On a professional level, the experience you recount teaches a number of valuable lessons, in my view: first, we live in a very violent country, in which many individuals with severe behavioral problems, psychosis, substance use disorders, etc., do not have access to good health care–or, if they do, may not enter or remain in treatment. Our health care system–including our mental health care system–is badly broken, as a certain President keeps reminding us!

Second, there are indeed “quiet heroes” among us, who seldom get their due in the “If it bleeds, it leads” popular news media. The cashier who stayed calm and steady brings to mind the adage from Proverbs 15:1–”A gentle answer turns away rage, but a harsh word stirs up anger.” Oh, if only our contentious and cranky country could adopt that philosophy!

Finally, your ability to experience some empathy under such frightening conditions is truly remarkable! As clinicians and therapists, we are of course trained to “listen with the third ear” and find a scintilla of empathy, even when dealing with very difficult and sometimes even abusive patients/clients. But it is much harder, in some ways, to feel empathy in the middle of the kind of situation you describe. I suspect that, in your role as nurse, you are also able to enter into your patients’ world with empathy and understanding–just what I had in mind by “Getting under the table” with somebody! —Best wishes, Ron Pies MD

http://psychcentral.com/lib/2009/ordinary-heroes/

One of them is Andy Schmookler, and another Hester Hill Schnipper at ‘Beth Israel Diaconess Medical Center’ in your area, and her husband is an oncologist there whom you may have heard off.

Hester and I did a lot of work together with a great online breast cancer support group.

And then there is you….

So, that never occurred to me.

Yes, of course I thought about you, and maybe I also just missed talking with you?

Thanks again,

KAT

In the circumstances you describe, the best source of information and advice, ordinarily, would be the psychiatrist who has been prescribing the Prozac all these years. But if (1) a psychiatrist has not been prescribing the Prozac; or (2) the prescribing psychiatrist is unwilling or unable to answer the question; or (3)the oncologist is making changes in the antidepressant without careful consultation with a knowledgeable psychiatrist, then the patient would be best advised to seek a second (“consultant”)opinion. That would involve the consultant’s discussing the matter with the primary prescribing physician(s) already involved in the patient’s care.

Ideally, the second opinion should come from a psychiatrist with a strong psychopharmacology background, or a consultation-liaison psychiatrist who has experience working with oncologists. An academic medical center’s department of psychiatry, or C-L service, could probably provide names of appropriate physicians to consult. –With all good wishes, R. Pies MD

If you had a patient who had been taking prozac for some 25+ years, (40 mg) and she was told that prozac may interfere with Tamoxifen, a hormonal drug used for breast cancer prevention. She is to switch to Lexapro because the latter does not create conflict?

Would you anticipate a smooth transition? (The prescribing MD is an oncologist with really not that much experience, never mind that the patient already mixed prozac with Tamoxifen for over a year?)

Should this be done very slowly? any thoughts?

Either way, thank you, Katrin

(and yes, I am the patient)

I would like to clarify the matter of “trickiness” and how it does–or does not–enter in to the kind of encounter Rabbi Nachman describes, and how it relates to psychotherapy.

In order to “get under the table” in an effective and meaningful way, one needs to avoid trickiness or even too much cleverness. In order to inspire any degree of trust in another human being–particularly a disturbed person–one needs to see the person as a “fellow human being”, not some ninny who needs to be “tricked”.

This is what the philosopher Martin Buber had in mind in his “I-Thou” relationship, as contrasted with the “I-It” relationship. If you “get under the table” with a patronizing or deceptive attitude, the other person will sense that at once and the encounter will be ruined. On some level–even if it is a very deeply-buried one–you must be willing to entertain the idea that perhaps the person who says he is a turkey is, in some sense, right–and perhaps you are a bit of a turkey yourself! Of course, I don’t mean this literally. I mean that you must believe sincerely that we are all in the same boat–we are all fallible, suffering human beings. If I am not psychotic today (which claim I believe accurate), it is “by the grace of God”–and that could change tomorrow, God forbid!

No matter how psychotic the patient, there is a core of enduring humanity that unites him or her to me. No matter how “sane” I may be at the moment, there is the potential for physical or mental catastrophe at any moment. In short, “getting under the table” means opening yourself up to the human predicament–not being “tricky”, but being human!

Thanks to all….Best, Ron Pies MD

Dr. Andrew Schmookler, and I, have over the years become good friends, and we in many ways enhance each other through our differences and similarities.

I sent him your article, and he in turn posted it on his websiste.

I wanted to bring this to your attention as you may be interested in knowing this, and also reading the comments.

Best, Katrin

http://www.nonesoblind.org/blog/?p=3441

And whenever I think that by now, nothing else, or more, can ever surprise me again, it always does, again, and again.

‘Kindness is the language which the deaf can hear, and the blind can see,’

Mark Twain

PS: When I was really going through a rough time, and there was nobody who would listen, never mind not blame, quotes became my best friend and therapist. Here, in this world, I felt understood.

The quote that became my favorite, and which I never understood before, but now it became so profound, was the following by Picasso.

‘Every act of creation is first an act of destruction.’

P.S. I may not always write back, but I am listening.

‘the respect of a civilized debate’!!

You also give that respect to people/patients who comment, and who share their problems with you/us.

Almost ‘NO’ therapist does that. When they hear someone mention a personal problem, they flee…literally ‘take flight’, as if dealing with a spider. They cannot handle it. Only in the secure little private office.