Docsplainin' -- it's what I do

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

Saturday, March 27, 2010

Huzzah, anyway

Apparently, some time last weekend, while I was distracted by all the kooks likening Mr. Obama to Hitler, the former snuck through a law to make pharmaceutical companies reveal in detail their payments to physicians, including which drugs they are flogging, where, and when. Doug Carlat writes:
It is this kind of granularity of information that will truly make doctors think twice before pursuing careers as hired guns.
Probably not, actually. Some docs, by virtue of the nature of their caseloads (geriatrics, families on welfare, psychotics, etc.) can pretty safely bet that their patients will not even know about the law, never mind have the computer access, cognitive capacity, or general literacy to do the research. Others will do the math and figure out that they are still better off as hired guns.

For example, if one makes $23,000 a year selling, say, one of the newer antipsychotics, one would have to risk losing 230 appointments per year just to drop to the break-even point. How many psychiatrists have 57 patients (each seen quarterly =  228 appointments) who are (a) going to look up this information, and (b) quit over it and go looking for a new doc? Out of those, how many will have the option of finding a doc who's geographically accessible and takes their insurance and is taking new patients and treats their particular problem? And who cares? Psychiatrists are generally booked months out: There are always more patients where that 57 came from.

Still. Some patients will, and even one life saved will be well worth it.

And colleagues like me can (and hopefully will) look up each and every doc to whom we refer, and alter our referring habits accordingly.

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Friday, March 19, 2010


Sumerian language cuneiform script clay tablet...Image via Wikipedia
I mean, what is it with Jason Aronson lately? Once the premier publisher of psychodynamic literature, they've gotten embarrassingly sloppy lately. Seems like everything of theirs that I pick up these last few years desperately needs editing: Their books are riddled with errors ranging from the merely distracting ("eliotogical" for "etiological") to the completely obfuscating.

As an example of the latter, I hereby challenge you to tell me just what the heck the the following sentence is supposed to mean:
Vaillant demonstrated that there is a very high correlation between the severity of a person's alcoholism and social deviancy/consequences, and the assessment and identification of these related factors has a much higher reliability than the measurement 'of ephemeral concepts of loss of control or alcoholism p. 17' and subjective reports on consumption levels.
Other than the obvious "p. 17" thingy floating there where it does not belong, I'm not even sure where the error is. Is Vaillant saying alcoholism is an ephemeral concept that can't be reliably measured in the very same sentence in which he is telling us it can be reliably measured? Surely that is not it, because the author is too critical a thinker to let that one pass. Perhaps the very occurrence of the word "alcoholism" in the second clause is itself in error. Or could part of the sentence be missing? I just don't know.

I give up. I've been studying on it for some time now, but I just can't sort it out.

This was at least the fourth error in 19 pages. There is "integratetively" on p. xi, a misattributed--or unattributed, it's difficult to say--quote (p. xii), and "lightening rod" (p. xiii). So far, we're running right at one error per page--and we're not even out of the Foreword yet, which was written by a Harvard professor, for heaven's sake. I think it's a safe bet these are not his errors any more than the Vaillant mish-mash is the author's.

The whole thing reads like it hasn't even been edited: One wonders if the new owner (Rowman & Littlefield Publishers, Inc.) laid off all the Aronson editors in one fell swoop during the takeover. Regardless of the cause, an error on every page is inexcusable.

(Although I will say, I kind of like "integratetively". That probably ought to be a word, except that it reads a bit like a visual hiccup, and is somewhat difficult to pronounce. So, well, maybe not.)

But to get back to Aronson, the shame of it is that this is a meticulously researched book by one of the greatest thinkers in the field. Aronson ought to hang their heads over how poorly they've served this author.

The last book published by Aronson that I tried to read, a collected work on technique, was so badly edited that I could not understand the first article at all. I am not exaggerating: It really was that badly mangled. It might as well have been written in Cuneiform. I didn't even try to finish that book.

Those of you who know me might, understandably, at this moment be thinking to yourselves, "Aw, that's just her being her usual hypercritical self." Alternatively, some of you may be thinking I'm just not smart enough to understand, say, a book on technique. So let me just mention here that I am also currently reading van der Kolk's latest on trauma therapy, and having no such difficulties with it. That book is no walk in the park, intellectually speaking, but if it is not 100% error free, I haven't found the goof-up yet. And that it is well-edited allows it to be not only understandable, but enjoyable.

By contrast, this current tome will be the last Aronson publication that I will ever spend money on. I had really looked forward to reading it, but it's being very frustrating. I'm not naming it, although technically I suppose I should in order to appropriately credit the source, but I deeply admire the author and am reluctant to slam anything that he's had anything to do with, especially in a manner that would pop up in a Google search on his name. And as I say, it's not just this book, this author; it's everything Aronson has touched lately.

It is my fervent hope that the author will find a new publisher for his next work.

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Therapeutic Texting

Texting on a keyboard phoneImage via Wikipedia
My young client arrived in tears. Seems she'd not only had problems with a date this week, but also with the friend to whom she'd turned for support. A good deal of these problematic interactions had taken the form of text messages back and forth between the three of them. My client scrolled back to some earlier texts to quote both the date and the friend.

And then, and this is where it gets interesting, while we were talking about all this, she received a text and dashed off a response. I considered asking her not to do that during the session, but what the heck? Here was the very interpersonal issue we were discussing unfolding in the here and now! So I sat back and waited.

Pretty soon, the little phone buzzed with a response, I asked her about it, and so it began: We would talk a bit, she'd send a text or receive a response, and we'd process them. The whole thing was most interesting, and different from work I've done in the past. People have printed out e-mails before and brought them to therapy, and have even brought their laptops in to show me MySpace pages, but this is the first "live" internet interaction I've processed in session as it unfolded. I think it was productive.

Having the actual texts as they unfolded gave us accurate data from her interpersonal world as a basis for discussion of gender roles and expectations--this gave the work a here-and-now immediacy, vs. the there-and-then that is all too often the stuff of psychotherapy. In the course of the hour we were able to establish that she doesn't like confrontation. Smart, perceptive, and funny as hell, she responds with sarcasm when wounded. She is a feminist. She is highly empathic and tries to be supportive to the important people in her world, yet finds herself again and again in non-reciprocal, sexist relationships.

If I have a problem with how the session unfolded, it is that if one has needs that aren't getting met in one's relationships, then the phone is a tremendous distraction from the face-to-face opportunity to get those needs met, available right here, live and in real time, in the therapeutic relationship. So I guess I wouldn't want to do this every week. But today? Cool.
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Saturday, March 13, 2010

#7: Patience is a virtue

Patient ContemplationImage by 1Sock via Flickr
Patients occasionally (okay, frequently) express impatience with their progress in therapy. Impatient with themselves, they become impatient with me for not fixing them faster. And they worry that perhaps I am impatient with them for not doing more, better, faster than they actually are. 

Wood's Rule #7: Patience is a virtue

Because cultivating this virtue helps you "cease contributing to your own suffering and confusion and perhaps to that of others", Jon Kabat-Zinn1 describes patience as a "fundamental ethical attitude" (1994, p. 48).

"From the perspective of patience," Kabat-Zinn writes, "things happen because[emphasis added] other things happen" (p. 48). You get sober, whether sooner or later, because you got drunk. The teenager you've brought to me for therapy will develop maturity and judgment (eventually) precisely because he has been immature and impetuous. For that matter, we can only learn patience who began our journey with impatience.

And if that is true, then it is also true that
what will come next will be determined in large measure by how we are now. This is helpful to keep in mind when we get. . . frustrated, impatient, and angry in our lives (p. 50). 
What will being impatient and irritable right now this two seconds create in our next few minutes, days, weeks, or months? Years down the road, what quality of life will all this rushing around and crankiness have produced for us?

So I would remind my patients to, in Kabat-Zinn's words,
. . . [remember] that things unfold in their own time. The seasons cannot be hurried. Spring comes, the grass grows by itself. Being in a hurry usually doesn't help, and it can create a great deal of suffering--sometimes in us, sometimes in those who have to be around us (p. 48).
It's how I think of you when you are struggling, when you have hit a wall. I know that I cannot make a flower bloom, or control its form and color when it does. All I can do is make sure to plant it where it receives enough sunshine (but not too much); then I must water and fertilize it (but not too much). It grows on its own, in its own time and in its own way. And so will you, dear, so will you.

Kabat-Zinn closes this chapter, poetically titled "The Bloom of the Present Moment", with a quote from Lao-Tzu:
Do you have the patience to wait
till your mud settles and the water is clear?
Can you remain unmoving
till the right action arises by itself
                            -from the Tao-te-Ching 
If I allow myself to become impatient in session, then I act before my mud has settled. It is not likely that anything that I do will come out of right mindfulness or right understanding. To the contrary, it is highly likely that I will do something to make your journey harder, or longer. And that would be unethical.

1. Kabat-Zinn, Jon (1994). Wherever you go there you are: Mindfulness meditation in everyday life, pp. 47-51. Hyperion: New York.
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