuff. That's clearly borderline to me.

One of the super-psychotic patients was in group therapy when they were asked to write down their goals to be ready for discharge. It was so interesting, I copied what they wrote (with minor changes to preserve privacy). This is how the psychotic brain works. He wrote:
"Can live with Ma,
like John Wayne,
living for Dragnet,
miles away with Old Yeller,
and my bullwhip."
What's interesting to me is that you can sort-of see the grains of truth in there - maybe living with his mother is an option, sounds like she lives in a rural area, is Old Yeller his dog? Would he watch Dragnet on TV? But that last line is a little disturbing.

I've started my supervision work for my therapy skills and finding that works. Rob is my supervisor and I think we "click". I have three patients that I see regularly now, with three different diagnoses. I've already had to ask Rob, does just therapy work for this particular disorder? Because I so badly feel this patient needs medication too, it feels like I'm hamstrung in terms of helping them. Yes, he was quite reassuring, and offered some specific approaches that I should use when meds aren't in the picture. But man, I am so glad that I will be able to do both in the future. It just feels like I'll be able to offer well-rounded, comprehensive care.

I'm reading all kinds of great stuff while I'm off. Some of it applied to my job. One of the books is about psychological masquerade, when patients look mentally ill but it's due to an "organic" disorder, such as a brain tumor. (I dislike that term "organic" because mental illness is organic, too.) Another book is a memoir of a bipolar woman. And I'm reading Margaret Atwood's Positron series, which is a disturbing view of the future. I had to order Christopher Hitchens' last book, on mortality. Having a Kindle is the best.

But by far, the most exciting thing about having time off is going to yoga more than once or twice a week. I can usually get there three or four times now, which just makes life so much better. It's funny, I want to recommend yoga to every single patient. I do always talk about overall lifestyle choices - I think that's one of the keys to good mental health - and I mention yoga, but I don't tell them how actually rabid I am about it.

Starting to Feel It

Things are great, the semester is winding up, but man I sure am glad it's almost over. It feels a little ungrateful to complain - I mean, I'm so lucky that I'm able to go to grad school.  But I basically took too many classes. And the delay starting clinical just compressed everything starting in October into this miserable so-busy-all-day-long Monday thru Friday gig. Like I said, I couldn't even schedule a haircut in the the month of October or November. (Actually, I just got that done today, after I had my first final exam. Yes, I can finally breathe.) I'm working as a therapist on my own now at one of my clinical sites and finding my way as a new clinician. It's exciting and humbling, and I don't take it for granted. As I told someone recently, I have a proper sense of terror when I close the door and it's just me and my client, looking at each other. It's one of the hardest things I've ever done, I can say that. As Ken says, it's a puzzle. People tell you what's on their mind, but you have to figure out so much more - like, what do they not fully realize about themselves? What are they hiding from themselves (and trying to, from you)? What formative event have they left out that needs to be discussed? In the last - I don't know, maybe 20 years - the psychiatric community has found proof that many of our disorders are rooted in genetics and neurochemical/structural makeup - it's not all "bad parenting", although that is a factor. And how do you assess that? It's not like I can do a head CT in the office, and the differences at this point are rather subtle. Diagnosis is hard work - makes me appreciate the TV show House all the more. For instance, one of my therapy clients came to me with a very specific diagnosis in mind. And it took her almost the full session to reveal this. She has a set of expectations now around this, and we have to discover this territory together. But I certainly can't dismiss her ideas - even if I flatly disagreed (which I don't). Because she is the expert on her own inner life. I'm just someone who's a trained guide. Hope it's worth the money (ha).

I have realized that I certainly don't want to work at the state hospital on the kids' unit. I like the vast majority of the patients - but the subset of kids that don't really belong there (those with severe conduct disorders that basically disrupt the environment completely) have ruined it for me. This facility is not the place for them, but unfortunately placement is such a problem in Texas that they end up there anyway. And I can't be a part of that. The other kids - those with treatable psychiatric illnesses - I really liked them. I look forward to working with kids in the community that need help. (And yes, I know that theoretically Conduct Disorder is treatable but not at ASH. We are not staffed or trained to treat that.)

I've managed to work some fun into the semester. Ken and I saw Duncan Sheik perform at the Paramount and it was such a treat. I've been a huge fan since 1993, with his big #1 hit Barely Breathing (which he did a smooth-jazz version of as an encore), but it was nice to introduce Ken to him. Duncan was so funny and generous and just what you want a singer/songwriter to be for you, up on that stage. He sure has a wicked self-deprecating wit. I love how he said to introduce one song "Have you ever noticed how every sensual....seductive....arousing....hot....(this went on for a while)...thing is better in the anticipation?" Anyway, it was funny. I obviously am not as good a raconteur as he is! And he sang my favorite song (Wishful Thinking).

Let's see....what else happened....AIDS Walk Austin was fun. Beautiful day, good cause. My biggest baby had to evacuate for the hurricane in NYC. Is that weird or what? We live in Louisiana (yes, we survived Katrina) for 20-odd years, and Dani goes to New York and is hit with a hurricane. We flew her home the day before it hit, and it's a good thing because it was a nightmare. We had to send her back after a week because classes resumed at NYU but she went back to a freezing cold dorm with no heat or hot water. Luckily, late the next day it was fixed but we were a little frantic. She spent a really shivery night.

The diagnostic bible of psychiatry (DSM-5) has been updated and it's quite controversial. We've been talking about it in class all semester. I didn't realize that I was getting involved in a profession that has such controversy surrounding it, but I am. The public is questioning pathologizing that may be going on - is hoarding really a psychiatric disease in its own right, or just a case of OCD? Is severe bereavement the same as clinical depression? Are kids over-diagnosed with bipolar disorder (yes)? Are the drug companies in bed with mental health providers, seeking to smooth over every bump in the road with a pill? One of the things I like about working now as "only" a therapist, before I graduate and have prescriptive authority, is that I'm forced to treat patients without turning quickly to drugs. My personal belief is that drugs are needed in some cases, but are probably over-prescribed in general. My goal is to not be in that camp. The other part about prescribing is do it right. I've already seen several patients that were prescribed a low starting dose of anti-depressant by their family doctor, and followup wasn't really done. They are still on that dose, and not feeling better after months. The doc wrote a quick prescription without a thorough psychiatric exam (maybe as part of their standard 15-minute office visit), and didn't titrate the dose. If you need psychiatric care, you need to see someone fully qualified in that arena, or expect sub-standard results. Just my biased opinion, folks.

And another biased opinion is something that I've changed recently. As a result of my experiences on the kids' psych unit, I no longer support legalizing marijuana. I can't tell you how many kids I've seen that think that's the answer to all their problems, but what is does is just suck all the motivation out of their brain. I have no problem with adults smoking a little here & there, but its effects on the developing brain are scientifically documented as terrible. And yes, I know that if it's legal, then you have to be 21, but how many of you drank alcohol before it was legal? Yeah - all of you. Me too. And the other thing is the brain is still in a high state of development until about age 25 or 26. I've always supported legalization, but I have changed my mind. I think society has to protect these vulnerable teenagers that choose this horrible thing that frankly, puts them in a fog and robs them of a future. The other thing is that I read the cartels don't really grow marijuana any more because the in-state cultivators have basically taken over the market. Ever watch Weeds on Showtime? So that's not a good reason any more to make it legal.

This last pic is just two cute kittens from the shelter. Don't you just want to kiss that little pink nose? We are still consumed with kittens there. It's been the worst year ever. If anyone out there wants a kitten, please please please visit the Austin Animal Center. Open every day from 11-7. http://austintexas.gov/department/animal-services