Hope and reality for '10

Getting ready for the new year. Full of hope and vim and vigor. High expectations for that championship season, that break-through discovery, the new romance, new job,new child, maybe even a warm day.

Just remember, and this is nothing personal, incompetence is everywhere. It isn't malicious, it doesn't have to be devious, it's just lots of mistakes, poor performance, distracted workers, bad software, misinformed, badly trained, or just plain sloppy.

That's why electronic records will cause as many problems as they solve, the air-conditioning only breaks when it's hot, the roof only leaks when it rains,luggage gets lost, and Saab is going out of business.

Here is one of my favorite examples. I have been getting rejection notices for a claim to an insurance company for which I am not a provider, and never was. This rejection is for people I have never seen, and for a procedure I don't do, and I am not qualified to do, and therefore have never billed for. But, the best part, is that I have been receiving this rejection notice once a week, every week, for twelve years! Yes fans, you read that right, twelve years.

Every two or three years I have made an attempt to stop it, just to save the mailman, and save a tree. But it is impossible to stop. Once, someone told me I could get them to stop if I repay the money that I was never given, about $94.

I decided not to do that.

So these notices will continue to come, once a week, long after I have retired, long after I have died, long after the insurance company has gone out of business. The paper will be put in recycling bins and be recycled to come out as rejection notices for a procedure I didn't do on people I never saw, at a place I have never been.

Enjoy the new year, but don't count on getting that much accomplished.

very quiet night

It's dark out now, and very, very quiet.

Very little light reflects off of the snow

Only a slight wind rustles the dry leaves and bare branches

Is that really all that is out there?

Santa,
This year give me more of what I want and less of what I deserve.

Wishing you all:

Merry Christmas,

Happy Hannukah

Joyous Solstice

A Wonderous Winter

and most of all

A Happy, healthy, prosperous, peaceful, creative and fun new year.

"Let's hope it's a good one, withour any fear.

Health care -swept away

It is becoming increasingly apparent that Mr. Obama had too much trust in his own abilities and the political process. He had hoped that by letting everyone participate, and trying to give everyone a voice, including Republicans, insurance companies, pharmaceutical companies, all the interests that opposed the Clintons, that he could reach a compromise and a consensus. He didn't realize until recently that many people would oppose him no matter what he said, and that others were never going to move from a totally self-interested position.

Many had no reason to compromise, for they felt with enough time and enough money, and a few hysterical distortions, they could get what they wanted. Others feel that their corporate livelihood is at stake, and they could not see passed that for any greater good. It is difficult to ever see a bigger picture than your entire wealth and position.

This is not a surprise. Anyone who has been working in health care has been able to see the the big players, such as United Health Care, Humana, The Blue
Shields, and the other major companies, were really no more threatened than the banks were last year -- even less because they did not screw-up their own incomes. I have known things were going to be bad since my heart-throb, Sarah Palin began talking about 'death panels."

The health care companies have been spending an average of $1,500,000 a day lobbying Congress. I mailed in $50 once.

I try to explain this to my clients when they feel overwhelmed by how unfair life is. They are correct; they are getting screwed; hardly anyone beyond a few friends and family and me, cares.

But that's what makes it interesting. The best course of action is to keep on fighting against the tide. It is an invigorating, and noble endeavor -- even if it is, perhaps, useless. If that becomes tiresome, then find a a way to build a wall, or construct a shelter, fend off the evil-doers, enjoy your family and friends, put on some good music, and dance.

genetics too, and parents too

There is a good article in The Atlantic of all places by a science writer, David Dobbs. He writes about research done by Marian Bakermans-Kranenburg who worked with children who were way over on the sensitive/reactive/irritable end of the spectrum.

Then he goes on to review other research to link these kids, in part, to a specific gene allele that was linked to the processing of serotonin. This is linked to a vulnerability to depression

What the article was mostly about was that some kids are genetically more reactive than others. It discusses how if these kids have a stressful childhood they often go on to have difficulties with anger, ADHD and impulse control in the rest of their lives. But the more surprising part seemed to be that if these kids were more nurtured and protected they often went on to not only do OK, they went on to be more crative, spontaneous and successful than others in many areas.

It is no surprise to me that people are made differently and that some of those difference can be helpful and exciting, but also, under different circumstances, the same qualities can get someone messed up.

What is new is that with new technologies we are finding ways to see more of what is interacting with what. We can watch the blood flows in the brain as the brain reacts to different situations and we can see gene patterns that emerge and are partly linked to personalities.

The implication is often that this can lead to new levels of treatment interventions that can be more specifically designed. However, at present, this is also very dangerous. Because what we are really seeing is that the mind/body/brain/environmental interactions are even more complex that we had conceived. These interactions are going on constantly, and thus the conditions are constantly changing and making new conditions. When you mess with two factors out of a thousand, you can't be sure of what you're going to get.

Interfering with this flow of events is really what I do. But I have to do it indirectly, by talking to someone. As I said a couple of posts ago, I can't get directly to the brain or the mind. But some some people are going to think that they can, and this will either be a great break-through or a real disaster.

I can imagine a time when knowing someone's genetic make-up could be helpful in designing a psychotherapeutic treatment plan. Some people are naturally more quiet and reflective. Others learn better from behavioral experiences. Do you think we will ever be able to tell who is which, just by looking through a microscope at a slide of someone's spit?

changes

I sat with Bob and we talked about how he has not sent his resume out. It has been six weeks. He almost did it. He is waiting for his girlfriend to review it. He knows he needs a better job. He's been stuck in this one for five years, going nowhere. He could probably get a better one pretty quickly too. He's good at what he does.

Alice should move out of Frank's apartment. They were roommates for a couple of years. Then they were kind of more than than. Then Frank met Betsy and she moved right into his room. Now Alice and Frank are kind of friends and everything is awkward. If she moved out she could see more of Paul, who was once Frank's friend, but isn't any more. But Paul likes Alice, so they meet at the coffee shop. If she wanted to she could move in with her sister....but she doesn't.

Me?? I've been doing the same thing for almost thirty years. Things are getting more diffiuclt, with all of the forms and regulations, and diminished reimbursemnts. Sometimes this almost feels like just a hobby.
I've been thinking I ought to do something else, or at least learn about something else. I've been thinking that for about eight years.

This week I signed up for a six week course. In six weeks my whole life could be changed.

In six weeks I may be a gastroenterologist.

No, that's not the title of the course. I'd better check-- but whatever it is, it's new and different.

new look

I had last seen her about three months ago. She had come in with her husband to give it one last try. They had come to see me over ten years ago to work out what was missing from their marriage. At that time the kids were young and she was struggling to hold it all together.

They came back last year with the same complaint, She said she knew he loved the family but he had never figured out a way to show it. She had raised the kids while he worked at his job and on the house. She had gone to work and made friends while he had gone to work and worked on the house. She had invited him out to do things but he worked on the house and watched war movies and The History Channel. She had gotten depressed, took several medications and went to bed and he worked on the house and watched war movies and The History Channel. Two years ago she went on the computer and found a Christian chat room. She began to talk to people who listened to her problems and encouraged her to work on her marriage. He worked on the house and watched war movies and The History Channel.

When they came back to therapy she had told him many things she hoped they could do together, including having sex. He said he loved her but didn't know if he could change and didn't like to be told what to do.

I didn't see either of them for three months.

She came to see me yesterday. She was at least twenty pounds thinner, had her hair done, put on some make-up and was colorfully, but appropriately dressed. She said she had been to a lawyer last week and was moving out after Christmas. She had lost weight because once she made the decision she felt elated, went off her anti-depressants and walked three miles a day. Without him she didn't need any medication to cope.

She was looking forward to her new life. It is clear that she won't have trouble finding it --- although trouble may be what she is looking for.

When you're done, you're done, and often a new look comes with it.

Enjoy the Season!

I hope you all had a warm and wonderful Thanksgiving. Mine went pretty well, we had friends, family and fun, and I did a lot of cooking.

Families can be the source of great pride, warmth and comfort. They can be nurturing, encouraging and/or just plain fun.

Of course there can be the other moments: if you younger sister is sleeping with your older sister's husband, or when Uncle Ben enters in his usual inebriated state and throws up on the turkey, or Mom gets offended when you spill the cranberry sauce on the table cloth so she runs crying to her room and stays there for three days. Did you miss cousin Rick because he's back in the slammer, and now you have to take care of his three totally undisciplined kids for three to ix years? Did your thin cousin mock your fat cousin mercilessly, until pudgy dumped four pounds of macaroni and cheese on slim's head. Or, when everyone raised a toast to say what they are thankful for, did Uncle Ray use the occasion to announce that he finally has the balls to leave Aunty Beth, after 27 years of a miserable marriage.

Feel free to join in on the chorus....

Happy Thanksgiving!!

ending treatment

I have been seeing Pauline for over three years. For almost two years she came every week, than it was every other week. Today we decided that we would meet once a month for the next three months, and that would be it.

She was a fascinating patient. She thought about things we said. She was a nurse, so she knew a lot about her own health and what to look for, and she wanted her life to get better.

Her problems were a combination of all the factors that affect how someone lives. She was a wound-up child who was crawling out of her crib at one-year old. Even then she hardly slept, and by the time she was three she was defiant.

Her father was over-bearing and tried to get her to behave by being loud and threatening. Her mother cried a lot. She married young and divorced early and was left raising two kids on her own. Along the way she developed an eating disorder and a drinking problem. By the time she reached me she had just bounced off the bottom of being frantic, drunk and suicidal. She had terrible panic attacks and had been isolated from the world. She had tried about eleven different medications, and an intensive group program. She is now on two medications that she agrees that she needs. They don't do wonders but without them she is awful.

During her time with me she got better, then got worse, and then slowly pulled herself together. And now we have reached a point when it seems to be enough for a while.

Her drinking has stopped. She is back working part-time. She had a terrible relationship with an older man, and now she is still sees him a lot, but they have learned how to deal with each other. Her being sober helps a lot and she is grateful that he stuck by her. He can still be selfish and irrational, but she has learned how to deal with him.

Her eating disorder lingers on. She won't go to a more intensive treatment program for it. She hardly even wants to talk about it. She finds ways to push it away sometimes, but it haunts her. I worry about how much it limits her, and so does she.

But over the last couple of months the tone of the sessions have changed and it is clear that we have reached a stable plateau, even if it isn't perfect. She is working, she has a relationship, she is out of debt, she is sober, and even enjoys herself once in a while.

She is a good example of how so many factors interact to make a life: genetics, family, environment, stress, health, other physiological factors, brain chemistry, as well as luck and random events.

We only have limited control of so many of these factors. We have to make the most of the leverage we have.

inherent difficulties

I treat, or try to treat, a lot of people who are depressed. Most are depressed because their lives are rotten: they are broke, they are in bad relationships, and even those end badly, their parents are/were, mean, abusive, negligent or crazy. Stuff like that. Loss, loneliness, illness, injury, all those bad things tend to add up.

When anyone gets depressed then their outlook turns negative, often hopeless. They feel that othing matters, nothing is enjoyable, nothing will help. That's what depression is.

So, when people feel that nothing will help, they don't show up for their appointments. Then I can't help them.

If they do come, I can help them. And things go well because they want to be helped, and they believe that there is hope. So, am I helping, or just being their while they get better?

If they don't come, they they have no hope and then they won't get better. Can I help that?

Dunno.

I can think good thoughts and send them their way, but it is difficult to know how far I can project these thoughts.

I can make a phone call, but who answers a phone these days.

So I leave a message.

Sometimes they call back.

more difficult social trends

Here is another thing I am seeing going on in our ever-crumbling society. It is interesting to note, however, as I continue to complain, that things have always been getting worse, no matter whom you ask, and whenever you ask it. Yet, in truth, things remain about the same. The sad thing really, is that despite all the "progress", things remain about the same. (But, consider the source here. Me; old, cynical, on the verge of being bitter, and enjoying every moment of it.)

Anyway, what I have been noticing that for many people who have graduated from college over the last five years, things suck. If they go on for more education, to become a lawyer, scientist, doctor, or in finance, then they seem to have a chance. But getting out of school with a B.A. in any of the humanities soon leads to a $25 to $35K job that has little chance of going anywhere fast.

What this seems to have led to is that there are a lot of people who live in apartments, drive old cars, and slip into fun, but tenuous relationships. This seems to be because they feel that the money it takes to settle down and raise a family is not going to be coming in the foreseeable future.

I have had several patients who are within three years of thirty in both directions, who are in relationships that last a year or two, and then they kind of move on, sometimes just by moving to another city, or by getting bored and finding someone new. They often stay friends with the old partner because nothing bad happens. But if there is not going to be a family, and there isn't much money, then the entertainment factor is easier to find in a new relationship, with a new body to rub up against and a new mind to tell the old jokes to. These kids(?) seem to dabble in music and art, and to have a decent time, but they also have the sense that their lives are stuck and that figuring out how to get out of extended adolescence is going to be difficult.

Really, it isn't their fault. They are caught in a bad time in America, when they can't even be corporate clones, and they realize that they don't want to be. Hopefully, they will create their own communities, in which they can buy and sell to each other, support their own lifestyles in new, close to the neighborhood ways, and turn the consumer oriented values upside down.

It's much more difficult for them than it was for me. I just got yelled at by old folks because my hair was long.

The sound and the fury

Another week blows by. All kinds of stuff. Stuff with the family: one kid bought a new house; another had an operation. We are hoping for more changes to come.

The parade of clients. Three didn't come because they said they had the flu. How many hysterical? Just as well.

Began with the woman who had left the bad relationship, gained confidence and is now leaving the bad job for a much better one. Bu† she has to leave me to take the job. Moving on. The woman on crutches with seizures. We talk of horror movies. The guy waiting for his disability hearing, still has to see three more MDs. The woman who began computer dating at 48, is IMing six guys at once. MT is sober for a year. JR for six months. TL for two weeks, but he's lying. One couple is still fighting over whose job it is to parent the other (no one wins that). Another couple has decided not to revisit the same argument they had three years ago. It's good I didn't leave town.

The week ends with SS. He holds the current spot in what somehow has come to be a long line of those who take the last, late in the evening appointment. Somehow I put them there. They are usually male, but not always. They have always been smart, accomplished, a bit overly intellectual, well read, and depressed. They usually have been raised by accomplished, emotionally distant, disapproving, often alcoholic parents. They have been married or divorced themselves, but often did not have children. Two had recently been treated with cancer.

The theme that they all have in common is that life, as they have experienced it and have come to understand it, is meaningless. What they have accomplished has not gotten them what they want. Despite houses, cars, big incomes, beautiful wives, they often have felt like phonies and failures. People have let them down, or worse. They feel distant and lost.

The other feature they have in common is that they have all love coming to therapy. Those who are a bit too vain, love to come and complain and have me take their complaints seriously for an hour. But for most of them, it is the first time they got to feel what it is like to be in a supportive relationship. That part is nice. It takes about six months for them to begin to feel it, and another three months for them to understand what it is.

Then comes the long process of getting to to believe that they can not only find someone else whom they can trust, who can be supportive to them, but that there are even more rewards in being the one who is kind, understanding and supportive. That, if you do things right, and choose right, and then become invested in a relationship, all of the craziness of the world, all of those things that they so accurately see as greed, violence, betrayal, and wickedness, seem like they are "out there" and are just part of the parade. They are no longer the feelings that live inside.

This is very gratifying.

But, then, after my last appointment, I want to go home, sit alone in the dark, and have a drink. I don't want nobody bothering me no more.

We have a problem -- 1

We in the psychotherapy profession have a problem, and it is going to be getting worse in the near future. I am going to probably take a few of the next several entries here to spell it out for you. I know that the world has been waiting impatiently for me to do this so I will try to work on it here a few times so that I have a chance of making sense.

Part of the problem is that we are low-tech. The world has become very impressed with technology. I know I have. As soon as my eye heals and I can read the small font I am getting an iPhone. 85,000 apps! My God, there is nothing I will have to do any more -- except psychotherapy.

Look at the equipment we need -- chairs. And we don't even need them, although it is better than standing for almost an hour. Sometimes though, I have gone for a walk with a patient.

But that is only a small part of the problem, The big part is that, after a hundred years of trying somewhat scientifically to deal with psychological, emotional and behavioral problems, there is still not direct way into the mind. In fact, we really are still trying to find out what the "mind" is. Yes, we agree, it has a lot to do with the brain, but it is not the brain; it is different.

Yes, but then, what and where is the "mind?"

See, we have a problem, and already it is getting complex and confusing.

But, given all of the marvelous new technologies, people expect that there must be some way to get in there and make people better.

As I said a month or so ago, when they fixed my eye they went in, cut out the bad parts, threw them away and replaced them with good parts. My eye is healing and I expect that soon I will be able to see pretty well.

Now, even though we have marvelous fMRI machines to watch the brain, lots and lots of drugs to pour into people, and we are even learning about the genes that contribute to our talents and temperaments, we still can't get right at it. There are thousands, if not hundred of thousands of attempts, but none of them have really been that successful. We don't even really agree on what we are trying to get right at.

Now, the new US health plan (whatever it will be) is on the way. And the plan will expect that there will we empirically validated and specific treatments for whatever we do, if we are to get paid.

See, we have a problem.

Seaonal Affects

Boo!

Gottcha with that one.

Big surprise. Scared ya. Right, didn't I.
The sun goes down early, the dark falls fast. The shadows of the swaying branches seem to reach out for you. The wind picks up, the dry leaves blow up and and around your face. Is that a leaf or a bat? Does it bite?

Yes, but it's darker in here, isn't it?

Darker in the depths of my mind.

Oh yes, I good caring therapist. Works hard to do good and be helpful.

Ha, sure.

What about all the resentments stored up after all these years?
The slights, the times I've been over-looked or not even heard.

The fantasies of going into those trashy bars that the downest of my clients go to when they are angry and depressed and looking for trouble. How I can be clever enough to set this guy up against that guy, watch the fight break out and then walk off with their trashy women.

And what about all my counter-transference problems, now that I've become an invisible old man?

But that's nothing; that's trite. It's really about the feelings and thoughts that well up like the slime and sludge that sinks to the bottom at the sewage treatment plant. It's the vileness, corruption, and decay that builds up after decades of being battered and beaten by the demons that come howling out of the night, a world that just won't give a guy a break. The demons of stupid wars, of needless excess, of vain-glory, of unrequited vengeance over the smallest, unintended indiscretion.

The soul get nicked, then chipped then cracked. It gets covered in scar tissue that hardens as it holds the remnants together.

It comes to the worst of all conclusions:

Trick or Treat?

Who the fuck cares?

Scary things

Driving home today I heard on the news that a psychiatrists was stabbed at a major Boston hospital. Also, and almost as upsetting, was the the guy who stabbed her was almost immediately shot to death by an off duty security guard.

It seems from early news reports that it was a man who stabbed a woman psychiatrist. The security guard did not work for the hospital.

Stabbing or shooting a therapist has happened s couple of times that i know of. Last year in NYC and a few years ago in a town up near whey I work.

I have really never felt frightened. There have been a few irate husbands who have blamed me for their wives leaving them. One wife told me that he was going to wait for me in the parking lot. That was about ten years ago. I still glance over my shoulder when I am the last car in the parking lot, and it is him that I have in mind.

I have been threaten in my office about three times. Two males patients got angry when I told them that their grandiose opinions of themselves were not warranted. I tried to word it more tactfully than that but apparently the message got through too clearly. Both threats were neutralized when I raised my index finger as a quiet reminder that they should sit down and reflect on what I said.

The third threat was from a woman who threatened to take her shirt off in the office. I guess I am not like the therapist on "In Treatment," who I hear has boundary issues. I think I convinced this woman that even thought I did care for her, it was not in that way, and that while the idea was tempting, it really would not be good for either of us, or what we were hoping to accomplish in therapy.

Being in private practice can be dangerous. I usually have other people who are working on the other side of a thin wall in our suite that has three offices in it. As a therapist it is important to be able to control the mood of what is going on in the session. I think that is comforting to the patient.

But if someone comes in angry and determined, and if unintended, unreal, or totally imagined slights or insults have festered in a mind that has not been working too well, bad things can happen suddenly.

I don't know if the reaction had to be immediate and fatal. That seems a bit too extreme and too American. Maybe he had to do it to save the doctor's life. I don't know, I wasn't there. Scary, all around.

In my pocket

There is a patient of mine who I still see once or twice a year who often would say to me, "Can't you just put me into your pocket and take me home?" He assured me that he wouldn't be any trouble, and that he just needed a safe place to be. He wanted some protection from the life he was leading, which was really, as bad as you can imagine.

Sometimes, as a therapist, I feel like doing that. At least I do while I am sitting and talking to some of my patients. Actually, when I get out of here I am very skilled at not thinking about anyone. But I do see some really interesting and fascinating people who are insightful and articulate, but who never got a break, and who have just retreated from blows of the world.

This guy today, Frankie. He began life as a minority immigrant. His parents sent him to his uncle, who was in this country. His uncle sent him to the grandparents, who already had custody of a few of his cousins. All kinds of chaos and craziness when on in that house, which left permanent psychic scars on Frankie.

But Frankie persisted. He went out in the world full of hesitation and doubts, but he got jobs and he started relationships. Not surprisingly, they ended, sometimes softly, sometimes in disaster.

Today he told me that he just lost the job he had for the last three years. Frankie has been in human services for the last ten years. He does very well taking care of the people no one will take care of. He is caring, empathetic and he treats everyone with dignity. Because of that he got into disagreements with the people who ran the program because he took too much time, he bent some regulations, he responded to the people he was taking care of more than to the rule book. When this was pointed out to him he wold explain how what he was doing took more effort, but it really was within the rules.

So, they fired him.

Now Frankie is not naive, and he is not really trying to be a martyr, but he has standards and sensitivity, and he won't go against that. But because of this, and because of his life experience, he is depressed, and he withdraws when he gets slapped down like this. It will take a while to help him re-group, stand-up, and get out in the world again. (Of course, he will only have insurance coverage for another two weeks, but we will have to deal with that too).

It is difficult to do the "empirically supported" cognitive/behavioral therapy when the patient's belief that the world is mean, unfair, and generally sucks has been well documented by his life's experience. Sometimes you know it would be much more beneficial to take him home, wrap him in a blanket and give him some chicken soup. Which is something he never had anyone do for him, ever.

bipolar?

I've spent a bit of time clicking around the blogosphere and I have easily found many blogs by people who have been diagnosed with a bipolar disorder. Some of them feel they have been successfully treated, some don't, and many are kind of in the middle.

There has been a dramatic increase in the use of that diagnosis over last ten years. This has been a part of the increased view of the biological basis of mind disorders. Some of it has to do with new medications that slow down the racing thoughts and temper the manic phase, and some if it has to do with more brain research.

Many more people who come to see me bring in this label with them, and what it means seems to be very varied. It covers people who have mood changes, who get irritable, who get very depressed. It gets put on people who spend $8000 shopping when they have $400 in their bank accounts. It covers CEOs who work 20 hours a day, buying and selling other companies.

My view of all this is that there certainly are differences in how people's brains function. I think that what is called bipolar disorder today will be called five or six different things if five to ten years. People brains vary over a range, but I think what we call bipolar covers different kinds of ranges. When the thinking is adaptive, such as when people are creative and have the energy to follow through on something that wouldn't seem like a realistic undertaking to someone who was more moderate, it can work in someone's favor. But often the thinking becomes rapid, tangential, skipping logical steps and ending up in a mess or personal disaster. Then things are bad, and it takes a long time to recover and sort it all out.

A real bipolar depression seems worse than just a depression. It seems more totally devoid of energy and hope. It is more dangerous because the thinking becomes not just bleak but unreasonable. Many people, who are just depressed are often more realistic.They can see how much the world sucks, and they have more difficulty than most overlooking it. A bipolar depression just seems to be like falling into an abyss.

So, to all of you who struggle with this, I can offer the encouragement that the more you can reflect on your own thought patterns, the better chance you will have to see when you are rolling a bit off track. It is often very difficult to know when the energetic feeling you get are going to be fun and helpful, or dangerous and destructive.

I think that is where a good therapist, who you can really trust, one who wants you to be happy, and not just under control, can be helpful.

I hope so.

in his truck

I am back at work now, searching for minds -- where they are, what makes them, and watching how they get stuck.

My list is all backed up. I put it on the phone machine that I am not taking any new people. That just means I get calls with people giving reasons justifying why I should see them.

One such call came from a woman who I had seen about twelve years ago. She was calling for her husband, a guy who we could not get to come to see me then. She was very worried about him. She said he would come. So, when my 3 Pm appointment canceled I told him to come in.

He came in in his work clothes. He works for the city, maintaining the trucks. He has done that for at least twenty years, probably more.

This is where his mind is:

For an hour or two every day he drives his pick-up truck to a spot that over-looks the river. There he sits and smokes and listens to talk radio. Sometimes it's Rush Limbaugh, sometimes Michael Savage. He sits and listens, and gets angry.

From what i remember he has always been angry. He has always felt that the world has not been fair, and that he, for some reason he can't figure out, has gotten the short end. He resents that. For years he had been a heavy drinker. He lost his license for a year because of a DUI. He got into one fight too many in a bar, and being older, got knocked cold by some kid. That was about eight years ago. He has not had a drink since. He resents that. He works for the city and will not get a raise this year. He is angry at that. He blames it on foreigners and socialists. I'm not sure how he works that out in his head, but he resents them too.

But he came to see me because he is scared. He remembers that his father was a guy who was also always angry. He remember his father as sullen, distant and mean. But what he remembers most about his father is that when his father was about the age that he is now he stuck a double-barreled shotgun in his mouth and pulled both triggers. He doesn't want to do that, but he finds himself thinking about it, often.

We talked about depression and genetics. We talked about how he hasn't spoken to his son in three years because they are both stubborn. We talked about how he never really figured out what his wife wanted from him. She seems more relaxed since has stopped drinking.

I told him that he really didn't want to blow his head off. That depression may have some genetic link, but genetics are not fate. I told him that here is a difference between thoughts and actions. Perhaps he could try some medication (no). Maybe he could call his son. Maybe he could take his wife to a movie. Maybe he should listen to something on the radio that makes him happy instead of angry. Maybe country music, maybe Mozart.

When he left he told me that I had helped him. He liked that part about genetics the best. I told him he could come back whenever he felt like it. I doubt that he will.

To paraphrase Darrell Martini (anyone remember him) "It is a wise man who rules his genes, it is a fool who is ruled by them."

the time it takes

I'm going back to work tomorrow. My eye, which gets tired when I read a lot, will be fine when I just sit and talk to people, even if parts of them look a little blurry.

First I go get the eye checked, and then I'm off to work. I am pleased at how well and quickly I am healing. It makes me wonder how awful it is for my patients. They come to see me and in the first hour we discuss a course of treatment, and what we hope will happen. But for most people, it will take months, if not years to make changes in their minds and lives.

I waited five months to have this surgery, and now I have to wait another three to six months before the swelling in my eye will go away, and I don't want to wait. I feel like they, those who do modern medicine, should be able to just pug in a new eye, and I should go on my way, seeing better than I ever have before. But nooooo, I have to wait until the swelling goes away.

At least my doctors operated directly on my eye. In my business we don't have direct access to the mind. We don't even know where to find it for Chissakes. Yes, it has something to do with the brain, but what? And we don't even have direct access to the brain; at least not for psychological stuff.

So how can any anyone really expect efficient treatment, given how indirect it all is?

I think we are lucky to be doing as well as we are doing.

When you find you mind, let me know where it is.

newsweek trashing

The whole profession got trashed in Newsweek this week. Some columnist named Sharon Begley read about, or spoke to a couple of guys who do research and they told her that clinicians don't pay attention to their research, so she decided that means that clinicians don't pay attention to science. She seemed to say we, especially those of us with experience, are a bunch of charlatans who make it up as we go along, based on our own whims and fantasies. Just another shot in the arm for those of us who are already over-regulated and under-paid.

She read an article that says that cognitive/behavioral therapy has been proven in the laboratory, but not all psychologists do cognitive/behavioral therapy all the time with all of our patients.

A few posts ago I wrote about how I reacted when I received the Guilford catalog. It's the same thing. There are books on their list full of research that has shown how to be helpful to someone who shows certain behavioral, emotional or physical symptoms. Now, none of those symptoms are exact, nor are they all indicative of the same underlying causes. The causes can be stress in the environment, in the family, in the sub-culture, or just in the person's mind. They can also be the result of an illness, perhaps a brain condition, or even some genetic factor. The truth is, and this is THE TRUTH, it is almost always an interaction of two, three or four of these factors.

And good clinician knows this. A good clinician takes what he has read in all these books, all the research, and research from more than just psychology, and puts together the best treatment he or she can, using all of his or her own experience of what works and how to do it.

And then, do you know what? Here is the reason we get trashed in Newsweek, because despite all of this science, experience, knowledge and the art of therapy -- there are cases when it all doesn't make much difference. We can't get right into someone's mind and make it change. We are not all Dr. Phil.

Sometimes we can do a great job: be helpful, healing, transformative,
Sometimes it bounces right off, rolls down the block and falls in the sewer.

But, none of these guys in the lab, these guys with the pills, the ones with the new machines have really demonstrated that they can do any better. You can look at the data.

survived

Hey, look at this. I can do it with two eyes now, which is kind of fun. Of course one eye is pretty blurry and I really can't make out any letters, but I can sort of see black smudges across the white screen, and that is about 40 times better than what I could see out of that eye a week ago. Now, sometime between three months and a year, the swelling in my eye and cornea will go down and I can get my vision corrected, and see even better. How much better? No one is making any promises, but this is a good start.

I was a bit nervous going into this. People had begun to quietly relate how they had a friend who went in to surgery to get his finger fixed and then died of a blood clot, or was asphyxiated by anesthesia, or were stabbed in their aorta, and such stuff. But, when I got to the hospital all I saw were people going into the door looking nervous, and people coming out with eye patches. Then, after almost four hours of just waiting, an hour of prep, a hour and a half of operating time, and a half-hour cool down, that was me, walking out with an eye path.

The coolest part (Warning -- this may gross you out) was that I was awake the whole time. I was mostly sedated with some relaxing drug. The effect of this drug was measured by the anesthesiologist who asked "Does it feel as if you had one drink or two?" Then he pumped a local into and around my eye, and I was off the surgery.

I watched as they covered m other eye, lowered a microscope and light over the bad eye, and then I could see more light when they cut the dead cornea off, and then removed the cataract, and then began stitching up the cornea. I had a team of two women surgeons working on me. They have worked together for twenty years. They gave and took directions about stitches and angles and placement. And they talked about their kids, and how they don't like electronic medical records, and how the paperwork is much worse.

The next day I went to the doctors office. She took off the patch and wiped away all the goop, and I can see. Not too clearly, but it certainly is a good start.

Psychologically, I was asked one question by the admitting nurse: How do you feel about this operation? I think it will help me see," I answered. "Optimistic" she put down. There was no follow-up question about my thoughts on waking up and being unable to move.

Doesn't matter, I'm moving now. Slowly, but that's fine.

stop by the O. R.

I don't think things were always this way, so fast, so busy, so far. We traveled a few hundred miles this weekend to be with a friend, and his friends for his birthday. One of my kids flew a few thousand miles to be with her friend for a wedding. My other kid started a new job, my son-in-law is about jump to a brand new company and take a risk. I have every hour booked for when I get back and a waiting list of about a dozen people who I have no time to see. All thin insurance companies are, again, slightly altering their rules, so I have to revise how I handle the paperwork. I am sure that the results of all this health care reform, no matter how it comes out, will be that they will pay us less. It makes me want to flee the system, except that 95% of the people I see are through the system.

And tomorrow I stop by the hospital and have two parts of my eye replaced. One will be replaced with plastic and for the other I will have somebody else's cornea stitched onto my eye.

I was getting kind of freaked out by the surgery until I read that I probably won't need too much sedation. I should be hone in a couple of hours.

I will see what I can see ....literally.

It's never one thing at a time

The Guilford Press catalogue came to my office again. I get them quarterly. It is full of books for therapists about how to deal with what faces us. Psychotherapy has moved far away from the time when grand theories of psychology, psychotherapy or psychopathology ruled the field.

Now everything is specialized. Each book is 450 pages about a sub-specialty. ADHD in the work-place. ADHD in Jr. High. Anxiety disorders in soc ail situations. Anxiety disorders in young women with abusive histories. Depression in older males. Depression in young mothers. Depression in Jr. High boys. Alcohol dependence in women, in families, in teens, in teens with alcoholic parents.

On and on two, three, four hundred titles. All of them are well thought out approaches. Some are well researched by very capable groups at major universities. All of them seem like useful and necessary additions to our knowledge and skill base.

Except they're not. Yes, it can be useful to learn what other people are thinking and doing, but really. My nine o'clock appointment was the depressed son of an alcoholic with a depressed mother, who was having anxiety attacks at work because his company is going out of business and his anxious, formerly addicted, wife, who is grieving for her recently departed mother is pregnant.

My ten o'clock appointment is a cancer survivor who has seizures, who lost her son in a motorcycle accident, and has a father who was alcoholic and a mother who is bipolar.

So, to be able to keep up with the latest theory and research I need to read at least a dozen books before my eleven o'clock shows up.

We, those of us here working the front lines, have to deal with the whole package. That's what makes psychiatric diagnoses a joke. Bipolar disorder isn't one thing in he brain, it is probably hundred of variations. Every body's brain is different and they have all been shaped by every one's life, all of which have been very different.

This kind of stuff doesn't come out of a manual -- despite what the insurance companies want.

So, it's surgery on Monday. And my figurative model of the Sydney Harbor Bridge has been partially knocked over by the tide. I will have to begin building most of it over again after my eyes recover. Perhaps then I will look at things differently.

bad habits

He walked in and sat down in a heap. He looked forlorn, again. This was his second session. He came last time telling me how terribly depressed he was, and he was right, he was. He had been for years.

He had started on medication about a month ago, and he said that he could feel that the medication was helping a tiny bit. He felt that some of the pressure in his chest was lighter. That was good.

But he said he was still miserable -- the foreclosure, his alcoholic father who was now dependent upon him, has wife's sometimes unstable medical condition,and worries about how long the company he worked for could last.

Then he said again, that he cannot remember a day since he was ten years old, when he had not at some moment, thought about committing suicide. Now, he's thirty-four. He was a bit fearful of how I would react. When he told this to his doctor the man had made him promise that he wouldn't kill himself until he was the psychiatrist, and the psychiatrist then sent him right on to me. He was afraid I would send him to a hospital and he didn't want to go.

But I just shrugged and told him not to worry to much ( of course, he worries all the time). Those suicidal thoughts are really just a bad habit. Your mind works like that. You run into a problem, you feel a negative emotion, or a bad thought pops up, and that feeling becomes tightly associated with other thoughts you have had in the past when you felt like that. The more this happens, the stronger the link becomes. Really, it's like taking out a cigarette when you have a cup of coffee, or thinking about sex when your girlfriend closes the bedroom door, or wanting a beer when they announce the starting line-ups. It's operant conditioning.

This guy sees a bill in the mail and then thinks about killing himself. It's a habit. It's a bad habit, but just a habit. If he hasn't done anything rash for twenty-four years I'm not too worried that he will now.

Still, I hope he shows up next week.

heath care rant of an old psychologist

I put the follwoing rant up on a psychologist bulliten board. I thought I would put it here too.

(rant starts here)

It looks like the Senate Finance Committee has delivered its version of the Heath Care Bill, and guess what …. We, as a nation, and psychologists as a profession, are f**ked. Not a big surprise.

The Senate version does not have a public option. Max sold out to the insurance and drug lobby. The Republicans are against a public option. They say that government can’t run anything well and they don’t want to trust their medical care to the government.

They have a good point. Here in Mass, where we have health care for almost everyone, many of the subsidized people are getting moved off of the usual Medicaid program and on to a new, more bare-bones plan. The plan is low-cost, with high deductibles and high co-payments. And guess what, mental health services get paid less, much less. And guess what else, they have carved out the mental health services to a managed care company from Dallas. So, what’s new there? Nothing.


America has a great deal of trouble finding a way to provide health care to its citizens. In my small mind there are three major reasons for this:

1. Too many people are making money on health care and they don’t want to stop. In most other countries doctors makes less, hospitals are run more efficiently, and not as a business, and no one financially benefits from asking for more tests, owning stakes in MRI labs, giving out the pills of certain pharmaceutical companies, running a nursing home, or using people’s illness as a ticket to leveraged riches.
As a note to this I need someone to explain to me how private insurance is allowed to sell policies to young, mostly healthy people, and to make a nice profit on them, and then, when they are old and need much more costly medical attention, they are then put on the government’s dollar, on Medicare.. Of course Medicare runs a deficit. They have all the old and sick people. The young people send their money somewhere else.

2. Americans hate to pay taxes. They feel that every dollar they acquire, through work, dividends, inheritance, lottery, poker, cheating, stealing, or lying, is their money, and they don’t want to give much of it to the government. Of course, the government should provide the infrastructure, should keep them safe, educate their children, blow-up all possible enemies, subsidize farms, banks, unions, scientific research, mortgages; keep air and water clean; save the fishes, worms and birds, and do anything else the population may need to make money and stay healthy. But no one sees a need to pay taxes.
Look at California. They approve of many great programs, for science, education, the environment, and many more BUT they don’t approve any money to pay for it. So guess what? They are bankrupt.

3. Too many people, and too many businesses lie. They probably always did, but now with constant, total communication, it just seems to be pervasive. I don’t believe any advertisement. Whenever I see something on TV, on a web site, or if someone is selling me something, I believe the opposite of what is being said. Perhaps I am old and cynical, but doing this has saved me a great deal of money and aggravation.
I have come to believe that we now live in a culture that accepts this. We don’t expect anyone to do much of anything that is not directly in their own best interest. We don’t want to see this country as a cohesive society. And we certainly won’t give a dime to an “alien.” It was not always this way. But once some people and some businesses began to take advantage of other’s good intentions, it became clear that unless you got tough and suspicious someone would take advantage of you. So people learned.
So many psychologists are good caring people, doing as good a job as they can with the limited tools at their disposal, and guess what? Most of us, who are part of the system, have not gotten a raise in fifteen years. Now, as a reward, we will get paid less, no matter how this turns out.
I think Mr. Obama made a sincere effort to change the system. I think at times he may wonder why so many people deserted him when he thought he was doing what they elected him to do. I’m sure he can’t understand why people are more willing to pay $900 a month to a for-profit company, when they could probably get similar service by paying $400 a month in taxes. But, as I said, they won’t pay taxes.
We will inch forward. We will probably find a way to make sure that people with existing illness can get coverage, and that even if you don’t have a job you can find a way to buy health insurance, even if it is a lot of money for a not very good plan. Yet, in truth, this is progress.
Anyway, soon I will be on Medicare. I don’t want the government messing with my Medicare. And “death panels” don’t scare me. When the time comes I’m buying a Harley.

(rant ends here)

A month away

I guess I have not written anything her for a while. It doesn't seem like blogging is the thing any more. Most people are on Facebook and Youtube. Blogging requires too much reading, takes too long; taxes the brain having to decipher all those squiggly little symbols. Then, once your have figure out the words, you have to look for ideas and concepts. It's easier to just watch some guy slide down the mud into the water. The concept is clear.

But there I go, getting cynical again.

Maybe its because I came back from vacation and have gotten at least ten calls from new people wanting to come and tell me how their lives are falling apart. That is not what bothers me, what bothers me is that our state doesn't want to pay for it. They don't want to pay the co-payments for the people who have state insurance, and they want to put people on a new insurance plan that will cut my reimbursement rate by 25 to 40%. It all makes me feel wanted, but not valued.

So, if there is a "public option" it is pretty clear we will get screwed. Then again, if there isn't a public option, we are getting screwed already. Most insurance companies have not given us an increase in 15 to 20 years.

Otherwise I have been busy. Since it is clear that I will get old, but not rich, listening to the amazing and creative things that people will do to each other, I have begun to spend some of my limited free time seeking new ways to amuse myself. So far this has proved to be the metaphorical equivalent of building a 2% scale model of the Sydney Harbour Bridge using only plastic straws from Double Ds. My early attempts have fallen down a few times, but recently it seems that I may have a shot at getting it to stand.

It is a long process, but I will let you know.

I hope you've all been well and enjoyed the summer.

I get parts of my eye replaced in three weeks.

More Diagnostic Troubles

Last time I mentioned how getting labeled, getting a diagnosis, is often part of the problem. It gets people into the mode of thinking there is something wrong with them. Often when people know their diagnosis they begin to feel that have something that needs special treatment and they can't fix it themselves.

Well the American Psychiatric Association is in the process of writing the new edition of their Diagnostic Manuel. The is one of the few branches of medicine that gets to make-up and then vote on whether something is a disease that needs them to treat it.

Some of the new categories being considered are "shopping addictions. internet addictions, excessive sex balanced on the other end by apathy, and also prolonged bitterness.

This sounds like a bunch of 60 year-old, pissed-ff psychiatrists who want to label 75% of their own 18 to 29 year-old children as having some kind of brain disorder. Who spends most of their time on Facebook, shopping, having sex, not looking for work and being angry at their parents. Almost everyone!

I guess that would be great for business. But I don't know if Obama's health plan will cover it.

On the beach, a treatment plan

I'm on the beach now, taking a few weeks off from driving up to the office, spending too much time indoors, listening, grunting, mumbling, a few slight of hand tricks, you know, the usual.

Today, I was standing in the water, up to my knees, just kind of taking it slow. A friend comes up to talk to me. Friends are important in keeping the mind going. I like friends, at least a few of them.

She begins to tell me about the daughter of a friend of hers. The kid is nineteen, anorexic, depressed, sometimes lost and suicidal. "Probably a cutter, too" I added, just to show that I was listening. Yep, she's that too.

So, I was thinking, happy to be here in the water, happy that she's not on my list.

Then my friend began to describe how this young woman's parents were trying to get her into a hospital, but there are problems with the insurance, problems with the screening, problems with the girl. She has already been on and off six kinds of medication. None really helped.

What is the best plan for her? my friend asked. I answered in my summertime, mostly ironic way, so that my friend thought I was being my usual oppositional self --except that I really wasn't.

What I said was -- get her the hell away from doctors and hospitals and medicines. Tell her that she is better, and that she had to go get a job and take care of herself. Don't call her sick anymore. The label is doom. It like Wittgenstein said, the meaning is caused by the language. If you call her that, then everyone thinks she's that, and then she is that. So don't call her that.

Of course, my friend hadn't read much Wittgenstein, so she thought I was nuts. I feel badly for the young woman, but she is in the system. Unless she gets up and runs away, she's fucked.

What he said, but what he did...

Two weeks ago I was sitting with Paul, who was forty-five years-old and had been a binge drinker since he was eighteen. His drinking had cost him several jobs, a marriage, and his driver’s license for a while. He had been totally sober for almost two months. He is now taking an SSRI for depression and Naltraxone to help diminish his craving for alcohol. No doctor would prescribe an anti-anxiety for him because he had such strong addictive tendencies that he was a very high risk to abuse it.

Paul told me at that session that he had been running from anxiety his whole life. He had always felt that he couldn’t handle things. This was partly because his father had always put him down and he had been picked on at school. Alcohol had always driven the anxiety away. But now alcohol was only causing problems. The new medications, and psychotherapy, were supposed to help him live with and overcome anxiety and his feelings of failure. He should be able to do this. he was intelligent, caring and, when he was sober, a very reasonable person.

“Anxiety” Paul said, “is a part of life. Learning to handle it means your growing up. I am, forty-five; it’s time to grow up. There are no drugs or chemicals that can do that for you. The good thing,” he added, "is that the more you handle it, the better you feel about yourself, and the less anxious you are.”

That insight was very true, and could have come out of almost any “self-help book. The problem is that insight, fortitude, medication and psychotherapy don’t have direct access to actually changing someone’s mind. Two days later, in an impulsive moment of frustration, Paul took a whole bottle of benzos that he had kept hidden and ended up in the hospital.

That’s the way the human mind really works. So far, none of us, psychologist, psychiatrists, neurologists, geneticists, priests, probation officers, self-help gurus, nutritionists, philosophers, or third-base coaches, really know how to get in there and change it.

Bif Poppi!

The word is out. Big Poppi added a few chemical compounds to his system and it may have helped him hit the ball a bit further.

That is about as surprising as a birthday party for a six year-old.

Now everyone is yelling about the "integrity of the game." Right, sure.

First, during the last fifteen years, was there any ball player of note who was not taking some kind of enhancers? Jed Lowry maybe. He's hitting .187. Brian Daubach?

But I love the part about the integrity of the game. This is the way the game is played. Any game in America. Did Karl Rove worry about the integrity of the U.S. Attorneys General. AIG didn't seem to have too many concerns about the integrity of the insurance game. How about Enron. Bank of America, Countrywide. United Health Care, which has paid millions of dollars in fines for defrauding Medicare. How about Haliburton? The War in Iraq? General Motors?

Does Fox News worry a lot about the integrity of what they report? Does Rush Limbaugh validate all, or any of his facts?

Even the American Psychological Association has been walking a very fine line about allowing psychologists to design brain-washing and torture techniques to help the government break laws and be unethical to fight terrorism. Integrity?

Lawyers? Do I need to say more? Stock brokers? Mortgage salespeople? Who do you trust? Rabbis selling body parts, priests playing with young boys. Presidents and interns?

How about professors who take Provigil to stay awake and finish journal articles, or students who take Adderol? Is that cheating.Is that OK if you have ADD, but not if you don't. What if you rush off before finals and get an MD ti give you a diagnosis for a week?

Is it OK for me to have that caffeine boost at eleven every morning? Does it make me a better therapist, or would it be more honest if I was falling asleep?
Baseball remains an American game. it reflects our culture. If someone is going to pay you $20 million to hit home runs, you are going to do what you can to hit home runs. You don't think any of the owners knew about McGuire or Sosa? Everyone knew, and everyone liked it.

I was at the game last Friday. Big Poppi came up and hit a fly ball to right. It was four feet short of the bull-pen. If he was juicing, it would have gone out. I paid $80 fuckin dollars for those seats. Can you believe that. $80 for a baseball game. If Big Poppi's had taken those drugs and hit the ball ten feet further, I would have been have been a happy customer. Isn't that what integrity is about? Giving the customer what he paid for?





















4

her list

A new client came to see me yesterday. She said she had been searching for a new therapist and that several people had mentioned me. I guess I'm a superstar in a crazy world.

She related her life history and it is pretty awful. She has been trying to get herself stabilized for years, and has had about four previous therapists. She cried, and was pretty anxious, but we did OK.

As she left she gave me something she had written. She said she knew that she would spend the session crying and not be able to say all that she wanted, so she had written it out for me. She handed me about six pages.

I like it when people put effort into their treatment. They have to do more than I do if they are going to change, and change is difficult.

She listed things that she was hoping to work on, and then she listed the reasons why she had left her other therapists, and other factors that have held her back and made her life difficult.

As I read it, I was impressed. But then I kept reading and I began to see that this poor woman has become a professional victim. While it is true that the world -- her family, her school mates, her one terrible relationship, her three terrible bosses, have all contributed to making her life difficult. While I am sympathetic, I felt like she was making a case for me to pick up the load.

I don't want to do that. I am going to have to tell her that the next time we meet. I will try to do it in a manner that will let her see that this is her life to lead. I'm afraid that she isn't what she is looking for.

I'll let you know.

She's gone

I can talk freely here because I know she doesn't have a computer.

She is an older woman who had a very unfair start in life; she and her mother shared a room and a bed for the first eighteen years of her life. Her father lived upstairs and worked two jobs. Her mother lectured her constantly about sin and warned her about the evils of men.

She was engaged to a man in the Navy. He came home from the sea and they were married. The marriage lasted three days. She sent him home realizing that she could never go through with it. She never did.

I saw her for five years. We met at the same time very week. She was always there, she always had things to talk about. She had insight into her situation and was often good with self-effacing humor.

I was her third therapist during a twenty year period. She said she was amazed that I had expected her to make changes and she that had been able to do so. She became much more assertive,she learned that she didn't have to act sweet and charming to people who treated her badly, and she learned that if she didn't want men to come-on to her she shouldn't flirt with them. She was able to deal with the world and move to a better living situation. She asked for help when she needed it. She even made one good friend.(She ran away from that relationship twice, but I kept sending her back)

But I was expected her growth to continue, and she didn't want to give up being bitter and resentful about things that happened fifty years ago.

When I hurt my eye she got scared that I wouldn't be able to see her every week for the next ten years, even though I only missed one week. Last month I told her that in august I was going to take three weeks off. Two weeks later she came to our session and told me that it would be our last meeting. She had made an appointment with someone else. She was worried that I was going to be gone too much and she needed regular therapy.

I think she wanted me to be shocked and upset. She said her last therapist cried when she announced that she had found me. I spoke to that woman who told me what a marvelous patient she was.

But, the truth is, I was kind of elated. Five years is more than enough. Medicare shouldn't pay for forever, and I was thinking of moving her to at least bi-weekly after the summer. Also, she didn't want to free herself from more of her limitations. She was comfortable using her anxiety as an excuse.

Now, if she wants that, it is perfectly understandable, but she doesn't need therapy to do that.

I realize, that this should be viewed as an issue in treatment, and should be worked through. It is about her fears of abandonment, of losing someone close to her. She should not take my actions in my as a reflection of how I feel about her. There are reasonable limits on different types of relationships. They are not all or nothing.

I didn't feel like doing all of that. I will let the new guy do it. I'm not perfect all the time.


She's gone. This week I used the hour to get a cup of coffee. I have someone scheduled in that slot next week.

Advice

This is what I've learned, from my own experience and from dealing with any health care system anywhere.

The best advice is that if you want to stay healthy -- don't get sick.

Once you get sick you get sucked into the system and then you have a tough time getting out.

I'm still walking around with one eye, knocking things over and wondering when it's going to knock me over. Stress. I've been taking eye drops and then I developed a rash on my cheek, which was probably from the drops. I showed the doctor and she acted like she didn't know and said I should see a dermatologist.

Right, sure, see another doctor. I just make sure the drops don't spill.

Once you go to the doctor and they start running tests "just to be sure" looking for things you never even thought about and now you're worried for two weeks. They forget to call you and tell you that there probably isn't anything wrong, but maybe another test would make it clearer.

Enough, enough!

Eat right, take walks and smile.

City politics

I have had many, many clients who have been in the government of the beautiful and hard working city in which I have my practice. Like any city, there is a great deal of nepotism, chronyism, pettiness and politics that overshadows those who are dedicated and caring city employees. For the most part I don't mind, at least people are working and getting paid, although now about 15% of the workers are being laid-off.

But right now I have three clients who are in the middle of dealing with the city and are not only being screwed, it is happening in such a manner that is obviously grossly unjust, unfair and out of order that any place with some kind of self-respect and dignity would be so terribly embarrassed that all parties involved would be thrown out on their ass -- but no one seems to be batting an eye.

In one case I am seeing a woman who had worked in a department for fourteen years. She is a talkative and breezy woman whom almost everyone likes. He attitude helps her do her job and relate to the people she has to deal with. But two years ago she got a new supervisor who seemed to feel uptight with the way this woman was outgoing and chatty.
A couple of months ago the big boss came in and told my client she was being put on paid leave, but that she would have to leave the building immediately. He said he couldn't say why. Three weeks later she was called in for a hearing in which she was charged with all kinds of things that she had no memory of ever doing, some of which, if she really did them she should have been fired on the spot, but no one had ever said anything, nothing was documented, and no one else could be found who had witnessed it.

She denied it all, asked for the union to do an investigation. Two weeks later she got a letter saying she was being fired. The union was never given any evidence. Word got back to her that the new supervisor who had wanted to get rid of her was known to be very involved, in an extra-curricular manner, with one of the men high up in the administration.

The other two cases are very similar. Petty grievances, jealousy, and incompetence seems to be the rule and not the exception. I could tell you more stories, that I can't tell.

I was about to say that I am not surprised, but I guess I am, even I, who have seen or heard almost everything, am a bit surprised by how once the bar gets set very low, everything falls apart. When the incompetent people rise to power their instincts are to protect themselves from those who can point out their flaws. They band tightly together and everyone in the community suffers.

I guess we used to call this The Bush Administration, now it's just on a local level, but it's just as insidious.

summer clients

I don't know if I have said this in this space before, but hey, how many new ideas can I have, in the summer I get fewer calls for new clients but the ones I do get are way above average of the intensity and confusion scale.

For a couple of weeks now I have been seeing a very charming, warm, caring woman in her mid-fifties. She is tired and worn out. But now she has to raise two of her grandchildren because their mother, her daughter, has never grown up or settled down and now lives in a neighboring city with a guy who sells drugs.

Then she shows me a letter from her son, who is in jail, and has been for seven years. The letter explains that he is evil, and still angry and when he gets out of jail he knows who he is going to kill first.

Her other son was shot by the previous boyfriend of his girlfriend. After being paralysed for three years he couldn't take living that way so he killed himself.

There is even more, but the point is that this is a perfectly reasonable, kind and caring woman. She says her husband is a nice guy, who tried to be a good father, but by now has just withdrawn.

I really don't know why all of this has happened to her. I think it helps to know that her father killed himself, as did two of his six brothers, but I'm not sure.

Fate, genetics, bad karma, or just tragic?

grumpy

I don't know where you are but everyone around here is grumpy. I get the worst of it because most of my clients are grumpy anyway. They are a not too happy a bunch, that's why they come to see me. My job is to cheer them up, and juggling doesn't always work.

But now everyone is damp, cold, moldy and sick of it. We haven't seen the sun much, and when it comes out it quickly goes away, which makes everything worse. I don't know how people survive in Seattle, although I hear it's nice out there now. Maybe it has to do with expectations. I guess if you live in Alaska in the winter, you know what to expect. Maybe all there is to do up there is get drunk and vote for Sarah Palin.

But it is supposed to be summer here now. It's supposed to be hot,and sunny. These are supposed to the the days that reward us for March. Instead it seems like March.

Everyone is angry and looking for someone to blame. It takes its toll on relationships, on businesses, on travel, and on everyone's view of how fair and considerate the world is. If people don't feel they are being treated fairly, they respond by being mean.

It all goes back to Reagan. When he and his advisers were first told about climate change they scoffed and put on sun glasses. Now we have 100 heat in 40 states and New England has had rain on 20 of the last 24 days.

Everyone is grumpy.

One Great Weekend

The wedding went Great!

What more can I say. My youngest kid, the tall, bald one, has been with this very attractive, strong-willed yet socially charming, while still being smart and ambitious, young woman for a couple of years now. He finally felt like he was ready, and that the time was right. She took over after that and made the arrangements.

About 100 of us drove up into the mountains. The rain stopped just long enough. Not being very religious they had a J.P. The J.P. made no pretenses at pontificating. She said do you take her, and do you take him. They said yes and then we had a party for the next six hours.

What more can you do?

Now I'm two for two in the "hope they marry great people" department.

Nothing left for me to do but wait around for the next chapter.

(I also want to thank Logo, along with many other of you, for the occasional comment. It's good to know someone's out there in virtual land.)

can't and won't

It is still so difficult to tell the difference between can't and won't.

With most medical problems, such as if you break your leg, catch a virus or rip your cornea, the problem is clear, and except for indirect causes, such as skiing, killing sick people, or smoking, you don't feel like the difficulty was your fault. It's different with mental problems.

People often come to me and they are filled with anxiety. They can't get to work, it makes them terribly jittery. flustered, and confused.

So we work together to find the stresses in their lives, both long term and short term. Then we teach them techniques of how to deal with anxiety, racing thoughts, negative anticipation, catastrophic thoughts and irrational fears. Often, we add some medication to the mix.

I try my best to get them ready to relaunch into the world. I feel that almost all of my clients try too, but sometimes, nothing really changes. They remain too consumed with fears, too trapped by their thoughts, too much just stuck in a bad place.

So, we try again. We do some variations, new explanations, new drugs, new ways of breaking down the obstacles, new ways to try and relax.

But then, sometimes, not much changes.

Then, I, the experienced, all knowing, all caring therapist, can only say:

"HELLO" this is all I have to sell. I don't have any more magic.

I begin to feel like I am dealing with a "won't" instead of a "can't." A some point in psychological treatment, the client has to take the risk of making the change. I try to arrange the changes so that they are not fatal.

But, who knows.

so many have slipped away

Even I, after all these years, still get a bit surprised by how many people there are right here in this land of opportunity of ours that just can't cut it, don't make it, can't do it, drop out, give up and flop.

I don't know if it is more than it was fifty or a hundred years ago. I remember when I was just beginning my training there were still State Hospitals, Institutions, Insane Asylums, which were full of folks who had been dropped off by their families or picked up on the streets. Once you got stuck in one of those it became very difficult to work your way out.

Then better medication came along in the late sixties and early seventies and these people were moved out into "the community." Most of it was done as a reason to save money.

So now there are many people, more that anyone who goes about their daily business

I think there may be more of them now because the world moves faster, expects more peices of paper, electronic transactions, passwords, ID numbers, menu responses, and real-time transactions over virtual networks. Once you fall behind it becomes difficult and costly to catch up. Once you build resentments, take it personally, and become defiant, you get trampled, inundated and pushed aside. Spindled, folded and mutilated they used to say.

It seems that once this mind/brain thing that we have been given starts slipping over the edge it gains momentum for the long slide down, and then stays stuck in the mud at the bottom of the psychic ravine.

Sometimes a parent, sister, or niece will try to bring one of these folks to my office with a note attached that says "fix this person." It's like towing a car to the mechanic after the engine has seized up. Except in these cases you can't go to the junk yard and get a replacement part.

Oh, I forgot, Igor did that.

mortality lurking

One thing that has happened since I have been limited by losing the use of my eye for a while is that I get more anxious when my clients come in with their tales of illness and loss.

Today one of clients was talking about how she has to fly home to see her father. He had not been feeling well and now, not surprisingly from the information she was getting, has been found to have cancer that is in several locations. He is five years younger than me.

So many of my clients come with problems dealing with their aging parents. I search for reasons to reassure myself that what is happening to them is not happening to me.
Usually I could brush away the fears pretty easily just because I felt good. I was energetic, active and rolling along.

Now, I feel pretty good, but I am limited, can't see things coming up on my right side, and I get skittish and feel a bit vulnerable. I can still take anybody on, but they have to stand a bit to the left and promise not to hit me in the head. Not exactly the battle cry of the warrior.

And my clients have to deal with really terrible things -- cancers, Parkinson's, ALS,which is totally awful or Huntington's disease which may be even worse. Also, the girlfriend of the son of one of my clients was killed by a truck in a parking lot in a random accident. The next hour the cousin of that client died when his truck rolled over somewhere in Texas.

The Reaper seems to be lurking in every corner once you start looking for it. No wonder everyone is anxious.

Can't get like that I guess. It does no good. Live until you die, and until then deny mortality. Pitch as if you are unhittable, dance beneath the diamond sky, howl at the full mood, drink the sweetest nectar.

And eat plenty of blueberries, watch you weight, get enough sleep, moderate exercise, and call you mother -- if she is still alive.

Jury duty 2

I came back the next day. I tried to tell them that I felt like they were penalizing me because someone else had hired someone to kill his ex-wife. I told the officers that due to my having to see the doctor for my eye I knew they could not seat me on a trial that is going to last a month. I told them I had eight people scheduled to see me.

Of course, no one cared. Their job was to call the numbers, in order, and my number was 151.

After four more hours of sitting, reading, writing some notes, and talking to the last ten people waiting to be called, I got sent into the court room.

I sat in the witness chair and the judge read the statement I had put on the form. Where the form asked if I had any dealings with the court system I had written that as a psychotherapist, over the last thirty years I had seen patients who were policeman, court clerks, lawyers, probation officers, corrections officers, as well as many people who had been arrested, tired, sentenced, and several after they had been released from prison.

The judge asked my if hearing from all those people had influenced my opinion of the legal system.

I told her that I have kind of a distorted view. I said that from what everyone has told me of what happened to them, and how they behaved, and answered questions, that I have come to believe that everyone lies.

The judge smiled and simply said, Thank you, you're dismissed.

I waited nine hours for a ninety second interview. Where is the justice in that.

jury duty

I had to miss a day of appointments today, but this time I scheduled it.

I had agreed to do my civic duty and show up to be a member of a jury. When I got there I found out I was in Superior Court and all trials would last from three days to weeks. I got sent to a room with about 100 other folks to be selected for the jury of what turned out to be a murder trial. It was a case I had read about and if I didn't have work and have one bad eye I think it would have been quite interested in witnessing how the drama played out.

They took so long to question each potential juror they didn't even get to me. I told them that I couldn't serve because my eye was busted and I have to go to the doctor next week, but I have to tell it to the judge. So now, I have to go back tomorrow morning and try and beg off.

It was interesting to watch my fellow citizens sit around for five hours. What has changed most since the last time I had to go was that fewer people read a newspaper and more play video games, either on their phones or on little hand-held gamers. Most people just seem to stare out into space. The only people who were talking were guys hitting on the more attractive women, although that changed in the later hours and more people just began to talk about how everyone was just sitting around.

The lack of newspaper knowledge was evident again wen the judge opened the meeting with some general information. Of the one-hundred people there I was one of two people who had heard anything about the case.

The most striking thing to me was just how people can just zone out. Everyone seemed relaxed and friendly, and vaguely interested at what was going to happen. But they also seemed to enjoy having a forced break in their hectic lives. They could take advantage of the time and do nothing, nothing at all.

I can never just sit. I read an entire New Yorker, especially about how conservative and privileged Chief Justice Roberts is (at least it was court related). I guess I'm not good enough at just chillin'.

client envy

I am adjusting to my one and one-quarter vision for the next few months, but I am functioning, going to work, doing all of the stuff I need to, and some of the stuff I want.

This week I caught up with one of my clients. She is an attractive, rather volatile thirty-nine year-old divorced woman. She has a rather responsible job with one of the larger public bureaucracies, which she seems to manage very well despite the instability in the rest of her life.

Last week she got home late from work and then received a call from her current, sometime boyfriend. He is about fifteen years older and works odd hours doing vague things that are probably just over the line from being legal. So at ten-thirty she goes out with him, pushing passed her mother who stood questioning at the door.

It was the night the Red Sox, Celtics and Bruins were all on TV. I guess the boyfriend had too much money riding on the Bruins, so when they lost he got in a bad mood and started dumping on my client. She told him to shut-up and when he didn't she demanded to be taken home. But he kept it up in the car, so at a red light she got out, slammed the door and walked away.

She realized she was about three miles from home and it was around midnight, so not wanting to walk, she went into another bar that was lively and close by. There she ran into the ex-husband of the woman who was now married to her ex-husband. He was there with a few friends. She sat down and had a few drinks with him.

An hour later, as the place began to empty out, the four of them left and found another place downtown. There she met three old friends from long ago and she had a few drinks with them, leaving the other group behind. When it got to be closing time there, they all went to a "private club" downtown, where they drank until three. She then got a ride home from a guy there, who I think she had dated while she was still married, ten years ago. He took her home, and probably stayed the rest of the night, but she was not too clear on that and I didn't push for details.

She said the next morning, which must have been about an hour and a half later, she got up and went to work, making major policy decisions.'

Now, from this behavior, I can give this woman about four different diagnoses. But, I wonder, is this a problem or is it just a good time?

Bonk!

Been a while for me. Most of that is because two weeks ago, at first game of my long anticipated return to he mound for the Pub Team softball. Bonk. It came from out of left field -- except I was talking to the first baseman at the time.

The ball hit me on the side of the head. That really wouldn't have been a significant blow if I hadn't had cornea transplants 40 years ago. The old stitches ripped apart, the eye bagan to fall apart, and now, two weeks and one two day stay at the best eye hospital in the world later, I am on the mend.

I have good vision in one eye and will most likely get as good vision back in the other eye - in eight or nine months.

Until then. Don't stand on my right side as I will either ignore you or walk right into you.

The lesson from all of this is that if you live long enough, and push your luck long enough eventually, usually, you get caught.

The solution of course is to be Dick Cheney, and expect that everyone is coming after you and everything is a danger. Then you can sit in a bunker with a shot-gun on your lap, drinking pomegranate juice and remaining hyper-vigilant that no one, or no thing can even begin to threaten you.

Of course, this may sometimes lead to shooting your friend in the head, but who can you really trust anyway. My real friends know not to make any sudden moves. A sudden move means you're a terrorist.

time passes

Yes, the picture is of Italy, in Tuscany, just outside of Lucca. Not a bad place to be.


I got back from being away for a week and then had the pay-back week, which often, but doesn't always happen. Seems like too many people needed attention, and too much water was delivered and no one else could do anything about it. We almost ran out of paper too. Can't anyone else take care of anything?

Today I drove into the parking lot of the building in which I have been working for the last ten years. It is basically a medical building. For ten years before that we were in a nicer building in a nicer office, but it was full of software designers, and unless they were clients, and many were, it made people uncomfortable, and they got rid of us when they finally could.

The parking lot sits on a bit of a rise and I can see the morning sun shining on the gray, red and brown buildings that make up the downtown. It's a hard-working, sometimes prospering, sometime suffering small city. Sometimes it feels as if I know at least thirty per-cent of population, even though I don't live too close to here and hardly have time to leave my office. Those I don't know I have heard about. I get before it reaches the paper.

I have been here almost thirty years. It's kind of weird to think that I have devoted so my of my life to this. Yes, there are more things I hope to accomplish, and probably will, but when I think of "what have I done with my life?" this has been pretty much it.

It's very interesting, and I still enjoy it here, although I sometimes wish the city was a bit more prosperous, but how many cities are these days? But it was kind of a weird moment to think -- this was what it was.

so much stuff

I was away, now I'm back.

It was too cold for too long up here in the North, so we took off to the South to find the Spring, and for the most part we did. It was a bit breezy in Augusta when we were there, but all the flowers were ready for the big tournament, everything was in bloom. We drove north to the Blue Ridge Mountains and found a bit of snow, but that faded the next day and it was warm and friendly. Those mountains are beautiful and accessible and fun as you can still get creamy, cheesy grits, that you can't find up here.

But then I returned and had to catch-up with the bills, the paper-work, the cleaning, the shopping, the sorting and the arranging. It all kind of sucks.

I have a couple of clients who refuse to do that. Yes, they are in debt, on the verge of being homeless and live in clutter, some in filth, but I can see their point. There is so much stuff to do, just to stay where you are. It is so time consuming and boring. Someone should do it for me!

I see how much time, expense and effort it takes for a family when one of their members can't, or won't do their part, at least for themselves. It can exhaust everyone. At what point do you cut them loose and let them sink, especially it it is your own kid.

I am very grateful that those who I have brought into the world have been able to fly off on their own. They seem to be quite able to slog through the necessities of getting their stuff done.

However, they best not forget from whence they came.

Liars and drunks

Me, Me! After all these God-Damn years I still get sucked in.

He is 53 years-old for Chrissakes. He has been seeing me for almost two years, the length of his probation. He got put on probation for trying to hit a cop. He tried to hit the cop because the cop was laughing at him when he was staggering down the front stairs of his house screaming at his neighbors. Then the cop flipped him on his chest, cuffed him, and brought him to jail. It was his third arrest in ten years for drunken/disorderly so they put assaulting a police office on top of it. He got two years probation. He had six weeks to go.

Sure, he had some slips, and he told me about some of them. How many he didn't tell me about I can't know. He found a bottle he had hidden and slurped it down and threw up all over his wife. He had a few other such moments, but they all ended privately.

Wednesday he was in my office. He spoke about how much his life had improved since he had stayed sober. He was employee of the month. He was building chairs in his basement. He showed me pictures. He said he would never work with ban-saws if he was drinking, he would cut off his hands.

He also told me how his attitude had changed in so many areas. Last week his car window had been smashed by some punks driving the streets. He told me how clearly he remembered how angry and vengeful he used to feel. So many times he had chased people for miles if they had cut him off. He had confronted people whose car doors had scratched his car. On Wednesday he was telling me how crazy that behavior was and how he relieved he was that he had finally out-grown it. Now he could just shrug it off and remember things he had done when he was a punk kid.

Thursday afternoon I received a call from his wife. She told me that Wednesday night he had been arrested for sitting on his porch and waving bee-bee gun at people. He was drunk and screaming that they had best never touch house and car again.

They arrested him and threw him in jail for thirty days for violating probation. He will probably lose his job.

Usually, when I see someone with an alcohol addiction, and they stay in treatment, they stay sober. I have had many people who drop out and go drink, and that's it. But to have someone who seemed so insightful, so convinced and convincing, yet so addicted.

He had taken all the pills, he had gone to all the programs, he was chairing a meeting every week.

Just say "no."

You can say no 10,000 times, and when the sun goes down you take that flask out of your hip pocket and think no one will notice.

Donald Barthelme

There is a new biography of Donald Barthelme that was reviewed in the NYT this weekend, and has been getting a lot of notice. I probably won't read the book because I already have too much to read, and I mostly only read reviews anyway, but it was good to read that Donald Barthelme is being fondly remembered.

I remember reading his stories and then buying one of his books of stories in the early 80s and reading them over and over, slowly. It was exciting. I knew he was trying very hard to do something, and I felt from the energy of the story that whatever point he was making was a big step. It was something of a turning point, probably very self-consciously.

I don't think I ever really got the point. I don't read enough for that. It was post-modern. It was beyond avant-guard and it was very descriptive of how I felt about the world, and probably still do. But it didn't really make much sense, which was I guess, part of the point. His stories had a beautiful flow, but no story, not even a narrative, hardly a character.

Each sentence was beautifully written, and constructed. But each sentence usually didn't seem to have that much to do with a sentence that was two sentences away.

Reading the review of the new biography made it kind of clear what I had kind of known, that his life was often a mess. A long time ago I had read about how he and his brother lost thousands of dollars gambling in Biloxi. He drank an awful lot, and had been married four times, which is different from me.

I kind of admire people who struggle like that, to find the edge. It takes it's toll.

I have clients like that. I try to find the balance between encouraging them, but making sure it's they who really want to go there, and not just me.

exploring on and on

There was this guy named Pierre-Simon Laplace, a French mathematician who died in 1825. He was one of the first to imagine how a huge IBM mainframe super-computer could be really helpful. He was excited by science and he felt that if someone could get all the information of where all the particles were in the universe and what direction they were moving, then he could predict everything that was going to happen.

It makes sense. There are supposed to be laws of science, they are supposed to be constant, and therefore if we know everything we can predict everything. No one really expects to know everything, but the more we can know, the better we can do.

I have been struggling with that a great deal lately. There are lots and lots of things coming out of new science and technology that could add clarity about what any of clients are doing and why. There are new brain imaging techniques that show what parts of the brain are operating. There are ways of taking blood levels and hormone levels that can show what physical state they are in. Physical and mental correlate much more than you think.

Then there is all this genetic information pouring forth. How much of what we feel and do was determined way back when our parents chromosomes joined? I certainly have evolved to look so much like my father. He also was a blogger in his own way, as I have a few of his tiny notebooks with all kinds of notations.

But now I have read a article about a computer scientist named David Wolpert. He has written a "proof" which demonstrates that you can't know it all, especially if you are part of the system. You can't measure the weight of the earth if you are standing on the earth, you can't know the limits of the universe if you within the universe and, I assume, you can't know exactly what is happening in someone else's mind by using your own mind.

I think that is true, no matter how many machines you have to measure brains, bodies, hearts and heads. It's kind of frustrating, because I always know when I am talking to one of my clients that something more is happening and I don't know what it is. If I knew I could be more helpful, more effective.

On the other hand it is kind of comforting. When I think about it, I really can't predict with any certainly what I will do tomorrow. So how much can I expect to know about anyone else?

Some, but not all.

Gone

Well, he died. I wrote about him back in January (1/10), how he was slipping slowly away, and now he is gone. He died of very natural causes, his heart, his lungs, his mind, all seemed to have had enough. The morphine made him more comfortable, and probably made everything more certain. He had officially been on an "hospice treatment plan" for less than a week.

He was 95, and of all the people I have known, he is one who could say that he achieved most of what he set out to do. He fit the true American ideal mold. He grew up poor, worked hard, made the most of a couple of breaks, kept working hard, and made a good life for himself. He was an older son who tried to care for his younger brothers. He had a wife and two daughters, and he tried to be good to them, in the classic, fatherly way.

He retired to Florida for years, played golf, walked the beach, and was generally pleased with himself, if not with too many others. For me, his son-in-law, he wasn't that easy to get to know, but he was easy enough to get along with. He was a business man and I was a psychologist, and I don't think that any of this "get-to-know someone stuff" made much sense to him anyway.

He was a man of his time, and he enjoyed doing what he was supposed to do. He did it with structure and discipline and that paid off. If his example of how to conduct business was continued by others after he retired in 1980 we certainly would not be in the mess we find ourselves now. He didn't try to get rich quick. He got up and went to work every day and tired to work harder and smarter than the competition, yet without trying to be ruthless enough to put anyone else out of business. And he enjoyed what he did.

Most of the people who knew him have died before him. He had four siblings, now only one remains. Most, but not all, of his marbles had rolled away before his body gave out. It was time for him to go, and you could tell he knew it. he had done almost all of what he set out to do.

A few weeks ago he said to his daughter, " I have had a good life." and he really did. That's the best anyone can say.