Tuesday, May 29, 2012

American Dream?

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

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

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

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

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

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

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

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

Monday, May 14, 2012

Tech is Taking us Somewhere

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

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

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

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

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

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

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

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

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

Monday, May 07, 2012

More Tech Fallout

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

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

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

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

Stress, conflict and misery.

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

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

And so do their families.

Wednesday, May 02, 2012


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

This is what I posted:

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

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

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

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

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

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

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

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

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

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

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


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

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