Coping and Traveling

First, I want to thank the people, those whom I know and those whom I don't, who expressed support and concern for my wife.  Although she is still a bit stunned and a bit pissed off that she is afflicted with this, she is paying very close attention to doing what she should be doing, as she usually does, and there have been good results from doing this.  She does seem healthier and more stable.  There is more to do, but progress is being made.

A while before the diagnosis was made we had planned to take the trip we are on now.  We know that Spring comes late in New England so we came South, in part to visit friends who are down here, and then relax for a few days  here where it is warm, friendly and beautiful, even if the food  is too rich.

But what becomes clearer every day, from seeing my friends and hearing their stories as they relate to my wife, is that getting old kinda sucks. Right now I feel pretty good, and think of myself as fit and flexible. In my head I am the same as I was thirty years ago when I was playing basketball once or twice a week.  However, if I make the mistake of looking in a mirror, or trying to run and jump, it becomes very clear how different I am from how I was then. Also, one of my good friends can barely move his legs, another just had a second heart attack, a third cannot eat anything with fat. A fourth is having both knees replaced this summer.  We even have a couple of friends who clearly are not as mentally sharp as they were ten years ago.  On and on and on.

Psychologically, it isn't easy, and in some ways denial is the best strategy, except when there are measures that can, and need to be taken.  But within the pretty near future most of my friends and I will all be seventy years-old and then it will be tougher to still think of ourselves as just " middle age."

struggles

I've written here before about how it is much more difficult for me, as a psychotherapist, to deal with the folks I see who are physically crumbling, hurting and in pain. I can deal with anxieties, depressions, wild ideas, bad judgment, bad behavior, as well as the lost and lonely, but the the suffering from illness, pain, especially when it is chronic and in a few cases, fatal, is the most draining for me.

Now, in my own home, my wife is dealing with a disease that is probably going to be chronic, is a long way from fatal, but is certainly life changing.  Although she has always been strong, healthy, active, alert, and for the most part living a much more correct and risk free life than I have, she has somehow contracted diabetes, in a form that seems to be a mixture of both Type 1 and Type 2.  Suddenly, from a life that was open and free flowing she has to take measurements, count carbs, and take a regimen of shots and pills that is still being calibrated.

I have no doubt that she will do all that she needs to do, and find a way to balance her life. Yet being hit with this, with really no warning or any way to anticipate that it would come, except for a sudden thirst and weight loss over a period of only a few weeks, is such a shocking smack of mortality that it has just washed me over with the sense of melancholy that comes with the realization that we are all so fragile and ephemeral.

As a husband, it is frustrating because I cannot reach in and turn her pancreas back on and drive away the virus, or toxin or whatever it is that has shut down that organ. I can only be here as best I can.

As a therapist, who works with so many other people who are suffering, and who has done so for so long a period, it seems to highlight how slow, inexact, and inefficient the process of psychotherapy is.

Since this has begun I have been more tired, and I have had to make an extra effort to be focused and attentive in my sessions.  What I see is that so many of the patients, who I have come to care so much for, really are more deeply troubled than I had wanted to see before.  Part of the way I work, which has been successful, is to regard all the people as basically able to function, and even if they are messed up I try to draw out their strengths and show them the expectation that they can improve their lives.  I am sure that this helps them reach for that too.

But when I really dig into their lives and minds I often see how difficult what they have to deal with is, and how their thinking  has been crushed by either/and emotions, family, illness, society or just bad luck.

And, as it is with my wife, all I can rally do is be there, reflect upon it, and talk to them about it.
These are not very powerful tools.

Turning the Corner.

       In the month since I have last posted something here many things have changed.  But what I feel most is that if I have not yet turned the corner, I can certainly see around it. The future may be full of fears and fantasies, but there is now a pathway through the fog, and for the most part, at least right now, it is exciting.

       The downside is that there is a large negative influence that has exploded upon the scene.  This is not just the constant addition of obstacles and impediments to the practice of my profession.  No, this is very personal and it is the diagnosis of a chronic illness of my wife.  It is something that can be managed, and it may not turn out to be as destructive as it possibly could, but it does change the way she views herself and how she will need to operate in the world.  The extent of the necessary vigilance is not yet known, but the impact of mortality, and of the randomness of fate, is now always present.

       This will mean more pressure from my wife, and from inside of me, to live our lives a bit more deliberately and bit more meaningfully – as if I haven’t been doing that.  She doesn’t like feeling that things are beyond her control. She is hurt and angry, so I get to be the victim of mini-slights and corrections, as if it is me who is out of control. But I realize that those slights are temporary.

       But before the diagnosis hit, and about a week after my last note here, I turned on this computer and sat in for the opening week of my on-line course on biology and genetics.  It is being given free ot any and all who are interested.  But it is not a consumer friendly version of anything.  It is the course given by Eric Lander, the leader of the Human Genome Project, last semester at MIT.  

       The only difficulty is that the course, to do it well, requires lots of time.  Because like any real college course about the Community College level, the tests require much more than answering questions about what was taught.  They require taking what was taught and using it to solve a problem.  The problem involves terms and concepts that may have been briefly mentioned in a lecture, but which take time to review, organize and understand.  For example, the course gives the list of amino acids, but never really clarified the differences, or how they bond, or how they interact with other proteins – or for that matter what proteins are and how they are formed.  But the questions make you go and find these things out, which is possible, interesting, but very time consuming.

       But the main thing for me is that the course is about what is being learned now.  It is about things that were discovered ten or five or two years ago, and how they are being put to use, may possibly be in the future,  Also, it is about a basic feature of who we are as people and how we got that way and how things inside of us work, or don’t work.

       I find this such a refreshing change from the vagaries and speculation of psychology and psychotherapy.  The genetic/biochemistry interactions that create many features, traits, and illnesses that we have are extremely complex, and most are not at all clear yet, but they are emerging, and ways to explore them are also emerging.  It is such a long way from the personal speculation about hypothetical constructs and pompous “interpretations” of slight bits of behavior that have been true in psychotherapy for decades.  These “interpretations” often reflect much more about what goes on in the therapist’s mind than in the patient’s.

       For me, now, this is exciting. It is new, it is evolving, it is fascinating and it could and should be useful.  Will I ever be able to use the knowledge I gain if I continue to pursue things of the same of similar nature.  That is my goal.  I don’t expect to ge a Ph.D. in genetics or microbiology.  I don’t expect it will be me who make any startling discovery, or theoretical break-though.  But I would like to find a way to show how so many things are tightly integrated, and highly interactive, both inside and outside of people.  How a change in diet, fatigue, air pollution, architecture, sunlight, muscle tone, or repetitive noises can influence someone.  This can interact with family relationships, work performance, a personal slight, a sexual flirtation, a political point of view.  These things can affect family, friends, neighbors or a whole subculture. Those things have political ramifications that can affect diet and air-pollution that can affect how glucose can form the proper bonds with other amino acids, which can help or hinder a gene from performing its function properly.

       It is vastly complex, and I understand that no one can really have a real grasp on the details.  But it is exciting, fascinating.  And mostly, it is real.

       And anyway, I’m not that good at details.

Still wondering

Looking back on almost thirty years of trying to facilitate changes in the lives of people who are suffering with psychological, emotional and behavioral problems I am still impressed with how complex we humans are.  There are so many factors that influence how we think and what we do, most of which we are unaware of.

There are the major things such as who your parents are, what is your families ability to provide stability, how healthy you are, and where you live, that determine so much of how you view the world and how you act.  But those can be broken down, and broken down to the details, and which details matter, and when they matter still seem so variable.

Why is my patient, Max, so anxious while his brother is so uncaring?  Same house, same parents, same community, most of the same genes.  But two very different people.  It's true in every family.

Of the five therapists in my office, four of us are Pisces.  In fact, the four of us have birthdays within three days of each other?  Does that really mean anything?

Some of the patients I see, who come to me after years of being anxious and depressed, work with me for six months and skip happily out of the office.  Other take five years and still stare blankly at me during our sessions.  Others leave after three or four meetings and I never hear from them again.

What's the difference?  Me?

Obama wants to begin spending millions of dollars to study the brain, to see what goes on, what makes it function, or function better?  Fascinating.

He compares it to how successful the Human Genome Project was.  Which it was.  But what do we rally know that is useful from the HGP?  We do know somethings, and we seem to be on the verge of learning others.  But, mostly what we have learned is that it is all much more complex than we imagined.

Despite the crazy pressures that may be crushing the way that I practice, these are the things that I still want to find out.  It will be interesting.  I may even be able to be helpful.

I will probably have to spend more time out of my office finding ways to search and research.  But that's OK now.

Turn, Turn, Turn

I went away for a while where everything was warm and relaxed. At the end of a good time I realized that it was one of the very few times that I didn't want to go back to work.  This year, 2013, has been different.  I knew things were changing but it really feels as if the roof is falling in. When I came home I tried to write it all down and after about six pages of telling myself what was going on I realized that there have been several changes piled on top of each other which reate more confusion, more work and less money.  So, I condensed it all into this:

Last November I took a trip to Italy and reflected upon how our profession was changing.  Change was coming, but I thought it would be manageable, and that I had a few years to continue to ease toward retirement.  

But 2013 hit, and with it the S**t hit the fan.  It all comes down to letters and numbers.  The first one is something I have been writing to my Senators about at thee to five month intervals, but the issue and the threat of drastic cuts never goes away.

The other four are either hitting us now or are on the horizon, coming rapidly to shore.  

SGR

EMR

90834

DSM V

PQRS

What all these letters and numbers seem to mean is that an individual independent psychologist, working in his/her own ideal office, who wishes to be able to see the entire range of people who seek services, and that means those people who need to use their insurance to cover the cost, will have a great deal of difficulty to find the time, and to meet the cost of adapting to those changes.

In some ways we created our own difficulties by marketing our services so well.  I remember, a long time ago, when I first opened my practice one of the biggest concerns we had was that people were reluctant to come and see us because of the stigma of needing help.  Now it seems, everyone comes for help, for almost everything that affects them: stress, relationship problems, work problems,bad judgement, bad behavior, excessive behavior, passive behavior........

Now the problem has become:  Who is going to pay for all of this?

It does seem as if, except in upper middle class, well educated neighborhoods, the model of sitting face to face  with one patient in your comfortable office and talking about the ripple effects of their parents' interactions is sooooo 20th Century.

I am not saying that what is coming will be better or worse, but it is coming. 

I just may not be a part of it. I'm not sure I can afford it.

And here is the musical accompaniment:

http://www.youtube.com/watch?v=L9EKqQWPjyo

Misguided Angel

I don't often give alive, mostly because it never works.  But I will offer this up anyway, just because  there are some things I have learned.

If you are a parent, grandparent, close friend, teacher, or other important person in the life of a young woman between 12 and 19, and you see that she is  becoming overly attached to "bad boys," then do whatever you can to get her away from him, and then find out why she does this to herself.

Now, this won't be easy. There is no more unquestioned, loyal, unexplained ridiculous love that that of a fifteen year old girl-- remember the original Juliet?  And fifteen year old girls never listen to their mother, especially mothers who have done the same thing.

Yet, you will save this woman, and everyone in her family many years of aggravation and heartache  if you can pry her away.

Tell her if she wantss to be a savior and a social worker she will be underpaid enough.

Yes, Hope for the New Year!

It is a new year.  We are about half way through the first month.  It's been OK so, far; good for me.  I have just completed a weekend of hosting a young woman who is fifteen months old, and then all of us went to visit another who is a very mature twenty-five month old little girl.  They seem to like each other.  They also like to run, chase, dance, jump and be silly. Now that I have finally recovered from my cold and ensuing cough I can fully enjoy their company.

While my practice is very busy the foundation upon which it is based is crumbling. It's going to be a bad year for many psychotherapists. Despite all the attention that is being suddenly paid to mental health problem, due to the rash of irrational killings, the attention is not tied to any resources, just rhetoric.  For reasons that remain obscure, this year we are now supposed to limit, and monitor, the number of minutes we spend in a psychotherapy session.  Suddenly we are supposed to average 45 minutes instead of 50 to 60.  I guess we can do what we want, but we will get paid less.

To me, it hardly matters, as I am not going to put in the time to fight the American Medical Association, United Health Care, Blue Cross and Blue Shield and the other corporate deciders who have never actually attempted to deal with a person who is stressed, depressed, or in the middle of a panic attack -- not to mention  attempt to smooth out the life of someone who has been raped, molested by their step-father, grew-up with a schizophrenic or drag addicted mother, or lost three of the five members of their family in a fire when they were eight.

It gets a bit discouraging to be expected to work hard, confront vast, complex individual and societal problems, and be told that we shouldn't really expect to get a living wage for that, and that in order to get what they will give us we have to keep better records, become more efficient, justify how we work, and document that we are following protocols that may or may not be relevant, and accept less money. So, if your therapist seems a bit stress, cut him/her some slack.

The prevailing American culture still makes it clear that money is still more important than actual people. I doubt that many of those decision makers spent the weekend playing run, chase, dance, jump and being silly. They were worried about the cost.

Too bad for them.

A Post about Posting

In some ways it was gratifying to see that my last post struck a nerve and was passed around a bit.  It wasn't quite "viral" but it was read by many more people than usually view my occasional thoughts.

If ever there was gong to be a critical moment in my life as a blogger that could have been it.  I should have followed up immediately with clever, insightful posting on each of the next five days, with the hope that my mumblings would become the "go to" place for psychological insight into the evolving and/or decaying state of our wired, digital, always on, always expressive society.

But I didn't.  I had a cold.  I still have a cough.  It is the holiday week so I only have to work one day of  eleven. Due to my coughing, and everyone else's illness also, we canceled our trip to the Big City, and I stayed home and read old books, old and new magazines, blogs and weird web sites.  I watched things on YouTube, I listened to things on SoundCloud, I almost caught up on my email, I watched really meaningless football and I spend some time with the grandgirls, who had been sick also.

After all of this I have come away thinking that before I say anything else; before I rush to post my brilliant insights out here in the great and ever expanding world of cyberspace, I really ought to have something unique and interesting to say.  Even then I have to make sure that I am putting it out there because I want people to read and comment on it, more than I want to become known for saying it.

Russ Douthat, one of the NYT's more conservative columnists wrote today that people should take the time to read opinions that don't agree with theirs.  They should try to understand that the opposition, no matter which side, may not be just a bunch of brainwashed nutjobs.  While I think that idea has a lot of merit, for me, at this time, I am recommending that I stop reading almost everyone.  The political noise has become deafening.  Everyone has an opinion, many people put them out there, and then even more people write mean, trite comments, dismissing what was said.

There is a constant flow of opinion, information, music, art, good and bad science, family pictures, famous people, naked celebrities, half truths, the other half of truths, ways to be creative, ways to be creative differently, ways to make money, creative ways to make money, ways to spend money, ways to stay healthy, things to eat, how to cook them, how to grow them, where to buy them.  Individually, people post about the parties they are at, the restaurants they go to, the drinks they make, the people they don't like, the pills they take, the things they buy, pictures of their kids, their plants, their private parts, on and on and on and on........

My friends and colleagues are making "apps" as I predicted they should.  One is even making the exact app that I had designed one day last summer.

Everything is in the marketing. My app, which I never actually finished, is no better or worse than her app, but if she can get it our there first and fastest, then maybe, perhaps.....

The good thing about having a cold is that I didn't feel like doing much of anything.  I just let myself stare out the window at the early setting sun and just let my mind wander, without the pressure of doing anything worthwhile, and without trying to keep up with what is going on.

What I seemed to learn from this was that things will keep going on, and on, but that they really don't seem to be going anywhere particularly quickly, except "over the fiscal cliff" which could happen because no one can make anything happen.

So, my job now is to make sure I move back a little, for a while.  I will just sit here, or walk somewhere, or play with one and two year-olds, and give my own mind a chance to clear.

I will finish Moby Dick, (only 1/3 left), listen to some Bach, and I will watch the sunset, and sometimes watch the sun rise.
Perhaps, if I gain some brilliant insight, I will write about it here.  But I don't expect brilliance, and that's OK. It's enough to be alive and getting healthy.

Happy New Year to all!

I hope all of you stay healthy,  find some peace, some prosperity, find some fulfilling activities, and enjoy being with a few people who are important to you.

What the NRA mean

I think i am paraphrasing here, but this is the jist of what the NRA said today:

The nice old guy

in the blue uniform

with the gun in his holster

making $8 an hour

in the school entry way

will be honored as a hero

after the first bullets from the high-velocity automatic weapon

pass through him.

And then we will have the funerals for the rest of the children.

Terrible, terrible, terrible

Anyone who knows or ever knew a six-year old has to be totally stunned and heart-broken at what happened on Friday. It is one of the scariest and most meaningless kind of acts that anyone can commit.

The U.S. is faced with another awful, expensive dilemma, as another part of our infrastructure is found to be neglected, underfunded, and ignored, and that again, it is revealed what happens when a problem is left to grow instead of being solved.

The first problem, and one I admit I have an interest in, is the huge amount of mental and emotional difficulties that are not dealt with.  There is a growing number of kids who are on the autism spectrum and/or have really difficult behavior problems.  These kids either don't get help and end up in jail, or they bounce from school to agencies, to probation to special schools, and if they are getting the treatment they need, and some do, it is very expensive.

Could this kid have been found and his behavior averted if there were more services available?  Perhaps.  That is very difficult to know. It is certainly worth the effort.  I think some of my patients could have gone that way, perhaps, but they got at least some attention.

And the other part is guns, especially automatic weapons, that can shoot dozens of rounds very quickly.  I have asked on some of the web sites I visit on which there are some gun advocates, for an explanation of why American citizens need to be armed.  I have not yet received an answer that I really understand.  I do not expect it to be rational, as perhaps my abhorrence of the availability to such weapons may not be rational, but I would like to understand the thinking, or the feeling.

Yes, gang member have guns, and drug dealers have guns, and so do legitimate hunters and backwoods men.  But we don't live in the 1820s any more.  We live in a time when all of our lives are greatly intertwined.  There are many more restrictions we have to live under if we are to have a society that functions.

But I really believe that there are many people out there who believe that the Muslim in the White House is about to declare Sharia Law, and that if we are not armed out women will be taken away. I guess tehy feel that if it can happen in Egypt, it can happen here.

Another Blow to the Profession

DSM V.

It's a joke, and everyone knows it.

It isn't enough that we, Ph.D. Psychologists have to battle it out with "coaches," gurus, Internet experts and mystics, now the entire field of psychiatry has disgraced itself.  Since 2/3rds of Americans really don't know the difference between Psychology and Psychiatry we get lumped in with this blatant attempt to bolster revenue by a profession that is even worse shape than ours.

Psychiatry has become a profession in which 96% of its practitioners have become nothing but pill pushers.  I don't think they get more than ten hours of training in psychotherapy.  So now, to help them out and to aid their fellow travelers in Big Pharma, the list of thoughts and behaviors that can now be considered "pathological" has been increased to include almost anything except brushing your teeth and going to bed early.

The worst part is that they did this despite a lot of pressure, even from their own members.And because of all of the disagreements, they skipped the part about getting anything close to scientific data to back up their ideas that a three year-old who screams and cries because you take your iPhone back, is having an out-of-control event that may require medicating.

The only thing they seemed to have left out is the "Delusional Grandiose Marketing Strategy" diagnosis that should be given to the entire  crew that put this thing together.

Let's just all start over with the big masks, and shake those coconuts with seeds in them.  That will drive the evil spirits away.

To avoid panic attacks

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

--Herman Melville
Moby Dick,  Chapter 49

Another Times Article

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

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

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

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

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

Their Children

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

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

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

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

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

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

Love, Money Power and Sex

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

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

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

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

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

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

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


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

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

Ravello

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

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


From Wikipedia:

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

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

not bad.

_____

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

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

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

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

As the Dali Lama says in one of his tweets:

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

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

Positano

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

 

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

 

 

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

view from hotel, looking down at beach

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

 

 

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

Napoli to Positano

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

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

Napoli to Positano

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

Reflections While Away, 1

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

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

I won't take it personally.




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

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




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




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




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

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




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

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

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

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

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

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

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




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




Perhaps,
as Fritz Perls said:


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





Perhaps not.

Tx M

Heading out again

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

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

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

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

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

Bye-bye form Pop-Pops.

Small Perspective

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

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

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

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

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


ALSO: on setting limits:

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

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

no diagnosis?i

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

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

That may not be so unique.

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

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

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

But it's not there.

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

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

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

Diagnosis:  312.10:  impulse control disorder, NOS

A life of the Times

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

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

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

It is also much easier.

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

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

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

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

new direction

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

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

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

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

Presentation

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

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

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

Let's see how it goes.

Men -- Fictional

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

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

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

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

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

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

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

Things are different now.

Better? That's for you to decide.

Before I go

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

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

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

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

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

But we know better.

Now, why did I write all this?