Don't want to be Polaroid, or DEC

There have been many big companies around here since I have opened my practice.  Three that come to mind quickly were Polaroid, Digital Equipment Corp and Wang Labs.  I used to like them because they all had great benefit packages and tried to take good care of their employees while they were making money.  DEC and Polaroid were always two great companies to work for.

They only thing they did that hurt all their employees was go out of business.  None of these three companies, and many others, lasted, because they couldn't turn the corner.  They didn't see that a new world was taking shape around them.  They had a model of operating that was successful, and they just kept following that success.  Once you find something that works, its very, very hard to see when it's not working, especially if it did you so well in the past, and if there were always normal fluctuations.

When is a loss just a dip, and when is it the plunge of no return?  You can't really know until it's too late.

In psychotherapy, with all the new technologies, and all of the new science, there are now many models of how to deal with emotional, psychological and behavioral difficulties.  You can come and talk to me; which is the old model.  Or you can take some complex new chemicals that may (or may not) affect your mind.  You can take pictures of your brain with an exciting new brain observing machines.  You can dip into your genetic code and try to rearrange things to alter you basic tendencies.

Some of these models have not had the kinks worked out of them yet.  The odds are if you dip into your genetic code you may come out being a two-toed sloth, which may not be a bad life, but it is a risk.

But the model I have been using is old.  It is very low-tech and inefficient.  Some people come and see me for years and hardly change their lives that much at all. Treatment sometimes ends because I get bored.  For many people this "talk therapy" model just doesn't work at all.  For many cultures the idea of speaking about your strange inner thoughts to someone you don't know, to anyone really, would be a disgrace.

But so far, I continue to struggle along, using the same old model, adding a few new slide-steps, spin moves and slight-of-hand tricks to my repertoire, just to show that I keep up with the times.  I don't think I will be the one to determine when the time has passed and other things work better.

So far, I don't see it happening.  And the demand for my little dancing act is still strong.  But high demand from the masses is no way to determine truth or validity.  There is a high demand for the psychic around the corner, and she doesn't have to get pre-authorizations,
AND she does parties.

Tech 4

There is so much stuff out there that just comes pouring in here, between newspapers, the too many magazines I still get, the web sites for all of them, all of the other news, science, psychology, web sites, chat rooms, list serves, journals, comments on the journals, etc, that it does get a bit overwhelming.

I am from the generation of having to go searching for information.  Every bit of it  seems like a find.  I keep piles of it, knowing I will probably never get back to it. Even if I do I get distracted by new things. I am not that good a weeding out, and staying with a few regular sources.  I try to get other view points, but there is so much noise out there.  Everyone wants to be heard, and the only way to really get recognized is to be extreme and ridiculous.

Donald Trump for President?  What could be more ridiculous?

Anyway, I read somewhere, I can no longer remember where, that it has become acceptable behavior, or at least commonplace, to be talking to someone who is with you, while at the same time holding a "text" conversation with someone else.  So many people are texting constantly.  Older people are constantly checking email.   Facebook. Beeps, chirps and chimes abound. Information flows in. Where are you? What are you doing?  What did you think of that? What is he saying?  Get this done,  Get back to me.  On and on in a constantly flow.

I sit in my office, one on one with people.  Most of them forget to turn off their phones until they ring, or beep or boop or rap, or erupt with heavy metal.  Even then they sometimes take the call, fearing it is about their kids, or their boss, or something very vital.  That has happened once out of about 200 times, that a kid was sick at school. Vital?  An instant response expected.

There is a lot of discussion now about doing therapy by phone, or Skype, or even just by instant messaging.  Is that better for people who can't reveal deep, dark secrets in a face to face setting?
Perhaps.

But my profession, the way I do it, remains very low tech.  We assume that real, direct, in-person, interpersonal relationships are more telling, more real, and convey so much more emotion and intensity.  It is so basic to being human.

Or, at least it was.

client called

At least once a month I get a call from someone I have already seen, but who I have not seem for a while.  Many people come to see me for six months to two years and that's about all I have to offer.  But usually by then they have be transformed into amazingly creative, caring, successful, problem solving individuals, whom everyone wants to know a be around.

Often a new situation arises, or some of the fairy dust wears off and they find a reason to come back for a tune-up.  This can happen after one to five years, and often happens again, one to five years later. 

But while I was away I got a call from a woman who said that she had been waiting to call me for a while, and she was pretty sure it was me she wanted to see.  I had seen her once before for a few sessions and put her life on the right track, but now, she felt the need to see me again.

She left her name, but I didn't recognize it.  I called her when I got back, and she explained that she had left her married name, and I would remember her by her maiden name. Also, she is 50 now, and I had last seen her when she was 17, in 1978, and I was working on the other side of the state.

There are a few things she wants to talk about that have happened since then.

Fine, I'm looking forward to it.

away, and back

I keep planning to do this thing on a regular basis, just for the discipline of it all.  Sometimes I think it would really help me clear up my thoughts if I could write them here, trying to be coherent, two or three times a week (ha!).  Other times I think that the kind of writing that goes into blogs, including this one, is hardly disciplined at all.  It takes time and revisions to think through an idea, and to present it well.

It would possibly be more effective to blog regularly, once a week. To begin on Monday, add to it, review it, edit it and post it on Sunday.  But hardly anyone, including me, expects that from a blog, so most blogs are read quickly, and anything that takes more than six minutes to read hardly gets read.

But, so far, I have had a tough time doing either.

My excuse this time is that I went away.  That's a good enough excuse.

We packed up and got out of the long lingering cold weather and journeyed to the far off Southland.

First we visited that stately town on the bluff, Natchez, Mississippi.  When we got there people asked us why we had come.  They seemed a bit puzzled.  Natchez turns out to be a smaller town than I expected.  But otherwise, it was more than I expected.

We went there to see the river.  And that was reason enough.  A mile wide, muddy brown, swirling in seven directions at once as it pushed itself downstream, the mighty Mississippi lived up to its reputation.  The people in the town said they respected and feared it a bit.  It was not to be taken lightly. The currents were strong and unforgiving, especially at this time of year.

The town was charming, a beautiful example of the old South.  The people were friendly, more than approachable, willing to talk, and happy to have some Yankees walk through. We saw the stately old homes. We ate some great Southern cookin', We drove a few miles up the Natchez Trace, which is something we hardly knew about.  A beautiful road, that winds by itself all the way up to Nashville.

But then we turned around and drove south, following the river, through St. Francesville, La, a town of simple pleasures and unique treasures, right on the river.  Then we drove past the oil refineries, and the tallest state capitol building in the country, which is in Baton Rouge.  We also saw where the River takes a turn, and the oil tankers come and go, under yet another huge Mississippi River Bridge.

The rest of the week was spent in and around the Big Easy.  The French Quarter, filled with tourists, music, a great deal of alcohol, better music, more alcohol, and great food.  The Garden district, with funky Magazine Street, some of the best graveyards in the country, and  some still remaining houses that were ruined in Katrina.  We saw alligators in the Bayous, and ate shrimp, oysters and grits everywhere.

Now, we have returned to New England and are again, freezing our asses off.

It's great to get away.  It's fun to talk to people who I don't have to try to help.

Again, I am left with the perception that I do not think in the manner of many of my countrymen.  I do not immediately look for a business angle of for the faster pleasures. I always seem to feel that things are more complex than what is being presented.

Often, I am left feeling that I just make my own life more difficult, but it's too late to change that, and I don't want to anyway, because, even though I say I'm open minded, I know I'm right.

But they sure do have some big boats going up and down that river.  I could sit in that warm sun, with a beer in my hand, and watch them go by all day.  Not much complex about that.

Pissed off

Back at work, and the pressure of cramming it all into three days still makes me uneasy.  It gives me the luxury of being selective. I have to give some people more time between appointments.  It forces me to choose even more; who to see and who to make wait.  In many ways it's healthy for all of us.  I can't just see people who want to unload on me.  I want to put the time into those who will use the opportunity, whatever it is we do together, to move forward.

But so many people are so angry these days.  There is such a feeling of distrust.  People feel that their employer cannot be trusted, many are angry at the government, for reasons that are never clear, they are angry at the pressure they feel for money, with rising prices and stagnant wages.  They are angry that so many people are angry.  And everyone feels entitled to be angry in response.

For thirty years I have sat with couples who scream a each other, but now there are lines that are crossed much more often.  Words are used that would never have been mentioned, very sharp verbal knives come out much quicker and cut much deeper.  So many people seem to feel that relationships are just temporary.  This city is very diverse, and yet this seems to cross many cultures.  Men slip away; women are quick to pull back, they detach and give-up on the relationship quickly.  It's not worth the effort to save it.

The drama of adolescents is much more intense also, and seems to be much meaner.  Kids always found ways to put each other down and define a pecking order, and those on the bottom always suffered, but there seems to be a relentless need for some kids, often young girls, to destroy others, to drive them out of the group, to completely humiliate them.  Everyone is at risk.

Tell me if I'm wrong.  Maybe I just saw too many people today, after doing nothing yesterday.  Nothing was kind of fun, but not very exciting. This is very exciting, but not really fun.

I worry, but...

I go back to work now, and only work three days.  It's very strange.  I am trying to adjust but it is difficult.  I take Monday and Friday off, so if the warm weather ever comes I will have long weekends to make sure the tide comes in.  But on Mondays I still feel guilty.  I wonder who gave me permission to stay home.

But work is easy.  Three days is nothing.  I could probably see a hundred people in three days, but I stop at 27.  That's enough.  Then I begin to get tired.  But, by them, I'm done.  I have a long weekend!.. It's a vacation!

I've been seeing a lot of people in their late 20s and early thirties, and I worry about them.  The ones that reach me, here in this struggling old mill city and struggling themselves.  Most of them are either still taking courses to finish college, have finished after five to ten years, or have dropped out.  They have jobs they don't like, and make enough to pay the rent if they live together.  They don't really make enough to get married and have a family.

They come from families that fell apart in their youth.  They have fathers they rarely see. Their mothers have had several relationships that seem to last three to eight years, but are destined to end badly, or to just fade away.  Many of those who I see really don't know how to expect something better.

Today's economic situation does not help. High paying jobs are scare and need specialized training.

So many of my clients, who are now 28 to 42, still live the life of a 23 year-old.  They drink too much.  They roll in and out of bed with friends and neighbors they hardly know. They rack up credit card debt that may or may not get paid in their lifetimes.

I see about five or six people like this now.  Each of them seems to have six to ten friends who are really worse off then they are, but are too scared to come to treatment.  Most of the ones that come to see me do so because they really want to do something about it.  And most of them do.  They slowly grow up, and do the difficult and/or boring things that growing up requires.

But it sounds like many, many of their friends don't.  They continue to drink too much, to give-up on themselves, to let life just drift by.

I worry about them.  There are many, many, of them who take too many drugs, still play too many video games, and skip work at Target or the supermarket or the call center, where they get paid $8.50 an hour.

But. in truth, although it seems as if our society is terrible, mean and demeaning, it has always been this way.  In fact, it is probably better now.

Things were worse fifty years ago, much worse a hundred years ago, and inconceivably bad before that.  But then, many people just got sick and died, and that was the way it was.

Now, with health care, machines,  and the marvelous new technology, there is not only the expectation, but also the capability of finding ways for so many more people to live decently, and become  comfortable and productive.

But, really, there is not the general will to care about too many people, especially if it may make you, me, or anyone, a bit more uncomfortable.

This is not new.  It seems to be part of who we are.

tortoise vs. hare

The two of the came in at successive hours.  Both extreems of what you can be.

One, out there to make millions, talking,  screaming, planning, forecasting out six months to ten years, putting things in motion: phone calls, emails, banners, social contacts, meetings all set-up.  My job is to keep him just this side of psychotic.  If he succeeds he will be thought of a brilliant.  If it all blows up and falls apart; he will be just another bipolar disorder, needing more medication.
   Look at the heads of many of your most successful start-ups and you will seem guys just like this.  But you can look at the guys standing outside of the pub, flicking cigarettes and talking rag-time.  The differences are slight.

The next hour the tortoise came in.  He carefully obsesses over each detail of each decision.  What are the possible reprecussions?  What can go wrong?  What will people think? Session after session he seems to go over the same things. But he slowly, cautiously moves forward, often aware of the price he pays for hesitating, but also knowing that worrying about the risk would have ruined everything anyway.

Thankfully, most people fall between these two.  But we all have tendencies to go more one way than the other.  Often people seem to choose areas of their lives to take risks and be a bit "out-there": business, investing, relationships, sports, drinking, drugs, sex, or just not doing their taxes.  I am no longer surprised to find how many people seem measured, reasonable and secure, and yet will do one or two really wild, fucked up things, and do them over and over.

Keeps things interesting.

Non-tech - just not good

A colleague of mine from across the city sent them to me.  He has been seeing her in therapy for eight years.  Another therapist we know has been seeing him for only three.  They came to me, I thought, to work on their relationship.

But soon after they arrived the husband announced, pretty clearly, that the relationship was dead.  From his years in therapy he had learned to finally express himself and to take steps to pull himself out of what was a long-term depression, that he didn't even realize he was in.

He said that for years he has felt unappreciated, disregarded, and demeaned.  He said that he felt his wife was always bossing him around and he didn't like it.  He wanted to get a divorce.

His wife broke into tears. She had not realized that he had reached this decision.  She was still hoping to learn what she could do to save the marriage.

Fine, this happens, I often see people who know that the relationship is over. Sometimes they need a safe place to say everything.  Then they leave.  His wife was not in favor of ending the marriage, but she seemed to realize that she cannot stay in it by herself.

But this was different.  After it was clear how this husband felt, I asked about his plans, and how he expected to move the process of ending the marriage forward.

He had no plans.

Did he expect to leave soon?  Did he have a place to go?  Would he work out temporary support payments? How did he want to tell the kids?

He didn't know.

I asked if he realized that now that he had laid this bomb out on the table, things would be different at home.

He said that he had been working for a long time to clear up his thoughts and express himself.  Now that he had done that he was very pleased.  But he had no idea of what the next step would be or when it would occur.

I think I can see why she bosses him around.

Really, there is a 50/50 chance that they will stay together.  He got it out, he made her cry, that may be all he needed.  Perhaps now he can assert himself in other ways that will make her happy, and then she can respect him and make him happy.

or, perhaps he is already screwing someone in his office and she makes him feel very special.

Tech 3, retail

It is clear that books, music and newspapers have been drastically affected by the use of the Internet, but those are just the most visible.  Every kind of retail sales has been totally changed by technology. 

Yes, a few people go to the mall to hang-out and look at stuff, but I certainly don't expect any new malls to be built around here any more.  Many are in bankruptcy, and most have obvious vacancies.

I love my iPad, but I am sure I ma putting more people out of business.  These are jobs that will never come back.  Retail is being condensed into a few leaders in on-line sites, and other sites that tell you where to find the best prices.

Have you been in a Staples story recently.  You were probably one of three people wandering around the entire, huge, retail space.

I have had about six clients during the last year who have lost their jobs and began looking for work.  Four have found jobs making much less money.  Two are still looking, and they are skilled people who are looking very hard.  They are draining the money of their extended families.  Support for the unemployed has dried up with all of this "deficit" talk.  The deficit will never get paid if no one is working, and no one can pay taxes.

My daughter, who has a job and is very busy, needed diapers for my grand-daughter.  She went on-line at 5 PM and spend about three minutes clicking.  The next morning, before 10 AM the diapers were delivered.  I don't know what store she would have gone to, but it won't be there in five years.  The jobs of the people who work there, and the rent that is being paid, will all disappear from our economy.

For everyone else, life is easier, probably cheaper, faster and more convenient.

Tech 2 -- People real or virtual

This won't come as any real surprise to anyone who has been on a dating site, and many of my clients have told me many, many stories of their experiences with them, but I had the experience last week of turning virtual relationships into actual ones, and it was fascinating.

Years ago, at least fifteen, I met some other therapists at a psychology convention.  We have managed to find each other several times after that, at other meetings.  We have formed a group of about six of us, sometimes four can meet, sometimes it's a different four or five.  But those meetings for me,  happen about every three or four years and our fatherings last for about two, perhaps three hours.

However, we began to correspond on a small email list, and exchange ideas, comment on happenings and keep track of each others lives, both business and personal.  It's been fun.  They all seem like intelligent, caring guys, who share many of the same views I do.

Last week someone arranged for us to all meet to view a couple of games that we could enjoy.  We are all kind of sports nuts, all within ten years of age -- I am the oldest, and all from very different parts of the country.  We spent three full days together, watching games, talking, driving, drinking, eating, and just hanging around.  It really worked pretty well, considering that we really didn't know each other that well.

What was most fascinating was that, although I got along with everyone, what I expected from each of them, how I thought they would talk, interact, take stands, lead, follow, be funny, be smart, know stuff, make decisions,  be creative, be trite, all the ways that people interact ... I did not predict correctly.

People, all of them except one, were very different in "real" life.  If I had to rank order who I expected to get along the best with, my order would have been wrong.  What people say in emails, how they say it, and what it really means, sends a very different message.

As I said, people who have experiences with dating sites know this only too well.

A great virtual friendship has often been ruined by a brief meeting.  It's not the same. This did not ruin anything, but alot has changed.

Tech 1

This is my new theme: technology is changing our lives.  It does not seem startling, but really it is, because the changes are much more far-reaching and long-lasting than people realize. for our old life-style it is a death by a million tiny cuts.

I am not one who believes that the great Singularity is coming, but things are very different.

My first post about it is simple.  It began with a tiny insight.

I walked into the waiting room to bring in my next patient.  There were four people there, waiting for everyone in our office.  We have the best magazines of any waiting room I have every been in.  We get, mostly for free, Yankee, People, Rolling Stone, Discover, and a few health and women's mags that I can't tell one form the other.

But, at that moment, and then I noticed for the rest of the day, one person, and she was about sixty, read a magazine.  Twenty people were playing with their phones: texting, playing games, updating apps, on Facebook, all of that.

Piles of unread, fancy paper, wasted.

Is  the world better or worse?  Not a relevant question.  this is the way it is and it will only become more so.

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.

Weekend's End ( while still in transition)

It's the end of the weekend.  I have two hours left to do whatever I want, then go to bed, wake up and begin the new week.

It is kind of different now, as I consider slowing down at work.  This is the first time in my life that I kind of feel that work could be optional.  We have reached a stage were we seem to have enough money that I really don't have to work too hard.  It's not that we are really up there with the bankers and the bond traders, but we are OK.  What I earn from now on will help, and money is certainly a good things to have here in America in the age of the Tea Party, but it isn't crucial.  I could hang around, drink coffee, read the paper, and visit my granddaughter, email my four friends, and still be able to pay all my bills.

Also, there is about two hundred feet of snow and ice out there.  The roads are narrow, the driving is difficult, the cold is uncomfortable, and more snow is coming.  That doesn't make me want to rush out and face the new challenges of the emotionally suffering.

But here, in the waning hours of the weekend, I just kind of stare out at nothing and let the time slip into the unstructured darkness.  My granddaughter is being taken away for a week to seek warmer air.  My wife is on the phone.  I could read more of the paper, but I already know enough about what's happening to stay upset, and new fashions are not my thing.

It's kind of nice to just sit here, with no pressure, not doing anything for a while.

I'm not that good at it.  I try and tell most of my clients to learn to do that.  They need to get away from the stress, not be constantly churning, not worry about every detail all the time.  Yet the world is in tough shape. There are so many families and many relationships and many children out there that are suffering and are a mess.  They could all use time and thoughtful attention.  There are too many people acting selfishly, or thinking sloppily and causing stress, strife, struggle, illness, injury and even death.
That's not good. It's not fair, it's not right.

But, that's not really new.  It's kind of been going on for 20,000 years.

I'll see how I feel tomorrow.

Right now  I'll take a Tums and maybe everything will feel better.

Bad Endings

Zine El Abidine Ben Ali has has been thrown out of Tunisia.  He ruled the country for twenty-five years, took a lot of money for himself, but stayed too long on the job.

Now it seems that President Hosni Mubarak of Egypt is having a tough time after thirty years.  As is President Ali Abdullah Saleh. who may have held on too long in Yemen.  The Middle East is trying to make  changes.

But it isn't just rulers who seem to reach ignoble ends.  I see several people in my practice who, given the difficult economic times here, are being forced out of jobs after successful careers: A long-time, well decorated member of a police force, an owner of a car dealership, an older lawyer who had been in practice for years.  I am even seeing a very successful salesman for a national corporation, and it is clear that he has out-priced his usefulness.   They are making it clear that after almost thirty years they want someone younger and cheaper.  It has shades of Willie Loman.

it probably isn't fun being Brett Favre at this stage in his career.

Here I am trying to makes changes myself.  My own profession is, again, going through turbulent times. Again they are looking for new ways to (not) pay us.  We are being blamed for the high cost of health care, when we have not only not received an increase in fees for over a decade, but now most insurance companies are cutting back.  It's easy to feel unappreciated.

So while I deal with my own feelings I have to deal with many people who feel that twenty to thirty years of their lives amount to almost nothing.  It is difficult to convince them that they have done a good job, supported themselves and their families, and accomplished something worthwhile, when they are made to feel that they are no longer good enough, and no longer necessary.

There are few good endings, not too many gold watches any more.  But at least most of my patients are doing better than the Ceausescus did on their way out.

transitions, still

I was away.
I went somewhere it was warm.  That was very nice. I kind of freaked out when I came down to the poll and it was full of people doing water aerobics.  Some hot chick was leading a huge number of people, many of whom were my age, through a stress-less, non-strenuous routine of  lifting and rotating their own limbs. I ran away as fast as my aging knees could carry me.

But it was 81 degree there.  It is 8 here.  I am still wondering why I came back.

I came back because I have a full week this week.  I was supposed to keep cutting back so that I can free up a day a week to do other things.  I can collect checks from out government soon.  That should help defer the lost income.

But what will I do?

I am still very torn about how to manage my time.  There is so much to read and learn about, but to what end.  If I just keep it in my head, so what?

I could write more blog entries -- which I should, just to try and remain coherent -- but there is so much noise and confusion going on out here in the blogosphere. Everyone has an opinion, which is good.  But no one, hardly even me, pays attention to anyone else.  Yes, sometimes I do read one of your blogs, and sometimes I lean that you guys are doing something interesting, or struggling in a fascinating way, or just trying to get by, which is also fascinating.  Many of you are doing and trying new things, which is encouraging.

But when it come to really changing anyone's mind, not much really happens.  Everyone is a pundit.  Everyone has an opinion. Usually, everyone is wrong.

I also see that few people are really interested in big-picture things, and that is the way I think.  I am messy at details.  But the details are what is interesting. yet, it is really big picture stuff that could benefit from change.  Yet, what is also clear, is that it probably won't happen.  At least not the way that I want it. ( won't everyone just LISTEN TO ME!! )

It's too easy to slip back into work.  I can take more calls and take more cases and full up my hours, even if the pay gets worse and the obstacles to collecting that money become greater and more complicated.  I won't admit it but it has become more tiring to keep up a full schedule after all these years.

But as I cut back the work becomes less fulfilling because I don't get to take new people, and I get stuck with the more chronic, unchanging folks who will never leave me until I force them to go away.

Maybe I will just use the free time to watch soap-operas --- too late, their not on any more.
    Maybe I'll study astronomy, learn to cook better.
         Then there is this grandchildren thing.......

By March, I promise you (me) I will be working one day less a week. No more than 25 clinical hours. Got that.  Promise.

Let's see, wanna bet? 

Dopamine ?

Guess it's all about dopamine on the brain. Over these last holidays I have been seeing four couples, of many variations, who are parting. it is not gentle on the brain to lose your lover,no matter how intense the conflict, how strained or how long dried up the relationship. When they leave, they leave a gapping hole in your life, and they drain the brain of huge amounts Of dopamine. That's what all the pretty pictures on the colorful fMRIs show.

It's bad, it's sad, and their ain't no cure, except maybe country music.

In contrast, for months I have been seeing two men whom I have been working with to open up, to not try to be impressive, to just be the good,open, honest guys that they are. Suddenly, each of them has found romance. Each is now in a relationship that is over month old. With that, almost all of their doubts, anxieties and listlessness have vanished. Their negativity and cynicism is gone. Their world is now full of sunlight and color.

Love! Better than cocaine; longer lasting, but even more addictive. Much better than any psychotropic medicine ever concocted, or ever will be. No contest.

2011

So, It's a new year.  What are you gonna do?
Lose weight? Drink more? Learn to SCUBA dive? Bet on nothing but Black and #27?

This year is going to be different for me.  How?  I'm not sure yet, but I am being told that it's time to make changes.

Change come with difficulty.  I know that.

All I expect to do is change one day a week.  Soon, the government will send me checks so I won't have to work so hard.  But what else is there to do? That's the question.

I can spend the time that I  gain from not working to stretch, exercise, cook well, eat right, and get more rest, so that I can live longer, and have more time to stretch, exercise, cook well, eat right and try not to die.  That doesn't seem too exciting.

Or maybe I will through caution to the wind and eat a lot of bacon-cheeseburgers and go heli-skiing until my knees fall off.

But I have been reading that doing and learning new things is the best way to rejuvenate my old brain and get it to perform better and longer in many different areas. So maybe, using this one a day week, I can learn to play the banjo and go to school and get a Ph.D. in genetics.

At least it will give me more time to write a blog.  Have to keep my mind open to all possibilities and see what emerges. 

Greetings of the Season!

Yes!

I hope all of you out there in the blogosphere had a happy, healthy, joyeaux day celebrating whatever you choose to celebrate.  And here in the US of A we celebrate the joy of allowing everyone to choose what they celebrate.

Health and Happiness
       Peace and Prosperity
            although it still seems to be that too many people feel that the last two are antithetical.

Still, I do hope that you are all enjoying the day, and hopefully the rest of your lives, and not creating too many problems for your therapists.

I leave you with this greeting:

As soon as you realize that almost everything people act on is irrational
   Then human behavior begins to make sense.

Love and Kisses of the Season.

A wrinkle in time

She is the fourth of six children, all girls.  What is worse is that, in a rhythm of brilliance, her parents decided that each girl's name should begin and end in A.  Alicia, Alexia, Aurora, Ava and the other two. it gets confusing.  But you know, things like that are not a helpful beginning.

And then, when the youngest one was about four, the father dropped dead. Also, not helpful.

About three months ago she came back to see me after an almost two year absence. 

The first time I saw her she was a real mess, just not functioning.  Her husband had left her, she was crying all the time and she began collecting things.  She was collecting things that had been discarded and was creatively finding a use for them. But she was not keeping up with the creative part.  However she could not part with any of the things she had collected.  She identified with all of them, as something of value, which had been discarded by someone who didn't see the value.

Slowly she responded to treatment, which stopped when she pulled herself together enough to get back to work. That was good.

But now she is back, and wants things to be better.  Now she is 62 years old. She cries. Things are bad and she doesn't know what she did that was so wrong, or what she can do about it now.

When you see her now she looks like an attractive, middle age woman.  She dresses well, she even carries herself well.  What you don't see was that twenty, thirty, forty years ago she was really quite beautiful.  You would unconsciously pick her out of a crowd and watch her walk by.  Many people did.  That was part of the problem.

The other part, of course is that after her father died her mother was overwhelmed, so she just screamed at all her girls and beat them down. Literally if necessary. So this woman learned to hang back, stay silent, and wait until what was expected of her was clear. When someone told her what to do, she did it, as long as they didn't get angry at her.

That made her vulnerable to people who came along,  who were attracted to her, and began to possess her and control her.  Her first boyfriend tried to keep her out of sight, as he knew everyone was after her.  When she got away from him the next one was nicer to her, but also very controlling.

Finally she settled with an older man who seemed to appreciate her.  He was wealthy and seemed to feel that she was a symbol of his success.  He took her places and showed her off.  She was well taken care of.

But then she had children and he had little time for her and them.  He was out in the world making money. She soon realized that he was spending time with younger, beautiful women too.

So she went to work, but never really felt that she was smart enough.  She had the sense that all of the doors opened for her because she was so attractive. But she really didn't think about it.  That's just the way things happened.

Eventually she was having a long-term affair with one of her bosses.  He was good to her, just like her husband was good to the women he was with. They were rich.  They sent their kids to prep school.

At some point her boss' wife left him.  She thought this was her chance to change partners and have a good, real life.  But that was not the case.  After a year or two of promises that man married another, more dynamic woman.  She was devastated. She was devastated, angry and depressed. 

She went home and confronted her husband about their marriage, about how there was no relationship, how it was really a sham.  He agreed.  She though he would want to make it better.  She was wrong.  He left.

But she still had her job, even though she tried to stay away from her boss.  But about a year after his new marriage he came to her and suggested that they rekindle their affair.  When she refused him, saying how worthless that idea seemed to her, he raped her. 

It was soon after that  I saw her the first time.  As I said, she was a mess. It took her months to tell me about the rape.

Now she has a much smaller job and has a boyfriend who is a nothing and does not treat her that well. Her kids are distant.  He ex-husband is wealthy, alone and alcoholic.  She has no idea what happened to her ex-boss, but she knows his business is closed.

But now, for the first time, after 62 years, she feels almost ready to make he own decisions.  She wants to learn how to decide what she wants to do, and not expect other people, men, to do it for her.  She wants to tell the people she doesn't like, who take advantage of her skills, charm and passivity, to fuck-off.

But she's never done that.

But perhaps now she will be able to do that.  She is not that beautiful any more.  The people who are trying to control her are not that powerful.  She may be able to set herself free.

3 directions at once

If you let it; if you don't push hard to make your own way, the flow of life will take you in certain directions.  I tell this to my patients all the time.  You have the "will" and the ability to push back, and make things happen in other ways, but there is a general flow to things that will happen naturally, just because of age, place and other external circumstances, and they exert a constant pressure to make things happen.

(as an aside--- I can remember walking through the streets on NYC when I was an impressionable, philosophical thirteen year-old.  I looked up in the sky and saw the words "Time" and "Life" flashed up on the top of a huge silver building.  For an instant I thought, wow, this city really wants you to stop and think  about what is going on in your life.  But the next thing that flashed across the sky said "Sports Illustrated" and I realized that they only wanted me to buy something.  I have been aware of that since then.)

As I reach this stage of my life I find that I am letting things flow, and the current is pulling me in three directions.  The first, and newest, is that I am aware of how much time I spend thinking about my granddaughter, and how different it is from how I thought about my children.  As a new parent you have to watch the kid moment to moment: to feed it, change it, watch it sleep, breathe and to wander what it wants and needs right then.  That's what parents need to do.

As a grandparent I find that I keep wondering about my new off-spring longer-term.  I think about how she is now, tiny and cuddly, and how much that will change so quickly, and I find myself considering all the possibilities, good, bad, marvelous and indifferent. What will she encounter and what choices she will have to make?  What will be the world that she will deal with.  With my own kids it was certainly moment to moment: deal with feeding, deal with sleeping, deal with sounds, words, sitting, crawling, walking.  But now I wonder about things that this girl will encounter, probably long after I am around for her to tell me about them.

In the meantime my life is beginning to change in other ways.  I will soon reach an age when, despite Republican opposition, I will be able to receive checks from my government just for staying alive, whether I work, pay taxes, or just decide to watch "Housewives of New Jersey."  The money is nice, but it really isn't a deciding factor as much as it is a demarcation of time.  It is time to alter my schedule after thirty years of coming to the same city and sitting hour after hour,  looking people in the eye and asking them "what the fuck did you do that for? You nuts or something?"  I am being pushed, by my granddaughter and others in my family to use my time and energy to explore different things. 

In theory this is a good idea, in practice, it is very difficult for me to not take new patients, and to not feel guilty about that.  I am supposed look around and find new things to do, and there seem to be so many, but I have to learn to let myself do some of them.

I intend to do some of this over the next six months.  I am trying to challenge myself to do interesting, worthwhile things, while not stressing about it.  I hope that they are very different from the things I do now.  I really hope that they don't involve "helping people'" which is what so many of my friends who have worked other jobs all their lives are trying to do.  I feel I have done that for forty years.  I want to learn to waste time.  Not easy.

But still, after I type this, I am going to work.  I will see a row of patients who I want to see, each of which is struggling in their own way to get through this holiday season.  I seem to be of some help to all of them, as they keep coming -- and none of these people need letters send to anyone. One has lost his job and is having the first rough holiday ever.  Another is now estranged from her family for very good reasons, another has a very sick child and a husband who is freaking out because of it --- on and on it goes.  I am still very into that, at least once I get to the office.

The biggest change is now the contrast between working and not working.  It is a bigger transition from thinking about my family to getting my head back into work. The world is opening up.  The river has divided into three broad streams and each seems to be going through the rapids.  So far I have been able to steer clear of the rocks.

I am an excuse

I still take a few hours away from tossing the sleeping child around to keep my practice going.  It is the holiday season, and who would want to miss hearing about all of the family dramas that occur this time of year when families gather to rip open old scars, and bleed out of old wounds.

But before I get into tales of toppling Xmas tress and inter-familial lust, I want to comment on a phenomenon that has been rapidly increasing:  that is how people and agencies use me as an excuse.  I find that in the last two years I have been writing more letters for people than ever before.  Having a psychiatric diagnosis, or being in therapy, can open doors to more services, or close doors to scary places.

I write letters to probation officers, to tell them that their wards are benefiting form "Anger Management." I also write letters to the court  for people who don't feel they can serve on a jury. Panic attacks or PTSD, will certainly free you from that civic responsibility.

I write letters to allow undergraduates to return after a semester of bad judgement -- drinking, fighting, stalking, missing classes, leaving classes, not finishing assignments.  These lapses can all be forgiven if you have ADD, depression, panic attacks, a substance abuse problem, an anger problem, or just "problems."

I write letters to get people out of work, and then get them back into work, using pretty much the same letters I use for people going to school.

With the terrible job situation, more people are applying for disability, because really, there are no jobs that many marginally adjusted people can cope with these days.  Car mechanics, laborers, and other semi-skilled or unskilled work has become mush more complex and much less available than even fifteen years ago.  Machines can do most of what people had once earned $12 to $18 an hour to do.

In many ways these schools, agencies, institutions and individuals are all just passing on the responsibility to me.  No one wants to make a decision about who is just not acceptable, or who can be re-classified as "unable" and therefore reap some kind of benefit.  I don't really get to make that decision, I get to be the cover for it.

Usually, I make a concerted effort to give as accurate and descriptive a summary of what the person's strengths and weaknesses are.  With that, the person receiving the letter has to decide what is acceptable.
Often, I feel that I have to make a strong case for someone whose difficulties are real, but may not be obvious, since psychological problems are not as visible as shattered knees.

But really, these are philosophical issues involving the question of "free will," although no one wants to acknowledge that.  I am being asked to determine if this person "can't" do something, or if they simply "won't" do it.  Will they be able to do so later, or will they never get there?  Could they do this last year, so why can't they do it now, or could they never do it and they need help?

These are very complex, and the judgements are based on very subjective evidence.  The definition of terms, the clarifications of circumstances, the delineation of expectations, and the understanding of capabilities all come into this determination.

Most of the letters consist of about three to five sentences.

I try very hard not to let people take advantage of me, but then again, someone who puts in that much time and effort to fool their therapist probably has a problem.

Legacy

There really is so much to write about, as parts of the world seem to be falling apart, while parts go blithely along, seemingly unaffected, even though they too are being corrupted.


Having a warm, round, large cheeked, snugly little thing resting peacefully between my shoulder and my neck not only takes a lot of time away from blogging, but puts everything in a new perspective. Watching the formation of one's own next generation makes me sad about how little really changes in the relationships between states, and between individuals.  Just when I reach the stage where it all seems like a performance piece that is done solely  for my entertainment, I realize that this little lump in my arms has a good chance to be here at the turning of the next century, and that will be long after Medicare, Social Security, and Afghanistan have used up all of the available money.  There is no certainty that any of those problems, as well as what to do about energy or the air we breathe, will be settled by then.  The solutions our generation seems to come up with has been to make a lot of noise, have blustering confrontations, often using guided bombs or suicide bombers, or just radio and TV rhetoric, and then actually do absolutely nothing. We do seem to be able to blame the Democrats, Republicans, Koreans, Chinese, Palestinians, Israelis, Iranians, Muslims, Jews, Irish, Swedish women who consent to sex and then change their mind.  Wki-leakers, Wike-pee-ers, the rich, and the poor.

Of course, all of the above are to blame, but no one seems to want to be part of a solution.


Handing all of this off to this little pink lump does not seem to be the way I would like to be remembered, especially if in seventy years she is left to breathe through a mask and shift through the rubble.  But my standing on the street corner yelling as loud as I can will not really effect much change, as those places are already full, as are most of the airwaves and  and millions of virtual bullhorns. 

The best I can do for now is to give her comfort, make sure she knows she is loved, and make sure she learns the value of peace, love and understanding.  She also needs to know how to work hard, and have fun.

But right now, when it's my turn, I will hold her so that her mother can take a shower and her father can sleep.

Cycles, the marvelous and the tragic

Well, she's a week old and it certainly is marvelous and amazing, and I haven't even spent enough time with her.  Her mother, my daughter, seems to be taking to her new role very well. Both she and the father seem really pleased to be parents and are smoothly shifting the focus of their now radically different lives,  are feeling the rewards of doing that.  The baby herself, whose identity I will protect to keep her from being hounded by the millions who are following this, is doing a very good job of being a week old.  She is already living up to her billing as beautiful, brilliant and creative. What else is a grandfather to think.

She certainly knows how to snuggle right in there and sleep off those heavy feedings.

Every birth seems to innately bring forth hope that there is a bright future, and that we will all do what we can to make the world happy and safe for this child and that she carry on with enthusiasm.

However, and when you reach my stage of life you know there is always a however, during these last two weeks at work I have been overwhelmed with stories of sickness and death.  By now you are well aware that i always deal with aggravation, stress, loss, conflict, loneliness, just plain old craziness, but recently there seems to be more severe illness and death than I was prepared for. Perhaps the contrast has made me feel it so intensely.

Two of my patients have just completed weeks of caring for their dying brothers, both of whom were in their fifties.  One of these patients buried her brother and the next week was told that her husband had lung cancer. 

It may be because of my age, and that many of my patients tend to be older now too, but so many of them have parents who are crumbling or dying or dead.  This process is never clear or easy.  The care that is necessary, the expense, and what is most difficult is the decisions that have to be made.  Usually, there are no good choices.  How to let people die, what to treat, when to stop, who decides, and based on what.  With all of the new possible treatments the lines get very blurry.

These are difficulties that everyone deals with, and there is really so little I can do to help.  I help people sort out their feelings, especially if their relationships with these people were not smooth, but endings are always difficult and always bad. If it is sudden people are shocked, and when it is drawn out then people are exhausted and horrified.

In addition, I have recently gotten three new patients who have come to talk about suicides in their families.  And then the Sheriff of our county was accused of corruption and responded to the charges by locking himself in a hotel room and blowing his brains out.  All of my depressed patients reacted to that.

Also, so many people seem to be related to people with the terrible, chronic, fatal diseases: Parkinson's. ALS, MS, cirrhosis or some of the more insidious forms of cancer.  I sit and wonder when it will descend on me.  I wonder about the pain in my stomach, until I realize that I haven't eaten lunch.  I worry about my prostate as I run to the bathroom, but I can still see that it is related to how much coffee I have that morning.  Why am I so tired? Why did I drop my pen twice today?

That's why it is great to feel with warmth of a new little snuggle-bunny, with fat, smooth cheeks, who has a hundred healthy years in front of her to enjoy whatever life brings.  It is better to live with hope and enthusiasm than to be scared of losing it.  Even if it means denying reality for a while.

Finally, on Thanksgiving

It's been a couple of weeks since I managed to scribble anything down here.  Mostly I've been preoccupied, as the holidays are always very busy at work, families being what they are, nurturing, caring, and warm, while at the same time being judgmental, angry, competitive, duplicitous and full of silent scorn.  It makes the season jolly.

But, this year we had one of the most unique and exciting Thanksgiving celebrations, as our first grandchild, a beautiful daughter, was born right in the middle of the turkey, stuffing and sweet potatoes  (and Patriot victory). She was more than a week overdue, so already she is showing a flare for timing and drama.  The whole family was gathered and waiting for the fatherly updates by test message. Being a female was a real crowd pleaser, and the whole group broke into cheers and applause. My daughter, the mother, was trying hard not to wish for a girl, although it was clear that she was.  She and her husband had steadfastly held out early knowledge of the gender, so it came as a happy surprise.

Today were the first visits, in small groups by most of the interested family members.  I got to hold my granddaughter and sneak off into a corner and tell her a few secrets about how the world works.  Just stuff she should know about whom to trust and how to have a good time.

What is amazing is how good and self-contained a one day old person can be.  She had a few little fusses, but was able to find comfort in the warmth of who ever was holding her, and also from her own hands and fingers.  When she became really wet or hungry, she was able to ask for help.  She learned that people are there for her.  She responded by settling right down and snuggling in close. It is fascinating to see how well, at one day old, she can already interact.  Whether she continues to be so successful, and becomes happy and self-assured, or whether she loses that ability to comfort herself and becomes anxious and fretful depends, to a great degree, upon how her environment, especially her parents, react to her.  I have a lot of faith in these parents.

She is coming into the world during an unsettled time, but I think that could be said for any time since the death of Ramesses II, the Pharaoh of Egypt in 1213 B.C.  There rarely has been a good time, as far as societies and nation-states are concerned.  But as far as her own immediate family, she could not be more fortunate.  Her parents are attractive, accomplished, educated, and financially sound.  They seem to get along with each other quite well, and both were very eager to have this child.  These parents are surrounded by over-zealous grandparents, who are each more than willing to fuss, and coo and help this child along.

Not a bad start.  I hope she feels that her first day was a success. She did very well.

To Do List

It's Friday.  I get to stay home and clean up all the administrative work for the week.

1. Wait for baby (still)

2. 5 return calls to clients

3. two calls to doctors

4. one call to lawyer -- conversation made no sense, we talk two different languages

5. Report for long-term disability

6. Report for short-term disability

7. 9 (count 'em) requests to three different insurance companies to authorize more sessions until the end of the year. This includes the "convenience" of going on line, having to put in a new password, after proving that I am who I am, filling out five different screens full of senseless information, and still not knowing if the new sessions will be paid.

8. Still waiting for baby

9. record incoming payments

10. send out list for this weeks billing

11. Two calls to track down two clients who "disappeared" who should know better but don't

12. 5 return emails to clients -- this is new over the last three years.

13. Write to Senator again to tell him not to cut Medicare payments from Medicare, the SGR issue

14. Watch videos of Celtics beating Heat

The easy part is seeing the clients.

the next big thing

It's not that I haven't been thinking, is just that I haven't been writing.  I wanted to give two or three examples of the frustrations I have, based on my last post.  But then the election got kind of heated, and my friend came from across the mountains, and mostly, we are waiting for this baby to arrive.

I guess a new generation kind of changes things, from what I've been told.  Having a sleeping, eating, crying dependent person enter your world can become the focus of attention, especially as this will be the first of the next generation.  I won't have to get up in the middle of the night that often, I don't think, yet.

But, she, my daughter, is in the end stages of cooking this thing.  Could be today, could be another week.

I've heard this has been done before.  But not by me.  And, like others, being a bit solipsistic, mine is probably the most beautiful, smartest, most clever, with the greatest potential.

Maybe next week I will post 500 pictures.

Right now we just sit and wait, and try not to worry.

But, you said

I have probably mentioned it before, but it burned me again this week.  One of my biggest flaws as a therapist is that I often underestimate the craziness of some of my patients.

I am easy to talk to; I am good at that.  I am also very accepting of almost anything, or at least appear to be, that way people relax and tell me everything.  That is helpful.  Often, when they relax and tell me all the stuff they do, it becomes clear  to them, as well as me that they are doing a lot of just plain old crazy shit.  They say the wrong things to the wrong people.  They over-react.  They feel really badly over nothing.  They carry grudges and forget why.  They mope around about things that were said to them ten years ago. They worry about things they said ten years ago.  Because of all this they don't show up for work, or don't pay their bills, or don't clean their houses.  All kinds of stuff.

Often, after we talk about it, it seems very clear to them, that not only should they change those behaviors, but after a while they are very capable of making those changes.  That's great.  Case almost closed.

But they don't.  They go out, and thirty-six hours later, the very same situation arises, the one we discussed, and practiced in the session, and they fuck-up again.

Sometimes it's even worse.  Many of my patients, especially the ones I thought were almost better and ready to be set free, not only make the same mistakes, again and again, they often create fantastic, unimaginable new ones, that go way beyond the old ones. This results in a new form of complex, destructive, painful chaos.

This can be annoying.

My reasoning

Today I was talking to one of the gentlemen I meet with regularly.  We were examining how anxious he still gets when he talks to a woman with whom he might want to begin a relationship.  He is in his mid-thirties, and still single. This anxiety has limited him badly.

We discussed how he had been a poor kid in a rich town, with parents who were awkward, often embarrassing, and always discouraging.  He could see how this has planted a strong reaction in him that he is not allowed to approach an attractive accomplished woman, even though he has grown to be an attractive, accomplished man.  It isn't the woman that makes him anxious.  He feels that someone else, some unnamed authority, with suddenly sweep in and and pull him out of the picture, telling him that he is not good enough and should not be doing this.

I mention this here because of what I have been talking about for the last week, that it is important to have someone like me, someone who is a bit out of step, who questions, who is not completely comfortable with the way things are run, to be your therapist. My reasoning is that, despite all my education, and all the research on internal intra-psychic factors, despite all the claims of biology, brain chemistry, genetics and psycho-neurological explanations, I feel that a great deal of the actual causes of what is called psychopathology are cultural.

Many of the people I treat are those who, for many reasons, sometimes gross and sometimes subtle, do not fit it well with the general flow of their surrounding culture.  They may have a different body-type, a different learning style, a different sexual preference, a different energy level, a unique reaction to stress or anger, or just be more sensitive than most people.  Usually, if these people have families that are accepting, or a circle of friends, or even one caring teacher, they can do very well.  But when the culture around someone becomes uncomfortable with someone, that person will often become even more uncomfortable being themselves.  This can lead to them acting in a way that others will consider odd, or even "crazy."

I think it can be a very powerful tool in treatment to be aware of what it is like to want to resist the pressure of conformity and societal norms.  It can be very validating to a person who feels as if he or she is an outcast, that they can still be OK, or even better than that, that they are strong.

I am familiar with several therapists who, because of their own nature, take the opposite stance.  They feel that part of treatment should be helping people learn to fit in, and to get along, and follow the rules and expectations of their culture.  Currently, there is a great deal of pressure from insurance companies that send out treatment guidelines, and in psychiatry, to see the goal of treatment as getting people to be calm, reasonable and pleasant.

I can understand that approach, but I don't agree with it.  In truth, I don't think it works; I don't even think it can work.  It can even cause a lot of harm to try and help someone to be what they don't want to be, and in many cases, can't be.

Perhaps, not so extreme

Before I write about why It is good to find a therapist who has some of my views, I would like to make slightly clearer what my views are.  That is why I write this blog anyway, to figure that out for myself.

So, we were driving back, over the weekend, on the coastal route.  We stopped along the way to see a friend, who happens, of all things to be a religious leader.  She is a good friend, and we know and accept each other.  She is even a Yankee fan, and I still call her a close friend.

We arrived at the time she was about to do some religious leading, so we attended.  She was doing an admirable job of leading, and I was not following very closely, but I was turning the pages in the book of prayers.  In the book I came upon a quote, but I can't find the quote anywhere though Google, so I will have to paraphrase it -- but maybe it was just put there for ME to see, or maybe they paraphrased it themselves.

Anyway, it was from Martin Buber, and it said something like:

"If people come to you and ask for help with their troubles, do not say something pious, and tell them to pray, and that God will provide.  Act as if there is no God, and that it is up to you to do all that is in your power to help them solve their problems."

That is the kind of religion I can be comfortable with.

Also, I said that I have a great deal of difficulty with Patriotism, especially when it leads to war.  Well, that is certainly true, but that does not mean that I am necessarily a pacifist.  I strongly believe that every country and every society has more than it's share of assholes.  And that there are people in other countries who do want to blow us up and take our money and rape our women.  We are a rich and aggressive country; so we need to defend ourselves.  Too often we are jerks about it, and do it badly, in the wrong places and for the wrong reasons. But we do need to watch out.


What do I think is important?

Basically, life.  I think that being alive is amazing, and can be full of fantastic, fun and satisfying experiences, sometimes, when it isn't tedious and boring, or it isn't full of pain and suffering.

Life, especially human life, is very precious, and should be treated that way.  No one life is more important than any other.  You have the responsibility of living your life as best as you can, in a way that you have determined.

We are all united by our insignificance --except to ourselves and those we love.