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.

stuck 3

Well, Dr. Therapist sir, what makes you so special that you can go about writing how other people get stuck in mind traps of their own making? Look at your life, look how repetitive and stuck you are, how you make the same mistakes over and over, each time thinking you have figured things out, when lo and behold, you haven't.

I have been doing my taxes over the last few days, and it's not fun. First I always hate the tediousness of going through all the stuff. I've been running this business for years and it's basically the same stuff with minor various in each line, from income to supplies, to answering service expenses.

Then look at my stock market returns. Of course, this year they were miserable, I guess that can be forgiven, but should it? I had years when I was doing marvelous, but that was when they moved the target in front of my arrow. Now I make the same mistakes over and over. Stuck. I chose the right stocks to buy, I buy them at the wrong time and then wait until just the wrong moment and sell them. I use the same logic to make these decisions, and each time I do I tell myself I'm not, but it really is the same.

And other things too. Each year I start a new project, but it really the same project over and over. I vary the way it sounds or looks, but I work on it for a couple of months and convince myself that I have found the right way, and then I take a month to re-consider, and I see that it really isn't that different. Then I stop, and shrug it off, and put it away. Two seasons later I get an inspiration and start over again, convinced that this time I can do it differently.

Is this the insanity that comes from doing the same thing over and over and expecting different results, or is it the dogged persistence and tenacity it takes to succeed.

We won't know until it's over, and I guess it's not over yet.

Half the fun is in trying, but half the misery is in being stuck.

Twitter?

Most of my friends and I can remember when TV first came out, and we were thrilled with color TV, almost twenty years later. Now, of course there are all kinds of new media, and everyone is a star and a celebrity, and everyone's thoughts and actions need to be monitored and recorded.

Wanting to be hip(is that still a word?) and not left behind some of us got on Twitter for a while to see how exciting out lives are.

The initials have been changed here to protect the guilty.)

7:15
AB; home eating cookie, drinking decaf.

BC: home, watching CNN

DE: home, reading The New Yorker

FG: home, hanging around waiting.

HI: driving home

JK: Home,watching re nun of Cheers

LM: home drinking 2nd Scotch


7:55
AB: finished eating, cutting skin off my corns.

BC: home, watching CNN

DE: Home, asleep with The New Yorker on my lap

FG: Home, my wife went shopping so I'm having sex with my sister-in-law who moved in last month.

HI: home, eating cold steak-sub

JK: home watching rerun of Seinfeld


LM: 4th scotch, yelling at bad memories

9:17

AB: home,reading about illness on Web MD

BC: asleep watching CNN

DE: in bed

FG: My wife is home. We are one big happy family, having a glass of wine together.

HI: home, arguing with wife, but I don't know what it's about

JK: watching rerun of Matlack.

LM: no message

fascinating -- maybe everyone should embellish their reports, just like JK.

trapped

Sometimes minds don't just get stuck, they get trapped. Trapped in an endless obsessive loop. the worst of these traps is when it becomes physical, then it's called an addiction. An addiction takes over your life, it becomes the focus of your thoughts and actions and you don't care about anything else. You drive your friends away and you steal from your family. You are out of control, way out of control, and you know it, don't like it, but there is little you can do about it.

There are harmful, but not physical addictions, such to your Blackberry, work,exercise, being thin, or the opposite, eating.

There are the obvious addictions: alcohol, drugs, gambling, sex, risky behavior,bulimia, things that give that dopamine rush, or things that just make you numb.

I work with people at all levels of addictions. Addictions are insidious because they come in so many forms and that allows for denial and excuses. The addict loses any chance at self-determination. They are worse than stuck. they are trapped.

But, treatment can work. All kinds of treatments for all kinds of people. You've got to find your own special key thatwill begin to set you free. It's very difficult and often painful. It's great when people get their lives back, or even parts of them. It great when you can see brains beginning to work and minds clearing up and becoming reasonable.

Those folks are very gratifying.

The others just stop showing up.

effective mumbling

So she came into my office today for the first time. She was composed but looked a little scared. She had never done anything like this before and wasn't sure what was going to happen. She hadn't even watched "In Treatment." I guess she didn't have HBO.

So I asked her if she had any trouble finding my office and she talked about the traffic and then she said she came from work so she talked about the stress from work, so I asked a couple of questions about work and about stress, and then about the pressure she felt being the most successful daughter in the family, and how her father was quiet and her mother always tried to solve every one's problems bu was always getting it wrong. And she kept talking about work, and her family and then her boyfriend who she like but thought he was lazy, and she didn't know how much that really bothered her, so she cried. Near the end of the session she began to talk about how she was realizing how much pressure she had been living with, and how it has been coming from all directions, and now she has to lay people off in her department and that is braking her heart and mind.

I mumbled (I really do mumble) a few off-handed comments near the end to lighten the mood so she could go back out into the world feeling decent. She thanked me and said this was much different than she ever expected, and she couldn't believe how much just talking about something could be so helpful.

"That's what we do," I said.

Next week I will make quarters disappear while juggling.

stuck

I tell you what's wrong with my clients, almost all of them. They're stuck. Their minds got stuck. I can't see what is wrong with their brains but I get to understand what goes on in their mind, and it's stuck.

I got back to work today and two of the folks are still having anxiety attacks. With anxiety, you're mind is stuck in worry and fear mode. Your body is tense and everything looks like a danger. Now, these are smart, insightful people, and they know that eating prepared food or driving on a highway, or walking to the back of a supermarket won't make them keel over, but to them, it sure feels like it. They want to turn their minds off, but they can't, it's stuck.

My job is to figure out how to get their mind out of the trench it is in, to break the loop that constantly repeats itself, and to free up their mind to do other, more fun, things.

To do this I have to create an experience that will detach the strong emotion of fear from the thought, whatever that thought is. Sometimes, medication will help do this, as it will, depending upon what it is, either relax the body, so that the emotion doesn't feel as strong,or slow the thought process, or keep the happy chemicals on the brain longer. Besides medicine, there are lots of experiences that I try to create right in my office, that will help people feel differently, and see that they can move out of their rut.

It is important that I don't get stuck. Everyone is different. Minds are different. There is a big movement on for 'evidenced based" treatments, which are pretty standardized for each diagnosis. I am not a big fan of those because, first the diagnoses are not too accurate, and second, everybody's case is different. Anxiety isn't like a broken nose.

Although it does have the similarity that when it is fixed, you can make it look prettier.

So, relax, don't get stuck. Things will work out. And don't say "What IF..... that only makes it all worse.

In-sight?

I am away, watching the sun set over the Gulf of Mexico, beautiful shades of orange, purple, dark blue and black. I love sunsets. What I don't like is freezing my ass off, but that is what we have been blessed with her in the Sunshine State. Yes, the sun is shining, but it is glistening off of the frost.

The good part is that I can it clearly. I got my new glasses just before we left. They are in new frames and make me look a bit cooler, but I also got a new prescription. I can see better. After all these years I got an improvement. My vision has never been great. My vision, while not terrible, is certainly no where near fighter-pilot clarity, so when I tried on my new glasses I immediately noticed that I could see a couple of notches better -- vision being graded on a scale of notches. That's good and bad. I can read better, even at night, but the news I read still isn't good. I can look in the mirror and see my new cool frames, but the face they are sitting on has aged considerably since the last time I could see this clearly. Look at those crags and wrinkles and jowls, who wants to see that so clearly.

Reality, not the best place to live.

slightly baffled

Sometimes things are so fascinating, so complex that even I, 50,000 hours later am still amazed.

I've seen this woman three times now. She is in her mid-forties. She is very articulate, very in touch with her often scary, often overwhelming feelings, and can describe things in glowing, flowing detail. She says she has skills in reading, writing, synthesizing ideas, and creating images.

Yet, she she says her house is a total disgrace. She has piles and piles of stuff and she is afraid to put things away because she doesn't know where they go. Also, she has no sense of spacial relationships. I have never seen anything like it. She has trouble finding her way from the parking lot into my office. I can see her hesitate in the waiting room, trying to figure out which door leads to my office. She told me that if I had a pile of pens and told her to put the red ones in one pile, the green in another and the blue in a third, she could do that. But if I said, organize those pens, she would stare at them for hours and not know where to start.

The causes of this could be anywhere and everywhere and I am certain it is both. It is psychological, neurological, genetic, and the result of familial deprivation. She has had a terrible life, having been in an orphanage until three and then adopted by a caring but crazy mother. That lead to terrible, abusive relationships.

But those are over. Now she is just a total mound of exhaustion and anxiety. And yet she is charming, outgoing, friendly and very caring to her friends and the world at large.

I would love to run about $100,000 of neurological and physiological tests on her. I doubt that they would find anything definitive.

Still cold

Now, the guy has been President for almost thirty-six hours and it's still cold. I guess he's not going to live up to expectations. But then, few people do.

I have that problem with clients. I see all the potential. Hey, if they weren't so screwed-up there is no end to what they could be doing. Sometimes I get all excited when I think of the possibilities. This one could be an artist, this one could be a teacher, that one could be governor with a little bit of energy-- it certainly doesn't take too much to be governor in lots of states.

But, then I have to back off. It scars them to feel expectations. Mostly they just want the fear to subside or the depression to lift. If they could sit and watch TV without having a panic attack or thinking about how miserable they feel, that would be enough.

But it's not. The only way you really get better is to get active. Get up, move, get your blood going, think about what you need to do, do some planning, plan to be good to someone else.

Aim high.
It's the process
Success really doesn't matter

Then you can watch TV

incidents

So you think that this job is all about sitting here, nodding and saying "how do you feel about that?" Sure it is. That's why we get paid the $4.50 an hour by UBH, but only if we get our forms in on time, with all the correct boxes checked.

But here are a few other things I had to squeeze in today.

I have a literally poor client, on SSI, Medicare/Medicaid,who received a letter saying that since she turned 65, and since she got a cost of living raise on her SSI check from $996 to $1026, she is no longer eligible for Medicaid as her supplemental insurance. To keep her policy she will have to spend $465 a MONTH for a deductible. So, she came in crying and we ended up calling the State Senator. We have to wait to see what he can do.

Another client who suffers panic attacks was pulled over by the police for something minor. She had a panic attack and couldn't talk or make sense. The cop thought she was on drugs and wanted to put her in his cruiser and arrest her. That really freaked her out. I had to talk to the cops and a lawyer for her. That one got resolved.

I have a guy who lost his job working for the state because of what was going on at work. They have stopped paying him and he is waiting for a hearing. He has been waiting for two years and is about to lose his house. The State knows he has a good case that is probably relevant to several other people so they don't want to settle it, or something. He is becoming desperate, depressed and kind of crazy. I had to try to make sense out of what his lawyer was, or wasn't telling him. No real progress has been made on that.

I have been working with another woman with panic attacks for months. Part of her problem, which is common, is that she is afraid to take a pill, as the pill might do something to her mind that she didn't expect and that would make her panic. But now she is ready to take the pill. I had spoken to her PCP three months ago to explain to him why the medication would be helpful. He was very agreeable. Today she went to him to get the prescription. He had nothing in his notes. I had to call him. He was at lunch, he was at the hospital, he was cutting his finger nails. Finally, I think that one got resolved.

I still have an hour left to sit and say "how do you feel about that." I am afraid to pick up any more messages.

The older old man

I was trying on my new glasses to show my daughter. They are gray on top, silver on the sides, slightly curved with no bottom. They are current. My daughter, who had closed her eyes so that showing could be more dramatic, open them and announced, "You look old."

She quickly added that I did look cooler, and more with it, and that I should not go back to my old frames, but that fact is, I look old. At least older than the people she has become accustomed to looking at, who are mostly twenty-five to thirty-five, and now bring along with them a new generation, who are mostly two months to two years. They look young, with rosely cheeks, dewy skin and sparkling eyes.

But, it was later, when we went to the nursing home to visit the older old man, that my daughter could no longer keep the tears from running down her cheeks, although nothing was really happening except age.

The older old man is 95, and after 03 years of holding together he is now afflicted with what is now considered the disease of deterioration, dementia and dying. The older old man was pleasant, and even seemed to kind of figure out who my daughter was, or at least he was able to fake his way through it, relying on his well established social skills, much the same way years ago when this very daughter had mastered the skill of appearing to read by learning all the words to "Fred and Ted."

But his presentation of holding it together had too many flaws as he asked, about every thirty seconds about his wife, who has been dead for nine years. He also, in a friendly, personable way, turned to my wife, his daughter, and asked her how her parents were.

And that was it. He was tired. He tried valiantly, and succeeded to get himself up out of his chair, and staggered in small, very quick steps traversing the three feet from the chair to his bed, grabbing my wife's arm so that he would not pitch himself full force into a frontal forced landing. But we got him safely into bed, clicked on an alarm gizmo, which is designed to call an aid if he tries to get himself up.

We put on our coats, and before we were out of the room he was asleep. He will spend the last of his days more asleep than awake before he slips over into eternal rest. It is very difficult to watch, as much for him as it is for ourselves. Especially those of us who will put on a new pair of current style glasses than make us look kool, but old.

It Begins again

I am here, still away from work, watching the new year begin.

It has been cold here. We were with friends and ate blueberries. We were safe and warm.

The next day the stock market went up as a sign of hope.

Today Israel marched into Gaza as a sign that nothing has changed there for sixty years, really for three thousand years.

From this distance it is difficult to tell what exactly keeps those people so entrenched in their "My Way or Death" positions. The Israelis have treated the Palestinians terribly. The Palestinians have never accepted Israel. The large majority of both populations are caught in the middle, until hostilities break out and then they cling to their side. They fight for power and pride, fostered by some kind of religious justification.

For someone in my profession, who labors for hours to help one person relieve their anxiety, it is difficult to watch hundreds of people be blown out of existence during a ten minute air-raid. But this kind of thing is not new to the world. That is what becomes so discouraging as we age,

Never give an eighteen year-old a weapon and visions of glory for using it. But every culture does. So it goes on.

The issues were too complex for President Bush, who believed in right or wrong. Perhaps a new administration, with more ideas, can bring the pressure of the whole world to bear on this conflict.

If the world can truly be different, the changes have to begin right there. Perhaps that is why it is happening now, just to show where the bleeding starts.

It's Dark

Look out the window. It's 8:30 and it's dark. It's been dark for hours.

And it's cold. Not actually that cold, but it's cold and getting colder and soon it will be very cold again.

It's New England, and it's winter. It supposed to be like this. We didn't move south to play in the hot humid. We stay here and watch the sun disappear behind the slate gray clouds. Then we go to bed under thick down comforters.

There is a condition called SAD, seasonal affective disorder. But, in 99.97% ( a rough estimate) of the time it's not a condition, it's reality. The dark affects people. It's so primitive, so visceral, it's a great thing.

Feel it.

Don't be afraid of you emotions. They are here to protect you. They tell you instantly what to like and what to fear. They have been wired into us over hundreds of thousands of years. Trust them. Don't try to hide from them or chase them away.

It's dark and it's cold. It's uncomfortable. It's even a little scary.

Have a little rum and go to bed with someone you love.

Make the winter work for you.

Greetings!

I hope that all of you out there in The Blogosphere are enjoying this season of a succession of holidays. The Solstice has passed, and slowly the light will be returned to us who reside here in the Northern Hemisphere. We expect it will help shed light on the truth and bring a rebirth of hope, honestly, caring and integrity. Hope springs eternal. That is one thing that humans do well.

So gather around those who are near and dear. I have read in respectable journals that two major aids to keeping you brain functioning well past four score and seven years are blueberries and friends.

So rejoice! Embrace and look to the light!

Me and the Medical world (again)

I had another incident of medical depression, and I wasn't even sick. I had an appointment to get my eyes checked by a new and more skilled specialist at a new place. The place turned out to be six floor medical factory, very efficiently run, but huge and depressing.

The staff were mostly nice, some more than others. They shuffle hundreds of people through each day, so it can't be too personal. They lead people through the maze of hallways , with the people following obediently behind, like mules on tethers. Most of the people, of course, are sick so that isn't too uplifting. Many are old and crumbling, and them come to be taped together for another six months, or six days. It is clear that so much of our medical expenses go to constantly slapping band-aids on what is really just natural deterioration.

I went from this waiting room to that sitting area, to this little room, to that next waiting room to the next little room. I was examined by very nice people and very high-tech equipment that beeped and flashed and spit out pictures and pages of printouts.

I sat and looked at the artwork on the walls of abstract local nature. I wondered if the artist had imagined that their heartfelt emotion laden images would end up here.

I heard a woman somewhere down the hall with the worst cough I had ever heard, and she continued her straining and hacking on and on, as nurses walked with frozen smiles down the corridor. I wondered how much coming here put me in danger of being sicker than I ever have been.

After an hour of this, the very competent doctor showed me some of the pictures and told me that my status was the same as the last visit with my previous doctor. She then offered me some new, very expensive treatments that I probably don't need, but are available. I asked how much they could help and she explained very clearly that they could be an improvement, but they may not actually work and then they would have to be re-done. She couldn't predict.

I thanked everyone and went home. It took me about four hours to shake the depression. It is clear to me how much worse I would feel if I actually were sick, and how powerful the psychological aspects of illness are.

My own office is not like this. I greet all my patients myself. We talk in a cozy room, with comfortable chairs for an hour. I do not in-put everything into a computer as we talk. I listen and smile and make little jokes.

In many ways psychotherapy is not medicine in the way the medicine is practiced in America today. That is probably why there is such a demand for it, and why it works so well.

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our next task

I sent this out today to many other psychologists, as part of a discussion about whether to push for a national health insurance plan:


At this time in our history, with "change" taking over our government, and the banks, mortgage companies, auto industry and who can guess what else being nationalized, the question about health care in America is a bigger question than just about National Health Insurance. Hopefully all of our thoughts about this issue are more complex than how much we will get paid for 90806.

IMHO, the best thing that could happen (I am not holding my breath here) is to have a bunch of doctors, therapists, patients, hospital people, non-patients, economists,and bureaucrats locked into a room somewhere. It would be their job to construct a health care system from the bottom up, to design a system that would do the best job of keeping America healthy at the most reasonable cost.

How much of our GNP should we spend keeping us healthy and alive? In this time of socializing everything I do not think we can let the desire for profit be the deciding factor in health care decisions. Every other developed country has found a way to pay for care without having sick people run the risk of going bankrupt.

Who will do triage and on what basis? Should Medicare spend $12K for a demented 97 year-old man to have his teeth removed and dentures built? How much do we spend to keep an infant alive who has a badly damaged cortex?

How much should mind/body interactions be part of the deciding factors? What would be the best education for a mental heath professional in the next twenty years? Is there any chance that someone can be educated to perform that function?

How would we pay for the development of the best new drugs, not just the most profitable ones? How many drugs are good for us anyway? How much should it cost people who don't live a healthy life-style, or is it part of our freedom to smoke and eat Whoppers, and then have the government pay for bariatric surgery?

The country is a mess. The world is a mess. That gives us an opportunity to tear things apart and build a new system Think outside the band-aid. Think outside the fifty-minute hour. Let's have a real discussion.

I think I will send this on to my friend, Barak. He asked for my in-put.

Hour by Hour

Last week I bought an appointment book for 2009. For me, and almost all of my colleagues, at least those over forty, and certainly over fifty, having a concrete, paper and pen, write it down appointment book is so much easier than anything electronic.

I moved my office a couple of months ago. I moved just down the hall. But in doing so I emptied out the shelves of the old office. I put over twenty appointment books into a big box and lugged them home for storage. All of them are Week-At-A-Glance types. My brain is set to see the whole week laid out before me. If the hours are not all filled in a feel a bit guilty, even though now, since I hurt my back, I am trying to leave spaces.

One thing I get from this job is a clear sense of time. Hour by hour, just like it is in the book. I feel the week, the month, the year, my life pass by. If I am sitting and talking to friends I can tell when the conversation has lasted fifty minutes. The timer in my brain goes off. I need to change positions, change topics, talk to someone new.

Yet, I don't feel my life is passing by. It seems much more like it is exactly the same. I am amazed that I have aged. I feel the same. I do the same thing -- although I am much better at it now -- and I just keep going, hour after hour. She is my "nine o'clock,"he is my "ten o'clock." Very often someone will take that spot for six months, a year, sometimes even two years, although usually if they are still coming after a year, they are coming less frequently,but some people last a long time. For a while I had all my ten o'clock appointments trained to bring coffee. But now only one is left. I have to get the new ones up to speed.

I picked up one of the appointment books that was ten years old. The hours were filled in. I could remember about ninety per-cent of the people; their faces, their dilemmas, and how they were when they left. About five people are seeing me now, although they all had been away for at least a couple of years, some have come back a few times But for most of them, I don't know where they are now. Their stories continue without me.

I'd love to have a big reunion and see how everything turned out. But HIPAA won't allow that.

creeping changes

This economic stuff is bad. Many people are either losing their jobs, or afraid that they could. Money is tight. People are finally afraid of credit cards/

These are not bad things.

Many of the couples I see who usually fought about money-- using it as one of their flash points, even if it wasn't the real issue they were fighting about, which is usually control, recognition, and who should carry the emotional load -- now they talk about survival.

In some ways people are very tense about making the bills. In some ways people are more relaxed because the pressure to make tons of money, to keep up, to buy more and bigger, is gone. Even the people who have money, have less.

Making tons of money is not trendy any more. It looks bad. If this were France in 1787 all those auto execs, and big bankers would be on their way to the guillotine. There is a lot of popular support for that.

There are signs that things are changing. Having a job seems more important than just making money. How you get your money is beginning to matter again.

May there will even be a return of things like ethics and integrity.

Well, let's not get carried away.

More about that

Thinking about my last couple of posting has made some things clearer about what is so compelling and also so difficult about this job.

It becomes clearer at holiday time when I am even busier than usual, both socially, and at work. What becomes clearer is that while I can really enjoy my time off, I often feel that when I am with people, it can be pretty boring. I mean, I like many, if not most of my friends and relatives, and it is good to see them, but in truth, no one has much to say. Or at least they don't say it.

My own kids kid me about the types of questions I ask. What are you doing? What are you reading? What are you listening to? What are you thinking about? What is really going on?!!

Yes, the politics are finally encouraging, the Celtics are doing well, adding the cranberries into the wine and then into the sauce makes it more interesting, but WHO are you and what are you BECOMING?!

Then I go to work and people tell me everything. They tell me things that they don't tell anyone. They tell me things that they have never told anyone. They tell me things that they don't even want to tell themselves. To me, these are the most intriguing and engaging conversations anyone can have.

Today I had a session with a very bright, attractive woman who told me that last night she spent an hour sitting on her kitchen floor with a knife placed just under her heart wondering if she could go through with it. She felt she had done things that if anyone found out about, she couldn't live knowing they knew. Then her husband came home and she jumped up and set the table. Today she went to work and no one had any idea what she had been thinking. She then told me why she had felt so badly.(I'm not going to tell you).

Yesterday I met a new young man who seemed like he had just come in from the wilderness. He had been out of school for two years and had been doing basically nothing but hiding in his room. But six months ago he read something on the Internet that opened an interest in psychology and philosophy and he has been reading and thinking since then. He was incredibly insightful, articulate and self-possessed, and yet he never knew his father and his mother has been screwing with guys in the other room for years, and no one knows how this kid thinks, or even that he can.

Of course there are downsides. These are very one-sided relationships. I realize that. The people I talk to come to me for help. that makes me feel good My friends don't put me in that position, but then, I don't have to help them. The responsibilities are different. But often, I don't need too much contact with people after thirty to forty hours of this. I get all listened out.

I'd rather watch a game.

Ring-ting-a-ling

Well it sure is holiday time. Many of my clients were out there last Friday at 5 AM ready and eager to spend money they don't have. At least no one was trampled to death in my area. That is kind of sick, don'tcha think? That shoppers have rally gotten that desperate.

This is always one of the busiest times for me. Some family gatherings are really great and nurturing and communal. Everyone gathers and buys gifts to show heir love and appreciation for each other. The warmth and love is what chases away the cold of the long winter nights. I actually see some people who have a family like that. The family has grand-parents who had eight kids and they all have kids, many of whom have kids, and they all get together for Christmas and share good tiding.

I actually have two members of that family who see me, and they give me very different views of what goes on, and who really likes whom, and what the underlying tensions and rivalries are. But at least everyone manages to pull it off for a day.

Most of my clients dread the holidays. I see about four Elanor Rigbys who will be alone unless a fourth cousin has some compassion, or the old man on the third floor invites them in. But if he serves wine they get nervous about his intentions and make sure they keep their knees tightly held together.

For many it is the guilt that brings families together. A mother can squeeze feelings of guilt an inadequacy out of a child for fifty years if she has the talent. And many do.

I also have two families in which one sister is now married to the former husband of another sister. That can make things a bit tense, unless families are rally into sharing.

So, if you have a therapist, make your appointments early. Therapy times fill up quickly around the holidays. Many of us therapists fill up many hours with appointments. It's better than being with our cousins.

The Letter

Before I get to wishing everyone a happy and healthy Thanksgiving, I would like to say, once again, that the job I have is "endlessly fascinating" {that's something my mother always said when she couldn't figure out what was going on} and also, often, a bit weird.

I worked hard this week for two days, getting people set to deal with whatever variation of family they have to co-exist with, when I got a letter. This is not the way I am usually introduced to people. These days a phone call, and now more often an email, is the method most people use to try to arrange a first appointment.

This letter was about seven single spaced typed pages. It gave pretty graphic descriptions of stuff that is supposedly going on in private in a town close to where I work. None of the exact details were included that would allow me to verify that the people mentioned actually exist.

The situation described in the letter was not actually that unique or that terrible. It was the letter itself, it's format, language and detail that makes me wonder what is really going on. who would write all this and why? I have my ideas, but ... those are just hypotheses.

At the end of the letter the writer said I would get a call after Thanksgiving to set up an appointment.

Perhaps things will be revealed.

Now, it is time to wish you all a Happy, Healthy and Prosperous, even in these times,
Thanksgiving.

Remember, appreciate the people around you. They are doing the best they can.

results of financial meltdown

I get to see some of the unexpected fallout from the downturn in American personal wealth. Yes, I have to deal with couples who have re-financed to pay their credit cards and now they can't pay their mortgage and their house isn't worth what they owe. Then they get tense and blame each other for it. All that stuff is commonplace.

What I see now are some things that are a bit unusual. I have two (2) situations in which there are three adults living in one house. In one case a man and two women, and the other a woman with two men. In both cases there was a marriage that was not going well. The resulting emotional distance morphed into one person becoming involved with a person outside the marriage. What followed were the usual hurt, anger, arguments, threats and general disruption

Then, as is often the case, one person threatens to move out. The other says fine, I am bringing my lover in. BUT, there is not enough money to move out and pay for another place to live.

In one case a man is living in the basement while his wife is screwing some guy in what once was his bedroom. In the other case the "other" woman is sleeping on the couch, while the family, kids and all, goes on with life as usual, treating this woman as if she is invisible.

Not a very emotionally enriching situation, but it does show that diplomacy and compromise is better than living at the shelter.

I am not sure how either of these will end.

Too much

As a discipline I try to post here every two or three days. It's supposed to be good for my brain, and it should help to live a more "considered life." But often, life gets in the way.

At those time I have so much to say and so much to sort out, but ther isn't time to do it.

Right now I have several personal and family experiences that illustrate how complex health care has become here in the U.S. of A. It's a mess but there are reasons for that, but it don't have time to get into that.

There is also so much going on with the family, and even more going on at work, and the world is going through a great deal of flux in politics, in the economy, and this has its ramifications on everyone, and everyone has their effects on the economy and politics.

And then the Internet connection won't even work for a while, for reasons that I totally can't understand, so I can't even get started.

"Still,tomorrow is going to be another working day,
and I'm trying to get some rest,
That's all I'm trying to get some rest."
P. Simon

More though times

Beside the financial crisis there seem to be other bad things that just pop up in clusters. Maybe it has to do with everyone being tense, but these things don't seem related.

My father-in-law, who I have mentioned here before, is 95 and has really been a tough old bird for many years. But now his body and mind are slipping away. It is taking a long time and is tough to watch. He fell and is in the hospital, but he isn't sure if he is in jail or visiting one of his old customers. When the nurse asked him what year it was he answered 1980, which was the last year he worked.

A good friend of ours is back taking chemo-therapy for a re-occurrence of her cancer. It is very difficult to know how well she will do. Then today, my son told me that one of his friends who had moved away and started a new life in a far-off land was shot and killed in a robbery.

We don't live in Baghdad or Mumbai but there are times when it feels like the world is crumbling around me. My wife gets upset, as well she should. I think I have developed too much of a clinical detachment. I have a circle of about six people, and if anything happened to them I would be rocked to the core, but beyond that, I can feel bad, but I have learned to just kind of shrug and go on.

It could be from working with so many people, and getting to care about them, at least to a point, and still realizing that in many cases, their lives are not going to improve that much.

Or it could be that I'm just really not that nice a guy.

Back at it.

The historic week has ended. I am envigrrated for a better world, but right now I have to deal with the one we have. That means that today I got up and went back to the office.

The misery business, as my father-in-law always called it, is booming. Financial pressure puts pressure on relationships; stress is everywhere. People are struggling, people are angry, people are sad. That's OK, that's what I have to deal with.

I'll tell you what's tough. It dealing with the narcissists. When people are in a difficult situation, or have difficulties in their heads, or are just difficult, that's fine. But when someone feels that all the troubles have been heaped upon them, and then they just sit there and complain that no one is lifting them off fast enough, that is when the job seems difficult and taxing.

Understanding your problems is helpful. Explaining is helpful.

Blaming is not.

Hey, don't blame me, I'm just the therapist.

Obama and Psychotherapy

If Mr. Obama can get people together and try to make significant changes in our society, then some of my clients can make the sustained effort necessary to get their lives going in the right direction. His administration can set the tone that we are working together to make things better.

"But," some of my clients will say in one form or another, "my life is difficult, I was dealt a bad hand, my father left when I was young, my mother was a starry-eyed hippie." Obviously, that can no longer be a lasting cause of bad behavior. Now that there is insight, change should follow. These clients may not have a totally devoted grandmother who will last with them until the very threshold of their greatest achievement, but they do have me. I am here, and I am attentive, and I will be at least until their insurance coverage runs out, and with the new parity bill that could be a long time.

So, let's use this as a time of transformation for all of us. Let us pay attention to each other, help each other along and begin to move in a good direction. But, also, let's raise the expectations of each of us, and we will all benefit.

YES!

I will admit that on Sunday I was very confident, but by Tuesday morning I could see a way that the election could be lost.

I sat with friends and family, trying to be friendly without telling everyone just to shut-up and pay attention. When PA was declared fairly quickly I began to relax. An hour later when Ohio was given to Obama I knew, like everyone else, that it was really going to happen. All the TV people seemed to know it all along.

For the first time in eight years I felt hopeful. I drove to work this morning and I did not cringe every time I heard the news. I felt I did not have to be embarrassed about how the people in my government were screwing up the economy, science, world trade, war, energy, the environment, health-care, health,and human relations.

Basically, I have some confidence that the people who will be running this country, while they certainly won't be perfect, and they certainly will be politicians, will at least be smart. They will understand that the world is complex. That it does not just consist of good-guys and bad-guys, and that the problems we have to deal with are difficult. I think they will have a better understanding that even if someone disagrees with them that doesn't make them terrible or stupid (although sometimes they are).

That's all I want, to feel that we have good people who are trying. For eight years I have felt we have had an administration and even a Congress who were stuck in their own mud and couldn't see passed their mind-set, and couldn't understand what they were seeing, and didn't try to understand it.

Now, we will have to wait and see. but I certainly do buy what Mr. Obama is selling, which is hope.

That is really a great deal of what I do in my own work. Get my clients to believe that their lives can be better. I know how necessary that is if any change is to occur.

Finally

It's funny about time, but if you don't do anything the world keeps turning and eventually, things come to pass.

This election has been going on for almost two years. I have really been pretty actively following it since last January. What with the wars never ending, the financial ups and downs and downs and downs, the current idiot President who has allowed the Justice Department, the Energy Department and the FDA to all become inept and corrupt, I have always felt that this is a crucial election.

Now, finally, I have seen my last client before I vote. I have encouraged all my clients to vote, but I don't get into politics unless they start. The election has really aroused more interest than even the Red Sox this year, and that was not the case four years ago. Four years ago many more local folks were intensely involved with the Sox, and their own local Senator was running for President. Now they seem to have awakened.

What happens next is completely unknown. The world is in a great mess, to a large degree because of how this country has been run for the last eight years. It will take years to clean it up. But at least, if the election goes well, the tone of national and international relations can change dramatically. The world will look at America differently, and we could be a bit different with each other.

But that has not happened yet. I am working tomorrow and then I will be watching every channel. Mostly I will be watching Florida. For me, that is the first major indication. Maybe I won't have to stay up until two in the morning.

six days away

The election is coming, so they say. Mr. Obama has been running for 21 months. Mr. McCain has been running, on and off, for eight years. The decisions, soon to be made by millions of Americans, some of whom have already completed the task, is less than a week away.

In many ways people have to decide if they want to protect themselves, their won interests and their own money, or they want o feel that they are a part of a larger society in which each of us has some relationship, and some important interactions with each other.

This economic melt-down is, to a large degree, the result of people not looking at, and not caring about, the consequences their actions may have upon the welfare of others. They trusted that their attempts to make money were basically honest, and although the things they did were risky, they didn't look, understand, or ever think about how inter-related we all are. There was all this talk about some kind of "invisible hand" running through free markets, and that would make everything balance, and determine a real and fair value of things.

Obviously, there were many flaws in that kind of thinking, just as their are flaws in "trickle-down economics."

America is a land of opportunity, but it can also be a very harsh place for those who slip and fall, or for those who never had the chance to stand up in the first place.

Should we look around and care about each other, even if it is at some cost to ourselves? Or, if we each do the best we can for ourselves, will things work out as they should?

To some extent, the people will decide.

The leaves, and times, are changing

Today was one of those days that they put in movies about New England. The was HD clear after the night's rain, the sky was a perfect autumn blue. The temperature was actually warmer than it should be, but no one complained. Here in Southern N. E. the leaves are at their peak, and because of the right amount of rain and temperature changes this is a good year for color. There are reds, yellows, orange, brown and even purple mixed against some still green. My neighborhood has big old trees, maple, oak, beech and pine, with occasional sassafras, walnut, tulip and even willow. The trees reach way up into the blue, each with it's own vibrant color.

As we walked we met other neighbors walking. We talked of the coming election, which seems like it will never come. Everyone in this small city is of the same mind on the election. We talk of the economy, and joke about keeping our jobs for another decade. Who really wanted to retire anyway? Some of these folks had real jobs and made real money. Some of them have retired. In some ways the great stock market crash represents huge changes in numbers, but no real change in the current lifestyle. But everyone knows that things a are different, and we will not be as plush as we had planned.

One friend, who does business in Europe said that the bad times have hit there hard now. The world blames the credit crazy U.S. for giving and then selling so many bad loans. But everybody bought them and tried to get rich. Now everyone is getting poor. Some much poorer than others.

For us older folks, there is some sense that we have been through some of this. We are not old enough to have been part of the depression of the 30s, but old enough to know that bubbles burst.

It just seems that the bubbles build and burst at a much faster rate now. People seem to be waiting around for the next one to begin. The idea of a slow, steady rise in the economy, based on real products and real work has not really taken hold yet.

Maybe new, "Green Energy" will sweep us up in a new wave of progress and everyone can ride that train back to wealth and consumption.

Or maybe not. Perhaps we will all be poor for a while, and stay home, have conversations and get to know each other.

But that's just an old man talking. Most of us will run around and keep in touch through text messages:
"Pizza?"
"2 late"
"OU812"

all fall down

I was away from blogging for almost a month. Why? Because there was too much else going on. Just one thing after another that needed to be taken care of. When I was done with all that my brain didn't have too many creative neurons firing. I went to bed.

I had to pay the bills for my practice, the bills for the house, and now the bills for my fading father-in-law. The car needed to be taken care of, so did my wife's car, not that I can do the work, but I had to drive it up and back. The house is being worked on and one day two guys were standing on the scaffold and staring right in on my desk.

Mr new doctor seems to question everything about my health. I have taken more tests than ever before, and I'm OK, just poorer. One wonders about why our health care is so expensive. "Just want to be sure." I wonder if it is my health, his pocket, or the lawyers he is really worried about.

I had to see my clients, see my kids and listen to my father-in-law not make sense and my wife get upset about it. I don't make much sense and she doesn't seem to care.

I took time to watch the leaves change color.

I did a bit to keep Obama moving in the right direction.

BUT, my life is a breeze compared to what I hear in my office, and usually my clients are not the ones who are the most lost, disorganized and overwhelmed, but they have to deal with people who are. A's mother is on cocaine and three months behind in her rent. B's brother is locked in a room and won't come out. C's sister came to live with her because her house has mold. Now she hasn't paid any rent, hasn't cleaned the room and disappears every weekend without any explanation. D's daughter has been suspened from school for fighting, three times.

This doesn't count all the illness that are impossible to deal with, Parkinson's Huntington's, ALS. These are the kinds of things tahat just suck life out of a whole family.

I hear about so many houses that haven't been cleaned in months, so many bills hat haven't been paid that people stop trying, so many lawns that haven't been mowed, so many roofs that haven't been fixed. Things are falling down.

It seems to me, and I've been doing this a while, that the pace of life, the price of life, and demands of keeping up have increased, partly because of technology, to the point where people can't keep up, and are dropping out.

Even without this financial mess, I think it's worse than it was, but maybe I'm just getting old.

Been so Long

Look at that. I just looked at the date of my last post and it was almost a month ago. I would have said maybe two weeks. It's amazing how life gets filled up with all kinds of stuff. I had even told myself that it would be good for my brain to keep writing often, but so much for my brain.

I have spent time having parts of my body poked and measured and scoped. Despite all their best efforts, and they really seem to be trying, they haven't found anything wrong with me yet. That's what you get for going to see a doctor.

I have also been doing what I said and trying to help the Obama campaign. The actual work I do has not been that meaningful. He has not yet called me to help do his mental health policy, although he should. I will lobby for that after I see that he wins.

I hope you noticed that the Mental Health Parity bill got stuck into the Huge Economic Recovery Package. It will be a slight help, although insurance companies will find ways around it. They didn't designate $770 million for mental health. They should have, as clearly everyone involved with this mess is nuts.

For me, the trouble mainly goes back to Reagan. It was he and his conservative crowd that decided that the purpose of America was to give everyone the opportunity to get rich. That was the only purpose. How anyone made money, how much it destroyed other people, other countries or the other values and fabric of our own society were not questions anyone even considered.

Also, those conservatives were the ones who began to target liberals as having useless tax and spend policies. While those criticisms were on target in some respects, what those people put in place were spend and spend policies. It has been the conservatives, and G W Bush more than anyone in history, who just spend money and build huge deficits. They created a climate of unregulated greed and here we are.

So, I am holding on to hope for the next couple of weeks. There are about 35% of the people would vote for the Republicans even if Sarah Palin herself were running. It does seem that for now, the independents and the often undecided voters have had enough of war, bad health care, a crappy economy, and watching this country fall into chaos and decline.

Even my most moribund clients are taking notice in this election. Only the ones who are chronically bitter and angry seem to be for McCain.