Transplanting a Seattleite

I went to my new PCP today and everyone was so nice! No problem parking. Pleasant waiting room; nice people waiting. The nurse who roomed me asked if I could be weighed today! Woot! I said, sure, and what number it would say (I was .4 pounds less than what I said it would be). She offered to chart what I said my weight was at home. Love this place!

They made sure I had been seated and calm for 10 minutes before taking blood pressure and made sure my arm was supported. I got the low end of what I measure at home! It’s been a couple decades since that was true — I’d started to doubt my cuff, honestly.

I got the referral I wanted. A student came in to poke at my face and answer questions about it. I got another week of Bactrim, sigh. Oh well. NP thinks the dermatologist may just yank the whole thing out tomorrow. That’d be awesome, altho I personally doubt that will happen. I think they’ll want the infection calmed down a bit more, but you never know. NP says that if I didn’t already have the dermatologist appointment tomorrow, she would have tried to clean it out some.

We did go to the therapist (all three of us). R. picked up A. while I was getting my antibiotics from CVS (another $1.20), and then I joined them. We had a nice conversation. It started off on something R. and A. had been talking about in the car, but I diverted to the conversations A. and I had been having about a student at school who is trying to get a borderline diagnosis (*let me just point out the incredible self-insight that adolescent must have to ask for that as a teen*). We had a nice discussion all around, that ultimately started poking at A.’s really high degree of commitment to making sure the people around her are happy. somehow, being in public school apparently resulted in some weird flavor of Stockholm Syndrome in my daughter. Probably very common, actually, now that I think about it.

In any event, it made me optimistic, because not talking about stuff isn’t usually helpful, and sometimes once you start talking, things improve very quickly. Fingers crossed.

In a weird development, when JB at the builder went over to Mercier to try to find a better option for the curved wall in the pool room, Mercier found some Forbo commercial wetroom product that they can order from Australia (!), and a Roppe baseboard to go with. I had actually seen the Forbo product online, but never brought it up, because I figured N (the architect) would have a really negative reaction to the word “vinyl” (we’re calling the siding “polymer”, apparently, whatever). When JB was talking about it during the OAC meeting on Tuesday, she said, I bet you already know about this. I was like, I bet I don’t. She showed the web page and I was like, actually, you were right I did know about this. LOL. Fingers crossed this all works out; it would be a fantastic solution and really help with acoustics in the pool room.

A. got up on her own for piano. The piano is loud, obviously, but even so, I usually have to go get her up. Not today! She got up in the middle of R.’s lesson, came down, ate, put her plate over by the dishwasher. I am stunned. She was up until midnight. I had warned the instructor that she might or might not be participating today and why. He was extremely understanding.

I decided to take a look at what the People Online have to say about parents, schools, students and therapy. Yes, I know, probably should have done this before!

Some discussion is teachers looking for guidance on whether it is overstepping to suggest to parents that therapy for the kiddo might help. They were discouraged in general, often on the grounds that this would result in therapy being the financial responsibility of the district. Let me just say, the amounts of money I shelled out for various therapies suggested by that flaming asshole OT that CASE inflicted on T. I have a policy, where if I am in conflict with someone intransigent, I will do everything (okay, nothing that is contra important values, obviously) they suggest will “fix” the problem. If things improve, yay! They were right! I had a good outcome! If things do not improve, or, as is more typical, got worse, I now look like the reasonable one (I tried the things I was told would help If I Just, and we’ve already exhausted their initial list of But If You Just). Over the years, this policy has become tattered and threadbare. It now stinks really bad. I’m probably never going to do this again. And also, I’m going to start attending to the timeline much more closely.

To be clear: it’s not that I will never listen to anyone again. I _do_ listen to people! They are often super helpful! My life is not All Conflict! Altho, a disproportionate amount of my blog is, in part because I need to have something to refresh my intentionally suppressed negative memories, and in part because Drama Makes for Engaging Content (<— that is mostly, but only mostly, a joke).

Some of the discussion online is about having specific behavior or attitude goals for the therapist and the kid to work on, and then leaving them to it and not being overly intrusive. There are also remarks about Don’t Expect to Be in Every Session with Therapist and Kiddo. All of _this_ is hilarious, not in a way that makes them _look_ bad (I mean, it kinda does, but that’s not WHY it’s funny; that’s just sad). It’s hilarious because I got the therapist for T. because he insisted that’s what he wanted. I didn’t have a goal. I just ask how things went and express generic hopes that it was helpful and/or enjoyable, and that if he ever wants to talk to me about it more, he absolutely can, but there is literally no pressure. The second therapist happened because I was getting a lot of pressure from the school psychologist to get A. a therapist and, “A. says she doesn’t understand why she needs or should have one” didn’t seem to be compelling as an answer to anyone (I was fine with it). When the pressure did not let up, I engaged in malicious compliance and got a Team A. therapist and consistently ignored all efforts to have any communication between the therapist and the school. A. wouldn’t go to the therapist without me, and the therapist does family therapy and was fine with this, so that’s what we do (oh, look, I have a therapist too! Whee!). I had no “goal” for therapy, and this also seems to be fine (I picked a relational therapist and I’m paying her directly). The rapid swap from the use of the word “punch” and the phrase “handbook violation” in an email from the vice principal (since retracted as noted in earlier post) to pressure to sign the form allowing communication is why I’m doing this research.

I’ll be back; I have to do before noon duolingo.

A.’s piano lesson really went great and she’s in a good mood. I said, hey, we’re going to learn a new Adult Skill: cleaning a toilet. She was not enthused, but I said, this is the Watch One stage. She helped clean the sink and the counter and we roped T. into helping declutter the counter. This was awesome!

T.’s off to see a play at the jr hi. We’ve scheduled a test drive for the first of a list of candidate vehicles to buy him for graduation. He identified the dealership and that they had the right car available. After the play, he’ll go over with his dad but in separate cars, and they’ll do the test drive and then T. is off to work, conveniently in the same town as the dealership. Progress on multiple fronts!

Meanwhile, A. is reaching out to a friendly-acquaintance, potential friend at school to schedule some online gaming. Mental Health Day is the gift that keeps on giving, along with a plan that gives us hope.

Back to the therapy communication research!

We have teachers wondering if they can recommend therapy and everyone piling onto them saying no, don’t put your district on the hook financially (*sigh*). We have advice to parents to set goals for the kid’s therapy. (*double sigh*) At least that’s being used to manage parental expectations / set boundaries. What else do we have?

We have an assumption that there isn’t a 504 or IEP already involved, and assumptions that the kid doesn’t already have a diagnosis. LOL. My kids have both had diagnoses since they were wee. They’ve been receiving services since pre-K (T.) and early intervention (A.). We’ve had to escalate to get appropriate services for T. AND we’ve requested return to district for T., when an appropriate in district program was created. Ironically, the district did not tell us that program was created, _even tho the teacher designing the program designed it with T. as the target audience_. I mean, what. (How do we know that? The teacher told us that’s what she did. I know it can be difficult to believe if you’ve recently had an interaction with me that R. would describe as I Disapprove of Reality So I Will Remake It the Way I Want It to Be, but I actually do care about relationships and I have some weirdly good ones with people.)

Anyway. None of this helps me? The school knows the sensory issues. _The school sent me email about evolving symptoms that are almost certainly seizure activity ramping up._ They did that when A. was in pre-K, too; they’d send email about her staring off into space and not responding and I was like, whatever, until they said, her face went white, and after I got over the initial, uh, she’s pretty pale, my brain caught up and said, wait, no, that’s a petit mal. We haven’t been able to get the sensory issues adequately mitigated in this school environment. Partly, that’s a Them Problem. A pass to switch classes early or late would help with the passing time crowding overwhelm; an escort would also help, and could help with the Too Much Stuff to Manage problem that means she doesn’t want to bring her over-the-ear headphones because it’s Just One More Big Thing to Manage. Until A. found the migraine glasses, we were seeing a _lot_ of seizure activity; the glasses absolutely fixed that.

If there’s a lesson here, it’s that I probably should have involved a neurologist last year. But we’ve never managed to get any action out of the neurologist we had, because we never actually caught anything on EEG (didn’t do a take home, just a sleep deprived, and honestly, that was the problem). We’ve done well enough managing triggers that I lulled myself and everyone else into a sense that the problem was gone, much like there are people around me who lose track of the food allergies and picky eater issues, because I’ve gotten so good at navigating restaurants. Fundamentally, we don’t really _want_ any of us to be on long-term medication (we resent having to take antihistamines, honestly). We are definitely part of that problem.

OTOH, I’ve _never_ thought it made sense to medicate so you can do something that makes you non-functional without the medication. Avoid the trigger! I’ve been on cruises and took a quarter tab of dramamine every 4-5 hours to do so. Yes, I am a hypocrite. Yes, I had to wake up in the middle of the night to take one. _And it was a cruise._ It wasn’t going to school for years. I basically got on a boat with my extended family and the boat entertained everyone else and I lay around in a haze for several days. The dramamine helps with allergies, and I could still have one drink, so it was actually a fantastic experience. The only downside was my sister kept wanting me to go do shit with them, and my entire plan had been to NOT do anything.

The specific reason I’ve been reluctant to get a behaviorist oriented therapist and/or have the therapist communicate with the school is because I believed that the goal for the school is to fit A. into their environment and have her perform at a high and increasing level. We all know that the school is a bad fit for what A. needs in life to thrive. I’ve expressed concern that this is not an appropriate placement (I did that at the junior high, too, but that was only 2 years, and those were the coming-out-of-the-pandemic years and everything was weird anyway. Plus, junior high.), and I did that when T. was transitioning from pre-K to K (and K was an unrelenting disaster that the district pulled the plug on before I had all my experts fully onboard with the plan).

On FF last night, E. really objected to me using the word “bad” to describe this environment triggering increasing seizure symptom situation. E. likes nuance, which is normally fine and also wildly insensitive in this particular context. I’m not sure precisely what she was getting at, _and I don’t care_. The second sense of “bad” in Oxford languages online (what you get when you google “define bad”) is “not such as to be hoped for or desired; unpleasant or unwelcome”. I just don’t understand how this word could possibly be other than the right word for this situation. E. tried a bunch of ways to express her values, and I suspect the core idea involved concerns about ableism. I think it’s obvious that if you are being pressured into doing something you don’t want to do, that is harming you, and that is causing you to have a lot of unpleasant seizure type symptoms, that’s “bad”. It’s not “bad” that you happen to be the kind of person who has this type of reaction to an environment that is unsuitable for you. E. is probably thinking about this in the context of people in E.’s life who are struggling to find appropriate niches, and whose appropriate niches become less and less supportive as the people in them age and eventually pass away. E. may also be thinking about how for some people, embracing the dissonance, the “not fitting in” is part of them “thriving”. I would _much rather_ be the boring person in the middle, than the person who everyone looks at and goes, this is definitely the one that doesn’t quite belong. I don’t want for me, or anyone else, especially my daughter, to always be the one that doesn’t fit in, no matter how hard they try to find their people. At some point, there is a surfeit of being special, an excess so great that even the numbing properties of great wealth and awesome vacations and amazing friends are not enough to overcome. There are not enough carbs in the world. At some point, ya gotta pull the plug and say, if I don’t fit in anywhere, let’s make a place where I do.

R. and I have been framing “homebound” incorrectly. We look at all the outside-the-home things that people don’t get to experience. But they _do_ get to fit in, within their home. I don’t want to be limited to my home (yet), nor do I want that for my daughter. I now want, badly enough, clearly enough, that I’m not going to tolerate any more, the places where I cannot fit, the places where my daughter cannot. I’m afraid I’m going to have to, once more, Replace Reality with a Better Way of Doing Things.

We are going to make our environment Fit For Us.

There are two more episodes coming; I will try to listen, review and link back to this one and forward to that review if I remember. In the meantime . . .

Nocera used to write at NYT; he now writes at Bloomberg. He has been fairly public about developing depression / bipolar disorder as an adult:

https://www.bloomberg.com/opinion/articles/2018-06-11/let-s-talk-about-kate-spade-anthony-bourdain-me-and-depression

This puts him in a really interesting and if not unique then rare position: he has quite a lot of visibility, he is open about mental health challenges, he has both resisted and pursued treatment AND he does not seem to have a bunch of truly horrifying stories about awful things he did to other people before attaining more stability. Either he really did develop bipolar disorder in mid-life, or whatever was going on earlier was at a low enough level that it did not lead to the kind of Hey Let Us Put That On TMZ type event that discredits people.

I am extremely pleased that he is using this if not unique then rare position to take on a particularly challenging problem: what about when you seek help, and that actually makes it worse?

The podcast is a romp of a story, if at times feeling like a psychological horror story. Nocera is humane enough in his presentation, and he has a gentle and compassionate sense of humor that keeps the focus on, what were people thinking as this process (being taken advantage of by a deeply problematic psychiatrist) ticked along over the course of years, or, in the case of some, decades. For me, “that’s crazy” is not the end of analysis, but rather the beginning. I want to know the mechanics of the crazy, and Nocera really does a dive into this one.

That said, I wish, a little bit, that Nocera had a little bit more perspective on the larger pictures. Obviously, what the therapist did was cartoonishly awful. At a minimum, overcharging for bad advice, with job lots of boundary violations thrown in (at least so far, no obvious sexual misconduct). Nocera spends a lot of time talking with “Judith”, about her issues with an abusive mother (a holocaust survivor) that led her to the psychiatrist, and who says she was strongly encouraged by the psychiatrist to cut ties with her mother, and not to be swayed to visit her as her mother was dying, or to attend her mother’s funeral or to sit shiva.

Abusive family relationships within tight knit communities which take sides when there is a definitive split are really, really awful. Without endorsing the advice given by the psychiatrist, it could be observed that “Judith” got a really great deal here: she got to avoid her mother, go to great parties, feel important and minimize contact with a community that was not working for her. Then, later on, when she wanted back in, she could blame it all on the psychiatrist. I smell splitting. I feel like Nocera should have caught a whiff of it, too, because the main story of the first few episodes reek of splitting.

Anyway. Great story, and if you are ever complaining about therapists who do not tell you anything about their own lives, but just basically encourage you to talk about what you are feeling and experiencing, or who only want to focus on supporting you in making concrete plans to do more of what is working and figuring out ways to incrementally approach the miracle of Being Better, take a step back and go, hey, at least this therapist is not like that therapist. Also, wow, what psychiatrists do has really changed since the 1980s.

ETA: First episode is how Nocera fell into this rabbit hole. Second episode is how the psychiatrist interfered in a sibling relationship. Third episode is how the psychiatrist weaseled his way into President of his client’s company and an employee at that company describing how good the psychiatrist is at lying with no tells at all. Fourth episode is the psychiatrist fostering relationships between patients, and the parties at the house. I started with 4, then listened to 1, 2 and am currently halfway through 3.

Subtitled: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward

It's not clear exactly when the last substantive revision of this kindle edition occurred. No OCR problems, typos, grammar issues, wtf were apparent in the course of a single read-through. Because the original book dated from the 1990s, the contents are somewhat, er, dated. For example, we have made much more progress towards what they call "social liberation" with respect to smoking, and to a lesser degree with respect to drinking. For example, most indoor and some outdoor public places in the US and many other developed nations are now, by law, smoke-free. Far more people have quit smoking since this book was written, and the phenomenon they describe (of smoking becoming increasingly covert, hidden even from family members) has progressed even further, albeit electronic cigarettes have produced a new wrinkle. Because I've been paying a lot of attention to alcohol portion sizes, the text has a single-alcoholic-serving as 12 oz beer, shot (1.5 oz) serving of spirits (both the same as now) or a 4 oz glass of wine.

Before anyone goes, OMG, do you drink/smoke/have a whatever problem, the answer is, of course I have a whatever problem. Almost everyone has a whatever problem. And this is a systematic way of thinking about whatever problems and what people do about them without involving professional assistance and when that works and, when it doesn't, why. Their theory, the TransTheoretical Model of Change (TTM) is a very 90s, pre-CBT approach to Helping People Help Themselves. Starting from then-current research that indicated that virtually all theoretical approaches in the helping professions (he calls them psychoanalytical theories, and quotes Freud without apology, altho fortunately not often) were roughly equally efficacious. Not too long after the TTM model was devised as a way to map approach to "stage" in the progression of change, the helping professions in general explored and adopted a bunch of Brief/Quick/client-centered approaches to helping -- they are now more or less lumped together as cognitive-behavioral therapies.

In any event, a bunch of people and organizations have adopted TTM as a way to better match therapeutic tools (whether that is consciousness raising or putting together a plan of what to do instead of whatever, or rallying one’s social network to provide support or any number of other things) to where in the change process the complainant/client/patient/addict/etc. is. In general, matching the appropriate tool to the person is a Good Thing; one of the major complaints about TTM is that 6 months out, a lot of people need a fairly significant Readjustment (whether that’s a relapse, or a secondary problem that was why the person had the bad habit in the first place, or one of their coping strategies has gotten out of hand, etc.). TTM is pretty much just like everything else in that respect, offering little more than platitudes about Hey, Lather, Rinse, Repeat.

Many brief, quick, CBT type therapies, however, address the readiness for action problem very differently. If someone is sitting in front of a professional, they are ready for _some_ kind of action; these therapies are much more rigorous about having the client define the goal state. Prochaska et al are here to tell you what your goal state should be, and thus they generate a lot more classic therapeutic resistance. They are _smarter_ about responding to that resistance, but they still generate resistance.

Prochaska et al also stumbled across some perceptual things (like how bad punishment is, how good praise is, ratios of positive to negative statements to be perceived as balancing out as positive, the importance of making a goal more attractive vs. the current state of being less attractive, and having some numbers on that) that are pretty widely recognized by NLP types. In good news, this group of authors is considerably less cult-y than some NLP outfits. In bad news, their therapeutic tricks are a lot sloppier and thus take longer and don’t necessarily “stick” as well.

But if you are looking for a theory of habit change, this is a good one. While the primary focus is on smoking, drinking problems, anger management, exercise/diet/weight control and other health interventions and so forth, you could kind of use it for almost anything. One of the most consistently wonderful things about this book is its honesty about the crankiness of people who are in the process of major self-change, and how a lot of bad habits are the result of people trying to suppress negative emotions or avoid enforcing boundaries, and other things that cause social conflict. They emphasize the importance of developing assertiveness, and recognize that some relationships may need to end (temporarily or permanently) if they are getting in the way of necessary changes.

They do devote a chapter to exploring how to tell when it is time to involve a professional in the change process.

However, I’m going to look around and see if there is anything better out there.