Friday, November 30, 2012

To avoid panic attacks

There are certain queer times and occasions in this strange mixed affair we call life when a man takes this whole universe for a vast practical joke, though the wit thereof he but dimly discerns, and more than suspects that the joke is at nobody's expense but his own. However, nothing dispirits, and nothing seems worth while disputing. He bolts down all events, all creeds, and beliefs, and persuasions, all hard things visible and invisible, never mind how knobby; as an ostrich of potent digestion gobbles down bullets and gun flints. And as for small difficulties and worryings, prospects of sudden disaster, peril of life and limb; all these, and death itself, seem to him only sly, good-natured hits, and jolly punches in the side bestowed by the unseen and unaccountable old joker. That odd sort of wayward mood I am speaking of, comes over a man only in some time of extreme tribulation; it comes in the very midst of his earnestness, so that what just before might have seemed to him a thing most momentous, now seems but a part of the general joke.

--Herman Melville
Moby Dick,  Chapter 49

Monday, November 26, 2012

Another Times Article

This Sunday in the NY Times Magazine section there was an article called "What Brand is Your Therapist."  It was clever and well written.  it covered some of the same material that I covered in my talk last month at the state conference.  People seem to notice that the"worried well" as we called them back them, are moving away from psychotherapy.  Part of that is because of restrictions from insurance, but most of it is because the lifestyles of people under forty are very different than they were forty years ago.

People expect information much faster  They expect much more action, and less thought.  They seem much more concerned about specific problems than the general overview of things.  Also, I think family life for them has been very different.  It is difficult to sit and talk about what your parents did to you when there have been so many people in your life -- other family members, step-parents, day care providers, coaches, teachers, and more.

Also, people don't work on weekly schedules as much.  Regular appointments are much more difficult to keep.  I have many clients who have to travel two or three weeks a month.  Also there are so many late or early meetings because of global teams, that it is difficult to keep a regular meeting time.

Unlike the woman who wrote the article, I have a very full schedule and have had for twenty years. Part of that is because many of my patients are not the "worried well."  Many of the people I see have been crushed or confused by circumstances, society or biology, or combinations of all of those.  They need to see a Psychologist, not a coach, or a guru, or a branded expert.

If your kid is throwing temper tantrums perhaps it is worth it to try to just call a "parenting coach."  If a month later the kid is still screaming, and you and your spouse are battling, and you life is spinning out of control, perhaps you may realize that things are a little more complex than they first appear.

Wednesday, November 21, 2012

Their Children

I noticed an interesting thing yesterday: of the eight people I saw, two were children of people I had seen years ago.  These were not their young children who live with them, but adults who are grown up, but when they got anxious, lost, or upset about something, they came to see me.  I had not seen them when they were children, although I had heard about them.  There have been several other children of former patients who I have seen, and others who I am now seeing.

Now, in part, I take it to mean that the work I did with their parents was helpful, and that the children heard about it somehow, and felt it would be helpful to see me -- also because I know their parents and what they had to deal with.

But I guess there is also a negative here, in that the kids felt that part of their upbringing was chaotic and unstable enough that it caused problems. I didn't cure their parents

But I overlook the second one, because I can see that the world is difficult for everyone, and the idea of coming to talk to someone like me is so widely accepted that it doesn't mean that people are crazy, or can't cope.  They just feel that coming could be really helpful during a bad time.

This is so true that insurance companies want to pay us a lot less --- because so many people use our services.  This is the opposite of supply and demand.  It is the Republican version of a "free market." That is, regulated for the good of profit and corporations, not for the people who provide or receive the service.

However, the fact that I am beginning to see children of several of my former patients means, really, is that I'm getting old.

Tuesday, November 13, 2012

Love, Money Power and Sex

Most of us know about Maslow and his hierarchy of needs.  Before you can build up to using your full potential, he hypothesized, you need to have your basic needs met, beginning with food and shelter, and working your way up through acceptance, love, and esteem, until you can feel totally free and secure, and then you can "self-actualize."

It was a good idea, popular and easy to understand.  It really was never supported by research, as it seems many people can skip some steps, while others get stuck enjoying the food, shelter and sex level.

But whenever I have been asked about what motivates people now, in the 21st Century, and I believe  (again, with no real research to back it up) that the big factors are Love, Money, Power and Sex.  Possibly today, with the way the world is, Fame, could be added as something many people seem to desire.  Being famous for being outrageous  and making a sex tape, seems to be worth as much as bringing peace to the Middle East or curing cancer.

The other things about Love, Money, Power and Sex (Fame), is that they are so tightly combined.  People want to be loved and respected.  Money almost can buy love, Power can bring Sex, Sex is related to, but isn't quite Love. Money is almost Power.  Men Love women who are attracted to Money and Power and will have Sex because of that attraction. Some women like to obtain Power to attract Sex partners, some get Power so they don't have to have Sex.  All of this is intertwined and everyone gets involved.

A lot of orthodox religions seem to have a lot of doctrines relating to Power and Sex.  Almost all give the Power to men, to determine who has Sex.

So it is never too shocking when Powerful men, politicians, generals, business tycoons, movie stars, get swept up in the excitement and the glory of their position, and end up combining admiration, Love, lust and Sex all in one bundle and find themselves enjoying the company of beautiful women twenty years younger than they are.

It's a terrible fate that ends up in scandal. Everyone loves a scandal, and they all involve Love, Money, Power and Sex.

So now, I am looking for someone to write my biography.  Preferably a women in her mid-thirties -- but older than my daughter, with a knock-out body and a good vocabulary.

When I raised the idea with my wife she just said "good-luck with that" and then she added that she would like to edit the book before it gets published to keep it real.

Saturday, November 10, 2012


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

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

From Wikipedia:

The town has served historically as a destination for artists, musicians, and writers, including Richard WagnerEdvard GriegM. C. Escher,[4] Giovanni Boccaccio,Virginia WoolfGreta GarboGore VidalAndré GideJoan MiròTruman CapoteTennessee WilliamsGraham GreeneLeonard Bernstein and Sara Teasdale (who mentioned it in her prefatory dedication in Love Songs).

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

not bad.


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

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

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

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

As the Dali Lama says in one of his tweets:
"Peace in the world relies on individuals finding inner peace."

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

Monday, November 05, 2012


By the time we reached Positano it was almost three PM.  The clouds were closing in rapidly.  There is really only one winding road in Positano; first it goes all the way down one long cliff, then it hits bottom and goes up the other side of a very steep canyon.  Fortunately our hotel, The Villa Franca, was only three 178-degree turns from the top. 
The hotel is beautiful and positioned spectacularly.  It sits on the top of a cliff, looking almost 700 feet straight down into the sea.  Every room has a balcony that reaches out over something: the town, the sea, or the beach.  The staff is friendly and helpful, the food at breakfast and at the restaurant, was as good or better than anything in Boston.  Bring money.
The next day we walked down to the beach and back up again.  Someone told that the winding staircase we had climbed up on consisted of 877 steps.   Since it was now “off-season” the only people in the hotel were American sightseers, German hikers, and a couple of gorgeous models from Albania, with photographers following them around.

view from hotel, looking down at beach

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

That afternoon, as my wife treated herself to a massage by the lovely Antonio, I sat on the deck on the top of the hotel with a drink in my hand and realized that I was feeling both marvelous and totally disoriented.  We were here; we were at the place we had set out to go.  I was literally on top of the mountain overlooking the world.
I appreciate that I have been incredibly fortunate.  I have had a great career, doing something both fascinating, and something I felt was intrinsically valuable, and it also, for many years, paid the bills.  I have had one, very good, long marriage.  We have two children, who both seem to be in good marriages themselves.  All four of them have very good jobs, doing interesting things. Each couple now has a charming, creative, beautiful, curious, affectionate daughter.  Both these young girls are enamored with their Pop-Pops.
I feel, like 70% of the therapists out there, that I am one of the top 5% in my profession.  But I also realize that the most brilliant thing I did with my life was that I was born two years before the big baby boom.  That gave me a step-up in almost everything I wanted to do.  I could get into a good, small liberal arts college, and then into graduate school, partly due to the lower number of applicants.  Three years after I bought a house millions of other people became ready to buy a house. I was part of the first wave of Psychologists to get licensed.  I left community mental health reluctantly, but when I began a private practice the competition was minimal, although the sigma of people going for treatment was still a factor.  I have been in practice in the same city, a mostly working-class mill city, with more prosperous suburbs, for thirty-one years.   I have been totally booked for the last twenty years.
But, sitting there, on top of the world, it was also easy to see how much I was a product of my times, and that times have changed.  The little talk I gave at the MPA conference was about how to use technology to enhance psychotherapy, but the real message was that people of this generation are different than the people of my generation.  Their values are different, the outlook and expectations are different, and their minds are different, due to how technology has given them access to information, and to each other.  And that makes the way they manage their relationships different.
All of this has made me see how much all theories, concepts and techniques of dealing with human behaviors are a reflection of the times in which they are espoused.  Sometimes it feels as if our profession has more in common with a newspaper than a web -site.  Just look at how kids are raised today, compared to thirty years ago; how many more people are in their lives.  How much they are exposed to. I’m already getting text messages from my granddaughter.  Look at how many subcultures are in the U.S. today, and how strong the effect of living in a Puerto Rican community vs. a Cambodian community vs., growing up in Chinese American family in a well to do suburb of Boston or San Jose. Compare that to the mind-set of a White Morman family in Utah, surrounded by nothing but White Morman families.

Is the best way to deal with the problems they face by meeting once a week for 50 minutes?
Yet, I also believe that there is nothing more comforting, and nothing more powerful to foster change, than a structured, face-to-face, well managed therapeutic relationship.  
For a while I thought about this while I was there, on top of the world, watching a ferry come in from Capri seven hundred feet below me.  I felt personally very fortunate, but still, as always, worried about the world.  It is not surprising that the world continues to change, now at a much faster pace than it did 1200 years ago when the church down at the beach in Positanto was built.  What is also becoming more apparent is that my life is in transition, as is my profession.
But there; at a place we had long wanted to come and see, I decided to try and relax and be in the moment.

Friday, November 02, 2012

Napoli to Positano

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

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

Napoli to Positano
I am not a good follower, nor am I a great joiner.  So my wife and I don’t take tours.  We map out where we want to go, try to learn about the place and head out to see it and enjoy it.  It is for that reason that after our plane landed in Napoli, we rented a Fiat 500 and headed out, on our own, to Positano.  I encourage you all to Google that route on Google Maps.
But, that route would only look like a twisting road, first highway, then through several tunnels and then along the twisting road on the cliffs high over the sea.  A road that makes Highway 1 South of Carmel seem wide and straight. 
But that is not the fun part.  The real fun came when we missed the exit to the road to Sorrento, went too far on the A3, and got off the highway.  Then you realize that the smaller cities of Southern Italy do not believe in stop signs or traffic lights.  Nor are the entrances to highways anywhere near the exits, and signs are also nonexistent.  To add to that the roads were built by the Romans, or earlier.  They consist of a narrow lane in each direction, heading right through town.  Two Dodge Dakotas could not pass each other going in opposite directions.
What you get is a constant flow of inter weaving traffic, either going about fifteen to twenty miles an hour, or not going at all. Then you need to factor in the motor scooters.  There are about ten motor scooters to each car.  They go at about  twenty seven mph. They weave around all the cars, in both lanes, going in all directions,  both with and against the traffic, wherever  there is six inches  of space.  But they take care of themselves.  It’s the predestrians you have to pay attention to.  They cross the street whenever, where ever they want, or else they just walk in the street, because the sidewalks are full of chairs and people sitting, drinking and arguing.  And in the traffic, everyone is yelling at each other.
My lovely wife could not bear to look, but it was fun.  It was like living in a video game; just keep moving.  If you stop, and let someone in, you will never get a chance again.  First gear, second gear; first gear, second gear – just keep going.
But, as we drove the narrow city roads, or the winding mountain roads, on which you could not see beyond the next curve, which was never more than forty yards ahead., I never saw even the slightest scrape or dent or injury.  Buses missed me by one to six inches,  Motorcycles  that were coming head-on,  would disappear  seconds before impact like ghosts behind the mirror.  After a while I had complete faith that everything would be fine, and it was.
After we reached Positano, and I sat in the lounge of the Hotel de Franco, at the top of the hill, looking about 700 feet straight down to the beaches and the sea on either side, I thought a bit about how this was part of the current difficulties being felt by psychotherapists, especially those with Ph. Ds.
It is usually in the character of good therapists to be compassionate, understanding and empathetic.  We see and feel the trouble in others. We want to solve problems, to look at them,  take them apart, and then help put things together  in a way that works better.  We do not usually push ahead and claim every small space to be ours and then grab at the next one and the next, taking what we can for ourselves, regardless of the effect it has on others. 
If we did, others would have to worry about themselves.  But no, our job is to worry about them, and to help them make things better for themselves.
But what we are learning now, and many of us figured out before, but many have not, is that if you want to be in your own practice, you have to learn the business part.  They don’t teach the business part in any graduate school.  You may learn therapeutic techniques, you may learn research skills, but you don’t learn marketing, and you don’t learn finance.
We also thought we were entering a profession, like a doctor or a lawyer, and that being a “professional” means that patients would just come to us.  But that is not the case for any professional any more, unless you are Miguel Cabrera or Tom Brady.
Also, what you may not realize is that some of patients you see, who could be diagnosed as bipolar, or narcissist personality, are often the ones whose business plans just did not work.  There are other people, perhaps people such as Rupert Murdock, Jamie Dimon, Lloyd Blankfein, Ralph Nader, even Madonna, who may have ended up being labeled with some kind of psychiatric diagnosis except that they pushed very hard, had unrealistic goals, moved people out of the way, and did not think about others as much as they took care of themselves.  They are regarded as very successful.
But so many therapists worry about confidentiality, about the possible impact of everything they might say, of what someone might think about what they are thinking.  And all of this may be important, at times, in the therapeutic process.   But it can leave you powerless in the business process, and it has in many ways, allowed the profession to become marginalized.
We think about ethics, and liability and therapeutic impact, and confidentiality, and some clown is out there, whose best qualifications are a good haircut and a big set of brass balls.  He markets himself as an executive coach, and charges $700 an hour to help the boss work out a strategy.  And then there is the Naked Therapist who got highlighted on Fox News.
We find that, if we want to be part of the mainstream process of bringing psychological services to those who need them, that the decisions about how, where, and how much we will get paid are going to be made a great distance from our offices.   Many of us will have to learn how to join groups (ACOs? roving bands of Psychologists?)  and work well with others, which is something I said at the outset that I don’t do well, Or some of us will take the position that we will only see patients who can pay us what we want, or we will only perform a service that gets us compensated in the manner we expect, but that means we have to find a market, and we have to learn how to sell ourselves.
You have to learn to constantly push ahead, just like driving though Napoli.  Keep your eye on the opening and go for it, and let the other guy take care of himself.   And sometimes you have to scream and use hand gestures.