Ravello

On a clear day -- they were all clear and beautiful days -- we got back into the Fiat 500, and drove to Ravello.  it took about and hour from Positano.  The road wound along the cliffs, about 400 feet over the ocean.  The road was laid out by mules; there were no straight parts.  The turns were 60 degrees, 80, degrees, 150 degrees, with scooters passing and buses coming the other way.  When we reached Amalfi, we took a left and rove up the cliff to Ravello.

Rovello, is spectacular, and precious.  It has old churches, beautiful gardens and a music festival that had just ended.


From Wikipedia:

The town has served historically as a destination for artists, musicians, and writers, including Richard Wagner, Edvard Grieg, M. C. Escher,^[4] Giovanni Boccaccio,Virginia Woolf, Greta Garbo, Gore Vidal, André Gide, Joan Mirò, Truman Capote, Tennessee Williams, Graham Greene, Leonard Bernstein and Sara Teasdale (who mentioned it in her prefatory dedication in Love Songs).

and me too.  We had lunch there, at a spot that was rated by some travel site as the 2nd best restaurant view in the world.  Here's a picture:

not bad.

_____

But now that was almost three weeks ago.  I look back at that lunch as a turning point.  I finally decided to relax, take it all in and be there.  I realized that during the weeks, perhaps months, leading up to the trip I had become pretty tense.  Sitting there, on top of that hill, eating marvelous food, sipping easy wine, smiling with my lovely wife, things became a bit clearer.

What I had been concerned about was how both my profession and myself seem to be slipping, very slowly, into a irrelevancy.  After more than thirty years as a therapist I am beginning to have some doubts.  I know that I have been very helpful to many of the over 5000 people I have tried to help.  But I also know that there were many who thought the whole things was a waste of time.  I also feel that the pace of life these days makes the inefficiency and ambiguity of psychotherapy more glaring and almost unacceptable.

I don't know of a better method, certainly not using more drugs.  But the way things are done now is not great.  Also, the entire health care system is going though major reforms, especially now that the election has made that clearer.  Where psychotherapy fits into this is very unclear.

But, at that moment, on top of that hill, it was time to let it go, live in the moment, appreciate how good my life is, and trust that I would figure things out --- at least for me.

As the Dali Lama says in one of his tweets:

"Peace in the world relies on individuals finding inner peace."

Isn't it enough just that the Dali Lama is Tweeting to make you happy?

Positano

By the time we reached Positano it was almost three PM.  The clouds were closing in rapidly.  There is really only one winding road in Positano; first it goes all the way down one long cliff, then it hits bottom and goes up the other side of a very steep canyon.  Fortunately our hotel, The Villa Franca, was only three 178-degree turns from the top. 

 

The hotel is beautiful and positioned spectacularly.  It sits on the top of a cliff, looking almost 700 feet straight down into the sea.  Every room has a balcony that reaches out over something: the town, the sea, or the beach.  The staff is friendly and helpful, the food at breakfast and at the restaurant, was as good or better than anything in Boston.  Bring money.

 

 

The next day we walked down to the beach and back up again.  Someone told that the winding staircase we had climbed up on consisted of 877 steps.   Since it was now “off-season” the only people in the hotel were American sightseers, German hikers, and a couple of gorgeous models from Albania, with photographers following them around.

view from hotel, looking down at beach

view from boat, looking up at hotel -- white buidling on top of hill on left.

 

 

That afternoon, as my wife treated herself to a massage by the lovely Antonio, I sat on the deck on the top of the hotel with a drink in my hand and realized that I was feeling both marvelous and totally disoriented.  We were here; we were at the place we had set out to go.  I was literally on top of the mountain overlooking the world.

 

I appreciate that I have been incredibly fortunate.  I have had a great career, doing something both fascinating, and something I felt was intrinsically valuable, and it also, for many years, paid the bills.  I have had one, very good, long marriage.  We have two children, who both seem to be in good marriages themselves.  All four of them have very good jobs, doing interesting things. Each couple now has a charming, creative, beautiful, curious, affectionate daughter.  Both these young girls are enamored with their Pop-Pops.

 

I feel, like 70% of the therapists out there, that I am one of the top 5% in my profession.  But I also realize that the most brilliant thing I did with my life was that I was born two years before the big baby boom.  That gave me a step-up in almost everything I wanted to do.  I could get into a good, small liberal arts college, and then into graduate school, partly due to the lower number of applicants.  Three years after I bought a house millions of other people became ready to buy a house. I was part of the first wave of Psychologists to get licensed.  I left community mental health reluctantly, but when I began a private practice the competition was minimal, although the sigma of people going for treatment was still a factor.  I have been in practice in the same city, a mostly working-class mill city, with more prosperous suburbs, for thirty-one years.   I have been totally booked for the last twenty years.

 

But, sitting there, on top of the world, it was also easy to see how much I was a product of my times, and that times have changed.  The little talk I gave at the MPA conference was about how to use technology to enhance psychotherapy, but the real message was that people of this generation are different than the people of my generation.  Their values are different, the outlook and expectations are different, and their minds are different, due to how technology has given them access to information, and to each other.  And that makes the way they manage their relationships different.

 

All of this has made me see how much all theories, concepts and techniques of dealing with human behaviors are a reflection of the times in which they are espoused.  Sometimes it feels as if our profession has more in common with a newspaper than a web -site.  Just look at how kids are raised today, compared to thirty years ago; how many more people are in their lives.  How much they are exposed to. I’m already getting text messages from my granddaughter.  Look at how many subcultures are in the U.S. today, and how strong the effect of living in a Puerto Rican community vs. a Cambodian community vs., growing up in Chinese American family in a well to do suburb of Boston or San Jose. Compare that to the mind-set of a White Morman family in Utah, surrounded by nothing but White Morman families.

Is the best way to deal with the problems they face by meeting once a week for 50 minutes?

 

Yet, I also believe that there is nothing more comforting, and nothing more powerful to foster change, than a structured, face-to-face, well managed therapeutic relationship.  

 

For a while I thought about this while I was there, on top of the world, watching a ferry come in from Capri seven hundred feet below me.  I felt personally very fortunate, but still, as always, worried about the world.  It is not surprising that the world continues to change, now at a much faster pace than it did 1200 years ago when the church down at the beach in Positanto was built.  What is also becoming more apparent is that my life is in transition, as is my profession.

 

But there; at a place we had long wanted to come and see, I decided to try and relax and be in the moment.

 

Napoli to Positano

This was written a few days ago, but with the storm, and Halloween .....

But here is the next installment of the trip, as I recall:

Napoli to Positano

 

I am not a good follower, nor am I a great joiner.  So my wife and I don’t take tours.  We map out where we want to go, try to learn about the place and head out to see it and enjoy it.  It is for that reason that after our plane landed in Napoli, we rented a Fiat 500 and headed out, on our own, to Positano.  I encourage you all to Google that route on Google Maps.

 

But, that route would only look like a twisting road, first highway, then through several tunnels and then along the twisting road on the cliffs high over the sea.  A road that makes Highway 1 South of Carmel seem wide and straight. 

 

But that is not the fun part.  The real fun came when we missed the exit to the road to Sorrento, went too far on the A3, and got off the highway.  Then you realize that the smaller cities of Southern Italy do not believe in stop signs or traffic lights.  Nor are the entrances to highways anywhere near the exits, and signs are also nonexistent.  To add to that the roads were built by the Romans, or earlier.  They consist of a narrow lane in each direction, heading right through town.  Two Dodge Dakotas could not pass each other going in opposite directions.

 

What you get is a constant flow of inter weaving traffic, either going about fifteen to twenty miles an hour, or not going at all. Then you need to factor in the motor scooters.  There are about ten motor scooters to each car.  They go at about  twenty seven mph. They weave around all the cars, in both lanes, going in all directions,  both with and against the traffic, wherever  there is six inches  of space.  But they take care of themselves.  It’s the predestrians you have to pay attention to.  They cross the street whenever, where ever they want, or else they just walk in the street, because the sidewalks are full of chairs and people sitting, drinking and arguing.  And in the traffic, everyone is yelling at each other.

 

My lovely wife could not bear to look, but it was fun.  It was like living in a video game; just keep moving.  If you stop, and let someone in, you will never get a chance again.  First gear, second gear; first gear, second gear – just keep going.

 

But, as we drove the narrow city roads, or the winding mountain roads, on which you could not see beyond the next curve, which was never more than forty yards ahead., I never saw even the slightest scrape or dent or injury.  Buses missed me by one to six inches,  Motorcycles  that were coming head-on,  would disappear  seconds before impact like ghosts behind the mirror.  After a while I had complete faith that everything would be fine, and it was.

 

After we reached Positano, and I sat in the lounge of the Hotel de Franco, at the top of the hill, looking about 700 feet straight down to the beaches and the sea on either side, I thought a bit about how this was part of the current difficulties being felt by psychotherapists, especially those with Ph. Ds.

 

It is usually in the character of good therapists to be compassionate, understanding and empathetic.  We see and feel the trouble in others. We want to solve problems, to look at them,  take them apart, and then help put things together  in a way that works better.  We do not usually push ahead and claim every small space to be ours and then grab at the next one and the next, taking what we can for ourselves, regardless of the effect it has on others. 

If we did, others would have to worry about themselves.  But no, our job is to worry about them, and to help them make things better for themselves.

 

But what we are learning now, and many of us figured out before, but many have not, is that if you want to be in your own practice, you have to learn the business part.  They don’t teach the business part in any graduate school.  You may learn therapeutic techniques, you may learn research skills, but you don’t learn marketing, and you don’t learn finance.

 

We also thought we were entering a profession, like a doctor or a lawyer, and that being a “professional” means that patients would just come to us.  But that is not the case for any professional any more, unless you are Miguel Cabrera or Tom Brady.

 

Also, what you may not realize is that some of patients you see, who could be diagnosed as bipolar, or narcissist personality, are often the ones whose business plans just did not work.  There are other people, perhaps people such as Rupert Murdock, Jamie Dimon, Lloyd Blankfein, Ralph Nader, even Madonna, who may have ended up being labeled with some kind of psychiatric diagnosis except that they pushed very hard, had unrealistic goals, moved people out of the way, and did not think about others as much as they took care of themselves.  They are regarded as very successful.

 

But so many therapists worry about confidentiality, about the possible impact of everything they might say, of what someone might think about what they are thinking.  And all of this may be important, at times, in the therapeutic process.   But it can leave you powerless in the business process, and it has in many ways, allowed the profession to become marginalized.

 

We think about ethics, and liability and therapeutic impact, and confidentiality, and some clown is out there, whose best qualifications are a good haircut and a big set of brass balls.  He markets himself as an executive coach, and charges $700 an hour to help the boss work out a strategy.  And then there is the Naked Therapist who got highlighted on Fox News.

 

We find that, if we want to be part of the mainstream process of bringing psychological services to those who need them, that the decisions about how, where, and how much we will get paid are going to be made a great distance from our offices.   Many of us will have to learn how to join groups (ACOs? roving bands of Psychologists?)  and work well with others, which is something I said at the outset that I don’t do well, Or some of us will take the position that we will only see patients who can pay us what we want, or we will only perform a service that gets us compensated in the manner we expect, but that means we have to find a market, and we have to learn how to sell ourselves.

 

You have to learn to constantly push ahead, just like driving though Napoli.  Keep your eye on the opening and go for it, and let the other guy take care of himself.   And sometimes you have to scream and use hand gestures.

Reflections While Away, 1

Note: Forgive the formatting:  I don't know why this happened. 

Two weeks ago I left the country. I realize that most of you had no idea, nor cared that I was away, but that's OK.

I won't take it personally.




While I was away I did some thinking about my profession and my life.  Now that I have returned I would like to share those thoughts with those of you who share my 

profession I am going to post this on several lists that I follow, so if you are also on      those lists don’t bother to read it all again.  If you would like to respond, that would be   fun. I would like some reactions. The great thing about sharing things way is that if you don't care, the delete button is milliseconds away.




Three weeks ago Div 42 of the American Psychological Association, Independent
Practice, held a conference to discuss ways in which a private practice can
develop and flourish.  I was unable
to attend the conference, but many who went seemed enthused. 




Two weeks ago, on Saturday, October 13, I gave a brief talk at a Massachusetts
Psychological Association Conference. I spoke about the possibility of using
technology to enhance psychotherapy. 
At that conference Suzanne Bennett Johnson, the President of APA, gave
the keynote address.  She made it
clear that the way most Psychologists will be using their skills in the next
ten years will be very different than how they operated even five years ago. 




I took
notice, people took notice; things are changing.  Some people want to adapt, some      people want to help build a
new system, some people want to circle the wagons and defend old positions,
some want to get completely out of the system, and many are just getting
anxious.

The next day, October 15, my wife and I took off from Logan Airport in Boston and
headed to Napoli, Italy and from there we drove to the Amalfi Coast It was a
trip to celebrate my wife’s birthday, paid for in part because we are getting
old. The good part about getting old in the USA, especially if you have been
self-employed, is that your medical expenses drop considerably. It may be  "socialism" but we had each been paying $750 a
month for health insurance, and now we pay about 1/4 of that. I have been
getting Medicare for over two and a half years; that’s a considerable saving.




The bad part of getting old is that a week before we left for the trip my wife’s cousin
died.  He was one of the few cousins I enjoyed being with, families being how they are, and he was only three years older than me. That made it seem all the more important   that we take the trip, see the sights, eat the food, drink the wine and enjoy and
appreciate each other, the world, and being alive, and basically healthy.

As the
plane was flying over the Atlantic Ocean, I sat in the semi-darkness with my
brain drifting around the way it does when there is not really enough oxygen,
I’m not really sleeping, but I’m not really very alert.  I thought about the conferences,  my own
professional past and future, and where I fit into all of this.

I realized that when, in the early 1960s, I decided to major in Psychology as an
undergraduate, and then go on to graduate school, I conceived that becoming a
Psychologist would be helping to build a new and better science.  At the time it seemed     that Psychology
was very intellectual, philosophical, and then scientific.  It seemed to involved questions such as "What is a Good Life?  How can we
help people live it, and How can we help people get along?” as much as the
dealings with the brain, the nerves, the neuro-chemicals and the genes.  Much of the    “science” at the time was
based on phenomenology and introspection. 

Graduate school was still full of Freud and the Post-Freudians, as well as the
Behaviorists. But beyond that, who we read, and argued about was Aristotle,
John Locke, David Hume, Emanuel Kant, Martin Buber, and J.P. Satre as well as
Albert Camus.  We studies “Theoriesof Personality,” many of which now seems like “made-up stuff.”  The Psychologists we talked about also included Kurt Lewin, Fritz Perls,Ram Dass and Jay Haley ( All Men! My wife always    points out). It was the '60s and '70s, so there was Humanism, and Gestalt, and T-Groups,and Radical Feminists.        Psychiatrists were still classifying homosexuality as a disease.

There was a war going on that everyone paid attention to, and there was sense that
the world needed to be changed –and that it could be changed – and that we were
going to be ones to do that. 
Everything had a bit of a political overtone. Money was not the major
focus. The government, NIMH, paid me to go to graduate school.  Community mental   health centers were opening up, and they needed well-trained Psychologists to run       them.

So, on this journey along the Amalfi Coast, in addition to the walks on the cliffs
over the oceans, the amazing food, the cheap but excellent wine, the stress
free time with my charming wife, I spent some time thinking about what has
happened in the thirty-eight years since I earned my Ph.D. and what I think
will, and/or should happen now.

I also, that while I was away, there has been a lot of meaningful, and
personal discussions on these lists about these topics, and I found those very
illuminating and fascinating. Clearly, many people are feeling the rumblings.




 Over the next few days I hope to create
several more posts.  I will try to
explain my thoughts about all this as I was walking, eating and drinking through
some of the most spectacular places on earth. 




Perhaps,
as Fritz Perls said:


“The only difference between the wise man and the fool is
that the wise man knows he is playing.”





Perhaps not.

Tx M

Heading out again

We are leaving for the airport in an hour to head out to the Amalfi coast.  I am leaving my patients, the crazy politics of this country, not that Italy is any better, and the state of my profession.

I gave a talk at our state Psychological Association conference yesterday.  I tried to show them ways to use new technology to enhance psychotherapy.  I was given a very good reception, but more for  the delivery than the message. At least I kept them entertained.

The professional lives of Ph.D. Psychologists is under a lot of pressure that the general public doesn't see, and really doesn't care about.  The changes health care system, which is complete flux, partly from politics, and partly because it is such a mess, does not pay much attention to Psychologists. We are more expensive than social workers or "counselors" and we are not MDs like psychiatrists, who also are getting marginalized.

I am older, and if they stop paying me I will stop working and find another way to keep busy and perhaps make a few dollars.  Maybe I will take the advice of the person who last commented about this blog, and jazz it up and market it and be another voice in the wild bloggosphere.

But for right now I am of to Italy, to set and watch the sea, eat grat food, and wonder where I will fit in to the world.  I will miss the grand-girls.

Bye-bye form Pop-Pops.

Small Perspective

This is a note about how important it is as a therapist, or anyone really,  to understand the perspective of the person with whom you are interacting.  But actually, this is just a chance for me, as a grandfather, to boast.

The older of my two grandgirls is now22 months old.  She has been walking for a while and is now talking in sentences and some short paragraphs.  She is also so cute that it should be illegal, but that's me, and I hope every grandparent feels that way.

All summer she was walking around, and being at her level, which is pretty close to the ground, she began to notice that the feet of many people, especially the women, were exposed.  It was even more fascinating to her because most of their toes were painted in bright colors.  She was just learning to recognize which color was which, so she would walk around, point to the toes and say "red toes," or "pink toes."  She also seemed to be intrigued that toes came in different sizes, so she would point out everyone's big toe.  "Daddy's big toe."  Pop-Pop's big toe."

But now it is autumn.  People have stopped wearing sandals or flip-flops and have put their shoes back on.  My granddaughter seems to find this a bit confusing.  She was really enjoying checking out all those toes, and now they are gone.  Now she goes around, points at the shoes and say: " Pop-Pops foot hiding." "Nanny's foot, hiding."  This has generalized to other things, such as "belly button, hiding."

So, you see, if you took that out of context, you'd think she was strange.  But if you understand the perspective of the person, it can all make sense.


ALSO: on setting limits:

The other granddaughter just celebrated her first birthday.  Her uncle gave her a big red, blue, yellow and white clown as a present.  The clown is about twice her size, but she is in love.  She grabs the clown, shrieks, jumps on it, bites it, rolls on it, laughing and screaming with delight.

But I told my son, her father, that if she continues to spend her time with a clown like that, I'm not wasting money on her college education.  Someone has to point out what's good for her and not let her waste her life.  I've seen that happen too many times to not take action.

no diagnosis?i

I recently began seeing a new person for therapy.  He is a tall, handsome man, which adds to his problem.

His problem is that he likes sex.  That is not so unique to him, but he takes it to an extreme.  He thinks about sex a lot.  The idea seems to cross his mind with almost every woman under 80 he sees.

That may not be so unique.

What is unique is that he often acts on his wishes, and has a great deal of success in meeting his needs.  His wife is mostly accepting of this, as are the women.  The trouble is that he has run afoul at his work, in his neighborhood, and with others who have to deal with the atmosphere he creates.

He is now in danger of losing his job, his marriage, and of being dismembered by several men who were involved with some of the women he became involved with.

So I went to give him a diagnosis.  I was looking for some kind of impulse control disorder related to sexual impulses.

But it's not there.

There are sexual dysfunctional disorders, but they area all about NOT being able to have or enjoy sex. Having too much is never seen as a disorder.  There are diagnoses for fetishes, for sadism and masochism.  But he is not like that.  he just likes getting laid.

There is the diagnosis called paraphilia, but that is mostly a fancy name for necrophilia, which is sex with dead people.  that's not him either.

Interesting.
too much sex, not a problem.  Except for him it is.

Diagnosis:  312.10:  impulse control disorder, NOS

A life of the Times

My life seems to have melded with the current way of being.  Information, tasks, people, roles, ideas, news, opinions, all pour in constantly, with no interruption.  There are times when I can't really tell if a thought comes from something I just read, something someone told me, or was actually an idea of my own.

Often, it feels as if my life has been divided into several separate segments that barely overlap.  My work life, sitting in my office, seeing my patients, wondering, thinking, planning what to do for them and how. this has gone on for over thirty years.

My family, which has been with me even longer, has changed greatly over time.  I am still a husband, but now with a wife who wants to ease into the next stage of life.  I am a father, and now a grandfather, which is a very different role, with very different expectations, responsibilities and really, a very diminished amount of authority.

It is also much easier.

I have friends and activities that are further and further away from work, as many of my friends have eased up, or have stopped working.

I have a life of ideas in my head, especially since I have begun to think about the talk I will deliver, which I find interesting and stimulating, and which is putting me in contact with totally new ideas and new people.

It is all very busy, which is good.  It gets confusing, and difficult to prioritize, but I can work it out.
the main thing is to keep going and stay healthy.

And also not to get upset by a missed field goal as time expires.

new direction

As I said, I am gearing up to give a presentation at the state psych association conference.  I am going to talk about how technology could change the delivery of mental health services by 2020.  I have been thinking about how there can be more mobile monitoring, more use of direct, real-time measures of change.  There can be immediate therapist/patient contact through texts and apps.  Lots of new things can be introduced.

For years I have talked about how psychotherapy remains one of the few low-tech professions.  A good part of why it works is due to the  face to face building of trust in an interpersonal relationship.  I still think that is important, but there are so many new ways that the relationship can be enhanced by using technology.

What I notice now is how restless I get using the old traditional, one office visit per week.  I have begun to text some of my younger patients, and they seem to respond.  There could be so many other things that could be used.  I am already eager to see it all begin.

I'm sure many people do not agree, but eventually, they will all die off.

Presentation

So, I am going to do a presentation at the local state psychology conference this fall.  I am going to talk about how we psychologists will measure changes in 2020.  That will be fun.

A lot of whatt I will say I have said here -- how technology will change everything. We will use apps. We will use real-time monitoring. I think it could be exciting and much more effective.

Right now I think it will be more fun to design it than to do it.

Let's see how it goes.

Men -- Fictional

I don't read novels very often.  I'm even in a men's book club, and we don't read novels -- I guess that's for mixed company. But it's summer and now that I'm on vacation I have read two novels in the last week.  They have certainly helped me see what has happened to American men.

The first book I read is by a man I respect and who is one of America's major novelist of this century, Dave Eggers.  I read his first book, and even though I was a bit confused by it for a while, I liked it -- and it wasn't even fiction (mostly). The book I read this week is a Hologram for the King.

Then, while wandering around at a local town book sale I bought a book by Louis L'Amour, one of those about the Sackett family.
Louis L'Amour wrote 89 novels beginning in the 1950s and going until the late 70s, most of them westerns.

Well, the men in these books could not be more different.  Mr. Eggers' hero, Alan Clay, is constantly full of anxieties and doubts. He is hesitant, impotent, and indecisive.  He is plagued by thoughts of his ex -wife, his father, his daughter whose tuition he can't pay, the job he lost, the job he has, and his place in the world.

In complete contrast to this, all Mr. Sackett needs is a horse, a rope and a gun and he can solve any problem, sort out any situation, with the clear knowledge of what is right and what is wrong, and with very little concern about who may get killed along the way -- as they were obviously wrong. No issues of self-esteem are even conceivable.

The American male, and his place in the world has changed a great deal during the past 50 to 60 years. The world is much more complex and enmeshed. 

However, there are many, many people ho do not want to acknowledge this. They want to believe they can live the way Mr. Sackett did.  Most of the stories Mr. L'Amour wrote took place in about 1871. 

Things are different now.

Better? That's for you to decide.

Before I go

I am leaving for a few weeks away.  It is August after all, and enough is enough.  I expect it may give me more time to scribble things here, or perhaps I will just calmly float away and not be disturbed by anything.

One word before I go.  A lesson I learned a long time ago, continues to prove itself over and over.

Never ask a human a "why" question, especially about his/her own behavior.  It's great in science to ask "why" of the world and the universe, but if you ask "why did you do that?"  or really --"What the fuck were you thinking?!?!  The answer you get will be meaningless, distorted and wrong.

It's the job of the therapist to figure out the motivations, causes, and conditions that precipitated the action. Then, together, you can figure out what to do, and how to make that happen.

Yes, it is often interesting to hear the reasons people think up to explain what they did.  Sometimes the reasons are very clever, and can cover a lot of ground.  But it's all in hindsight, and it's usually only to make the person feel good, or at least rational.

But we know better.

Now, why did I write all this?

3 Reasons to Be Tired

#1.
I can tell I am getting tired.  It seeps into my body, my mind and my soul.  This is part of getting ready for vacation, which now is just a week away. To go on vacation it is necessary to be tired.  A vacation should be earned.  For me, it is difficult to just walk away because you can; you have to be tired.

So I am getting tired.

#2
It seems like many of my colleagues are tired also, and a bit scared.  They can see that the landscape is changing.  This whole health care delivery discussion makes everyone wonder what's going to happen.  It is reasonable to assume that those who will be making the decisions will have no idea what they are really talking about -- on a therapist to patient level.  The decisions will be based on money.  Those of us who still bill insurance companies for our services have already seen that the way insurance companies will cut costs is to pay us less. 

The other way will be to not pay us at all.  The model that most psychotherapists use, seeing people in their office for about 50 minutes at a time, once a week, was created about a hundred years ago.  It hardly fits today's world.  Two things are happening.  Well trained, Ph.D, or M.D. therapists are being replaced by Master's level people who are paid less.   Also, technology will enter into the mix.  People will be treated by text messages and Tweets. How much does it matter?  I think it does, but it is very difficult to demonstrate. I am the best therapist in the world and I only help about 62.347% of the people I see.

All of this makes everyone discouraged, and tired.

#3
When I'm rested and on the top of my game, doing therapy is challenging and fascinating. When I begin to get tired I can feel the resistance.  I can still deal with it, but it is there.  What happens is I feel badly when I open the can of worms and really see what's in it.  Today I was working with a guy I have been seeing for about six weeks. I like him.  He is bright, interesting and came to me for anxiety problems.  I am good with anxiety problems, especially if they are , you know, anxiety problems.  But they are not always just anxiety problems, very often they are more than that. It can take a while to find out.

Today, I was doing what I do, which is when someone with anxiety is still just as anxious even after I have sprinkled the first wave of magic dust on them, I probe a bit to find out what' s going on. Now, this is a guy I really like, as it is with most of the people I see.  When I like them I don't want them to be too fucked up.  But I still have to look under the rocks and see what's ticking.  So today, I looked under the rock and found out the the guys isn't just anxious, he's full of self-loathing and has cut himself.

I was tired.  I didn't want to find this out.  I want him to be OK.  I wanted it to be easy.  I can handle it, but then I'll go on vacation.  Now I have to do things to make sure he's OK.

It's not that I'm complaining, because this is what my job is.  It's just that I'm.......
complaining.

I am OK -- but..

I am OK.  In fact I am doing surprisingly well. This has been a great summer.  I am in good shape and healthy.  My eye is better, my knee is better.  Nothing really hurts.  I have been very active kayaking, biking and chasing my grandgirls -- only one of whom can actually walk, so it's not that hard -- but the one who can walk loves to run away.

I like hot weather, so the summer has been good to me.  We go off to the beach house and play.The kids have been coming and bringing their kids. Friends have been coming. We discuss how the world is  falling apart while sitting in great comfort.

Then I go to work and things are different.  but that is the nature of what I do.  People very rarely come to me to tell me how happy they are, or how excited they are about the interesting, creative, fulfilling things they are doing.  That happens occasionally, but that means it is the last session.

But I have been doing this for years.  I can deal with depression, even terrible depressions.  Anxiety; hey, everyone I see is anxious, also I can be helpful for loss, loneliness, confusion, stress, relationship problems, addictions, even violence. Hey, let's talk about it. My kind of therapy at least doesn't have side effects.  It won't make you constipated or gain weight.

But you know what upsets me.  Dealing with people who have chronic, physical pain.  I mean pain that has lasted years and comes from degenerative diseases.  Diseases that not only resist treatment, but that the treatments for them seem to create other painful conditions.  The drugs lead to passing out, or digestive disorders or kidney failures.  Pain raises blood pressure, the drugs for that causes dizziness, people fall down, cut themselves and go to the hospital and pick up a staph infection. The antibiotics for the staph infection cause colitis, which leads to a colostomy.  But still the pain, from the degenerating bones, or the pressure on the nerve from the back injury, or whatever it was that began the whole process goes on, and no one can really find it, and if they find it they rally can't do much about it.

Part of why it bothers me is that I am getting older, my friends are getting older and my clients are getting older.  For me, I can no longer run and jump.  For me, who played basketball for 25 years with the same group of guys it is a loss.  But I can cope.

What i know is that more is coming.  More of my friends have had knees replaced, hips and shoulders too.  They are on all kinds of meds because this or that number comes up too high. I take one little pill. Other friends have stents in their bodies, or have difficulty getting out of chairs, or even, are dead already.

So far, most of my friends and family are basically OK.

I plan to be immortal, until I am dead.

Back to work

The summer will continue, but for now, I am returning to my office.  I did have a marvelous week at the beach house.  I did get to go to the beach with my grandgirls, although Elmo stayed at the house.  We threw rocks into the waves, we sat on the edge of the water and made splashes. I got to see my children be parents, which is kind of weird, but certainly an experience, and it made me very happy and  a little sad (becasue I don't want to be old)..

Now I am in the re-entry phase.  I picked up my messages and made several phone calls.  I have a lot of appointments this week before I get to go back to the beach.  Some of them have already canceled, others have left messages seeking an appointment and they will will the openings.

Also, I have been perusing some of the blogs of my colleagues.  Most of those are done as kind of marketing tools.  They usually try to spread some psychological wisdom around the Internet.  They give suggestions about how to be active in the summer, how to get people to listen to you, how to be more confident, how to daydream creatively, how to daydream destructively; in general how to live your life in a better, healthier way, if you have any time left after reading how to do all those things correctly.

But this blog is not like that.  As you know this is the anti-marketing blog.  This is where I tell you that I have a very busy week ahead, but there are a few people, a real minority, like 15%, that bother me, and that overshadows my thinking about the folks I am eager to see.  Most of the people I see are working hard to change their lives.  Many are struggling against "strong headwinds." as our President likes to say about the economy.

But there is this small group of patients are really nuts, and they ain't going to get much better, and they weigh me down.  They are the ones who make phone calls while I'm away.  They are bad with boundaries, they are bad with time, they make bad decisions and they don't take responsibility and have little insight, and they talk and talk and talk.

I am sure every therapist, especially if you have been in business for a while, has a bunch of these, but they don't seem to talk about them on their blogs.

So, put on a smile, as it helps your neurology, develop a positive attitude, enjoy the summer, be nice to your friends and family, eat only food that is good for you, don't go into debt, exercise regularly, sleep well, don't worry needlessly, stand-up straight, breath deeply, meditate once in a while, think before you act, and break your addictive habits.  And don't call your therapist unless you need to change your appointment time.

Summer, again, briefly

Wow, it's been a while.

That's becasue it's summer and there is so much to do.  so much to do without thinking about it.

Right now I am officially on vacation for a week.  Before this I was working days and then taking off whenever I could.  Here in New England, when the sun comes out you had better be there because it all ends quickly. It doesn't matter if you're out to get in the water, hit a ball, ride a bike or just take a walk; the time is short.  We don't get Spring, except for about three days.  It goes from 42 degrees and drizzle to 87 degrees and heat.

Work in the summer is different.  There are fewer patients but they are nuttier. Everyone half same takes off and gets outside.  The fragile ones go into crisis. It's the heat, the moon, the outside.  It's the alcohol, the half naked women, the resentments.

The day before I was leaving I get an emergency from someone I had not seen for three years. Falling apart, laying on the floor of the H.R. office crying.  The next day I guy I hand't seen for four years comes to my office ten minutes before my first appointment.  He needs to talk.

"Some people claim that there's a woman to blame." And they are correct.

But tomorrow the Grandgril comes, and after Elmo, I'm one of her favoirtite guys. Let's go to the beach.

Something Good

She was referred by one of my crazier patients so at first I was a bit skeptical.  Well, she wasn't exactly referred, she was brought.  There they were in the waiting room, so what could I do.  I gave her an appointment for the next week.

She is seventy years old, and she looked it, with her slightly unkempt gray hair and leaning on a walker.  She could have been eighty.  A few days before I was to meet with her I had a session with the patient who brought her.  She told me that she was clear that I would never mention either one of them to the other, of which I certainly assured her, but then she told me that she would be coming again with the new woman because the new woman admitted to my patient that she didn't know how to read or write.  My patient did not know if the woman would tell me that, at least not right away.

Given that, I didn't know what to expect, because in our brief meeting she seemed articulate enough.

The session began with this new person and the woman told me she had never been in therapy before but she thought she could use some advice.  Then she told me that she never learned to read. She said she had been traumatized by nuns.  Her parents came from overseas and no one spoke English at home.  When she got to school in first grade the nun was embarrassed that she had a student who not only couldn't read, she could hardly speak English. So the nun placed her in the basement of the church and made her copy the alphabet every day.  She got no further instruction, but has beautiful cursive handwriting.  When she tried to tell her parents what was happening they could not believe that the good Catholic Church would treat anyone that way, and if they did, they much have their reasons.  So nothing was done.

In second grade she sat quietly in the back of the class. She thinks that  he teachers must have thought she was retarded, but no one ever did or said anything. That remained true until high school.  She went to a vocational high school and took up cooking.

At seventeen she met a man four years her senior.  He decided that they should have sex. when her parents realized they were doing that they decided they should get married.  She married him and had four children before she was twenty-two.  She realized that he only used her for sex, and was also having sex with others, so she one day she locked the door and told him if he opened it she would break his head open with a hammer.

He moved to Florida.  Only one of her children ever had real contact with their father., and he took that son for a few thousand dollars.

From then on she took control of her life. She opened a catering business that she ran, very successfully for forty years. She had a staff member write the menus, and she didn't need recipes. She raised her children by herself and they are all on their own and doing pretty well.  The two who still live close by keep in touch with her often.

She retired five years ago and moved in with one of her daughters. Last year, as her grandchildren were entering adolescence she decided that she did not need to be around the noise and chaos, so she moved into what she thought was elderly housing.  The problem is that "elderly housing" in the city where I work is also filled with many interesting and colorful souls, and her hope of hanging out with some nice older women who would talk about their children, cooking and sewing met the harsh reality.

However, before she came to the appointment she had already begun to make some contacts away from the apartment complex, to find some people she may want to spend time with, and to learn how to be polite but distant with those around her. I was able to help her sort out who to see and where to go that could be more enjoyable.   She seemed to be very insightful, and we decided to meet a few more times to make sure things work out. I don't expect that anything more pathological will emerge; she was a very unexpected surprise.

She also told me that now that she is alone in her own place, with no one to push her or evaluate her, she is teaching herself to read.  She expects to have the hang of it by the Fall.  She wants to read that Fifty Shades of Whatever, that her daughters are talking about.

More American Worries

Went back to work again this week and the more I sit and listen the more I have to worry about.  My patients are the least of my worries.  They come for help.  Most of them have a good idea of what is wrong and they are trying to get their lives together, many from very chaotic situations, crazy families, and a tough economy.

But it is what my patients tell me about what is happening with their families, extended families and communities that worries me more.  There is such a growing number of people who are slipping away.  There are more and more people who can't function well in this world as it becomes faster and more complex.

Much of it is the result of all the new technology, the globalization, the recession, and the deterioration of families and the educational structure.

There are three kinds of populations that are really not doing well and they have very little hope of improvement.  They will become increasingly expensive to society and no one seems to have a real workable approach to solving these problems.

The first group has always been there but now there are more of them; the poor, minorities, unskilled, learning disabled, and left out.  These people are now unemployed all over the world.  More and more places are looking like India with some very rich people, and many more very poor.

Now there is a second group that had been a rung above the forever under-class.  Now there are more mainstream people who had been working but are no longer needed.  The older ones, who worked for twenty to forty years in jobs that have been made obsolete by technology, or out sourced, are just lost and depressed.  But there are many younger people who never really found a place, never really learned how to work hard, and have kind of faded to the side.  They are home playing video games, they are taking too many drugs, they are often angry and causing trouble, they are having children they don't know how to take care of.  These are from places and families that were doing OK before, but now many of them can't keep up, can't find a way to really be independent.

There is also a third group that is under the radar, and very difficult to talk about without sounding mean.  These people didn't exist fifty years ago, but they do now, and they are very expensive.  They are people who would not be alive except for the fantastic progress in medical care.  Some of them were pre-mature births, some were from in-vitro multiple births, some were kept alive by amazing interventions, and others have illness that were previously fatal but now medicine can keep people alive, but not really very healthy.

I don't mean to imply that these people shouldn't be alive, or that they don't appreciate all that has been done for them, but there are many more like them who are in pain, have severe learning disabilities, ADHD, and other major handicaps.  Many of these people can't work, and they begin to get disability payments and complex, expensive medical treatment at an early age, and while it is good to have them around, and their families mostly love and care for them, it is very expensive and very time consuming.

As of right now, I don't have an answer for all of this.  It will probably take more than just me working on it to solve these problems.  But they are here, and they are getting worse, and no one is really paying attention to the magnitude of the problem.

American Dream?

After a very fulfilling, enjoyable, gratifying long weekend spent down at a cottage by the Bay which was filled with what is now three generations of family, I drove to work today and was very aware of the huge difference between the fortunate life that I lead and the lives of many of my patients. On the drive I heard that NPR is going to do a series all summer long about the state of "The American Dream."

I have often told people that the most brilliant thing I have ever done in my life was to be born two years ahead of the Baby Boomers. That meant that when I applied to college, not that many people were applying yet, when I bought a house the big wave of home buyers would follow me and my house would be worth more.  My children were two years ahead of most Boomer's kids. I went to grad school when the government wanted psychologists, so they paid me to go --very unlike today. I had enough money to begin to buy stocks in 1979.  Although I made a zillions bad stock purchases I did buy MSFT, RIMM and AAPL when they were new companies and that made up of all the losses
( missed GOOG, I have not yet bought FB).

My wife is still good-looking and still a force whose ideas need to be constantly considered.  My kids are healthy, employed and already own their own homes.  Their kids are round and cute and curious and smiling. We all went to the beach, played golf, had cook-outs. There are always a few ripples in this perfect picture; I only hope they are enough to drive the jinx away.

Every year of the thirty years that I have worked has felt as if our social environment has made my job more difficult. There was AIDS in the 80s, and lots of divorces.  There was crack and lots of bad drugs in the 90s, as well as perverted priest and rampant speculation. There have been huge changes in how we live and think which have been brought about by technology. There were the credit card and re-mortgaging binges of the 0's that were a big part of what led to the world financial collapse.

But I have never seen so many people who feel helpless and hopeless when they look to the future.  This is felt most dramatically by people in their mid-20s and mid-50s.  There are not enough jobs for either of those groups.  The younger ones can't get started and the older ones have been tossed aside.  The combination of a global workforce, the economic slow-down and technological worker replacement has hurt people not only financially, but in their sense of purpose. It is very difficult to gain any traction in your life when you feel the world doesn't need you.

I do believe that many people will realize that it is foolish to try to jump through corporate hoops and to live your life chasing after money and fame.  I believe that eventually many parts of our society will establish a more worthy sense of values that will guide them towards happier more meaningful lives. But I am struck by the number of people, young and old, who are really lost and cannot function well in our new, more complex, more interconnected world. Many young people are lost to video games, Facebook, pot and pills.  Many older people, who are still too young for Social Security, seem to be trying to become pathetic enough to go on disability.

Some people feel they were screwed by the system ( and they were).  Others really don't know what it means to work hard and take care of themselves.  Often, it's the same people.

The American Dream is that things will always be getting better.  I think many of us need to decide what "better" means.  Then we can figure out how to get there.

Tech is Taking us Somewhere

Despite my age, and that I sometimes have difficulty in figuring out how to operate the remote control devices of entertainment systems that are not my own, I have been fascinated by the impact of technology upon our lives. Since as recently as 2007, when the first iPhone was put on sale, there are very few aspects of our lives that have remain unchanged by technology.

How we work, where we work, how we bank, how we shop, how we date, how we teach, how we learn, how we meet people, how we communicate, what we read, what we see, what we think about, how we think, how we feel about the world, our friends, our real selves, our projected selves....... all of that and more has been altered by the use of Os and 1s being magically transmitted over cables and through the air.

This is not going to stop, so where is it all going?

One trend that will definitely continue and gain momentum, is that so much more about you will be known and much of it will be generally available.  There are so many new and improving ways to explore, measure and view, what is going on with your physical self. We can see the blood and electricity flow through your brain.  We can get a printout of your personal genomes. We can do CAT scams and MRIs of all of your body to see what works, what is broken what is twisted and what is missing. You can get an app that will constantly measure your heart  rate, blood oxygen, blood pressure,caloric intake, caloric usage, all on your wrist.  All of this can be stored in "the cloud" and can be retrieved by your physician, perhaps by anybody.

In addition there is all the information we ourselves choose to put out there about ourselves, on Facebook, Linkedin, Twitter, Tumblr,YouTube, Match, and the hundreds of other sites that we click on, shop at, comment on. At MIT they are creating devices that can almost immediately conjure up an entire profile of a person as he or she walks by you, based upon their image, and everything about them that has been placed on the web.

As with everything, there will be positive and negative aspects of all of this.  But that won't matter that much because these things will, to some extent happen.  What does matter is what the effects will be, both intended and unintended. This should help us be better equipped to stay healthy and prepare ourselves for our own, individual futures.  We should be able to have an easier time finding people who we will enjoy getting to know and spending time.

But, at least as I feel so far, we will continue to be overwhelmed with information.  We will have to find away to sort, select and evaluate what is real, true and important. We will have to learn to deal with  how we feel the electronic presentation of ourselves really reflects who we are. We will have to see how all of this affects how we evaluate other people, and how we think of ourselves in relation to the world.

It will all be very different, and have much more of an impact than the changes brought about by older technologies, such as when so many people began spending their time watching TV.

In many ways the medium is still the message. But now, so much of the medium is us.

More Tech Fallout

One thing that I see very often in my office, that our nation and our government is struggling to deal with, is how the fantastic new advances in technology is changing everyone's lives and minds.  We act differently, we think differently, we relate different, and certainly every business in America works differently because of the digital changes that have happened just in the last five years.  I date the latest major transformation to 2007, when the iPhone first went on sale.

For many people the new technology has made jobs easier, or even just made them possible.  People can, and do work from everywhere.  But so many people are being put out of work, and so many are just not necessary.

The latest to come into my office is an angry 37 year old man who has been wit the company for 11 years.  Which company; the phone company. He knows, but he won't really admit, that they just don't need him any more.  He is an installer and repairman for land lines.  The landline business is fading as quickly as the video store rental business.  The phone company could probably get by with about 1/3 of the workers they have.  It is only the union that keeps hanging on.

But, the phone company, being a big corporation, is using technology to get rid of the people.  They have GPS systems tracking their every move, they send the workers out with hand-held devices that report back as each task is done, each job is started, each is completed, and how quickly the worker moves from one to the next.  Then they raise the expectations of what is expected in a day.  Then they raise them again.  Then they get on the worker for not meeting expectations.

Stress, conflict and misery.

My patient knows his time is limited and he should learn new skills and find his way in the new world. Instead his fear and uncertainty is turned into anger at the company.  The company would probably do better to take him and many of his colleagues and retrain them.  Teach them to deal with wireless technology.  Teach them how to operate the cloud. At least give them the opportunity.

But that would involve using skills that most big corporations don't have. So, things will end badly, and more people end up in my office.

And so do their families.

statistics

Intro:
Last week I began to write this as a blog post.  As I continued with it I thought it would be interesting to post it  on a list read by other practicing psychologists.  Part of this was in response to an editorial that I wrote about last week.  I was curious to see if other therapists would really discuss what happens in their practices.

This is what I posted:

For no particular reason it seems to be the time to gather statistics and demographics.  We Psychologists, especially those of us who still accept payments health insurance companies, have been told for years that we had better be prepared to demonstrate that what we do is effective and efficient, as well as medically necessary.

Of course, there is no agreement on  how to define or measure any of those things.  Over the last four years three different insurance companies devised three different ways to attempt to do this.  They tried to survey either the therapists, patients or both about different ways in which the patients were functioning, suffering, changing, or just wasting time and money.   Within a years time, give or take, all three gave up the effort. All of the therapists were offended, felt intruded upon, and reported that the measures were misguided and not relevant.  The patients all objected to being subjected to Big Brother about confidential information, or else they couldn't understand the questions or where they came from or why they were being asked.

The insurance companies found a better, simpler way to deal with our effectiveness and efficiency: they reduced our pay.

So, tonight I decided to do some statistical evaluation, just to get a reading on how I was doing as a private practice therapist after 30 years.  I looked back to April of 2011 and picked out the first 50 people I saw  (there were 54) that month.  I do not claim this to be hard science.  I admit to nineteen flaws in my methodology, but hey, no one gave me a grant. But I thought it would be of interest to the folks of this division, as few people ever say in much detail what they do, how hard they work, or how it turns out.

Of the 50 people, a year later I am still seeing 29 ( 59%).  Of those, over half (16) of them I have already seen for over two years without any significant break.  But of those, there are only two that I still see weekly. The others are bi-weekly (6), monthly (6), or 4x a year (2).

Of the 21 people who terminated over the last year my rating scales of success in treatment ( held to a standard of consistency over 25 years, with a very high rater reliability, however the N of raters is 1.)  3 of the 21 did not do well at all, despite my efforts and skills.  3 did OK, and 15, in many ways accomplished what they hoped to realize from coming to see me.  Some of them really, really changed during the time they saw me.  Others,(4) I need to add, came with very specific problems such as an isolated phobia, a problem with a grow-up child or such., and they just wanted to sort out that matter.  Four others of the 15 came to get something specific from me, mostly relating to work or school, such as a letter or a report that they were not dangerous, or drug addicted, and could go back to work.

Of the 50 people, the rating scale shows that 36  (72%) did, or are doing well, or really well.  14 (28%)did not or are not.  Of those 14, I still have almost reasonable hope that 4 of them will still show significant improvement.  Of these 50 people, no one in the sample came for just one session, although that happens.  The shortest time in treatment was three sessions, and that was one of the people with a specific family problem.  Everyone in the sample got treatment for something that I feel was clearly "medically necessary."  Five people (10%), less than it feels like to me, have a diagnosis of "completely nuts," and will remain that way.

Yes, the rating scale is based on how I feel my patients did, with some feed-back from them.  But I believe this is fairly accurate.  I can tell that I enjoy seeing the people who are changing and doing well, and much less so when the therapy is not working. This year I have begun to implement use of Duncan and Miller's three question ratings, but not with everyone.

I can also (not) tell you that I averaged  $XXXX ( I wish) per hour of treatment.

I can do more analysis and determine how long I have been seeing everyone, and how severe their presenting problems are, and how that correlates with their socio-economic status (not as much as I thought), or with the success of treatment.  But I'm tired and this is enough for now.

I hope this was of interest and perhaps inspires others of you to evaluate your efforts.  It also helps to see who you work well with and who you don't, and see if that changes.

END OF POST


I was pleased that I did my own analysis and I think I will look at the figures more closely.  I did get several responses, but most of them talked about ways to do an analysis, or questions they were interested in looking at.  However, and this surprised and disappointed me, no one was revealing about their own practice.  No one talked about how long they see patients, or how successful they feel they are, and by what measurement.


I don't want to jump to conclusions, but it makes me wonder.  About a lot of things.

another sleaze

There is soooo much out there to try and keep track of that it gets ridiculous.  The idea of keeping up with the new research in brain chemistry, physiology, cognitive therapy, fMRI studies of someone's brain in every mood and situation, of behavioral genetics, of unconscious social forces ..... all kinds of stuff comes rolling in.  So often one study will contradict another one, or someone needs attention so he will hyperbolize even the slightest indication of a determining factor.

Then, this weekend, there was a series of articles in the NYT Magazine section, telling the world that depression is a complex disease of the brain, and that psychotherapy, which is often the most successful  treatment for it, hardly gets mentioned.

Now the psychiatrist who wrote about the brain disease did discuss two things I agree with; first that most of the current psychiatric medications don't work for most people, and second, that the term "depression"  probably covers several very different conditions, some of which really are caused by a malfunctioning brain, and others which are really reactions to terrible, stressful situations. But then he went back to treating the brain, as if it was "the mind" which it isn't, yet.

There was also an article in the Magazine about taking LSD when you're old and dying.  this is stuff I have known about, and I am looking forward to .....but not yet.

Then there was the article  in the Review section by Jonathan Alpert, sleaze-bag who decided that psychotherapy often goes on too long and is done that way because therapist are unskilled and just want the money.  Now Mr. Alpert, who says he has an advanced degree in psychology, right there is showing what a sleaze he is.  He has a MA of some kind, and under NY licensing laws he should not imply that he is a psychologist.  He also has written some book about how to change your life in 28 days.

What is shocking, and harmful, is that the Times gave this guy space.  Somebody must be doing someone some kind of favors.

Anyone who has read this blog knows that I am not an advocate of endless therapy.  I have even written about it.  But some people need it. And to imply that most psychologists do it is the kind of thing that could discourage people who need help for seeking it, for fear that a therapist will entrap them forever.

He also says that what most people need is an aggressive therapist who will tell them what to do.  Clearly, this guy has not done much therapy.  80% of the people who come to see me know exactly what they should be doing.  It's finding out why they don't do it that is necessary, and then finding a way around those, often self-imposed obstacles that makes therapy work.  If you just need someone to tell you what to do, then send an email to Dr. Phil.

There is so much psychological garbage flowing through the Internet, it is a real shame that the Times has to add to the pile.

Money comes and goes

Last week I was messing around, trying to send a few pictures of my granddaughters to my friends.  I worked out this quick way to take them, edit them and send them, without even using words or anything.  Then I got a call from some guy in California offering me $500 million for the whole idea.  Can you imagine the nerve, $500 million.  I told him not to call again unless he would give me at least 2X that.  Now I'm working on something even better.  It only does pictures of kittens.


Nooo, that didn't really happen.  What did happen was that I was in my office seeing all kinds of people with all kinds of problems.  In fact, on one day last week I saw two different people whose father died, one person whose cat died, one person whose dog died and a woman whose husband was just diagnosed with cancer.  


 I was trying my best to do something for them using the limited powers of my skill set.  I realize they are limited because Medicare, followed by other, "private" insurance companies, cut what they pay me by 5%.  Medicare had been giving me raises of 3% +/-  per year, but this is an election year.   Two of the private companies have not raised what they pay me for 20 years!


But, I also read that the CEO of Liberty Mutual Insurance Company last year was paid $50,000,000.  That's I guess because of his brilliance at cutting what everyone else gets.  His board voted him that salary.  Of course, he pays his board $200,000 to come to four meetings a year and vote on his salary.  That is what they call a "free market."


Money comes, money goes.  If you think too much about it will drive you crazy, You will end up in my office, and I will not be getting rich by seeing you.

Me and Phil

 For the last hour, when I was not just watching the sun,sky and trees, I was reading the reviews of the books of Philip Roth. I guess he won another Mann-Booker Prize this year so there is more about him being written.  He is quoted in the NYT today saying that he no longer reads any fiction.  He said "he wised-up."

 He has written 53 books now. I have read four. He is now eighty, about thirteen years older than I am. He grew up and often writes about the area about five miles from where I went to high school. Some of the streets he mentioned in many of his stories are a block away from where I lived. Mr Roth is a bit more intense than I am, but many of his themes are the same that I deal with every day I'm in my office: family, the lasting effects of parents, sex, trying to determine the right thing, trying and failing to do the right thing, feeling guilty about not doing the right thing. sex,  struggling with relationships, struggling with religion over and over again, struggling aging, and struggling the crazy politics of America.

Reading Mr. Roth has always intrigued me and annoyed me.  I guess because our backgrounds are similar in some ways, and what he thinks about overlaps so much with what I see, and think about.  But he is soooo self-absorbed, and so pedantic that I find myself telling him to just shut up and cope. 
also, the thirteen years difference puts him in a different generation.  His views are shaped more by the depression, war and Holocaust than mine are. But he is so often correct,as  I can see even now as a scan several of his books through the graces of Amazon and Google.  I would not have this easy access to all these writings  even seven years ago, and now I can read it anywhere at any time.

Given that the world works that way now, with everything immediately available, everyone immediately visible, and much too much immediate knowledge, perhaps he's right.  Who needs the creations of a fiction writer when reality is constantly available, in all of it's complexity.

I guess there are still many who want to see the world in terms of good and evil, good guys and bad guys, right and wrong.  That is the fiction.

Listen to the silence

I am currently seeing two patients who are suffering from a huge fear of flying. Is is not only the fear do plumiting helplessly to earth from 30,000 feet as much as just being trapped in a long aluminum tube without any chance of getting out for hours. Relax, sit back, enjoy the time off. Fat chance But I did. I got on a plane and flew out here in six hours. On the plane i read a great article on panic attacks. The plane landed, we picked up a car and three hours later we were up on the high desert. Joshua Tree National Park. Amazing rock formations, spectacular cactus, and high, flat arid lands that go on for ever. We walked the trails, gazed at the rocks, and wondered at the creation of it all. At one point as my friends walked on I climbed up on a rock formation. I climbed up and over several layers of rocks on top of rocks. I stood and looked over the long stretch of valley, flat, dry, accentuated with those beautiful Joshua cacti. I took a slow deep breath and realized, suddenly, there was no wind, there were no birds, there was no traffic. I held my breath and realized there was a kind of complete silence that I have not heard for years. The sky was clear,the rocks were immovable, the world was still and so quiet. I stood there on top of a small rock pile,looking over the valley, listening closely to the silence. I could not take a picture of it, I couldn't record it, I couldn't put It up on Facebook to share with my "friends.". I could only be there, in the moment, being me in the world, letting the moment envelope me; just being. Maybe five of the most alive minutes in months. The my wife called, wondering what happened to me. I rejoined my friends, and became part of society again. But more than before, being me, in the moment.Grateful to just be alive.

By contrat

Sometimes it gets tough:  my first patient was in a wheelchair and his bones are deteriorating and there isn't much anyone can do.  My second patient was talking about another relapse to heroin and was feeling suicidal, my third has been out of work for twenty months and has lost hope .... with five more to come..

But the last three days, because of family obligations, I have been forced to get home in time to spend at least an hour with someone who is almost 16 months old.

Now I know clearly how to recognize the symptoms when someone has the complete opposite of depression: Joy, excitement and exuberance!

From throwing a ball and watching it hit the wall and come back --- what could be funnier than that?  How about hide and  not-hide, or making funny sounds.  Hysterical! Amazing! Fantastic!

The world is full of wondrous, joyous, ever surprising events happening every minute.  And you don't have to look very far to find them.

And you can keep going until bed-time.

But go to bed without too much fussing so we can do it again tomorrow morning at 6:42.

Talking, listening, and Not

   Some people talk a lot.  I get to see them in treatment.  Often I don’t have to say six words in the whole hour.  They want to hear what they have to say even more than I do.  Therapy often helps them as few other people will to listen to them that much.  Many of these people really do get to hear what they have to say, and it does them some good.

            Some people are very good listeners.  They don’t say much.  They pick up a lot of information and they roll it all around in their heads.  Many of these people have nimble, open minds, and they can take in new ideas and make use of them.  They may not say much, but they have a lot going on.

            While most people fancy themselves some combination of the two, and most people are, there are also those at the wrong ends of the spectrum.  There are those who talk a lot and really don’t know what the hell they are talking about, but they don’t want anyone else to talk, because it may prove frightening and embarrassing, as their lack of knowledge may become apparent to them, as it already is to most others.

            There are also those who don’t talk, but they don’t listen either.  They are stuck with the ideas that are already in their head, and do to fear, a rigid personality style, personal conviction, or just plain stubbornness, they are not very open to new ideas, and don’t want  to hear about them. Sometimes, these people make it even worse, when they think that other people ought to know what they are thinking and feeling, even though they have never said anything.  Then they get insulted when those other people don't respond correctly.

            Sometimes, especially in couples therapy we call that "a misunderstanding."  It is caused by the always popular "lack of communication."  But really, it is a serious form of magical thinking.

For this?

We have all this marvelous new technology:  The Facebook I love everyone, the Google I can be everywhere, and the Apple iBrain.  There is a commercial on that mocks people for learning this 15 seconds later than their friends.

But what is much of our newly discovered powers of search, find, learn, store, categorize, compare and retrieve.  Two things I read over the last week:

1.  The NYT Magazine article about how Target targets it's customers.  It has the data and it uses it to bring you back into their store.  Nothing sinister or illegal.  All their brain and computer power goes to get you to spend your money in their store.  Things you may want and need, and other things you may just get sucked into.  It's all fine with them. Just spend your money.

2.  The New Yorker article about the goings-on at the Davos World Economic Forum among the most  rich, most famous and most powerful, ends with a scientist and an entrepreneur walking out together.  The scientist is intrigued that the entrepreneur has decoded an algorithm of  human behavior.

What has he been able to track and predict?  He can tell when a gambler has lost so much money that he decides he must quit and leave the casino.  But with this new knowledge the casino can send someone up to him, give him a meal or a coupon that will lure him back into the room so that this poor loser will then give even more money that he does not have to the corporation that is raking it in.

Fighting world hunger?  Don't see it.  Finding out the algorithm for preventing wars between rival nations? Not unless there is a major profit.

Perhaps I'm just reading the wrong articles.

I should be listening to Rush.  He wants the new technology just for porn videos.