sinking low down

I would say that I am low, blue, in a funk, but not depressed.  Many of you seem to know what real depression is, and this isn't it.  This is a bad day.

I woke up this morning and it was snowing.  Not a good start.  The snow drifts around here were beginning to diminish.  I could almost see a car coming around a corner.  The frost heave at the top of the driveway was being pushed back into the muck.  The packed ice mounds had been surrounded by small, or large puddles.

But now there was new snow, covering the old snow.  The sky was gray.  the wind was damp and biting.

Sunday morning we read the papers.  Middle class people all over the USA were fighting with each other.  One group was trying to make sure that the very rich continued to get all the benefits, and that the few benefits that some middle class people still enjoy should be taken away, just to make things even.

Then we go to a movie club every other Sunday.  We see a movie before it is released so we can start a buzz about it.  We are the old cognoscente.  Today we saw a movie called "Poetry."  It was made in South Korea.  We well acted, beautifully filmed, emotional, moving, 2 1/2 hours --- depressing as hell. About a 66 year-old woman raising her grandson on her own.  She finds out that she is in the early stages of Alzheimer's, and that her 14 year-old grandson is involved in a gang rape, after which the victim had killed herself. Not too cheery.

Then, just to round out the day, I have spent the afternoon doing my taxes.

Going to work tomorrow will be like a min-vacation.

more churning

What follows is a little propaganda for the good guys, who went to school a long time, worked hard and studied the art and science of what they do.

I did not mean to imply that a machine can be a better therapist than a trained, experienced, intuitive, sensitive clinician,  I only meant to say that people will relate to a machine, and sometimes find it helpful.

Dogs are helpful too.

If I were to refer my best friend's sister to a therapist, I would refer her to a Ph.D. psychologist.  As I said in the last post, having a Ph.D. does not guarantee that a person is a good therapist.  There are many good therapists who do not have a Ph.D.

But the odds are better, if they do.  It means they have learned about a lot more stuff: brains, culture, families, bodies, child development, learning theory, and how to evaluate research so as not to be fooled or manipulated.  It means they have been supervised by several different supervisors, probably with several different orientations  (MSWs usually get that too).

Also, although they may not be fantastic therapists all the time, seeing a Ph.D. really decreases the odds of getting a BAD therapist.  There are bad therapists.  They are not trained as well, they often think they know more than they do, they don't see boundaries clearly, they want to be Dr. Phil, or they are not aware of their own shit and how it can spill over everything.

Machines are usually insincere.  They may sound like they care, but they don't.

still churning

Since I wrote the last post there has been a lot of discussion on some of the lists I am on about the future of our profession.  The pressure is building on any kind of health care provider like us, to cut costs, or to justify the added price.

The truth is that it will not be an easy task for our profession.  Not that psychotherapy is not worthwhile, and we are actually a contributing factor in keeping of health care costs down.  But, as I have said, I have hardly gotten an increase in payments in twenty years, and the one company that had increased payments on occasion, this year made some significant cuts.

That does not make me feel loved -- not here in America, where money is how we measure worth.

There are some studies that show that people who come for therapy have lower health care costs overall, mostly because they deal with their problems in life directly, and therefore develop fewer stress related disorders, or don't somaticize their complaints.  But most health insurance companies don't look at anything over-all or long-term; they see that the cost of mental health services has been rising, so they want to cut it.  For twenty years they have been trying to find ways to cut services, by limiting sessions, or limiting who they would pay, or trying to track diagnoses, or treatment outcomes.  But all that gets very complicated, and people keep demanding to use our services, so now they just cut the fees.

The real question however, is how can we show what we do is effective, and is there a kind of therapist that does it better?

Well, I have found the answer to the first one, and I like it, but I'm not sure the insurance companies will accept it.  Three psychological researchers, Duncan, Miller and Sparks have come up with a method to track how much the therapy is helping the client.  Their basic method is this, and it's amazing:  They ask the client "Is this therapy helping?" and a few, very few, other similar questions.
Their research shows that this method really can measure success.  That's science, at its best.

Now, as to the question of who is a better therapist, well this is where the therapistmumbles begins to mumble. As people have reacted to my last post, it seems that getting a Ph.D. offers no certainty that it will make you a better therapist.

I am sure that it takes many qualities to be a good therapist.  I think that the knowledge and understanding that a more comprehensive education, such as I got in graduate school, is one of them.  But there are qualities, such as compassion, empthy and patience, that often come naturally to some people, and others can learn to be that way, to some extent, but you don't need five years and a dissertation to obtain those kinds of skills.

I also know that a large amount  of what I learned in graduate school, those many years ago, I consider worthless information now.  I also think that a great deal of what they are teaching now will suffer the same fate.

I got a Ph.D. because it seemed to add some wight and heft to my credentials. Mental health issues were still seen as almost mystical and incomprehensible then.  Also, getting a MSW just seemed wimpy.  I think my big degree helped me get esttablished in a private practice.  Many (most?) people still don't really know the difference between a psychologist and a psychiatrist, but they also get confused between an LICSW and a welfare worker.

But the trend now is much more based on cost, and most Ph.D.s think they should get paid more than people who did not survive the obsticle course of obtaining that degree.  That may put us at a disadvantage unless we can make a stronger case that demonstrates our superiority. So far, we have not done a convincing job.

I am afraid that a lot of wimpy people also can be good therapists.

Watson Wins, and continues on

By now many of you know that the IBM computer "Watson" blew away the competition on Jeopardy, and showed that very clever algorithms, as well as four terabytes of hard disk storage, which it could rumble through in milliseconds, can dig up trivia faster than anybody we know.


Now, we sometimes play Jeopardy at home, but it's Old People Jeopardy, which works like this:  some gives an answer, such as "She said ' just put your lips together and blow." Then, I would say " I know, I know, it was, it was the woman who was in those movies we used to see at the Brattle Theater.  You know with what's his name, all the time around exam time.  You that was the one about, was it the statue, no it was the hurricane.  It was, it was, I know, Lauren Bacall.  And I would get credit for that answer.


But Watson' hard drive is cleaner than that, and the algorithm makes it's associations differently, without all of the personal history and going to the movies during final exams, and of drinking too much coffee, and being all hyped-up and happy because of going to the movie with the woman who you are eventually going to marry, of all things, which is something that Watson has no concept about how that can feel.


However, Watson is going to be moving into the health care field.  In a collaboration between IBM and Nuance, the company that has vastly improved speech recognition software. They will be using it to improve the diagnostic ability of doctors.


As the press release says:


IBM offered a scenario in which a doctor who is considering a patient diagnosis could use Watson's analytics technology and Nuance's voice and clinical language understanding solutions to consider all the related texts, reference materials, prior cases, and latest knowledge in journals and medical literature. Armed with this information, Watson could help medical professionals determine the most likely diagnosis and treatment options.


Clearly, the doctor part of this team is the most expendable.  The doctor could just as easily be replaced by a nurse, and then by a "technician" and then by the kid who knows more about video games than he does body parts, but he is more comfortable relating to a machine.


Now don't say that this can't happen to psychotherapy.  Perhaps you are thinking that psychotherapy is too personal, and that therapists are one of the last remaining professions that utilize the powerful healing value of genuine, human understanding and empathetic interpersonal interaction.  And that is true, for that is probably the basic force that psychotherapy brings to bare.  


However, many years ago, back in 1966, an MIT professor Joseph Weizenbaum, who was studying linguistics devised a program on a very early computer that would simulate client-centered therapy.

Weizenbaum, J., "ELIZA -- A computer program for the study of natural language communication
between man and machine", Communications of theACM 9(1):36-45, 1966.


This program gave students the chance to sit and tell their problems to a non-judgmental, 
confidential machine, and they loved it. They talked to the machine about things that they 
had never talked about with real people. It seems that so many students liked to talk to the machine so much that Dr. Weizenbaum became afraid that they were becoming dependent 
on it, and he had to remove their access to it.


That program was a very early version of artificial intelligence, and it has been improved 
and updated and has been used recently in the Turing Test contests that have been held for over a dozen years. There is a good article in the recent Atlantic about being the human in that contest.


So, here we have Watson, and IBM and Nuance, moving into medicine. Is that bad?  
Probably yes and no. 
Old people will still make a big fuss about wanting to have a human doctor to hear their 
complaints, but younger people will probably have more faith in robotized medicine, have
 grown up spending more hours with computers than people anyway. Many young people believe that machines are better at everything anyway. Many techies are waiting for the Great Singularity, when we will all be absorbed into the cloud and become one with the cosmic, computerized, web intelligence.


It's just that another whole bunch of professionals will be out of work.  
They will be home playing video games.


{note: somehow the technology of this post could not provide consistent formatting, for 
some reason that some of you may understand -- but not me.}

I have a Ph.D. (so what?)

Wow, two weeks, and I thought I was keeping up.  Life gets confusing when there are so many virtual conversations running through it.  it wasn't this way before all this e-stuff and i-stuff.  There was a times when I went to work and came home.  I read magazines, tormented my kids, watched the Celtics and went to bed.

Now there is email, list serves, national small group conversations, international strange group communications, family pictures, and even friends who expect messages and responses.  All of this is good, but it clutters up the mind. And I don't even do Facebook.  It's not good for therapists to "friends" with people.  We are not really too likable anyway.  We tend to be shy, overly intellectual, too observant, and make people uncomfortable.  If you meet an really out-going, energetic, up-beat psychologist; you know he either is all schtick, or else he hasn't been paying attention.  All of us good therapists are sullen and depressed by how much we know about the world.

And, speaking of depression.  The reason I have not been on this blog is that I have been in hot correspondence with other psychologists about the imminent demise of our profession.  It may not be obvious to you, but the opportunity to see a Ph.D. Psychologist for psychotherapy is rapidly slipping away.  We are being replaced by medications, neurological brain scans, and Master's level therapists.

I don't know if any of you care what degree your therapists has, and probably most of you who have been in therapy may not even know what the difference is between a psychiatrist, psychologist, MSW, MA, LICSW, MFT, and various other types of after-the-name letters that can make one seem to have the experience and/or training to help people having difficulties.  I know that when many people don't know what to do they go to a psychic.

But, although psychotherapy done by a Ph.D. Psychologist has been reimbursed as a health insurance benefit for over thirty years, and will probably still continue to be covered, most people are being steered by those insurance companies to lesser trained people, who get paid even less than we do, and we have not had a fee increase in twenty years.

Even psychiatrists are seeing their role diminished as PCPs are being told to give anti-depressants to anyone who cries, and nurse-practitioners are now writing lots of the prescriptions for psychiatric medicines.

I know I can make the case that a Ph.D. Psychologist is more learned, better supervised, and probably has a more comprehensive understanding of all the many factors, physical, emotional, cultural, familial, genetic and inter-psychic, that determine how and why people think, feel and behave the way they do.

But does this make them better therapists?  And how can we prove it?
AND
Does this matter to anyone by Ph.D. Psychologists.

I'm afraid not.

Puff, we disappear.

a new part of the problem

It is snowing again.  The rest of today's appointments are cancelled, and all of tomorrows are crossed off already.  I have not been kept away from work for two days in a row since 1978.  This will be a winter to remember.  Until next year.  It seems pretty clear that theses "hundred year storms" now happen almost every year.

Still there are those who will say that industrial production and energy sources have nothing to do with it. I guess it depends upon who is writing your pay-check.

But before the snow began I had the unenviable task of meeting with one of my patients.  It was difficult because this fellow has endured some of the troubles of Job.  He had been married and had two children with a charming woman, but much of the time she was out-of control.  She often drank heavily, and when she did she acted out in many other ways, sometimes leaving the family, and vanishing for a week at a time.  Sometimes her diappearances would end with a call from a hospital.  He would take her home, and nothing would be explained.  Sometimes some guy would call, just to see if she was OK.

About eight years ago, her luck ran out, and she died in an emergency room of a brain hemorrhage.  This left my patient with two children, the oldest was eight.

But I began treatment with this man in October of this year, two months after the oldest boy committed suicide. 

It is never easy to deal with parents who lose a child.  That is not the natural order of things. At best it leaves gaping hole that can only be thinly sealed over, at worst it can be fatal to the parents.

Awful as it is when something tragic happens by accident or illness it is worse when a child does it to himself. I have had to deal with this twice before in my long career.  One was somewhat easy to understand as the boy had been psychotic several times, and he had often done bizarre things which were unexplainable outside of his head.  The other was completely incomprehensible, as the young person seemed popular, happy, and reasonable.  Dealing with the grieving parents; all of whom were single parents at the time, can be pretty grueling, as there is nothing  anyone can really do to bring about a desired result.  It is already to late for that.

In this case the man had realized that his son was struggling. He knew that the boy had always felt like an outsider; he had actually mentioned it.  He had brought him to a therapist a couple of years ago, but the boy didn't really open up.  The father was pretty sure that his son had struggled with his sexuality, but he couldn't get him to talk about it.  The young man had few friends. He was clearly anxious in social situations, and avoided them if he could, even with the family. He had been a good student and seemed to like school.  He hardly ever missed a day. But more and more, he stayed by himself.

In this session though, this man brought up a point that I don't think would have been as important twenty or thirty years ago.  He said that he knew from his own experiences, and he could see from his son, that life today is very, very competitive.  It never seems to stop. It is true at work, in sports, at school, and even among friends.  Outside of a family, there are very few really supportive networks in this country.  Even churches are competitive.

This man had stayed out of work for a couple of years after his wife died, and he found that in order to get a job he had to not only compete with others for the job, but compete with others in his own company who had the same position (in sales and marketing) as he did. Trust and cooperation were talked about, but they put you at a disadvantage if they were actually practiced.  Everyone seemed to understand that.

He feels that this hyper-competitiveness was part of what made his son just give up.  He felt that the boy never had the confidence or the social skill to push himself through all of those situations that were constantly confronting him.  Competition in school, or to make friends, or to run track, or to get a job, or even among friends playing video games.; it was always about beating someone, pushing someone out of the way, or looking for an advantage.  If you couldn't do that, you would get knocked over and trampled upon, and then blamed for not being strong enough.

It runs rampant through my practice these days.  I see people who are unemployed, and feel invisible because no one even acknowledges their calls or emails. People who are employed are being pressured to work harder to keep their jobs or they will be easily replaced.  People with vital positions at businesses  feel a great deal of pressure to meet deadlines, to beat the competition, to keep their company in businesses.

President Obama talked about the need for America to create and innovate.  It's because the world has changed.  Many basic jobs are now unnecessary. They have been replaced by technology.  Farming, manufacturing, constructing, even selling, were things that people did for centuries in order to keep the world running.  They are all done now, but by machines of some type, and they need only 5 to 10% of the people to get them done.

It is much harder to just find a job, do it well, take care of yourself and your family, and live a life.  There is much more competition for much fewer spots, and the competition is not just from those around you, it's global.  Someone in India can pick up that phone, write a piece of software, and even read an X-Ray just as well as you. Robots weld cars, mix medicines, answer phones, take tolls, guard buildings, run trains, and do it better than people.

Many people are very scared.  And if you are hesitant and fragile to begin with, it could seem like too much, as it was, tragically, for this young man.

I believe that we live in a more difficult age than we realize.  Most people don't even acknowledge the problem yet.  I believe some of today's political craziness is the result of people who are aware of what is happening, and fear it so much that they need to work hard to deny its existence.

That makes arriving at a solution, or many different solutions, even more difficult.

We have to find new ways of living together on this planet.  The current ways are leading to a greater concentration of wealth and power than any time since feudalism.  It is not a healthy situation, nor one that can be peacefully sustained.  Much of Egypt's current uprising was the result of very high unemployment among it's young adults.



It will be fascinating to see how they deal with that problem.