One of my initial trips to psych Ad-Seg (a sub-set of Ad-Seg in general) in the Central Valley was an experience, if only because of the infrequency of these inmates' release on parole, necessitating contact with me. By comparison, it was a relatively small unit whose occupants were frequently designated as "Mentally Disordered Offenders" and were transferred to state hospitals. It was also at a time before Governor Schwarzenegger banned tobacco smoking (and I emphasize tobacco), thereby creating another lucrative inmate commodity, A study published this past March by the National Institute of Drug Abuse, suggests that 24% of the US population has a lifetime prevalence rate of tobacco smoking, while the prevalence rate of tobacco smoking is an approximate 58% of psychiatric patients in need of hospitalization. Therefore, I found the combination of florid psychosis and unsupervized "flame" troubling.

One of the staff psychologists was looking at my list of patients to be seen and said she would "introduce" me to my first customer of the day. Getting in to Ad-Seg was an ordeal in itself: first, go through a sally port into a control building & show your ID (meaning they actually took and examined the card) & sign in; get buzzed through to the "street,"where my general destination was a good 10 minute walk at a "brisk" pace; get to the yard where you duplicated the ID procedure and are buzzed onto another street leading to the specific gate; get the CO, with the (NOTE: Should you do so, this will be a totally gratuitous click) bigass automatic rifle around his neck,in a booth atop the wall, to identify you, then let you onto the yard (I can't recall if I've written about the terror this same guy provoked in me when, on state-wide lockdown following the brutal murder of a CO in Chino, I was walking away from him and he screamed at me, "Where the fuck are you going!" I slowly pulled out my ID around my neck & turned around to see him with that weapon in his hands; recognizing me, he apologized and said, "It's tense around here." No shit); sign in at the Mental Health office; try & find someone to unlock another gate approximately 100 yards away (for some reason, after trying for a year and a half, they would not issue me a key - the hair?); shake the handle of the Ad-Seg Unit door (knocking generally was unacceptable in this facility), which if it failed to rouse attention meant you had to start yelling "Control" at the small window above the door to summon the Control Officer (and beyond once generally pissed the CO off), also armed with the bigass automatic rifle, who was responsible for every door; sign the log, sign out a mandatory stab-proof vest, and you're in.

The unit consisted of 4 "pods," self-contained cell-blocks with a flat back-wall (so no one could elude the sight of the Control Officer) and two tiers of cells. The security level increased as you walked the hall from pod 1 to 4, and pod 4 was was what you would consider "Super Max": one man to a cell with a window in the door; in-cell confinement except to shower (the shower being a locked cell with bars, a metal plate attached to the bars extends from waist to knees) or outside recreation alone in a "dog cage," approximately 15' long, 8' wide, and 10' high. It is a bit unnerving to see, painted in red 12" letters on the walls,"NO WARNING SHOTS!" in English & Spanish. I am told this is, because of the shape of the pod, "ricocheting" bullets pose a danger to the "uninvolved." That would be me. Psychiatric & therapy services are either done at "cell front" (literally talking through half-inch space between the door & the wall) or cuffed and in a "cage" (the size of an old phone booth) bolted to the pod's main floor. The psychologist & I climbed the stairs to the 2nd tier and stood before a smoke-filled cell whose occupant was standing in the toilet. He was a tall, very thin, very young appearing Black man with toilet paper in both nostrils, smoking a cigarette, and wearing only boxers and a U. of Georgia baseball cap (it took me a few times to figure out that these were not "bulldog" fans, but it was a gang symbol). "Mr. WTF-in the toilet?, this is Dr. Starfish & he's here to help you with parole." This unleashed about a dozen psychotic thoughts culminating in, "And I don't need no help, man, but thanks for coming." Alright then.

Next patient, floor-level cell, equally smoke-filled, but this single-occupant is a morbidly obese man, whose struggle to get from the bed to the door is painful to observe, as getting from bed and 5 steps to the door left him totally gasping for breath and his face bright red. He was gasping, "Please don't go," & I kept assuring him I was in no rush. When he had finally slowed enough to speak, he seemed to be asking more questions of and about me, and I continued to redirect the discussion. When I had finished, he was disappointed I had to leave & kept thanking me until I finally walked away. About 2 months later, as I was walking down the hall, I heard someone calling me by my first name, something that never occurs in prison; generally ascribed to the issue of safety, I suspect it creates a necessary distance for CO's & staff. I turned around, and literally jammed into a cage outside the nurses office was the morbidly obese man. They had to click 2 pairs of cuffs together to get his arms behind him. "I thought you'd be gone already?" "I got a 115 (administrative violation) and they gave me 120 more days." "Why?" "I wasn't getting up fast enough for them, so they started pulling and I banged my head on the bunk bed. I got pissed and hit a CO." When I told him I would come back before he paroled, he response was both surprising and disturbing: "Please, when you come back, can get them to let me out to the cage so we can speak face-to-face. I never get to speak to anyone."

To be continued...

Well, amongst the usual glut of lunacy that accumulates in in my email (e.g. a "phishing" notice that my Bank of Nova Scotia Accounts were frozen until I returned to retch up all my vital information - I actually have fond memories of Nova Scotia, though no bank accounts) my dear friend, POTFP, forwarded me an OpEd I'd missed in the Times, Recession Behind Bars". I digress for a moment to say, Pal, if you are going to present Two Liars, how could you possibly miss liar-on-the-left's droll statement to the press that "The charges against the owners of Studio 54 are a sham" (as the Feds rolled out the financial records on carts behind him) which rang about as truthful as his (delusional?) insistence, "I do not have AIDS!" in Angels in America. Maybe we need to "team up" once in a while. As you know, my head swims with useless data.

I admit from the outset that the story of Jack Henry Abbott, self-taught prison philosopher/psychopath, "progeny" and spoil of Norman Mailer, who emerged from 25 years of prison only to murder & return to prison before the parole papers were dry, leaves me with a coldness for writings such as Kenneth E. Hartman submitted to the NY Times. In particular, my eyes were drawn to the fact that he is the author of the "forthcoming" Mother California: A Story of Redemption Behind Bars." Perhaps it's the mention of "redemption," his unnecessary use of the word, "schadenfreude," or maybe it's just memories of Norman Mailer. I'm not sure, but I'm also not sure it matters, if only because I was there, surrounded by liars in places where lying is an acceptable and expected - though infrequently unacknowledged - manner of daily life, and I can only imagine death. I am reminded of Clinkshrink's dilemma in identifying a patient, who may or may not have needed preventative medication, when presenting information differed from what the computerized record indicated (I couldn't find the specific post, but if you ask - nicely - I'm sure a ShrinkRapper will direct you). In fact, lying without a perceivable reason or benefit is symptomatic of psychopathy. Dilemma? Yeah, dilemma. Why? Because voracity is an unknown quantity in the forensic setting. Or at least a clinician can begin to believe as such. I only ask you to imagine an environment that, at the least, promotes a certain paranoia that everyone is lying.

Hartman, however, makes several interesting observations: 1) while CA is a "blue" state, it is, at least on paper, "red" on crime, and in my own observation, with a BIG intolerant magnet for the mentally ill (in my town, for example, building a baseball stadium "downtown," attracting (pardon me) white people several summer days & evenings per week results in some rejoicing in the "end of urban blight" - blight as in "scary homeless mentall ill" who all come out of hiding when the Padres predictably tank); 2) Simply put, in my tenure, a lot of folks "managed" the CDCR - save Rod Blagojevich, but there's still time before he switches teams - with little impact, driven by a governor and legislature that consistently flaunt the state's constitution requirement of a timely balanced budget and federal judges nudged awake to toothlessly threaten them; and 3) I validate Mr. Hartman's observation that the "construction bubble" in CA drove developers to within yelling distance of the fences of some of CA's meanest and highest security correctional facilities. Perhaps it's time to finally jump on one sitting 100 yards outside the gates of CIM (see post below)? While the CDCR did, in fact, attach the "R" (as in "Rehabilitation") to its nomme de guerre, Hartman is incorrect in stating “Costs be damned; lock ’em up and be done with it” was an unofficial motto. Oh, and an all-inmates' shout out to scumbag Richard Allen Davis who pretty much single-handedly sealed the "3 Strike" crime sweep nationally by murdering Polly Klass. Mr. Hartman is in the "life-with-no-parole" category for murder, and while I do not mock his "redemption" in the least, better it was achieved at the State Prison at Lancaster, rather than any institutions I might frequent. You always knew when a once great Russian priest & scholar began his eulogy with, "We are not his/her judge, God is his/her judge..." that there was a question, undoubtedly related to truth. And so it goes...

And finally, I ponder the physicians' - and in specific, the psychiatrist's - role in this forensic moral, medical, & fiscal "recession" of the Golden State? Appear "medical" & don't be a sucker? And in the words of another gifted writer, Walter Chinaski, "Drinks for all my friends!"

Because of my imposed silence, I was unable to comment on the recent riot at the California Institution for Men (CIM) in Chino, CA. Chino is an odd place, approximately 2 hours north of San Diego, which, as near as I can tell, constitutes nothing but a significant number of God-awful smelling cow farms (and I raise the stakes in summer), and 3 CA prisons: CIM, CIW (for women, including the last identifiable women of the Manson family), and CRC (rehab center), all of which I have had the pleasure to serve. CIM is a grossly over-crowded prison & reception center and the site of the last murder of a CA Corrections Officer, Manuel Gonzalez, in 2005.

Approximately 200 inmates were injured, but no staff were harmed. You would have to imagine if no staff was injured, the inmates had "other fish to fry," as it were. I suspect that for a significant portion of the 200, a riot simply constituted a "setting" for retribution otherwise unleashed because of confinement and inaccessibility. I've heard both wardens and CO's say, "They (inmates) let us run the prison, because we are so outnumbered." CO's rule inside by attitude, voice, pepper-spray, and a baton. Oh, and a whistle. The real power is on the outside, and to my observation, just waiting to come in. I still wonder what they do with those gigantic rubber mallets I saw in the armory closet at San Quentin...

My recollection is walking across a silent yard, so dry and bereft of any form of vegetation that I fully expected tumble weeds to blow by. Most times you must bang (hard) on the door for an officer to hear you and unlock the door. This is simply because it is so deafeningly noisy that you can barely be heard at a low yell. Giant "hurricane" fans are blowing in all directions, and even those who should seriously reconsider has his shirt off because of the heat. Directly in front of the control center ( a bunker of sorts that houses the mechanisms to electronically open and close some doors, generally (purposely?) dark, where officers sit with feet propped up on desks reading, writing, and whatever...) is a massive single cell, formerly serving as a "day room," and now filled with bunk beds. Home to a massive number of men.Back in the far right corner hangs a TV, and nearly every time I was in there, Jerry Springer was blasting at a pitch suitable for Madison Square Garden (could there actually be a Jerry Springer station?) Secondly, if no "offices" were available, you had to "improvise," standing in a niche in hallway to conduct your confidential psychiatric assessment. And behind the control center are the showers, hot moisture blowing from the hurricane fans into the "halls & day room." It is sad to say, but, by far, the "nicest" facility is reserved for those chronically ill and/or dying, HIV/AIDS, transvestites, and the seriously mentally ill. It was clean quiet, with a low inmate-to-CO ratio, a real medical facility, and a nurse 24/7. The ill are actually treated humanely.

All I can say to those I know working there, thank goodness you're safe, albeit terrorized. Let it always be this way, and better you than me.

A further certified "arrival": at 1:05 am I sat down in the relative calm to read my email. "Why feign sanity?" I ask myself as I hear the cops arrive with several "frequent-flier" rowdies. A wonderful, helpful, supportive charge nurse quietly asked "Starfish," can you please deal with "bad boy #1" because you're more experienced, blah, blah,blah" Translation: the new residents will take forever. Gentles, mark my words: a nurse (s) WILL SAVE YOUR ASS at some point. Invariably & unquestionably. This particular nurse had more than earned her request, but never, and I repeat never piss off a nurse, especially when you are exhausted & and on call. Heed me not and you will receive a phone call every 40 minutes asking a "procedural question": "Can we PRN Tylenol for Mrs. contentedly-sleeping-soundly for back pain?" "Is she in pain?" "Not at the moment, but she might complain later." By morning, you've gotten the message. Trust me.

I approach Gentleman #1 appropriately gloved, and "half-masked" (very stupid, but it's so uncomfortable...), and try to check the obvious cut over his eye, and without even touching him, he head-butted me and spit in my face. I distinctly recall a switch go off and "better call the homies 'cause it's about to go down" ring in my ears. "GET THE CUFFS OFF THIS ASSHOLE! I'm trying to help you & you spit in my face? GET THE CUFFS OFF THIS ASSHOLE!" Bear in mind, if Gentleman #1 and his cohort are enjoying the moment (and you know they are), look for the hook in your lip... In my raging blindness, in steps the massive cop, cool as the proverbial cucumber, to walk me away, to save me from myself. "Do we need to sedate you or will you let me check you out?" "Go ahead, I'm cool." We both laugh as the cop (good naturedly) asks, "Do you want to press charges?" Yates wrote something about the ladder to heaven "always begins on the ground," and I suspect he had read Dante, concluding this phenomenon to describe the term, per diem.

Sitting back down to the computer, I became aware of how much the "head-butt" hurt; I was squinting and there was a dull sort of buzz in my head; described in the vernacular as "having one's bell rung." I told the charge nurse I was going to lie down in the dark. The lack of stimuli was immediately calming and I recalled reading in nearly a single sitting what I strongly recommend (blatant commercial) as a phenomenal read, My Stroke of Insight by Jill Taylor, a Harvard-trained neuroanatomist who, at age 37, experienced a rare (only 2% of all "bleeding") hemorrhagic stroke from a burst congenital arteriovenous malformation (in this case, an artery, rather than passing through the capillary bed - sorry, I know it was a cheap convention -- connected directly to a vein. Interesting in itself, it is unique that this is written by a gifted neuroanatomist who was able, first-person, to perceive exactly what was happening as she sequentially lost the ability to walk, talk, read, and define herself, yet managed to force herself to get help.

I was reminded that it was only several short years ago, I experienced a significant TBI with a bleeder inflicted by a psychotic, violent patient that left me on disability for nearly a year; a "lost" year. I continue to experience short-term memory deficits, cannot calculate numbers in "my head" (and I believe I've mentioned I've had to memorize portions of the MMSE because I can't remember!) I've twice contracted "Community Acquired pneumonia," and viral meningitis, and have had surgery 3 times for injuries "on the job."

You probably are aware of the story from Luke 10:25-37, otherwise referred to as the Parable of the Good Samaritan: A man is beaten by robbers and left for dead by the side of the road. The "good" people pass by, in too much of a hurry to bother with the poor injured fellow they see & choose to ignore. And along comes a lowly Samaritan - and if you didn't know, residents of Samaria were universally loathed and despised and were treated accordingly. One did not associate with a Samaritan. Obviously this adds to the poignancy of the story. He who is the most loathed stops and carries this injured fellow to the closest inn, offering a "down-payment" for his care, with a promise of full-payment upon his return. We are to imagine that the poor beaten man was treated with kindness & recovered, and the Good Samaritan served as a lesson in "integrity & mercy" where one would not ordinarily expect it be found. All's well that ends well, or does it?

I'm walking to the all-night pharmacy at about 10:30 pm, "camared," looking for the contrasts in light that intrigue me. It was an unusually cool evening for August in San Diego, and I had ducked back in my door for a light jacket before proceeding. A block away from the pharmacy, I come upon a man wearing (in my estimation an unfair qualifier) "wife-beater" t-shirt, and sandals with no socks:

"Hey, man, can you help me out? A few bucks for a blanket? I'm really cold" He is shivering, but what do I know...

"Come on to the pharmacy with me, I'll buy you a beach blanket or something."

"I can't man, I sprained my ankle."

"Then wait here. I'll be right back."

"It's so cold man, too cold to wait here."

"Look, I'll get you a blanket and you can have some bags of recyclables I have..."

"No, I broke my wrist. Just a few bucks?"

And the now disengruntled Samaritan mutters, "Get out of my face. Get the fuck out of my face," and moves on. I actually bought a beach blanket, came out, and he was long gone. Heading home, I venture upon a man seated at an outside table with grossly infected needle tracks, approximately 6-7 inches long, fiery and oozing, from injecting who knows what. He has a full bottle of isopropyl alcohol he is slowly pouring over the "wounds," and he has a roll of cotton dressing. He looks up at me, young but already missing teeth, and says, "I got an infection from a cut; can you believe it?" "Pal, you're slamming and you better get yourself to the ER 2 or 4 blocks away." "Nah, I'll be OK. The alcohol will clear it up." I start to say more, but set the blanket on the table and started home. Disengruntled, indeed.

It's a long time 'comin before the dawn.

I have, literally, been blocked from Blogger and anything but receiving email - and I suspect I should be grateful for that. I was informed I was not entering the correct password, and what I believed (and still believe) to be the correct password suddenly was "wrong." I'm not complaining about Google security at all - given the number of account "hijackings" I read about - but waiting 24-hours, etc. as they suggest did not work for me. Nor did asking them to reset the account; wherever I was to be forwarded by clicking their link didn't happen. Actually, I have no idea why, suddenly, when I clicked on password help today, it sent me immediately to the "reset" screen and actual access to my account. It all started when a hard drive unexpectedly died... For better or worse, it's my blog again. NEXT: On the Neuropscyhiatric Sequelae of Traumatic Brain Injury and the Parable of the Good Samaritan or "This is how they can get away with charging $10,000 for a limited-edition of Norman Mailer's account of the Moon Landing." Granted, it includes a chip of "real" moon rock. For better or worse, it's my blog again.

PREFACE: If you are a sworn peace officer, I support you - and since this has become such a "trite" and meaningless "monkeyphrase - let this be specifically interpreted to mean that a number of my colleagues & myself feel & have felt compelled, without thinking, to come directly to your assistance when your safety was jeopardized.

Having said this for the purpose of context, and contemplating the nomination of Maria Sotomayor amidst an already shitty week, I was surprisingly stopped and questioned, à pied, because I "appeared to be weaving" on University Avenue at approximately 10:00 pm. Oddly enough, what flashed through my mind like a short film of David Lynch was a, surprisingly cogent recollection of my father; and that would, albeit, have been during better "better times."

I basically have no explanation for the limited, "factual" (i.e. corroborated) information I have of my father. And this is despite the fact that he was literally present - actively pushing air - though divorced from my mother. Likewise, it's probably better that what I have "memorialized" about him - if only to be able to suggest a "relationship" as I now understand it - originates from my young age when things could, indeed, be corroborated. At the same time, the truth is that every virtue I am able to memorialize about him, he seemed to have committing himself to minimizing; and I have no reason to believe this sourced from humility. And please, if any of this strikes as overkill, I would refer you to any child, of most any age, head in hands, who cannot consistently and/or reasonably predict what might emanate from the lips of a sick parent. Both God & John Bowlby are on the same team when it comes to the juxtaposition of detachment & childhood resiliency. But it seems God alone appreciates the devastation which seems to escape other family member "obvservants."

The issue at hand is this: at a too young and and during extraordinary circumstances, my father became a most noble Четници a defender of God, Motherland, the King, and the people. But captured.This, at least, I am able to verify from independent photos & writings. Secondly, I am also to corroborate that he spent the final years of WWII in the Dachau Nazi Concentration Camp in company with the Blessed Saint Nicholai (Velimirovic) of Ochrid & Zicha, and the Serbian Orthodox Patriarch Gavrilo, all of whom suffered tremendously. As a child at bedtime, I didn't want "bedtime stories," but for him to repeatedly describe the glorious and joyous day when US troops, mainly African-American, "liberated" them from Dauchau. He came to this country with the greatest respect for our Constitution, for liberty, for religious freedom, and each and every any right afforded by our Constitution. At the same time, he was equally intolerant and outraged at those who "demonstrated" anything he believed as disrespect and ingratitude as, conceptually, incomprehensible, unimaginable. "If you could have seen..." Two examples were demonstrative: When John Kennedy was assassinated, he was absolutely devastated, and I vividly recall on that Friday night in our church, as a child, in the dark, candles and incense, clinging to his leg, attempting to understand his sobbing and sorrow. And secondly, during our times of American civil "unrest," he bought a flag, a pole, and a shotgun. He set the pole in concrete, raised his flag with pride, and placed the shotgun inside the front door, stating simply, "Let anyone touch my flag." It never crossed my mind that he would actually harm someone, but it was merely an expression of the veracity of his belief. That he later had close friends who were judges and volunteered for youth probation were insignificant, by comparison. My respect was formalized and "memorialized." And so, I fully believe that I am constitutionally required to identify myself to a peace officer when requested, and to show respect and to cooperate in the exercise of their duty. When I finally, politely asked if I might now leave, he tossed some cheap "Why? Is there something you don't want me to know?" questions at me. What I wanted to say was "Sir, you broke my father's heart."

So, while administering the customary "gleaning" of an otherwise monotonous batch of junk mail, I open a message forwarded from POTFP; always a pleasure and a virtual "visitation"... Whatever... The text was, shall we say, casual, bordering on the downright colloquial:

Heya, how are you doing recently ?
I would like to introduce you a very good company which I knew. Their company homepage is www.im-a-low-life-thief.com. They can offer you all kinds of electronical products which you need, such as motorcycles, laptops, mobile phones, digial cameras, TV LCD,xbox, ps3, gps, MP3/4, etc. Please take some time to have a look at it, there must be something you'd like to purchase.
Their contact E-mail: imalowlifethief.com
MSN : www.im-a-low-life-thief.com
Hope you have a good mood in shopping from their company!
Regards.

So, I'm amused as to even visit, immediately directed to the crook's site with a URL ending in .cn, which would be China. Funny, though I've personally never considered a motorcycle an electronical product, and I must concede that I've never ventured further east than, well, the west coast (despite having a first cousin quite renowned in the east), I can't seem to find motorcycles as advertized. But wait. WTF! A Gibson Custom Shop 50th Anniversary Sunburst guitar - listed at $4,999.00 at my local purveyor - only $380!!! AND, Free Shipping if you purchase more than one! POTFP's daughter plays guitar...

As I battle the urge to actually read their "Payment Policy," I Google the "company" to find a flood of identical reports of "Chinese hacking my Gmail account, deleting all my messages, & sending [the same message as shown above] to all my contacts from my 'vacation' setting." Oh, oh... I email my friend, only later to receive the simple response, "I got hacked."

I am reminded of the time my checking account was gutted - an event, I report with some irony, that I discovered immediately upon returning from a visit with my friend and his family - in a series of ATM withdrawals by a thief to my south. The bank turned out to be quite conciliatory, immediately restoring my funds, but making the odd request that I be so kind as to file a police report. Possessing, in fact, an unlikely "association" with law enforcement, I (apparently) naively inquired, "Do you think they'll go looking for them?"

My concluding thought here is two-fold: 1) This has befallen a most-undeserving victim; and 2) If you, perp, are, in fact, in China, live your life ill at ease, sleep with one eye open. Trust me on this...

Several evenings ago, I spoke to a friend who is a new attending at an out-patient psychiatry clinic associated with a major east coast medical school. She told me that she conducted an initial screening of a man who was a walk-in to the clinic, checked the schedule, and gave him an intake appointment with the first available resident the following week. She then went on a scheduled trip to Europe and returned approximately six weeks later. Upon returning, she was told that the patient, with whom she had spent approximately 30 minutes, had committed suicide. She was referred to an affiliated psychiatrist to "process" the event, and attended 2 group therapy sessions for clinicians with a similar experience. For her part, she could not even remember the patient. Now, I do not report this because it is ironic - and I struggled not to say absurd - but rather to contrast what happens when you are affiliated with funding. If you have access to funding, you can, apparently "err" on the side of well... what's right. And on one of the saddest days of my life, as I was writing case notes after a group therapy session, a colleague came in and told me that the Medical Examiner's office had just called to inform us that a patient of mine was found in a hotel room, having completed suicide. They connected him to us by a prescription bottle they found with him.

Because I have the reputation of working with a specific patient "demographic," I will get calls that usually begin with, "Hey, I have this wo/man who lost his/her insurance and can't continue at this clinic..." Hey, always good to hear from you too. Right. Nevertheless, a patient who has actually had commercial health insurance, in my experience, presents with some significant "protective factors" personally, and "advantages" administratively. Paradoxically, in my experience, these patients nearly always result in administrative conflict, probably because they can be incorporated into treatment in a expedited process (i.e. disrupting the protocol).

I find that patients who have actually had health insurance tend to be in a better state of over-all health, generally, than the typical off-the-street public clinic patients. Secondly, they generally are "well-documented," preceded by a medical chart that sometimes includes an accurate medication & medical history, and sometimes (sorry) a psycho-social assessment conduct by a reliable clinician. Oorah.

And so, the patient in question here came to me because he had been laid off from, "not just a job, but my vocation," based solely on "seniority." In fact, he was a much-valued, well-acknowledged, and well-compensated employee. He had a significant history of a moderate major depression; a history of both child physical & sexual abuse; was in recovery from alcoholism - extended & continuous; and was acting-out sexually to the point of "devoting" hours each & every day to cruising his gym, a bathhouse, and Craig's List for "hook-ups." His affect was markedly depressed & anxious, but he reported his mood as "a little depressed, but hopeful." I will forgo detailing our actual work together. When he did not appear for his scheduled appointment - the first ever - I called, and we rescheduled for the next day. The next day, when he neither showed nor called, I again called, & when I got his voicemail, expressed my concern, asked him to call me immediately, and re-enforced a point in our treatment contract: no attempting self-harm or suicide without first calling me, 911, or the Emergency Psychiatric Unit. He had checked into a nice hotel that afternoon, and the Medical Examiner estimated that he died early Sunday morning.

No one in clinic, from the Program Manger to the supportive staff, said anything to me; everyone was gone by the time I had completed my notes and returned the charts. No one. I locked the place up & went home. If you are a clinician & reading this, it is my sincerest hope that this never, ever happens to you. I spent the entire night scrutinizing, me. What did I do wrong? What did I miss? I poured over my notes from beginning to end; attempted to "recall" the specific details of every session described. WHY? By morning, I was overwhelmed. I sat through the staff meeting, and the suicide was never even mentioned. When enough was enough, I simply stated, "I am devastated, and I going to our "Employee Assistance Program" (EOP). Perhaps POTFP could explain such programs, as he is truly a pioneer & expert regarding the topic (and be sure to click over there regardless) - but one aspect of an EAP is to be a confidential (even to your employer) source of referral assistance for situations like I have described. I can say that my perception was that the sponsoring organization of my clinic - who didn't really advertize the availability of the EOP (alright, they never mentioned it after the initial hiring session) - pretty much resented paying for 6 "free" therapy sessions. Now go back & read the opening to this post... All said, may he rest in peace.

I generally experience the term "minority" as a pejorative, often "masking" term for disdain. There are, however, times when I could not be paid to abandon my "vilification." Microsoft, according to surveys, took an old-fashioned ass-kickng at the hand of Apple's "I'm a Mac, I'm a PC" advertizing campaign. Somehow thinking it wise to retaliate, MS has embarked on a campaign of corporate dis'. Now, there are those rare times when you are unexpectedly (and I'm going to presume inadvertently) provided the opportunity to actually delight in witnessing someone shooting themselves in the foot, cutting off their own nose to spite their face, laying a trap for others & falling in themselves:

POW! And there you are. No, baby, you are not cool enough for a Mac.

Finally, these are Holy Days, which explains Vladyka Lauras of blessed memory featured at the top of this post. While I cannot explain it, around 11:00 pm last night, I gathered up some big-ass bags of my recyclables (returnable cans & bottles) - which I am altogether negligent in returning, even for the cash refund - and went out walking. For me, selection in such matters is totally subjective, and probably for the better. I'm sure I looked quite crazy - or perhaps completely, "contextually" acceptable taking into account that it was, after all, me - to the evening hipsters heading to the clubs and restaurants. I passed any number of "qualified" & otherwise worthy individuals, but without a feeling of appropriateness. Spontaneously turning into a poorly lit alley, I eventually encountered a small man approaching me, and the closer he got, the fact that he and his clothes were absolutely filthy became increasingly obvious. Upon me, I asked if he could use some cans & bottles, and this man absolutely lit up.! He was so happy, repeatedly saying, "Oh, man! Thanks!" as I helped him gather up these big-ass bags, that I was laughing and smiling right along with him. The reality, however, was that the smell of this guy was triggering my already hyperactive gag-reflex, and as he repeated, "Oh man!" I moved on. Walking in the front door, my roomate said, "What's up? You're smiling?" All I could say was, "These are Holy Days."

Sunday was Easter, and an exceptionally temperate & beautiful day, & upon returning from a walk on the harbor, I'm stopped at a traffic light where 6-8 young men were dressed in pastels and wearing "bunny ears." They are also wearing t-shirts emblazoned with the words: "YOUR God made me this way!" As you might imagine, they are provocative, engaging with traffic whose drivers were of varying degrees of "acceptance." You couldn't pay me to live in the suburbs...

It turns out that my "porn industry" patient came upon the industry by chance (if you believe in such matters). His mother had put him out because his "life" consisted of television and marijuana: "She said, ' If I don't put you out, you'll never leave.'" As customary, his affect betrayed nothing; a continuous variation on "diastole." Was this a good move on her part? "I'm out. Even I was afraid I'd never go." Current arrangement? His "boss" befriended him, offered to take him in, give him his own room, meals, buy his clothing, provide a limited amount of actual cash, etc. in exchange for his described work. "And <insert euphemism for masturbation> every night before he goes to bed." WTF. "He's older. He has AIDS. I wear a glove. He gets lonely & I help him out. He doesn't want to have sex with me; never asked me, never pressured me." Were you surprised at the 'industry?' Were you shocked?" "No. I just see it as a business." thump-THUMP. Well, is it (was it ever) arousing? Sexually stimulating?" "No. I pretty much am bored with it all." thump-THUMP. Diastole. Yeah, passivity - and let's distinguish projective identification (where, paradoxically, one can experience the feelings of another as one's own) from counter-transference, which is an unconscious phenomenon - is particularly difficult for me.

To digress for a quick moment. I had the incredible opportunity, back in the day, to train at the Ackerman Institute for the Family on E. 78th St. in Manhattan. I emphasize that Ackerman trains family therapists in an intense & rigorous (make that, for the clinician-in-training, terrifying) manner: every session was observed by a team behind a large mirror in the room & everything was videotaped for later "scrutiny." I raise this issue because one concept that was continually emphasized was self-awareness: how do you appear to the patient. Remedies? Utilize a mirror to see yourself; I was told once to try sitting on my hands to preclude my "physical demonstration" detracting from my spoken words. I raise this only to say that I would love to see the expression on my face when a patient, for example, tells me he masturbates his boss nightly as a function of his work. How would you word that on a resumé? One benefit of working in prison: little direct eye-contact. Wow, I am easily distracted...

Let me again clarify: I'm no scholar, philosopher, "exegete," or classic translator - once, having actually enrolled in a under-grad course entitled "On the Translation of Poetry," one meeting and a few days of sobriety quickly revealed the wisdom of that decision - and while I didn't dream up or invent, I will be emphatic in utilizing bald-face interpretations that serve my argument. But then again, it is my argument. I will say that I have some "unfounded" theories here (i.e. I am only able to support this by a mixed literature), and like any scientist with a "vague" notion, will conclude with the suggestion that "further investigation is necessary." Science is, indeed, sweet. You have been warned.

The Greek word "pornia" πορνια, the "root" of "pornography" (and note that while "graphia" γραϕια frequently is interpreted as "writing" - e.g. think biography - I believe it is better understood in terms of "conveyance," in the sense of "a greater" truth," as opposed to simply "setting pen/pencil to paper") apparently means a lot of things to a lot of people, one-and-all as potentially bald-faced and self-serving as my own: fornication, pervert(ion), and plain old immorality. And the wonder of the internet provides me some (I force myself to limit it to two) ultimate distractions: the truly unexplainable UM " "?. ITY O. PORNIA SAN DIEGO HANDFUL OF EXOTICS, and my support for the Minister, forced by both irony & dumbass parents to tread the way of this life as the Rev. Eddie Pornia (not Ed or Edward, mind you, but "Eddie"). Who am I to suggest a standard for morality (though I'm sure we could agree on some universals), so for my purposes, I will interpret pornia as something contrary, in opposition, to my already-posited position of Evdokimov, below. Contrary to what I suspect to be a highly "rationed," infrequent human experience, pornia suggests to me a lack of transcendence, and so it shall be defined.

The psychiatric literature of pornography is slim to non-existent, save some, for example, fMRI & hormonal studies on sexual arousal and the like. Further, limit your search to studies in regard to industry "performers,"^* and I could find nothing I would consider significant or, for my purposes, helpful. I would point out a notable researcher, the late Robert J. Stoller, MD, Professor of Psychiatry at UCLA, who wrote several "insider" (behind the scenes) books related to the production of movies and videos. While noting a significant caveat that his material is dated, as near as I can tell (and you can bet I'm not laying out Yale University Press' outrageous price to specifically find out), Dr. Stoller seemed to find very little "pathology" among industry participants. Curiously, however, while concluding that "most porn scripts are not 'simply anti-female' . . . these stories are often full of freedom--women depicted having a marvelous time,"a Publisher's Weekly review summarizes his position as "anger or rebellion against one's parents and society underlies most pornography, that it exploits men as well as women and that a desire to degrade or be degraded is an element of pornography." Um, I don't know, kids, but without the science, this conclusion - and there are an abundance of similar conclusions - strikes me as too, too simple.

Ennui is generally translated from the French as "boredom." However, if one were to pursue Camus, Sartre, du Bouvier, and Genet, for example, ennui has a profound meaning in the nomenclature of existential thought. I will suggest "indifference founded in meaninglessness" is more likely an appropriate definition than, "this blog entry is boring the living hell out of me." Purpose, "meaning," utility. Satre cloaked the whole mess into the word Nausea: "Nausea [is] dull & inescapable, [which] perpetually reveals my body to my consciousness... a desacrilization of the romantic torment and the transforming of it into nausea of ennui" (emphasis mine).

OK. Contrast the patient's statement, "I'm pretty much bored with it all," with Ms. Randall's lament,"What happened to the good old-fashioned, passionate sex scenes?" ENNUI! Why do I seek out the scariest, most gruesome and vilifying horror movies hitting the market in record number? ENNUI! To feel something when nothing feels. To relieve the "dullness," to diminish the desacrilization, to... Um, kids, does this sound too, too easy? I'm stopping at maybe.

I thought I'd be done here, but I am notably verbose & connot summarize my thought in toto. And somehow, I can't leave out my female "talent," whose interaction with began with, "I just got out of jail. All I remember immediately before that is that I was so pisssed that I went into a bar across the street to clear my head..." Further investigation is necessary. You should have seen it coming.

Jo says she'll do you for the cost of weed, but there's more to it than that.
She'll want to talk. Sometimes an hour, sometimes more.
Camus, Sartre, Beauvoir - over and over.
Next thing you know, you're both grinding away under the sheets.
Your mind's been elsewhere, worthless in all this screwing.
You try to catch up, but she rolls you over. She's finished.
And you look down - so are you.
Let me tell you: Existential ennui makes lousy foreplay, but I think she gets off on this whole thing.
She puts out, and yet, she keeps it to herself.

^* I will simply footnote my fundamental lack of understanding of the "industry" distinctions regarding "amateur," "performer," and "actor/actress." My immediate thought is that it is a "distance-providing" ego defense - like trying not to identify with a "cadaver" as a human being in Gross Anatomy. And in case it crossed your mind, here is an explanations as to why "acting" in pornography is not prostitution, at least in California. I have got to re-consider law school...

First, I decided to use my own photographs whenever possible (regardez), and when I have accumulated enough randomness I will try to lay it to rest:

In the past 2 weeks, I have been literally flooded by phishing email. If you don't know about phishing - and you absolutely should - you can get the complete explanation here. But a quick description is that thieves construct websites of financial institutions that can be virtually indistinguishable from the legitimate sites, to the smallest detail, then send mass emails that, for example, inform you that your bank account has been "frozen" because of a security problem: you need to immediately follow the link they have provided to resolve the matter. When you click the link, you are transported to the fraudulent site that appears to be the legitimate site. You are then asked to sign in with your username & password, and to provide, depending on the scam, everything from your Social Security number to your shoe size. When finished, you are kicked out to the legitimate home-page of the financial institution, while they go about taking as much from you as possible until discovered. As far as scams go, this is pretty ingenious, leading me to imagine that it was contrived by somebody in prison, devoting their psychopathic "mother of invention" to no good. Now, being a certified dumbass, if I were to be phished, it certainly would be because of the "randomness" of the email; you just don't get these every day. That is until last Thursday, when, through the course of the day, I received 7 (yup, count 'em, seven) separate emails, specifically from my bank. Do you take me for a fool? Don't answer that... My best advice? Song #1, Buddy Guy: "You got my nose open, baby, but I got my eyes on you."

Continuing the thought, my all-time spammers are those (purported) sites peddling Viagra, Cialis, and every variant available in the pharmacopoeia. As I write, I have 75+ Gmail spam from such sordid characters as othell Atyl, Qycima, Abe Christensen, Charity McDonald, Jane Dalia, Shawn Jule, Kas, Racquel Mitchell, Pufue Jonid, Somer Thi, and 20 from the ubiquitous "me"; one & all concerned about my ability to "get the job done." Kazuw Citun writes, "I worry about you.. [yeah, that would be 2 periods] Offline for so long," while Coa Qnu is beside him/herself, "Called you 7 times! Damn:" Some of these folks are clever as well, telling you to reply "Unsubscribe" if "you no longer wish to receive" their email; respond, of course. and you have opened the gates of spam hell. Hey, and how about those Nigerian 419 scammers! Directly from today's email:

United Nations Compensation Commission (UNCC) In Affiliation With Barack Obama Campaign to Assist Scammed Individuals In The Settlement Of Disputes Through ZENITH BANK NIGERIA PLC .

Attention:

How are you today? Hope all is well with you and your family?You may not understand why this mail came to you but kindly read for your perusal and follow the giving procedures for your claim.

The United Nations Compensation Commission (UNCC) was created in 1991 as a subsidiary organ of the UN Security Council.Its mandate is to process claims and pay compensation for losses and damage suffered as a direct result of Internet Fraud. This email is directed to all the people that have been scammed in all parts of the world, the UNITED NATIONS in affiliation with Barack Obama Campaign have agreed to compensate them with categorical payment sum of US$ 100,000 each. In its decision 17 of 24 March 2006, the Governing Council established basic principles for the distribution of compensation payments to successful claimants.

The Governing Council therefore devised a mechanism for the allocation of available funds to successful claimants that gave priority to the three urgent categories of claims and which, within each category, would give equal treatment to similarly situated claims. Only when each successful claimant in categories "A","B"and "C" had been paid an initial amount up to US$2,500 would payments commence for claims in other categories. Accordingly,the first phase of payment involved an initial payment of US$2,500 to each successful individual claimant in categories "A" and "C". However,for humanitarian reasons, all category"B"claims will be paid in full of a total US$150,000. A total of US$3,252,337,997.09 was made available to 1,498,119 successful individual claimants in categories "A", "B" and "C" under the first phase of payments.

You are advised to contact Mr. Jim Ovia of ZENITH BANK NIGERIA PLC , as he is our representative in Nigeria, contact him immediately for your approved bank draft of USD$150,000. This funds are in a Bank Draft for security purpose, so he will send it to you and you can cash it in any bank of your choice.Therefore, you should send him your full Name, telephone number and your correct mailing address where you want him to send the Draft to you. Contact Mr. Jim Ovia immediately for your Bank Draft.

Thanks and God bless you and your family. Hoping to hear from you as soon as you cash your Bank Draft.

Making the world a better place.

Regards Ban Ki-Moon.

(UN Secretary-General)

Apparently, my ship is in but, for humanitarian reasons, I always seem to fall into Category B. It appears I was never destined to be an "A."

And finally, on Monday I stopped by the state university in this town to visit with a friend of mine who is the single psychiatrist for this entire university. Nice gig, but he hardly comes up for air. And so it goes... After, as I approach my car, the phone rings & it's my friend. Hey, the iPhone even shows you your contact's picture & plays an "unique" ringtone. His? Rage's Bullet in the Head. Psychiatrist, bullet in head... Forget it. Anyway, he abruptly says, "You need to go and get a haircut now. I know you and you even looked crazy to me." "OK, I'll take care of it..." "No, right now." So, as I do trust my friends, & even despite the fact that it was 15 minutes from the start of the NCAA basketball final, I made a quick call and within another 15 minutes commenced the shearing. I must say, even I was stunned: enough hair was removed to carpet POTFT (always a Category A, by the way) and at least 2 of his brothers (and trust me, we're talking about considerable territory), and it still remains "substantial," albeit markedly neat & "groomed." Whether I continue to appear "crazy" remains to be seen. And on top of it all, I was able to watch the ballgame live on the iPhone. What a country.

I feel compelled to make a preliminary comment in regard to "cockroach-longevity" spam - in my case, in the form of a truly astonishing number of (purported) sites employing an astonishing variant of the human name attempting to avoid filtering - who make my email an object of considerable annoyance. And so it goes... But standing out from among this clutter of detritus is a (purported) MD, Ph.D., GR, who "raves" at my blog content (thereby immediately making himself a focus of suspicion), and offering to make me something of a net healthcare celebrity. As near as I can tell, his deal is attempting to sell "traffic" to your site as a pitch to assume your content. Once (and once only) I was, in fact, polite in rejecting his offer. Now that I have removed the hook from my lip for ever responding & thereby opening Pandora's Box, I conclude this short rant by stating, "Dr. GR, fuck you and the horse you rode in on." Perhaps now he will conclude (if he has ever read this blog at all) my content is unsuitable for his vast readership. Desperate measures...

In my mind, the details of sexual activity is a sensitive, uncomfortable issue. I do not mean to imply that I am "prudish," or "squeamish" around the discussion of sexuality: as a practice, I always inquire if a patient is sexually active, if they have been tested for STD's (notably HIV/HCV), and if they employ safe sexual practices; and likewise, I always inquire if a patient (male or female) has experienced sexual abuse. I find that all of this information is essential to good clinical practice, but is rarely "offered" unless specifically asked. Nevertheless, I have long believed in what has been so dramatically, elegantly, and profoundly elucidated by the Russian philosopher/theologian Paul Evdokimov: sexuality is defined in intimacy, and conversely, intimacy is defined in sexuality. And in fact so intimate as to be a literal act of human transcendence (the paucity of such events, it would seem to me, makes it difficult to argue) as to be placed beyond simple "scrutiny." Mind you, please: I am neither a philosopher, theologian, a particularly "deep" thinker, nor did I ever meet Evdokimov. I can reasonably imagine he might conjecture "deviance" or "aberration" as inconsistent with a "transcendent intimacy" - but I cannot speak for him - nor will I speak to the "conditions" (read the book!). Nevertheless, I strongly suspect he would not be surprised at the level of angst and/or ennui we so frequently observe in clinical practice as relates to issues sexual. As a clinical instructor noted, "Sex will fuck you up." And so, to the termination...

My "adult film industry" patient is only the third I have accepted into treatment (which is generally 3 more than any of my colleagues) and which also includes two which I did not, but I make no claim to be knowledgable. And apart from an attempt to fathom a definition of intimacy within the context of "the industry" (and all five referred to the "players" in a general cloak of "the industry" and "the talent"), the dynamics do not interest me particulalry. Further, my pursuit into this context, frankly, left me feeling a touch foolish and naive; managing, I suspect, to elicit every stereotype I ever had rearding the "production" of pornography.

My gentleman presented as markedly depressed in affect and demeanor. He walked in a sort of stooped way, avoided direct eye-contact, and though quite young, fell into the chair with a sigh of breath. In a good-natured opening (and God knows I'm good-natured), I explain that it is my practice for physician & patient to "interview" one another, and in the end attempt to come to some conclusion as to whether the patient believes I might be of help, and, likewise, if I believe I might be helpful. As with a good 60-65% of new patients, he indicated, "I don't exactly know why I'm here." I believe I then, imperceptibly, sighed. The work begins. As a clinical instructor once reported, "I ask enough questions until an image of what I believe the "issue(s)" might be begins to crystallize, and I continue until I have a working hypothesis." OK.

This gentleman reports a "dead end," going no where" lifestyle that he perceives makes him unattractive to would-be companions, and he is lonely for a "real relationship." "What does this mean?" "Well, I work in the adult film industry." And here begins, at least in my mind, a blowing of the dust off every stereotype I have gleaned from Boogie Nights; 2 documentaries relating the stories of porn "actresses," otherwise "girls-next-door" types who, in a frenzy of drugs, sex, and disillusion, complete suicide; a Rolling Stone biography/obituary of a spectacularly-endowed "pioneer" of porn who succumbed to drugs and AIDS; a "panel" of actors/actresses on a "talk show";and the biography of a male porn actor, required reading for a course on Human Sexuality that, to this day, I perceive as seduction rather than education; we won't go there.

The patient before me bears absolutely no resemblance to any of my stereotypes: virile; attractive; (at least for the camera) out-going & uninhibited; comfortable with himself & his sexuality (though I'm not exactly sure what this means); and, seemingly, enjoys his work. Well, it turns out that my patient is not an "actor," but on the "production side" of gay pornography (an "industry" I assumed flourished farther north in Los Angeles): greeting potential "talent" (Semper Fi, indeed), making them "comfortable" ("They're pretty much always nervous when they arrive") and preparing them for the shoot" (No, I didn't ask); adjusting lights and "scenery"; and "cleaning up" (you knew somebody had to do it). Pointedly, the patient stressed that, despite engaging in "activities" relevant to the task at hand, "I am not gay or bi." Thus, with the summation of the facts, while I am confused, he, apparently, is not, and that is all that is important. Or is it?

What shall we make of the word angst, and does it have have a place in psychiatry? While I do not believe you will find it in the DSM-IV or Kaplan & Saddock, it is certainly a familiar concept in psychiatry. From my reading (and acknowledging a limitation in translation) angst seems, in the vernacular, to infer both "anxiety" and "panic." If I read Kierkegaard correctly, angst is a: "byproduct of drifting, or more specifically, the absence of rules, form, and shape that accompany it [and thus "panic"]. There is a hegemony of rules & shapes and laws precisely because we feel chillingly uncomfortable without them." Later, "This dread is explicitely connected with freedom and choices, with the uncertainties and lack of boundaries that freedom entails..."

Deep within every human being there still lives the anxiety over the possibility of being alone in the world, forgotten by God, overlooked by the millions and millions in this enormous household.''

Now, if you're like me, you hear a profound echo - freedom inextricably bound with anxiety & panic - and know it to be Irvin Yalom in Existential Psychotherapy: yes, the primitive drives, plus the terror of death and the dilemma of freedom. Freedom, the drifting with an absense of rules, boundary, and laws, by a seeming paradox, unhinge us. Ironically, while lacking the fundamental curosity of Kirkegaard or Yalom, and, without my pejorative intent, I suspect without even appreciating the content, porn filmaker Holly Randall writes about the "pornographic angst":

With high-end productions pushed to the side to make way for amateurish, extreme content, we created a market for what I call the Porn Olympics. It wasn't about the beauty and sexiness of the girl anymore, it wasn't about the chemistry between the performers, or the setting, or the quality of the production. Now it was a question of how far you could push the envelope: how many men can you have sex with in one film, how many ***** can you fit in your orifices, how many ways can you eat ***? In the attempt to one-up the last guy, scenarios I couldn't even dream up became, well, somewhat normal.

What happened to good old-fashioned, passionate sex scenes? You know, the ones with the beautiful women, the gorgeous settings, the beautiful clothes and superior lighting? Oh that's sooo boring…. I mean, who can get off to a scene if someone's head doesn't get pushed into the toilet while getting ****** from behind?

Better we move on to ennui and sum up my observations...

This otherwise non-descriptive image is of a building that exists on the quiet end of a major street in my town, and I cannot imagine the number of times I have passed it without notice. There is no address, no sign, absolutely no indication of what lies inside. In passing, it seems quite limited from the street, but upon investigation, this is the entrance to a substantial facility. I recall on occasion noticing that, with the front door propped open, you catch a glimpse to the left of black & white tile and what seem to be lockers. I also recall thinking it to be a private health club or spa. But a patient pointed out to me the other day that this is, in fact, a "bath house"; and if you're thinking removing urban grime by "soaking in warm, scented luxuriance," think again.

If you even spent a moment with the above reference, you find that gay bathhouses are certainly nothing new, and, in fact, historically served a supportive social and psycho-sexual function for a significantly repressed and oppressed body of the community. But if you also lived and worked in healthcare in NYC in the 1980's & 1990's, the notion of "support" frighteningly morphs into a vision of the Prophet Micah: unmitigated contagion and holocaust. HIV & AIDS silently struck the core of a community that believed it had fought for and earned its right to "exist." For the decade and more that followed, the rest of us stood by, literally, with nothing to offer but what we now so euphemistically refer to as "palliative care." And the epidemic, so tragically, so shockingly, and so brilliantly recorded by Randy Shilts and Paul Monette seemed, individually and collectively, unforgettable.

While I will always entertain the argument, I do not consider myself naive. If only by virtue of working in corrections & reading the epidemiological data - as frequently as a weekly review - I am aware of trends, anecdote among clinicians, and activities in the community. Patients describe quick "hook-ups" through Craig's List, cruising specific areas in town, certain bars and clubs, blah, blah, blah. But I must admit the poigniancy, the shock I continue to feel at the revelation of the "bathhouse." Pursuing the issue, I found a published interview with the owner (manager?) of the bathhouse who indicated he was "scrupulous" in making condoms "available" (and one patient told me of a "punch bowl") and did not permit nor condone the use of methamphetamine (emerging as the single-most significant risk factor for unsafe sexual practices in this community), he concluded, as I suspect we all must, "You just can't force people."

The Centers for Disease Control's most recent publication of data regarding HIV & AIDS in the US is from 2007 (and comparing the period of 2003-2007), and was released on 02/18/09. I do not intend to make this an extensive analysis of a report you can read and/or download to read on your own but, it is striking that "From 2004 to 2007, there was a 26% increase in estimated annual HIV/AIDS diagnoses among [male-to-male sexual transmission]." And while noting that "incidence" (i.e. new infections) may be partially attributable to more accurate surveillance by the CDC, "[male-to-male sexual transmission] increased all four years of the analysis, with the largest occurring in the last year" (emphasis mine).

Further, the CDC released a report on 01/28/09 examining the effect anti-retroviral therapy (i.e. medications) had on the sexual transmission of HIV; meaning, if you are already infected with HIV, actively taking anti-retroviral medication, and apparently having unprotected sex, are you less likely to infect your sexual partner? "Observational studies" and "models" were inconclusive, with the notable exception of those persons with "complete viral suppression," but this was qualified with "as might be achieved by more potent and tolerable regimens [of ART]," obviously speaking to the ART of the "future." Finally, the CDC issued new guidelines for the prevention and treatment of oportunistic infections in HIV/AIDS on 03/28/09. If you need to address pretty much any horror occurring from the degradation and collapse of the human immune system, you'll likely find it there.

As near as I can tell, all of this voluminous data - so ironically reminiscent of Saramago's All the Names - is mockingly and pathetically summed up by the CDC in a "new" publication of 12/28/08:

Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of STD pathogens.

Overall, the preponderance of available epidemiologic studies have found that when used consistently and correctly, condoms are highly effective in preventing the sexual transmission of HIV infection and reduce the risk of other STDs. Consistent and correct use of male latex condoms can reduce (though not eliminate) the risk of STD transmission. To achieve the maximum protective effect, condoms must be used both consistently and correctly.

I believe we discovered this 30 years ago.

Sometimes, people can be pushy. Sometimes it's necessary.

I noted in the post directly below that the reclining gentleman is a metaphor for an attempt at "longer-term" employment. It would be easy to interpret what is portrayed below as one in a long line of "negative outcomes" - and trust you'll find no argument from me - but I have also suggested it is endemic to this particular population. I can live with that fact, and apparently it seems necessary to significantly adjust clinical expectations in relation to a predictably and increasingly morbid process; necessary if you don't want to "melt-down." In my mind, this means that "satisfaction," personally & professionally, is determined by training, self-scrutiny, and integrity. Obviously, I over-simplify an intensively personal process, but is it possible to "get the numbers" and be a slacker at heart? Duh.

I can't imagine anyone enjoys being scrutinized, even knowing that it is the basis of education, skill-building, and practice. And I must admit that, for me, it is next to impossible to separate the personal from the "professional." I believe I have mentioned the violation I filed on a child sexual perpetrator who was screaming "You fucking quack!" at me, without my ever uttering a word, in front of 80 locked-down super-max prisoners. But within the context of education and supervision - and ask anyone who has been in "live observation" or video-taped for "critique" by colleagues - though uncomfortable, is somehow eventually "palatable." But this philosophical license does not extend to employment interviews.

If you have read Snakes in Suits by Dr. Robert Hare, psychopaths should be expected in the workplace. Likewise, I suspect that, with the current "financial scandals," ranging from Bernard Madoff to the AIG bonuses, Dr. Hare's observations have become more poignant. In this context, hiring must be an unusually harrowing task. Gone are the days of simply relying on a resume, personal interview, and simply providing references upon request. Today, Google et. al is everyone's friend and/or nemesis, and HR is trained in structured analysis and parametric testing. Or, if you will,

Returning to the issue at hand, I was one of two viable candidates for a position focusing exclusively on "dual-diagnosis" out-patients, meaning psychiatry patients with a diagnosis of mental illness and a chemical dependency. I digress for a moment to point out that this "buzzword" is annoyingly redundant in that all substance-abuse disorders are contained in the DSM-IV as "mental disorders." Let it ride... Now, the only thing worse than a job interview is multiple interviews that exponentially add persons steps above in the hierarchy. What did I say last time? Am I contradicting myself? My head spins... And now to the actual beheading. At a given point in a very relaxed "conversation," I was asked my opinion of administering psychotropic medication to individuals who continue to actively "abuse" alcohol & other mood-altering drugs. Perhaps it was the "conversational" character of the meeting, perhaps I assumed they really wanted my opinion, and it is here I stepped in front of the bus.

First, I began by expressing my experience, which seemed significant in that, given the limited resources in the county, patients, quite literally, rotate among clinics as if one milling body: it was the rare, statistically insignificant, and anomalistic patient whose cessation of drug/alcohol use could be directly correlated with the administration of a psychotropic med. I could not think of a single example. But most importantly (and you knew this was coming), the literature does not support the practice. Several recent examples:

• 01/09 Of 149 patients enrolled into the open-label [VPA & LICO3] acute stabilization phase, 79% discontinued prematurely (poor adherence: 42%, nonresponse: 25%, intolerable side effects: 10%). Of 31 patients (21%) randomly assigned to double-blind maintenance treatment, 55% (N = 17) relapsed (24% [N = 4] into depression and 76% [N = 13] into a manic/hypomanic/mixed episode), 26% (N = 8) completed the study, and 19% (N = 6) were poorly adherent or exited prematurely. CONCLUSION: A small subgroup of patients in this study stabilized after 6 months of treatment with lithium plus divalproex. [That would be 8 patients]
  
  
• 11/08 While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring substance use disorders [though I cannot locate them], this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic.


• 02/08 Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis... In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak.


• 09/06 Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively.
  

We could go on (and on), and if you'd like citations, ask.

The tension in the room was palpable; eyes were averted; mice were heard sloppily consuming cheese. I then heard the playing of "Taps" and felt the life-raft drifting away. The chief psychiatrist quietly stated, "Prescribing these medications is our practice." Said the program director, "We'll be in touch." The inevitable phone message thanked me for applying and indicated they were "moving in a different direction," but would keep my CV on file.

Factually, have I worked in similar situations where identical treatment philosophies were practiced? Yes. Did I agree with the practice? No. Did I ever resign or quit over such practices? No. Why object now? Because I just felt like it. Because I couldn't take it. Because I'm a dumbass in tough economic times.

Hey! Google my ass. I hope you land on the unconscious fellow below, undoubtedly pumped full of some grossly expensive SGA and who knows what else, which he summarily washed down with a nice chianti.

So, I went out yesterday, a beautiful, sunny March day, intent on mailing a letter, running some errands; the ever-present camera at hand. I randomly looked across the busy street and happened to see a former patient, sitting casually on the bus stop bench, legs comfortably crossed, drinking from a paper bag. Why did I remember this guy? Frankly, he dwelt among the nameless, vaguely-familiar "cohort" that wandered into our clinic for a variety of reasons - and in my estimation - the least of which was psychotropic medication. But what distinguished this gentleman, actually, was his ZZ Top-bearded side-kick (street-christened, "Smokey"), who upon initial contact with me, pulled from his pants pocket and back-pack 2 massive knives that he pointedly banged on the counter in front of me, thereby heeding the worn sign that forbade "weapons" within the clinic. Now, if you are familiar with the persistently homeless, they tend to "hoard" a tremendous amount of I'm-not-exactly-sure-what in trash & other bags, frequently tied to bicycles and shopping carts. Who, exactly, would inspect these "belongings?" But it was the response of the gentleman in question to my, apparently, amusing reaction to the knives that I recall: being already "unsteady," he laughed so hard he fell down. Approximately 40 minutes later, as I returned to the area, I found him as you see above. Without ranting, the scene is a very busy commericial area, and I am just not surprised to see such a sight so blatantly ignored by the hundreds walking past. Two guys literally cut through the bushes, stepping over the man, to tape signs on a lightpole. He was shallowly breathing, twitching, but otherwise unresponsive to me. Gross spider angioma of the face; swollen hands and ankles; bright red palmar erythema, obvious flexion deformity of the hands, and deformity of the nails & nail beds. Comment of the Chief Resident: "Why are you bothering me with this shit? Banana bag him in the hall & let him sleep it off." I sit on the bench & call 911 who seemed more interested in identifying me - three complete attempts at spelling Starfish - before switching me to paramedics who wanted to instruct me in counting the rising & falling of the gentleman's chest... Thankfully, a police officer, pulling on his blue surgical gloves to the sound of the ambulance but blocks away, sort of mumbled thanks on behalf of the citizenry, and as I moved on, never went closer than 2 yards to my former patient.

And believe it or not, this will all lead to an explanation of how I talked myself out of a job...

I have been enjoying the eclectic, significantly stress-reduced lifestyle unassociated with the slings and arrows of a maximum-security corrections facility, and liking it. Probably too much. I've given a few guest lectures, done some "per diem," some "consultations," and even turned down some opportunities to re-join mainstream clinical work doing things I really don't want to do. And I must stress the triomphe of actually rejecting things I really don't enjoy. Not exactly rock-climbing, but different enough... At the same time, I cannot possibly imagine how anyone could possibly survive on $480 of unemployment compensation per week, the most California allows. My heart still aches for my single-parent ex-colleagues. And so it goes. But a friend called and suggested I look into the opportunity of replicating some of my previous work in corrections - completely on the "outside" - on a county level. In this manifestation, however, you need to take a civil-service "examination," and this set off a series of peculiar events.

It is the custom of my friend & cohort, POTFP, to send a family Valentine in lieu of other "seasonal" greetings. And because Madame is a real photographer and artisan, these cards are breathtaking portraits of their children (and one unfortunate, yapping canine). And, it generally arrives late. For the holiday. At least to me. Nevertheless, after, again, being stunned, I set the card down & sent an email suggesting that an argument could reasonably be made for parthenogenesis. I concluded my chiding with a mention that I was taking a civil service exam on Saturday morning.

Early Saturday morning, I arrived outside of a county facility to join a cadre of similarly "milling mad wo/men," before a sign indicating, "The door will open at 8:00." So, with a few moments on my hands, I sent off an iPhone email to POTFP, reporting on the (customary) observation that I appeared strikingly different than those with whom I waited; and that would be "professional" and/or like a cop. Noting that this is a touch anxiety-provoking, I concluded with something like, "WTF, all aboard."

I digress for a moment to say that San Diego County's civil service exam bears some solid warnings about revealing the contents of said exam. I will not defy this signed oath by divulging specific information, but it seems reasonable (and somehow necessary) to comment on the content. For reasons I have discussed previously, I appear a dumbass in regard to spelling. Alright, I am a dumbass in regard to spelling. In my estimation, San Diego county is inordinately concerned with spelling. Enough said. Fortunately, I am considerably more fluent in regard to grammar... I think. We were offered the opportunity to "dispute" the validity of any exam question(s), and I felt compelled to make a notation that, at least in the example given in question #8, the NY Times Manual of Style would suggest that "who" is equally acceptable as "whom" in modern usage.

Exam concluded, I turned in my materials, turned on my phone, and headed out to the car. Immediately a number of "chime" notifications issued from the phone indicating email & voicemail. Taking the email first, POTFP responded to my earlier mail with, first, "What?" and then a short succession of "What is happening????" Turning to the voicemail, POTFP is distressed, requesting an immediate callback. Huh? I'm thinking, "Could he be that concerned about my considering a return to corrections?" I dutifully call, only to leave a voice message. Later, I'm on the highway & hear the phone; without the headset, and driving directly behind the highway patrol, I pass. It's illegal here. When I stop, I listen to the voicemail and finally understand the proceedings: apparently, POTFP "glanced" at the email I sent without reading that I was taking the test. So, reading that I was "standing in front of a county building," on a Saturday morning and the seemingly cryptic, "all aboard," suggested to POTFP that I was "taking hostages" and on the brink of a Saturday morning induced-halocaust. Mild-mannered me? Madonna mia, Pal, get yourself a decaf!

And now, a "proof-of-concept." As I mentioned in my discussion with the OG, I can find no reasonable explanation for the pronunciation of "heroin" on the street. But perhaps, should you not have believed me, listen to Rodney King & Seth Binzer, from a "reality show," to which I shall return later. The Newcastle Brown will still bring you down.

King HAIR-on