Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Tuesday, June 30, 2009

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:

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.


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-

Saturday, June 27, 2009


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.

Friday, June 26, 2009

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.

Tuesday, June 23, 2009

Are these people for real?

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

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. . .

Sunday, June 14, 2009

There are no battered women,

Description unavailableImage 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.
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Friday, June 12, 2009

Word of the Day

The word of the day is obloquy. It means, according to, "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.
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Thursday, June 11, 2009

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?


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.
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Saturday, June 6, 2009

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.

Tuesday, June 2, 2009

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.