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?

3 Reasons to Be Tired

#1.
I can tell I am getting tired.  It seeps into my body, my mind and my soul.  This is part of getting ready for vacation, which now is just a week away. To go on vacation it is necessary to be tired.  A vacation should be earned.  For me, it is difficult to just walk away because you can; you have to be tired.

So I am getting tired.

#2
It seems like many of my colleagues are tired also, and a bit scared.  They can see that the landscape is changing.  This whole health care delivery discussion makes everyone wonder what's going to happen.  It is reasonable to assume that those who will be making the decisions will have no idea what they are really talking about -- on a therapist to patient level.  The decisions will be based on money.  Those of us who still bill insurance companies for our services have already seen that the way insurance companies will cut costs is to pay us less. 

The other way will be to not pay us at all.  The model that most psychotherapists use, seeing people in their office for about 50 minutes at a time, once a week, was created about a hundred years ago.  It hardly fits today's world.  Two things are happening.  Well trained, Ph.D, or M.D. therapists are being replaced by Master's level people who are paid less.   Also, technology will enter into the mix.  People will be treated by text messages and Tweets. How much does it matter?  I think it does, but it is very difficult to demonstrate. I am the best therapist in the world and I only help about 62.347% of the people I see.

All of this makes everyone discouraged, and tired.

#3
When I'm rested and on the top of my game, doing therapy is challenging and fascinating. When I begin to get tired I can feel the resistance.  I can still deal with it, but it is there.  What happens is I feel badly when I open the can of worms and really see what's in it.  Today I was working with a guy I have been seeing for about six weeks. I like him.  He is bright, interesting and came to me for anxiety problems.  I am good with anxiety problems, especially if they are , you know, anxiety problems.  But they are not always just anxiety problems, very often they are more than that. It can take a while to find out.

Today, I was doing what I do, which is when someone with anxiety is still just as anxious even after I have sprinkled the first wave of magic dust on them, I probe a bit to find out what' s going on. Now, this is a guy I really like, as it is with most of the people I see.  When I like them I don't want them to be too fucked up.  But I still have to look under the rocks and see what's ticking.  So today, I looked under the rock and found out the the guys isn't just anxious, he's full of self-loathing and has cut himself.

I was tired.  I didn't want to find this out.  I want him to be OK.  I wanted it to be easy.  I can handle it, but then I'll go on vacation.  Now I have to do things to make sure he's OK.

It's not that I'm complaining, because this is what my job is.  It's just that I'm.......
complaining.

I am OK -- but..

I am OK.  In fact I am doing surprisingly well. This has been a great summer.  I am in good shape and healthy.  My eye is better, my knee is better.  Nothing really hurts.  I have been very active kayaking, biking and chasing my grandgirls -- only one of whom can actually walk, so it's not that hard -- but the one who can walk loves to run away.

I like hot weather, so the summer has been good to me.  We go off to the beach house and play.The kids have been coming and bringing their kids. Friends have been coming. We discuss how the world is  falling apart while sitting in great comfort.

Then I go to work and things are different.  but that is the nature of what I do.  People very rarely come to me to tell me how happy they are, or how excited they are about the interesting, creative, fulfilling things they are doing.  That happens occasionally, but that means it is the last session.

But I have been doing this for years.  I can deal with depression, even terrible depressions.  Anxiety; hey, everyone I see is anxious, also I can be helpful for loss, loneliness, confusion, stress, relationship problems, addictions, even violence. Hey, let's talk about it. My kind of therapy at least doesn't have side effects.  It won't make you constipated or gain weight.

But you know what upsets me.  Dealing with people who have chronic, physical pain.  I mean pain that has lasted years and comes from degenerative diseases.  Diseases that not only resist treatment, but that the treatments for them seem to create other painful conditions.  The drugs lead to passing out, or digestive disorders or kidney failures.  Pain raises blood pressure, the drugs for that causes dizziness, people fall down, cut themselves and go to the hospital and pick up a staph infection. The antibiotics for the staph infection cause colitis, which leads to a colostomy.  But still the pain, from the degenerating bones, or the pressure on the nerve from the back injury, or whatever it was that began the whole process goes on, and no one can really find it, and if they find it they rally can't do much about it.

Part of why it bothers me is that I am getting older, my friends are getting older and my clients are getting older.  For me, I can no longer run and jump.  For me, who played basketball for 25 years with the same group of guys it is a loss.  But I can cope.

What i know is that more is coming.  More of my friends have had knees replaced, hips and shoulders too.  They are on all kinds of meds because this or that number comes up too high. I take one little pill. Other friends have stents in their bodies, or have difficulty getting out of chairs, or even, are dead already.

So far, most of my friends and family are basically OK.

I plan to be immortal, until I am dead.

Back to work

The summer will continue, but for now, I am returning to my office.  I did have a marvelous week at the beach house.  I did get to go to the beach with my grandgirls, although Elmo stayed at the house.  We threw rocks into the waves, we sat on the edge of the water and made splashes. I got to see my children be parents, which is kind of weird, but certainly an experience, and it made me very happy and  a little sad (becasue I don't want to be old)..

Now I am in the re-entry phase.  I picked up my messages and made several phone calls.  I have a lot of appointments this week before I get to go back to the beach.  Some of them have already canceled, others have left messages seeking an appointment and they will will the openings.

Also, I have been perusing some of the blogs of my colleagues.  Most of those are done as kind of marketing tools.  They usually try to spread some psychological wisdom around the Internet.  They give suggestions about how to be active in the summer, how to get people to listen to you, how to be more confident, how to daydream creatively, how to daydream destructively; in general how to live your life in a better, healthier way, if you have any time left after reading how to do all those things correctly.

But this blog is not like that.  As you know this is the anti-marketing blog.  This is where I tell you that I have a very busy week ahead, but there are a few people, a real minority, like 15%, that bother me, and that overshadows my thinking about the folks I am eager to see.  Most of the people I see are working hard to change their lives.  Many are struggling against "strong headwinds." as our President likes to say about the economy.

But there is this small group of patients are really nuts, and they ain't going to get much better, and they weigh me down.  They are the ones who make phone calls while I'm away.  They are bad with boundaries, they are bad with time, they make bad decisions and they don't take responsibility and have little insight, and they talk and talk and talk.

I am sure every therapist, especially if you have been in business for a while, has a bunch of these, but they don't seem to talk about them on their blogs.

So, put on a smile, as it helps your neurology, develop a positive attitude, enjoy the summer, be nice to your friends and family, eat only food that is good for you, don't go into debt, exercise regularly, sleep well, don't worry needlessly, stand-up straight, breath deeply, meditate once in a while, think before you act, and break your addictive habits.  And don't call your therapist unless you need to change your appointment time.

Summer, again, briefly

Wow, it's been a while.

That's becasue it's summer and there is so much to do.  so much to do without thinking about it.

Right now I am officially on vacation for a week.  Before this I was working days and then taking off whenever I could.  Here in New England, when the sun comes out you had better be there because it all ends quickly. It doesn't matter if you're out to get in the water, hit a ball, ride a bike or just take a walk; the time is short.  We don't get Spring, except for about three days.  It goes from 42 degrees and drizzle to 87 degrees and heat.

Work in the summer is different.  There are fewer patients but they are nuttier. Everyone half same takes off and gets outside.  The fragile ones go into crisis. It's the heat, the moon, the outside.  It's the alcohol, the half naked women, the resentments.

The day before I was leaving I get an emergency from someone I had not seen for three years. Falling apart, laying on the floor of the H.R. office crying.  The next day I guy I hand't seen for four years comes to my office ten minutes before my first appointment.  He needs to talk.

"Some people claim that there's a woman to blame." And they are correct.

But tomorrow the Grandgril comes, and after Elmo, I'm one of her favoirtite guys. Let's go to the beach.