50% success rate for New Year's Resolutions

Despite the Guardian's grim headline (New Year's Resolutions Doomed to Failure, Psychologists Say), what the psychologists in question actually seem to be saying is that if you follow basic behavioral principles developed by psychologists over decades of scientific research, rather than mere impulse or self-help blather, you have a 50-50 chance of achieving your goals this year.

1. Don't pick something on impulse. Pick something you've been thinking about doing for a while and have had a chance to plan a bit.
2. Set a series of small, measurable goals instead of one giant one. 
3. Keep records of your progress.
4. Enlist support: Go to Alcoholics Anonymous meetings, or tell your family what you're doing, or get an exercise buddy.
5. Focus on the positive--don't plan to lose weight, plan to add 5-9 servings of fruits and vegetables to your daily diet.

Ethical Dilemmas in Fiction

I have a brief review of Stephen White's Privileged Information--with an even briefer discussion of privilege and confidentiality--up on my website.

APA Statement on Senate Passage of Health Care Reform Legislation

APA Statement on Senate Passage of Health Care Reform Legislation

Abortion

This month's American Psychologist came in the mail yesterday, and it includes an article surveying research on the supposed causal links between abortion and subsequent mental health problems.

Major, B., Appelbaum, M., Beckman, L., Dutton, M.A., Russo, N. F., & West, C. (2009). Abortion and mental health: Evaluating the evidence. American Psychologist, 9, 863-890.

What they found was this:

"The most rigorous studies indicated that within the United States, the relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy is no greater than the risk among women who deliver an unwanted pregnancy. . . Most adult women who terminate a pregnancy do not experience mental health problems." (p. 863)

Some history:

• 1989. After two years' study, then-Surgeon General C. Everett Koop informed then-President Ronald Reagan that there was no data to support the idea that abortion either was or was not psychologically harmful to women. That same year he testified to Congress that all available data indicated that abortion was physically no more dangerous than carrying a fetus to full term.
• 1990. An American Psychological Assocation (APA) panel of experts concluded after a thorough review of the literature that women cope with abortion just about the way they cope with any other life stress.
• 2008. An APA task force reported that the relative
  risks are no greater than the risks of delivering an unplanned
  pregnancy.

Are you beginning to see a trend, here?

The authors of the current article reviewed a whopping 58 papers from five countries published over the course of the last two decades and concluded that

1. as stated above, the risk of carrying an unwanted pregnancy to term and the risk of a legal abortion are about the same
2. termination of a wanted pregnancy because of either the mother's or the fetus's health poses no more risk than if that pregnancy were to end in stillbirth, miscarriage, or neonatal death
3. any mental health problems that do occur in individual women following an abortion are not caused by the abortion itself. Rather, both abortions and unwanted pregnancies co-occur with pre-existing social, financial, personality, and behavioral problems (e.g., addiction) that can result in mental health issues "irrespective of how a pregnancy is resolved" (p. 885)
4. most women do not regret the decision to terminate.

What?

According to this month's AARP magazine, Sting (the artist formerly known as Gordon Matthew Thomas Sumner) says that winter is "a time when we reflect. As global warming takes over, we're losing some important balance in our psychological makeup... we need that time to regenerate."

As Riley the parrot is fond of asking me, "Whatwhatwhat??"

We, who? Northern white male European honkies like Himself? What about all those people who live in the Torrid Zone? Africans must have been seriously psychologically out of balance for thousands of years, hunh. Central Americans, too. Wonder how they managed to produce some of those magnificent civilizations of yore without all that reflection and regeneration time?

What about all those people for whom it's all winter, all the time? By this theory they should have produced truckloads of "reflection". Inuits and Norwegians must have some kind of lock on psychological balance, hunh.

This is why people who (a) don't know anything at all about psychology, and (b) are so glaringly culturally short-sighted should never, ever pontificate about the subject. Especially not for attribution.

You're not going to tell my parents about this, are you?"

How much privacy does a teenager have a right to in therapy?

Not much, actually, as it turns out. Here's why.

"Privacy" is how we typically think of the kinds of issues such as whether a parent has the right to go through a teenager's room, read his text messages, examine her browser history, or friend a son or daughter on Facebook. In that regard, how much privacy a child has will vary from culture to culture, and within a culture, from family to family, because it's a value question. As relates to a child's mental health records, "privacy" has to be distinguished from terms such as "privilege" and "confidentiality".

Legally, we have the right to protection from undue intrusions into our private lives, and that includes the right to have our medical records kept private. "Confidentiality" is the client's expectation, and our professional obligation, that we not further disclose the private information shared with us. A client can waive that by signing a release; in the case of a minor, only the parent or guardian can do that, and they can do it against the client's will if they wish.

"Privilege" is a special exception from the obligation to testify in open court to what we know from a client's communications in therapy. As such, privileged communications are protected from discovery, which means that they can't simply be subpoenaed. A client can waive privilege, and in the case of a minor, the parent or guardian can waive it--again, whether the minor wants it waived or not. If the client's legal representative makes his mental health an issue in a legal proceeding, that is an automatic waiver.

On the upside, most states allow minors to seek treatment without parental consent for such issues as sexual abuse or substance abuse, and in these sorts of situations of course the point is moot. By definition the minor will have control over his records.

So how much privacy a kid in therapy has depends on what kind of information-sharing we're talking about, and with whom. A minor client generally cannot act on her own behalf in that regard, any more than she can in any other legal matter. Ultimately it's going to be up to her parent(s) or guardian. And this includes the power to compel the therapist to discuss the child's therapy with the parents, and even to let them read the record. So the real question becomes, "How much right do parents have to information about their children's treatment?"

Legally, in most situations, they have every right to all of it. Practically speaking, however, privacy is a sine qua non for therapy. No teen is going to share any but the most banal of her thoughts and feelings if she thinks I'm going to trot (well, ok, limp) across the hall to the waiting room after our sessions to report to her parents, "Guess what your daughter just told me!"

For that reason, most of us who see minors try to negotiate the gap between what's legal and what's practical before therapy begins. We discuss the dilemma with the client and her parents. We ask the parent(s) to sign a statement agreeing that they will (a) not have access to the record and (b) be given only general information about their child's progress in therapy unless there is some threat to that child's safety.

This is the pertinent language from my Consent to Treatment paperwork:

MINORS & THEIR PARENTS

Patients under 18 years of age (who are not emancipated) and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the minor client or s/he and I agree otherwise. Because privacy in psychotherapy is ESPECIALLY important to progress with teenagers, it is my policy to require an agreement from parents that they consent to give up their access to their son or daughter’s records. I will provide general information about the progress of a teen’s treatment and his/her attendance at scheduled sessions—and nothing else. I will also provide parents with a summary of their son/daughter’s treatment when it is complete. Any other communication will require the teen’s consent, unless I feel that that s/he is in danger or is a danger to someone else, in which case of course I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the minor client, if possible, and do my best to handle any objections s/he may have.

The older the child, the more likely I am to obtain his permission, too, because it is a decision that affects the minor and I believe minors should progressively take more responsibility for their own lives as they approach adulthood. Developmentally, this is a gradual process, not an ability that manifests full-blown on the day a person turns 18. That, and being out of control of one's life not being a pleasant sensation: Anything I can do to increase a client's sense of power and control must therefore necessarily be A Good Thing.

So far, so good. Sounds simple, right? Well, no. In the first place, the written agreement may not be enforceable. Fortunately, most parents get the need for privacy, and, having the children's best interests at heart, will respect it. But if push came to shove, I probably would have to open the records to a parent or be in contempt of court. That's never happened in several decades in practice: My problem is more usually that I have decided I need to bring the parents in on something, and the teen does not wish to.

The second problem is, how do we define "danger"? Some things are obvious: A teen has suicidal ideation, a plan, the means to do it, and clear intent (like a time and a place) and I can't negotiate any solution in the session. A no-brainer, that. I pick up the phone and call the parents.

But what if the child is using drugs? Having unprotected sex? Does it make a difference whether it's pot or crack? Whether the sex partner is a kid his age or someone 20 years older? What if he's driving drunk? Or just driving too fast? Do I tell parents if a kid is ditching school?

Therapists constantly weigh these questions, and in practice different ones of us resolve them differently--depending on our values, the minor, the parents, and the situation. So in practice, there's a lot of variability. Some practices don't limit parental access at all. Others believe that minors, especially older teens, should be entitled to the same protections as adults, regardless of what the law says. In this view, the child is the client, and it is to them that we owe our duty of confidentiality. Thirty years ago, the American Psychiatric Association had a task force look at the matter, and they recommended that the age be dropped to 12.

The American Psychological Association is not much help. Their recommendations range from respecting a minor's privacy at the same level as an adult's, to establishing local policies in accordance with the law, recommendations which are obviously and completely contradictory.

So while legally a teen has little right to privacy, in practice most teens have complete, or nearly complete, confidentiality observed. But again, there's lots of variation. So if you are a teenager thinking about getting into therapy, or thinking about sharing something big with your therapist, my best advice is to ask her or him what her policy is, and what she might be likely to do in a given situation.

Tommy Bryan on World War I

My Mom's Dad had three war stories.

In the first, he is marching toward the front when his squad passes through an olive grove. He claims that he'd always loved olives and so began picking them from trees near the road, carrying them in his helmet and eating them on the march. Which apparently made him quite sick.

In the second, he is in the trenches, watching the little aeroplanes go over, thinking that was the place to ride out the war--safe home at base every night. So he applied to be a pilot, but was not accepted. I am glad, in retrospect, because while I certainly would have wished him out of the trenches, the death rate for fighter pilots in those days was staggering.

He did manage to transfer into a supply/transportation battalion and would spend the rest of the war driving food and ammunition back and forth from the front. He might not be at home base safe every night, but he would be most nights. In this, his third war story, he is driving toward the front and is close enough that he can hear the guns. His truck slides into a ditch, sort of accidentally on purpose, and he spins the wheels "trying" to get out until he is well and truly stuck there. He is happily sitting cantilevered into the ditch, eating a sandwich, when along comes a French tanker who insists on pulling him out.

He would giggle at this point, that funny hee-hee laugh of his, and tell us that no sooner did the tanker pull him out than he promptly slid back into the ditch. Again, the Frenchman, cursing, hooks up the chains and pulls him back out. Again, my grandfather, making a big show of his incompetence, slides into the ditch. The Frenchman throws up his hands in Gallic disgust and rolls on. My grandfather ends the story by telling us that was as close to the front as he ever intended to get.

I do not think my grandfather was a coward: Quite the contrary. He never spoke of his experiences other than this. You just could not get him to. My grandmother, however, once said that he came back from the war with his health ruined, and that it was years before he got it back. You don't ruin your health sitting in a ditch eating a sandwich and giggling. So I always believed that he suffered, as infantry did in that war, horribly, and was lucky to return home alive. And that it was a combination of modesty and discomfort with painful topics that kept him to his three-funny-story repertoire.

As an adult, and later as a mental health professional, I found this pattern pretty common. Vets tend to talk to vets, and to demur with everybody else.

My father in law never said much about his World War II Navy service, either, but I watched him light up when he met my cousin who'd also served. They spent the whole time during that family gathering comparing notes on their experiences. On another occasion, we took my father-in-law to a movie about the Pacific war. I don't remember which one. But again, I remember how he perched on the edge of his seat, eyes riveted to the screen, excitedly whispering to us, "That's where we were. . . yes, it was just like that!" and so forth during various invasions and sea battles throughout the movie. And then not one word in the car on the way home, nor did he ever mention it again.

Vets are pretty sure we won't get it. They may be right, but we have to be willing to try. We owe them that, and so much more.

Disturbed patient, disturbing therapy by St. Cloud psychologist | StarTribune.com

Somebody on Twitter alerted me to this story. Briefly, a therapist got over-involved with two of her clients and was disciplined for it. The problem, at least as it is framed by the local newspaper, is that she has poor boundaries and poorer reality testing: As they so cutely put it, she believed the client's delusions more than the client did.

The line between a memory and a delusion is a fine one, especially in Dissociative Identity Disorder (DID). DID occurs in people who have suffered especially severe and often bizarre, but quite real, abuses while at the same time there is an unreal quality to the disorder itself. Real memories, in other words, quite commonly exist side-by-side with unrealistic beliefs in DID.

Therapists are not, and cannot be, in the business of validating clients' memories. However, when a client questions her/his own memories, we can encourage reality-testing by the client. In doing so we must not forget that perpetrators of abuse quite naturally go to great lengths to hide what they are doing, so that validating a specific memory may simply not be possible. We also need to caution clients against attempts to validate that may be dangerous, such as directly confronting perpetrators.

Sometimes the only validation available is indirect: We are working on a dysfunctional behavior in therapy, a memory surfaces, and the behavior “spontaneously” clears up. Other examples of indirect validation that come to mind include addicted and sexually-acting-out siblings (possible co-victims) and an arrest of a relative for a related crime. None of these things proves the validity of a specific memory, but it does lend credence to the client’s family portrait.

It is a myth, by the way, that a person has to remember in order to heal. Or that survivors have to remember more: To quote the late Ann D. McAllister, Ph.D., "What [they] already remember is more than enough." Digging for additional memories runs the risk of (a) producing "memories" that aren't, and (b) completely unraveling the client's ability to function in the present.

Since disbelieving real abuse can be as harmful as becoming part of a delusional system, the therapist serves the client best by focusing on current functioning. The focus of treatment becomes teaching the client to manage flashbacks, switching between alters, emotions, appropriate boundaries, insomnia, self-harm, addictions, self-image, etc. And the key phrase here is “teaching the client to manage,” not managing it for the client. Treatment for DID is emotionally intense, and it’s not going to happen without a degree of dependency developing. But throughout the therapy, the therapist maintains the boundaries of the working relationship and encourages the client’s independence.

National Novel Writing Month

National Novel Writing Month

I thought this looked like fun. Quite naturally, mine will be about a murder in a psychology practice.

9/11 still killing

I get my news on the internet these days, and as I was browsing blogs with my morning coffee in my hand today, I found this. "This" is an epic Fail on the part of this entire country to appropriately care for 9/11's first responders and the residents and workers in the immediate neighborhood.

But as if "this" wasn't bad enough, I looked up the law proposed to remedy it, and that was worse. "That" includes Congressional findings on the aftermath of 9/11. A few high points:

• On average, a New York City firefighter who responded has lost 12 years of lung function.
• Nearby buildings are, as far as anyone knows, still contaminated with "caustic" dust, to which workers and children are still being exposed daily
• All told, a half million people were exposed
• Nearly a third of the firefighters were still sick five years later, and 65% of them are scraping by on less than $15,000 a year because they can't work.
  
• Many lost their health insurance, Workers Comp has been jerking them around, and a lot of folk are going broke paying for their own care--or going without and dying.

And guess what? There's a lot of posttraumatic stress! Well, duh.

Go read the bill, please. And if it shocks you like it does me, contact your legislators and ask 'em to vote for it.

For my part, I will treat--absolutely free of charge--one person who can demonstrate to my satisfaction (a) that hir psychological problems stem from their presence at or near the Twin Towers on 9/11, and (b) that s/he does not have the financial resources &/or insurance to afford treatment on hir own. I'm on Main Street in Woodstock, GA.

Call me: 770-924-1818, extension 307.

It's the least I can do.

A few facts

This will break your heart:

22,000 people between the ages of 25-64 die every year due to poor health care provision/ lack of health care.

Between the time Mr. Wilson yelled, "You lie!" and the time you and I go to bed tonight, 60 people will have died for lack of care. Could be my son, or your grandmother.

For some more statistics along these lines, visit Prof Susurro's blog.

Silly Season

I wish that the President could simply have declared that the Silly Season was over, as of last night.

/sigh/

At the first commercial break, however, some PAC or other ran an ad with a woman actress telling how Canadian health care denied her life-saving treatment, and she had to come to the US for top-of-the-line care. It ended with a tag-line to the effect that no government should come between us and our doctors.

There are three lies in this:

#1. We are not replicating the Canadian system, thank you very much. The public option as currently proposed is not government-run healthcare, but a single-payer model.

This would, by the way, save a metric shit-ton of money. Unless you are in health care yourself, you have no idea how much time and money we fritter away verifying benefits for a dozen of different insurance plans every day, applying for pre-authorizations, recording pre-auths in the billing software, getting re-authorizations every few weeks, billing, re-billing, going to different websites to bill different payors, printing hard copies of all these transactions, paying for electronic billing services' monthly charges plus transaction fees, tracking payments, filing appeals, entering different insurance company discounts in each policy-holder's books, applying to be on panels, renewing memberships on panels, submitting to audits by insurance companies of our books and clinical charts, billing patients for the portion insurance does not cover, and explaining patients' benefits (or lack thereof) to them. We spend on staff, training, computers, printers, storage systems, phones, software, paper, postage, and space (a portion of our overhead expenses such as rent, utilities, tenant's insurance) for this work in addition to the time away from patients and continuing education. And after all that, we write off thousands of dollars in uncollectible fees when it turns out that the insurance companies won't pay for what their policies and pre-auths indicated that they would and the patients don't have the resources.

But I digress.

#2. We do not have the best care in the world, as the ad claims. We spend more than other industrialized countries, for some of the worst results in the Western world. Higher infant mortality rates, for example, than anybody in Western Europe--or Canada, for that matter.

#3. The current system does not give you and your doctor complete control of medical decisions, people. Ask anybody who's ever been denied coverage by their private-pay, nonsocialist, for-profit insurance company for the medication their doctor prescribed, or a treatment their doctor recommended. Ask anybody whose private-pay, nonsocialist, for-profit insurance company dithered about pre-authorization until a critical treatment window was missed. Ask anybody who's gone bankrupt paying for their own treatment because their wonderful nonsocialist, private-pay, for-profit insurance company refused.

Heck, some of you have never even met your primary care physician. Our current system is so expensive to the practitioner and pays so poorly that they all use so-called "physician extenders" now. You see a nurse-practitioner or a physician's assistant. Not that there's anything wrong with them, but let's don't pretend we have direct relationships with our physicians under the current system, ok?

And the ad conveniently forgets that up until Congress made it illegal, it was our citizens organizing bus trips over the border to Canada to get affordable medications. It also conveniently overlooks the recent 'health tourism' trend, in which U.S. citizens go abroad for affordable surgeries.

No, I'm afraid the silly season is far from over.

GlaxoSmithKline used ghostwriting to promote Paxil - The Boston Globe

Just a quick note, as, if I had any sense at all, I should already be in the car on the way to the office, not sitting here in my jammies blogging.

In a new article in the on-line version of the paper today, The Boston Globe adds GSK to the list of pharma con artists.

GlaxoSmithKline used ghostwriting to promote Paxil - The Boston Globe

The fact that five ghost-written articles were placed in at least two prestigious professional medical journals is significant. When you perform a literature search on a medication, you would typically get a handful of review articles. If five out of that handful are bogus, that is going to significantly slant your view of the medication. Add to that the fact that most physicians do not do lit searches but rely on articles handed to them by the reps, and you have trouble.

In and of itself this is no indictment of the drug. But it does mean that your physician may not have had all the facts when she prescribed this medication for you.

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soulful sepulcher: honesty on the rocks and make it a double

soulful sepulcher: honesty on the rocks and make it a double is another great post, and right on target.

Drug reps are so ubiquitous, I always assume a doc is influenced by them. I was impressed that Stephany's doc banned them. Good for him!

It never occurred to me to ask my doc if he has ever accepted trips or speaker fees, or ghost-written an article: I thought that was stuff reserved for the big names at the universities. Apparently I have been naïve. I intend to start asking, every time I'm handed a 'scrip.

The Carlat Psychiatry Blog: Eli Lilly Posts its Grand Deception

The Carlat Psychiatry Blog: Eli Lilly Posts its Grand Deception

Funny, a client and I were just discussing pharmaceutical marketing this morning.

This one's for you, T.!

The most important part of Dr. Carlat's post is the line about medical "educators" having to use the slides the pharmaceutical company provides. Real teachers don't do that, folks.

With friends like this. . .

. . . who needs enemies?

There I was, minding my own business, when an old friend from my high school and college days just up and slapped me in the face.

Some people read the daily news over their morning coffee. I log on to see what's happening in the world. And this morning, when I logged in to FaceBook, there it was: I almost blew my breakfast. My entire laptop screen, it seemed, filled with some of the ugliest hate speech I've seen since--well, come to think of it, since I read that cop's e-mail the day before yesterday. But that's another story for another day.

There's a poll on facebook asking whether people think gays should be able to adopt. As I said in my comment when I voted, these surveys are ridiculously unscientific, but at least some of them get people talking. The talk swirling around this one, however, is frighteningly ugly. Here's what my erstwhile friend had to say:

If queers want children, they should not be queers. Keep hoping natural selection would weed them out eventually.

That's just so hateful, and such a shock hearing it come out of his mouth, I don't even know where to start with him. I suppose I could start with the assumption we're all straight and will agree with him (or at least not be hurt or offended), or that people choose to be gay, but I've had that argument so many times that, frankly, the prospect exhausts me. Or I could start with the evolutionary angle, but, again, I have had that argument so many times that, frankly, the prospect exhausts me.

The subject of hate in general, and homophobia in particular, is easier to handle from an objective psychological-science-y standpoint than it is when I'm suddenly feeling viciously othered, in a very personally threatening way, in a space that no longer feels safe, and by someone I once loved and trusted.

So if you will kindly indulge me, I'm gonna go all clinical on y'all for a bit.

Search "homophobia" on PsycNET and you get a whopping 1,878 returns. Here's the Cliff's Notes version, along with some personal experience and clinical wisdom.

Psychodynamic theory originally posited that people who loudly proclaim that 'gay is awful' are actually gay themselves and just don't know it. Research results are mixed on that one. What does clearly seem to be going on is that people who express prejudicial attitudes have (a) defined the minority target as 'bad' and (b) are shoring up their own identity as 'not bad', distancing themselves through expressions of hate. So while homophobia may not be related to one's own sexual preferences, conscious or otherwise, the expression of homophobia may occur precisely as one's identity has been threatened--for whatever reason.

In plain English, the secure are not prejudiced: Expressed prejudice is a sign of insecurity according to this theory. If this is true, then when prejudicial statements are made in the context of a therapy session, the therapist need not address the prejudice at all, but may choose instead to hone in on the feeling behind it. Resolve that, and the prejudice should follow. Education won't work, if this theory is correct, because the person whose identity as 'good' is threatened needs some action (expressed attitude) to shore it up. If lesbian/gay people become 'not bad' through education and the dissolution of stereotypes, some other target will have to take its place.

Homophobia has also been associated with hypermasculinity: Together, these two theories might explain the otherwise puzzling behavior on my friend's part. You see, we both have disabilities. We both have experienced ableism. Wouldn't you think that we would be especially sensitive toward other minorities? But society almost ungenders the disabled, we are so perceived as 'not sexy'. Perhaps my friend is dealing with an internalized sense of self as 'less of a man', triggered recently by some bit of ableist aggression directed at him, by being 'not gay'.

Homophobia specifically by men against men has been related to a specific type of identity disturbance whereby feminine aspects of the self are disavowed (split off). Of course, this only works if you stereotype (gay=fey) and only works for hatred of gay men. It is also at present theoretical, not empirical.

Homophobia has been associated with a general lack of empathy (difficulties in perspective-taking), low Openness to Experience in trait theory, and with (in)tolerance for ambiguity. Contrary to many homophobes' claims to moral superiority, there actually may be a negative correlation between moral development and homophobia. From a psychodynamic perspective, homophobia has been found to correlate with the defenses of denial and isolation.

One thing researchers have learned is that right-wing authoritarianism and traditional gender role attitudes are associated with homophobia. And we know that right-wing authoritarianism is a personality trait before it is a political identity. Studies also support the idea that the various "isms"--racism, sexism, etc.--are related. If my friend hates gays, he may well also hate me as a woman, doubly hate me as one who eschews traditional roles, and Maud knows how he feels about my politics: Radical feminists are, after all, nothing if not anti-authoritarian.

Or maybe he's never noticed. Maybe, as a female, I'm invisible to him. Either way, we apparently have some talking to do. The prospect overwhelms me though, so I'm going to take refuge again, with your indulgence, in a little more science.

There is some evidence that education can reduce prejudice, but insofar as it works at all, it seems to have more impact on women. My personal experience has been that you can talk to prejudiced people until you turn blue in the face and it will not put a dent in their attitudes. Perhaps that's because it's inborn: One enterprising research team did a humonguous twin study which seemed to demonstrate that, via assortative mating, homophobia (or lack thereof) is transmitted genetically. Interestingly, they found support for the common observation that males are more likely to be homophobic than females.

Perhaps I am naïve; any road, this kind of thing challenges my assumptions about the world's benevolence. My review of the research literature on homophobia did not help. While I have happily maintained the fantasy of late that things are getting better, I found that in reality they are not. There are a number of recent studies on, for example, nurses that show that health providers in mind-boggling numbers would refuse to treat gay patients if they could. Other recent studies show the effects of homophobia in academe and the halls of justice. And therapists are not immune: Studies show that large numbers of therapists discriminate. I have personally known therapists who treat lesbians and gays while making extra-session statements to the effect that same-gender sex is "gross".

A couple of interesting sources I found via PsycNET:

Co​-​occurrence of rape myth acceptance, sexism, racism, homophobia, ageism, classism, and religious intolerance.

By Aosved, Allison C.; Long, Patricia J.

Sex Roles. Vol 55(7-8), Oct 2006, 481-492.

An examination of the relationship between moral development and modern prejudice.

By Barrett, Kimberly Ann

Dissertation Abstracts International Section A: Humanities and Social Sciences. 57(6-A), Dec 1996, pp. 2331.

Homophobia in men: A symptom of gender identity disturbance.

By Debiak, Dennis Michael

Dissertation Abstracts International: Section B: The Sciences and Engineering. 56(4-B), Oct 1995, pp. 2320.

The impact of a human sexuality course on anti​-​gay prejudice: The challenge of reaching male students.

By Finken, Laura L.

Journal of Psychology & Human Sexuality. Vol 14(1), 2002, 37-46.

Intrapersonal and interpersonal manifestations of antilesbian and gay prejudice: An application of personal construct theory.

By Moradi, Bonnie; van den Berg, Jacob J.; Epting, Franz R.

Journal of Counseling Psychology. Vol 53(1), Jan 2006, 57-66.

Genetic and environmental influences on individual differences in attitudes toward homosexuality: An Australian twin study.

By Verweij, Karin J. H.; Shekar, Sri N.; Zietsch, Brendan P.; Eaves, Lindon J.; Bailey, Michael; Boomsma, Dorret I.; Martin, Nicholas G.

Behavior Genetics. Vol 38(3), 2008, 257-265.

Attribution Style and Public Policy Attitudes Toward Gay Rights.

By Wood, Peter B.; Bartkowski, John P.

Social Science Quarterly. Vol 85(1), Mar 2004, 58-74.

I am not entirely sure that these links will work if you don't have a subscription to PsycNET: If it turns out that they don't, please consider this my advance apology. College students and faculty can access them free through Galileo; others may be able to find some available open-source.

let's talk. (about ableism)

"let's talk about the way we practice internalized ableism towards each other": an excellent question that really grabbed my attention.

I see internalized ableism in my practice all the time. Which is to say, I see it in my clients.

My clients frequently express hatred of and disgust toward their bodies. Interestingly, however, more of them express shame that they are not able to work than over the perceived inferiority of their bodies. The men aren't macho enough if they have disabilities, the women not sexy enough. But in a materialist society, apparently, the ultimate failure of the disabled is that we don't make money.

Never mind that discrimination is responsible for the largest portion of the wage-differential between, say, able-bodied white guys at the top and disabled women of color at the bottom--it still feels to us like some kind of character failing on our parts. Never mind that materialism is a rotten way to value people--we still feel like losers.

But how do we practice internalized ableism toward each other? That is harder to see.

• Am I, outside of my awareness, guilty of speaking for my clients?
  
• Are even clients with disabilities of their own making assumptions about my professional abilities based on my physical (dis)ability?
• Do I make a space where other people with disabilities can feel welcome?
  

Please Hold While I Connect Your Call

We had a spirited discussion in supervision last week about what it is exactly that we as therapists do for our patients. Job #1, as I see it, is to make connections.

Our clients are invariably suffering from some form of alienation. Perhaps they are alienated from their feelings: They don't know what they feel. Or they don't know why they feel it. Perhaps they are alienated from their selves: They don't know who they are, or what they want. They don't know why they do the things they do. They see-saw back and forth between contradictory wants, thoughts, feelings, actions, and self-images. Or they might be alienated from others: They can't maintain a relationship.

So what we do is we help them re-connect to alienated, denied, repressed, suppressed, split-off, and projected parts of themselves.

If people are alienated from their feelings, we help them get back in touch with them. Some people are all in their heads, some have split off their feelings and either projected them onto someone else or created alter personalities to handle them. Still others drink and drug to numb their feelings. Some just deny that they have any, and hope that will make it so. Women in my practice are frequently (if not usually) especially alienated from their anger. We might help them make the connection between their abuse of alcohol and drugs and their wish to avoid feeling angry. Or their wish to reduce inhibitions to the point that they can let loose some anger. We help them re-own anger they have split off and projected, be it onto another person or into another personality. We help them look at patterns in their lives and what their anger might mean in response to people, places, and things. Maybe we help them learn to use their anger as valuable information, as signals.

Which brings us to power. Most of my clients are no more or less powerful than the next person. But women in particular tend to believe they are powerless: They have become alienated from their own strength, usually by the same social process that alienated them from their anger. Therapy, therefore, may involve getting women to exercise that particular muscle as well.

Other people are alienated from their reason and ruled by their feelings. These folk need to be re-connected to their rational sides. We can do that, too. Therapy is a whole lot more than getting in touch with your feelings.

Some folk have become alienated from their very selves: Their parents split off experiences that would otherwise be intolerable and projected them onto the patient. Or tried to live vicariously through the patient. Instead of mirroring for the child what the child is actually like, these parents' eyes are as inaccurate as funhouse mirrors: No child looking into them all day ever day is going to grow up with a realistic self-image. Therapists, if we are doing our jobs, help clients look at themselves with their own eyes (through ours) and begin to see themselves as they actually are. They learn what they really want, not what somebody else has been telling them all their lives what they should want. We reconnect them with their own opinions.

And we reconnect them with their voices. Perhaps a child has been told all his life that what he has to say isn't important, or is incorrect, or must not be spoken of at all. This child, as an adult, is alienated from her own voice. We help her re-learn to speak her piece, often by simply listening objectively, without judging her or injecting our own points of view.

As a psychodynamic therapist, of course, I thrive on making connections between peoples' pasts and their presents. Why do they do what they do? Where did they learn that? What impulse/fantasy/wish/fear are they acting out? Where are its roots in the distant past? How does what goes on in the therapy session connect with how they conduct (or fail to conduct) themselves in their "outside" relationships?

The list of possible connections is endless. What is alienated and needs to be brought back into self-awareness varies with each client. Our job is to help them ask the right questions, observe themselves, analyze the data. We listen. We observe. We make connections.

So that's what therapists do. We are the telephone operators of the psyche.

Impostor Syndrome

Back in the late 1970s, there was a draft of Pauline Rose Clance and Suzanne Ament Imes's 1978 paper on the impostor syndrome circulating among female academics and professionals in and around Atlanta. I probably still have my copy somewhere, but with my filing "system" the chances of ever finding it are slim to vanishing.

In it, Clance and Imes proposed that professional women, no matter how accomplished, continued to believe deep down inside that they were and always had been 'faking it' and would soon be unmasked as the impostors that they were. For my generation, which came along after theirs, it is still true. You can't grow up hearing tens of thousands of sentences over the years that begin with "Girls can't. . ." or "Women don't. . ." without coming to believe in your heart of hearts that whatever it is you are doing now, you really shouldn't--and indeed, can't.

In the published paper, the authors described a self-perpetuating cycle in which, because women attribute their successes to luck or other temporary outside forces, they are unable to internalize any success as proof of their very real abilities. So no amount of success can convince them otherwise: Each new level reached in their careers is a mistake and only brings new pressures and fears of being unmasked. Indeed, many of us who read the draft back then were convinced it didn't apply to us because we really were impostors.

This may be in part motivated by the adaptive function such a belief in one's own ineptitude serves: If a woman is not really successful or smart, then she gets to keep her femininity. She's not really a threat to the men in her work group/profession/family. It is the obverse side of sexual discrimination that society "rewards" women (in a manner of speaking) who live out the feminine stereotype, just as it punishes women who do not. Look at the recent flap over Barbara Boxer wanting to be called by her correct courtesty title--not "ma'am", but "Senator." Little girls observe this very early and adjust their behaviors accordingly.

In 1985, Clance published a book about it:

The Impostor Phenomenon: Overcoming the Fear That Haunts Your Success

As for younger generations, I suspect it might still be true at least to some degree. I had a little kid in a session about 20 years ago who wanted to play with those little metal cars and trucks. He was divvying up toy vehicles for us to "drive," and commented that "Girls can't drive dump trucks." He kept that one for himself and gave me a sedan. Women could and did, even then, but it was just not part of his world view. Oddly, this post-Second-Wave child, raised by parents of my generation, was perfectly comfortable with the concept of women astronauts, having seen Sally Ride on the TV--just not women truck drivers. His generation is old enough to be raising kids of their own now. Wanna bet what they're probably teaching them?

But I digress.

Clance and Imes, supposedly feminists, totally missed the root cause of the phenomenon, locating its origins in one of two family dynamics, despite their recognition that it is gendered. Based on their explanation, there would be no reason to expect any more women than men to have the problem. Yet, as the authors recognize, research into attribution theory shows that women by the age of ten are habitually explaining their successes and failures differently than boys. It cannot be coincidence that in a patriarchal society little boys claim credit for their successes, while girls do not.

If Clance and Imes are wrong about the etiology, can they be right about the intervention? Probably not, since if the problem is located at a societal level, then an intra-personal, individual intervention hardly addresses it. Possibly so since, on the other hand, psychologists as agents of change often must start with the individual before us. Clance and Imes begin by recommending group, with which I heartily agree. People can see things in others that they cannot in themselves, and thus group becomes an ideal setting in which women can confront each other's unrealistic self-images. The authors recommend cognitive-behavioral techniques, such has having a woman practice different expectations or eliminate behaviors like compulsive work habits that reinforce the cycle. And they recommend role-playing both sides of a conversation in which she is alternately telling people she's brilliant or telling them that she's really an idiot but has had them all fooled. These are all great as far as they go, but I believe that if a woman is not consciously aware of how her "problem" functions in a social context, she won't be able to hang onto the changes she makes in the protected arena of therapy.

A therapy group is but a tiny raft in a sea of bigotry. If the raft's occupants don't understand the environment in which they are adrift and their relationship to it, they will not survive. Consequently, in my work I believe that it is of core importance that women come to see this as a gendered, social issue. The family is only the agent of society in socializing girls to be women. It is vital that women understand that men, and other women co-opted by patriarchy, will not be comfortable with their new comfort in their own skins and will work to return things to status quo ante. If they don't know this, they won't be prepared to protect their gains in personal growth.

Reference

Clance, P. R. & Imes, S. A. (1978). The impostor phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research and practice (15), 241-

Busted!

A psychiatrist who practices at Peachford has been indicted for sexual exploitation of a patient. Psychologists' ethics specifically forbid sexual relationships with patients, as does Georgia law, and as do most professionals' ethical codes--for good reason. The doctor-patient relationship, whether the doctor is a doctor of medicine or a doctor of psychology, is not an equal relationship and gives the doctor the power to engage the patient in activities that are not in the latter's best interests.

Adult patients who are exploited are usually female, and there has been some argument that such an ethical/legal prohibition is therefore sexist. It has even been said that, male or female, such prohibitions might deny adults their constitutional right to freedom of association. But studies of this issue have consistently found that it is not usually a case of two consenting adults falling in love (or lust) but rather one in which the therapist has serial affairs with patients, acting out her or his own issues in the treatment, much to the detriment of the patients. So I'm gonna go out on a limb here and predict that now that his mug has been on the 6:00 news, there will be more patients coming forward to report that they, too, have been taken advantage of in this fashion.

Often, it is not until someone else files a complaint that a patient realizes that s/he has an unethical therapist. In the first place, some such patients have been abused before (e.g., incest survivors) and have very poor boundaries to begin with. Their idea of what is abnormal is way, way out there, based on their growing-up experiences, and a little kiss or a date with a therapist doesn't even come close to tripping their radar. To them, this is business as usual. Therapists who are sexual predators in this way are no different from child sexual abusers in that they have a well-honed instinct for who is exploitable. Is this client emotionally needy? Does this client lack a good support system? This re-traumatization is an especially awful betrayal of what to my mind is a sacred trust placed in us.

Seduction by a therapist then proceeds in much the same way as an adult/child exploitation: Early inappropriate behaviors are highly deniable and serve as a test of what the therapist can get away with. Test behaviors also serve to 'groom' the victim, as the therapist (like any sexual predator) gradually increases hir demands. The victim is sucked in one small step at a time, and by the point that s/he feels things are badly out of whack here, s/he (a) is too far from the exits to be able to extricate hirself, and (b) has come to feel complicit in what is going on so is too embarrassed and ashamed to tell anyone. Plus, these therapists, like all sexual predators, instill the importance of secrecy in the victim's mind long before reportable, criminal behaviors occur.

In some cases, the therapists told the patient that this was part of their treatment. For example, the therapist may tell the patient that s/he needs the experience of feeling attractive, lovable. Or that sexual inhibitions can be worked out in therapy by having sex. An unsophisticated patient really has no way of knowing any better: S/he trusts the doctor and complies. This is so not a love relationship, people. It is an abuse of power, pure and simple.

This particular psychiatrist has also been charged with inappropriate prescription practices. Reading between the lines, I'm guessing that the drug was part of the exploitation. This can happen in one of two ways: First, the drug impairs the patient's judgment. Second, the patient may become dependent upon the drug, and by extension, the psychiatrist. This is especially an effective trap if no reputable psychiatrist would prescribe the particular drug, or so high a dose of it--the client has become addicted to it and can only get it from her perpetrator. If she reports him she loses her source. See what I mean about power?

Psychologists' ethics do allow for relationships between therapists and former patients under certain conditions and after a certain period of time has elapsed. This, too, is controversial. These rarely (if ever) turn out well because the power imbalance from the original relationship persists. The roots of these relationships are in transference-countertransference manifestations that were never properly worked through in the therapy, but which, instead, are now being enacted outside the therapy. By definition, then, the therapist wasn't doing hir job in the therapy, and the patient by definition got short-changed.

These are the same interpersonal relationship dynamics that probably brought the patient to therapy in the first place: If they caused the patient problems then in hir relationships, they will cause problems in this one. Similarly, the therapist's lack of self-understanding, poor boundaries, and behavioral disinhibitions exhibited during treatment spell disaster for any outside relationships as well, including especially one with a former patient. Two such relationships of which I am aware became physically abusive; in one, the patient wound up killing hir former therapist in self-defense--and went to prison for it. In a third case, the pair got married, the therapist made the former patient hir office manager, and then proceeded to be unfaithful--with patients!

There are cases in which the patient initiates sexual contact. This is no defense of the therapist: Freud long ago recognized that when the patient falls in "love" with the therapist that it is not the therapist the patient loves--and that the therapist would be a fool (not to mention an under-analyzed narcissist) to think so. The patient/victim in some of these types of cases has been previously victimized, and presents with all sorts of sequelae of previous abuse that makes hir more likely to sexualize the therapy relationship than a patient without an abuse history. When such a patient introduces sex into the mix, it is clearly a therapeutic issue and should be analyzed, not acted out. And it is the therapist's responsibility to make sure that this happens. As one of my clients is fond of pointing out, "That is what you are getting paid the big bucks for."

The ethical and legal prohibition against sexual relationships with patients is a sound one. No good can ever come of it, no matter the participants' rationalizations to the contrary. If your therapist has said or done anything even slightly sexual before, during, or after one of your sessions, run like hell in the opposite direction. And please consider filing a report with hir licensing board and/or the Ethics Committee of hir state and national professional associations. The affirmation that your therapist was in the wrong will do you a world of good.

Hypothetically speaking

It is not possible to diagnose someone we have not met and properly evaluated, and by extension it is not ethical to suggest publicly that one can. That is why when the media have a psychological question about a public figure, the experts will only offer hypotheticals.

What we have here, accordingly, is a hypothetical.

If you were to ask me about someone who has tricked out his property like some children's amusement park, names his home after Peter Pan's (a story about a little boy who never grew up), has never had a mature adult sexual relationship (two sham "marriages" do not count), and who invites other people's children for "sleep-overs", I would venture out on a limb and say that there is very high risk that you are dealing with a pedophile.

In fact, I would go so far as to say that you were dealing with the fixated type offender: Adults who inside are still children and identify with the age group from which they choose their victims. This type does not often even see what they are doing as victimization. In the deepest emotional/psychological sense, they see themselves as these kids' peers. As they see it, they are giving and getting "love".

Pedophilia is a highly compulsive behavior, like unto an addiction. The one victim you know about is just that--the one you know about. There are likely to be many, many more. The older the perpetrator, of course, the more likely this is to be true, as s/he usually has been offending since reaching her/his own sexual maturity. If the accused is, for example, 73, then s/he has been at it for 60 years or more. That's a lot of victims. I have had cases in which the perpetrator had more than a dozen victims across three generations within the immediate family alone. One particular fella who comes to mind abused his sisters, his daughters, the children he conceived with his daughters, his grandchildren, his nieces, the children he conceived with his nieces, and his grand-nieces.

What typically happens in any child sexual abuse scenario is this:
(1) It is almost never stranger on stranger. The kid doesn't run home and tell mama and papa. (In fact, the abuser usually is mama and/or papa, but that's for another post.)
(2) Perpetrators know how to single out kids who don't have good parental support/supervision, who are emotionally needy, who are not likely to tell, who are likely to comply with sexual demands, etc. Often these are children who are the offspring of survivors who themselves lack good boundaries or assertiveness skills. Such parents may not be able to spot potential trouble or to act to protect their offspring when trouble occurs.
(3) Because it is not a stranger-on-stranger crime, the non-offending parent(s) is (are) in a bit of a dilemma. Who do you believe? The family friend you love and trust, or your kid? The church VIP or your kid? The perpetrator never would have abused this particular child in the first place if s/he didn't think s/he had very, very good credibility with the family.
(4) That's if the kid says anything at all. Pedophiles have, by the time they get to your kid, had a lot of practice at this. They know how to convince a kid either that this is normal behavior or that the kid needs to keep it a secret, or both.
(5) Pedophiles often have a position of power in the family/community that is virtually unassailable. This is, in fact, how they gain access to children in the first place. Consequently, even a parent who believes her/his child may be loathe to press charges.

Child sexual abuse is damned difficult to prove in a court of law.
(1) It doesn't often leave evidence. Children's skin heals quickly. Bruises and tears and even infections can have a number of other plausible explanations. Rape kits are useless if the parents only learn of the abuse weeks or even months later. Depending on the sexual act performed, there may be no scarring or semen in the first place.
(2) There are no witnesses other than the victim, and children's testimony is problematic. Just for starters, a young child especially may not have the verbal skills to put into words what happened. Children may not be able to give details like dates and times, and an unskilled investigator/prosecutor may not know how to get at that information. Etc.

One often hears that the non-offending parent(s) put the child up to making the accusation and coached the child's testimony either in a custody dispute or to get money from the accused. To that, I would say that it would be damned difficult to coach a child to hold a sufficiently detailed story together over a sufficient length of time to get through an investigation, preliminary hearings, criminal trial and civil suit. Not gonna happen. It'll all fall apart somewhere in that lengthy process.

Emotionally and psychologically speaking, it's a hard way for a child to make a buck. You aren't going to find many genuine victims who are willing to go through it, never mind fake ones.

Are these people for real?

This is from the actual Remarks section of an actual Explanation Obfuscation of Benefits received in the mail today:

Remarks
D214 -- We have reviewed your previously denied claim. We have found you to be eligible and are overturning your denial for that reason. Your claim has been reconsidered and has been denied. . .

There are no battered women,

Image by kalandrakas via Flickr

conceptually speaking; only battering men.

By which I mean that there is no one personality type of woman who gets battered, while men who batter all seem to have gone to the same school.

Word of the Day

The word of the day is obloquy. It means, according to Answers.com, "abusively detractive language or utterance; calumny." Here: I will use it in a sentence for you.

"To mention Simone Weil is to be reminded of the obloquy to which women are subjected if they deny themselves the arts thought necessary to their true nature, their 'womanliness' (Heilbrun, 1979, p. 70)."

Ms. Weil

Heilbrun goes on to describe fashion as "the mark of women's slavery" (p. 70). Then she quotes Adrienne Rich as saying that women are taught to "lie with our bodies" with makeup and such, and to "wear clothes that emphasize our helplessness" (p. 70).

One Big Lie
Raymond Spekking/Wikipedia

Heilbrun goes on to say that "Lying, with one's body and one's words is, among the oppressed, a dreadful necessity. . . Only women, I think, have also consistently lied to themselves (p. 70)."

Fashion is not about competition between women, although it is often framed that way, on the old principle of "divide and conquer." Diet, fashion, and acting feminine are all about pleasing and maintaining dependence on a man. While it is true that the woman who better pleases men lives better, competition with each other is secondary. There are, after all, more than enough men to go around. The end result, however, is that for as long as we see ourselves as in competition with each other for men and through men, sustenance, we cannot find common cause. And for as long as we spend our money, time, and talents on frivolity, we are not applying those attributes to accomplish big things in the world.

I believe that it was Naomi Wolf who, in The Beauty Myth, estimated that what American women spend every year on face cream alone would fund one battered women's shelter in every state in the nation. The end result, and therefore possibly the goal all along, is that women are frittering away their freedom and their power on pantyhose and mascara. They are trading self-determination for lies that will attract a man to be responsible for them. Because we have been taught that this is what we must do, that this is how to be successful women, we have been co-opted into trivializing ourselves. And then condemned for our frivolity.

IBTP because I believe that no woman who is conscious of this trade-off would continue to make it, would continue to lie to or about herself in this way, would voluntarily fritter away her time, money, and talents on keeping herself in servitude. Women who do see it, articulate it, and opt out are subject to a number of tactics to bring them back into line. They are told they need to fix themselves up. They are called plain, ugly, mannish, or dykes, or slobs who don't care about their appearance. They are warned that they will never get (or be able to keep) a man. They are subjected to all sorts of obloquy.

And for that, you bet your bippy I blame the patriarchy.

Heilbrun, C. G. (1979). Reinventing womanhood. New York: W. W. Norton.

Don't get me started!

In which Dr. Wood gets all fired up about a magazine cover

I was minding my own business when I spied, out of the corner of my eye (because of course I wasn't reading anybody else's mail), the current copy of OH magazine in a colleague's inbox.

I thought it was Oprah's, at first. But no: This is Obesity Help's magazine. It is a women's magazine, because of course fat men do not need one.

Be that as it may, what got my attention was one of the articles listed on the cover, to wit, "Exercise Your Right to Bare Arms." Why, you may ask, does this irritate me?

Well. I'm glad you asked!

In the first place, how much comment has there been over the last few months about Ms. Obama's predilection for sleeveless dresses?

FLOTUS

This is a woman with an Ivy League education, an attorney, and we are supposed to all fixate on whether her clothes have sleeves or not? Puh-leeze. But yes, we are, and in turn we are all supposed to mimic her fashion sense and go sleeveless ourselves.

In the second place, can you (I mean, really: Can you?) imagine such a stupid article in, say, GQ? Or Esquire? That alone qualifies it as sexist.

But mainly, now that a woman's right to exercise choice is being threatened (again), now that we have Hillary Clinton serving as Secretary of State and Sonia Sotomayor nominated for the Supreme Court, it's time for the press to remind us all of what's really important: Those flabby upper arms!

Reminds me of those stupid "Every Woman Needs a Platform to Speak From" shoe (get it? platform shoes?) ads they ran back when Geraldine Ferraro was Walter Mondale's running mate. Trivializes the hell out of our real political ambitions and concerns. Insults our intelligence: You know those silly women--all they can think about is shoes (and sleeves).

I blame the patriarchy.

I love a good diagnostic challenge

One of the most interesting ever was a guy who had some weird kind of seizure/sleep thing going on that a couple of medical types had ruled was hysterical. Not funny, I mean, but entirely in his own mind. That didn't fit with the history, though, or with his presentation either, so we did some psychological testing, and the resulting personality profile clearly didn't fit with any of the somatoform, histrionic, or factitious-type disorders. So, not being a physician, I didn't get to say what the guy really had, but I could say I was about 99.99% sure it wasn't psychogenic, and that was cool. I love it when I get to say something definitive, clarifying, and helpful.

Recently, I had a young lady come in with three diagnoses from her previous therapy. But while I'm sitting with her, I'm thinking this isn't right. For one thing, the history doesn't quite fit, e.g., onset of symptoms in late adolescence for one diagnosis that is pretty firmly in place by early childhood, and for another that usually presents earlier or later. For another, the symptoms don't all quite mesh. And again, there's the presentation: She just doesn't feel like A, B, and C. So, I'm thinking, instead of A, B, and C, maybe her problems are X, Y, and/or Z. Then at the end of the session she tells me how much she's been drinking and drugging. And here beginneth the lesson.

When presented with a client who uses frequently and heavily, it's important essential to your differential to look at the onset of the symptoms. Somebody who starts having symptoms of a mental illness at about the time he started drinking could be drinking to cope with the illness. More likely, he doesn't have the illness at all, but the symptoms are a reflection of the intoxication/withdrawal cycle of the addiction. This is absolutely going to be the case if the symptoms of the supposed mental illness began after the alcohol and drug abuse. So unless you know different, the primary diagnosis and what you will treat first should be the addiction, people.

If, on the other hand, from the history you can clearly see that the symptoms predate the addiction by many years, then by all means go ahead and give a diagnosis of bipolar or borderline or whatever. Otherwise, you would be well-advised to get the client clean and sober and see if, 90 days or so later, they are still having symptoms before you give a diagnosis. Especially before you slap something as pejorative as a character disorder on 'em.

Regardless of which comes first, you can't do therapy with someone who is actively abusing substances. At a minimum, they need to not drink/drug 24 hours before and after a session. This allows them to not be anesthetized when they show up for therapy, so they will have some affect to drive the work, and it gives them a bit after the session to metabolize the work they've done. It's a minimum.

But as far as I'm aware, therapy never got anybody clean and sober, and therapists who think that working on the "root" of the problem (addiction is its own root, people, I'm here to tell ya) is going to help their patients proceed at great risk to the patient. Addiction is a progressive, lethal disease. And even if the person is "just" self-medicating, it can still kill them before you get to the root of whatever it is that you think is the real problem. So let's clean 'em up, if not first, then early in the treatment. You could save a life.

But I digress. We were talking about diagnosis, not treatment. Let's get back to that. Flip side is, if you have somebody come in who's in recovery and still having terrible anxiety or depression 90 days or more after her sobriety date, you have somebody with a free-standing mental illness. For the love o' Mike, diagnose it and treat it. Un-and under-treated depression, just as an example, is a notorious trigger for relapse. And remember, addiction is a relapsing, progressive, terminal disease.

And if you have somebody who's well-advanced in recovery, they've worked all the Steps, they have a sponsor and are going to meetings and working a good Program, and they still have character flaws left, right and Sundays too, then please feel free to give an Axis II diagnosis. And treat it. It's the only humane thing to do.

Regardless of what you do or don't diagnose, and decide to treat or not to treat, if you are a psychiatrist, don't give medications with abuse potential to clients who are drinking and drugging. You tryin' to kill 'em, or what? You are certainly aging me prematurely when you do that.

There endeth the lesson.

Heartwarming Nature Crap*

Well, I got through the second day of my new job without breaking any plates.

Everybody's been really nice, really welcoming. But I'm tired from the move, so I knocked off a little after four today, went to the bank, and stopped off to explore an abandoned horse farm just down the road from the office.

It's about 85 acres, and For Sale. Which, presumably, means it will be developed ruined before too much longer. I didn't want to miss a chance to photograph it before it's gone forever. I figured it would be good for an old barn or two, but the barn is gone. There's nothing left but quiet. It's weird: You can see cars on the roads, but you can't hear them. There's nothing here but trees, birds, grasses blowing softly in the wind, and blessed quiet.


It was too early in the evening for the light to be good, and so all my highlights are blown. And for some reason--I guess my eye is as blurred as my brain, today--I couldn't get anything in focus.

After the driveway ends where I guess the house used to be, there's a faint track you can follow (provided you have four-wheel drive: Gawd, I love my little truck!) around the pastures. I saw a big, black snake, have no idea what kind, Mourning Dove, Northern Mockingbirds, White-breasted Nuthatches, an Eastern Phoebe, Blue Jays, Northern Cardinals, and wildflowers. None of the birds would stand still long enough for a photograph; but on the whole, the flowers were pretty cooperative.




And this bug. Ain't he a handsome divil? He kept waggling his antennae at me. I thought maybe he was flirting until he flew over to the next thistle and started up with another bug.


I was on my way out when I found the chair. It was the only human thing left out here. There was not even a stick of lumber left of the house or barns, then this chair.

I could not help but wonder what the person who left it there was watching. Or thinking about. There's a whole story in that, I'm sure. But I'm too tired to write it right now.

*with a tip o' the hat to Twisty Faster, late of this planet.