Wood's Rules

Going Home; Finding Peace When Pets Die, by Jon Katz (Villard, 2011, 166pp., $22.00 US)

2011-08-31T20:39:00.001-04:00

Going Home; Finding Peace When Pets Die, by Jon Katz (Villard, 2011, 166pp., $22.00 US) is a sort of manual for pet owners on pet death and grief, and when it’s necessary, on the decision to euthanize. It’s so much more than that, though—it’s also a paean to our pets and our relationships with them. Indeed, Katz characterizes the grief itself as an expression of our joy in the animal’s life.

Since the book covers both natural and assisted deaths, stressing the need for preparation, it makes useful reading for owners whose pets are still living and healthy as well as for those already grieving either form of loss. Katz includes sections on children’s experiences of pet death, and this is also covered thoroughly in Dr. Debra Katz’s Afterword (which the publisher’s notes refer to as a preface).

Katz works three themes throughout the book. One, we are responsible for making choices that are in the animal’s best interests, not on the basis of what we want or what other people think we should do. Two, grief is normal and natural, and even a good thing, for it cleanses, heals, and stands as testimony to the love we had for our pet. Three, both the decision and the grief go best if we are prepared. What constitutes the animal’s best interests, and how do we tell? How do we grieve? And how do we prepare for deciding and grieving? The book addresses each in depth, including how to involve, prepare, and support the children. Katz approaches each task—which, as he points out, we commit to the moment we bring the animal into our homes and our lives—practically, spiritually, and compassionately. In doing so, Katz is incredibly generous, giving of himself in ways that few would have the courage to do in print. He shares his own grief, his personal failings, and his dreams (in chapters titled “Animal Dreams”).

Three of me read this book and we all loved it. The writer in me admired Katz’s ability to be both succinct and eloquent at the same time. This is the most eminently quotable book I have read in a long time—which is frustrating in a way because the publisher asks that nobody quote it yet as the ARCs are all uncorrected copy. (On which subject, this “uncorrected” copy is in better shape than some books I’ve seen in recent years that are in 2^nd and subsequent printings—and still riddled with a ridiculous number of errors. My hat’s off to the editors at Villard.) I have resolved that dilemma by quoting it anyway, as it is just too good to pass up.

The clinical psychologist fell instantly and completely in love with the book. Its message of comfort, its exhortations to responsibility for our animals, its sweet photographs, and its moving stories all made me wish I could order a case of this book to hand out to grieving clients and friends.

And finally, the dotty old woman who still mourns Rosie, who's been dead now for three years, hesitated to even start the book. When it arrived in the mail, I wondered what on earth I had been thinking when I requested it! But I was hooked on the first page. I read it in fits and starts, on lunch breaks and sometimes when I should have been doing paperwork, and I cried every time I picked it up. Sometimes for myself, sometimes for my Rosie, and sometimes for Katz or for whichever animal’s death the current chapter was about. But I found it tremendously comforting and anyway, as Katz put it, “I would hate to have a dog or cat for whom I did not grieve.”

The three of us have only a few, small quibbles with the book. One, and really the only substantive one, is the psychologist’s, and it has to do with the title: I’m uncomfortable with euphemisms like that, seeing them as a denial of the reality of death. The animal is not “going home”. It is dead, not somewhere else—gone. If clients’ personal spiritual beliefs include an afterlife or rebirth, fine. But I am not comfortable leading with that myself, preferring instead to follow the griever’s lead. Another, and I admit that this is so small it borders on petty, is the writer’s. Katz’s otherwise masterful story of The Perfect Day is marred, in my estimation, by the mention of a camera by brand name and model. I had that one myself once, and loved it, but really. That was just kind of jarring. And lastly, the dog owner found herself getting worked up over some of the folk (not Katz) in the book who let their animals run loose, but that’s not a quibble with the book per se. Just be forewarned that’s in there.

Going Home will be available after September 27, 2011, and I highly recommend that if you have an animal, any kind of animal, to which you have become attached, you go out and get yourself a copy. Do it now, not when it gets sick or hurt or old. Buy one for a friend, too, while you are at it.

Hell

2010-08-14T16:26:00.000-04:00

In you are here: Discovering the Magic of the Present Moment, Thich Nhat Hanh writes,

To me, the definition of hell is simple. It is a place where there is no understanding and no compassion. We have all been to hell. . . If there is compassion, then hell ceases to be hell. You can generate this compassion yourself. If you can bring a little compassion to this place, a little bit of understanding, it ceases to be hell.

Then he writes what, to me, is the perfect definition of the psychotherapist's job:

"Your practice consists in generating compassion and understanding and bringing them to hell."

The 24-Hour Experiment: Love Your Body

2010-08-11T09:39:00.000-04:00

Yes, that's right. Love your body.

Identify something your body can still do right (and it's doing something or you wouldn't be reading this. Then appreciate it. Tell your body you appreciate it.

Then for 24 hours, treat your body like you would an adored child. Rest it, wash it, dress it, and feed it like you would a precious infant. Play with it. Talk to it.

Bigotry is not a mental illness. . .

2010-07-19T20:02:00.000-04:00

Image via Wikipedia

. . . and neither, ladies and gentlemen, is domestic violence.

I had planned on another A.A. blog post today, either about individual members who try to cram their personal God down your throat, or what to do about the ones that want you to stop taking your meds "or you're not really sober."

But then, alas, up pops yet another female apologist for Mel Gibson, and I just couldn't let this one pass. Alicia Sparks is a layperson who writes for PsychCentral, which I usually recommend but am lately having doubts about.

"...think about why Mel Gibson (and anyone else, for that matter) has done these things," she writes.

OK. Here's my theory:

1. He drinks because he is an alcoholic.
2. He abuses women because he hates us. And because he can.
3. He uses intimidation, threats, and physical force to get his way.
4. He's bigoted because, well, because he's a bigot.

Ok, Ms. Sparks. Next?

"The verbal abuse and threats were bad, yes."

"Bad?" Oh, oh. Anybody else here see a minimization coming? Sure enough:

"The physical violence was bad, too (if there was any – there’s now speculation as to whether Gibson actually hit Oksana Grigorieva in the mouth, as she claimed, or if that all plays into the extortion theory)."

The link takes you to a brief Entertainment Section story which refers to photos Ms. Grigorieva has given to the police of herself with damage to the veneers on two teeth. Apparently, "sources familiar with the medical charts, photos and examination notes of Grigorieva's dentist indicate there is no evidence Oksana was struck in the mouth."

Well, no sh*t, Sherlock. How could there be? Unless the dentist got DNA off Mel's fist from between her front teeth, all he can say is whether her injuries are "consistent with" or "not consistent with" being punched in the mouth. What he actually said in a sworn statement was that she showed signs of blunt force trauma, and that he was concerned enough for her safety to offer to shelter her himself.

So first, you have a non-professional blogging on a psychology website. Second, she's citing entertainment pieces as if they were investigative journalism. Third, she's accusing Ms. Grigorieva of extortion, and doing it without the courage to come out and say it directly herself, using the mealy-mouthed "there's been speculation".

OK, just for the sake of argument: I think I'd like to strike out on my own with a child, leave my husband. I think that I will cause myself some extremely painful, potentially permanently disfiguring injuries, and tell him if he doesn't give me money, I'll claim he did it to me. Does that make sense to anybody? And does anybody really think that Grigorieva bruised their daughter herself, to make money??

For what it's worth, the police have opened an investigation into the DV allegations. They have not opened one into the extortion claim.

Sparks is also conveniently ignoring two other little minor details, that being Ms. Grigorieva's description of the alleged incident on tape, followed by a little snappy repartee from Mel, to wit, "You know what? You f**cking deserved it." And then there's the photo of the baby, with bruises.

Details, details.

Next, Sparks asks,

But even amidst all that, it is possible to eventually set aside the inevitable shock and confusion and anger and evaluate the situation. If indeed Mel Gibson is suffering from untreated mental illness, which would be better: Hoping he seeks (and benefits from) professional help, or writing him off as a lunatic lost cause?

Here, the logic breaks down entirely. But let's try to follow it.
#1. Who's confused? You? Not me. I see a clear case of domestic violence here. Yeah, yeah, I know, innocent until proven guilty and all that, but we are not in a court of law. This is a blog.
#2. If indeed, Mel is mentally ill, what does that have to do with anything? Domestic violence is not a mental illness. It is not even about mental illness. (It is not about anger management either, but that's another rant for another day). No, ladies and gentlemen, domestic violence is about power and control. Period.
#3. Bigotry is not a mental illness, either. Not as it is expressed in racism, anti-semitism, or hatred of women.

I defy Ms. Sparks to find me even one sloppy study that shows that bigots or wife-beaters can be helped with diagnosis and treatment of a mental illness.

Alcoholism, of course, is a disease. However, I would also like to see the study that shows that sobering a guy up will make him quit spewing hate-talk, making anti-semitic movies, and hitting people.

Just one. Even a sloppy one.

#4. Mel, according to friends quoted on MTV's website (yet another shining example of investigative journalism, I know, but there you are), is already in therapy. And he already knows he needs to quit drinking.

So what, exactly, is Sparks' point here? Is she saying he shouldn't be held accountable for what he's done? Does she want us to give him a pass?

#5. Who's writing him off? There's a straw man argument if ever I heard one.

No, going back to the title of her piece, I think what she wants is for us to have compassion for him. So I looked it up. Compassion means "deep awareness of the suffering of another coupled with the wish to relieve it."

Funny thing, that describes exactly how I feel about Ms. Grigorieva.

Suicide, again

2010-06-06T10:08:00.000-04:00

Jolene over at Graceful Agony had a suicidal person Google her blog on the way to trying to find out "the best drugs" to kill herself with.

Jolene's response is thoughtful and on the money, so I'm going to limit myself to putting up a link.

Blue Cross Blue Shield Of Georgia Is Skimping On Mental Health Care, Says Georgia Psychological Association

2010-05-24T20:44:00.000-04:00

This story is from last year. I found it when I Googled Blue Cross/Blue Shield tonight looking to download an Outpatient Treatment Report form for a patient. Given the problems I've had recently had getting treatment re-authorized, I also downloaded a 50-page explanation of what Blue Cross/Blue Shield considers "medically necessary". You can read that for yourself here. I found it enlightening.

Because I am on their panel and neither wish to be tossed off it nor to have clients convicted by association, I'm not going to say anything more.

You can read the article for yourself as well:

Blue Cross Blue Shield Of Georgia Is Skimping On Mental Health Care, Says Georgia Psychological Association

Enjoy.

Why I Hate Managed Care in General, and the Medical Model in Particular

2010-05-19T14:48:00.000-04:00

Image via Wikipedia

So this arrogant psychiatrist in another state, who has never met nor spoken to my patient, decides in less than 10 minutes on the phone* to deny coverage for depression and ADD because she's made only minor progress in 12 weeks of outpatient psychotherapy ("three months!" quoth he, obviously horrified).

Oh, yeah, and because she's not getting "standard" (read: "cheaper") treatment, to wit, psychotropics.

He actually asked me why I was asking for more sessions! Um, because she's still depressed? still has family issues? Still doesn't know what she wants to do with her life? After all, he says, it's not working, is it?

Yes, it is. It may be slow, but it is working. Her problems have been years in the making and we're not going to turn them around in three months. He seemed astounded by this concept.

He implied more than once that my treatment of her was substandard. She wants a non-drug solution and I'm not forcing the issue, partly because her depression is moderate, therefore not an emergency, and partly because most of it is environmental in origin, not endogenous. As for the ADD, well, it is definitely holding her back, but it's not going to kill her, and I see the decision whether to medicate or try adaptations and accommodations as a personal one. I respect patients' ability to make decisions like that for themselves, and support their right to do so.

And by the way, the standards of care are written by--wait for it--the American Psychiatric Association.

Not to mention, success with medication is hardly guaranteed. I have had dozens of patients who have not responded to medication after medication after medication. Do insurance companies then want to stop paying for any more drugs? No. This is about money, pure and simple, and it pisses me off. This, people, is why we need national health care.

So if your insurance company doesn't want to pay for ongoing psychotherapy, fine. If it doesn't fit within their definition of "medically necessary," fine. I get that, and I have no problem with it. But don't imply that my work is substandard, dude. Do not go there.

*actually, he'd clearly already made up his mind before he even picked up the phone, based on a one-page request form I'd faxed in. I suppose I should have claimed "moderate" progress on the form. Her role functioning has improved because she's learning to structure herself better ("yes, but is her concentration better?" the insurance company care manager wanted to know) and she's made one of the major life decisions she came here to make. But I really feel we're just getting started. "Moderate" to me implies that we're about halfway through. "Major" progress would be close to the end, right?

While I was writing this the care manager called to see if I wanted to appeal. You betcha! And she pointed out that this all happened because I didn't return their calls quickly enough to suit them. I got passed on for this "peer review" thingy (Do you really think he's my peer? Do you think he's got a doctoral degree in psychology and 30 years experience providing psychotherapy?) partly to punish me.

Anyways, if I had, she went on to say, she "might" have given me two more sessions!! to get the client to agree to a med consult.

Makes me want to set my head on fire.

Mental Housecleaning Time

2010-05-10T20:08:00.000-04:00

"What's on Your Mind?" is the prompt for Facebook status updates.

Recently, I've noticed that there's a lot of junk on my mind, much of it unpleasant and worrisome. We unconsciously shovel in junk all day with the news, tv shows, and even the books we read! So after serious consideration (and one of those "last straw" experiences) I'm giving up reading fiction with any form of violence in it.

Which means most of my beloved murder mysteries and thrillers. I used to love, for example, the Dick Francis mysteries because they were all about horse racing. And you know how I feel about horses. But the novel I've just finished involves bad guys abusing horses, and one disturbing mental image in particular stuck with me long after the book was done. And I thought, why would I traumatize myself like that on purpose? Don't we have enough in our real lives to worry about as it is?

Jon Kabat-Zinn suggests that we think of what information we take in the same way we think about our diets: Pay attention to what floats up unbidden in your mind from things you've read, heard on the radio, or seen on tv. Be mindful of what you shovel in during the course of a day. See what you might want to change.

I can't believe I p***ed away the whole morning on this, or

2010-04-18T13:13:00.000-04:00

OMG! Someone's wrong on the Internet!

I had other things to do this morning. Lots of other things to do. But this is a subject that absolutely gets my blood boiling, because I believe it is harmful to steer people away from AA and its sister programs. This is my entire response to yet another gross misinterpretation of 12-Step philosophy. Basically, the poster conceptualizes mental health treatment and addiction recovery as opposing forces, compares AA to Scientology, and calls 12-Step programs blaming, punitive, and "dangerous". I am not giving a link or naming the poster, a professional who is at least in part touting her book with her post, as I have no wish to give her argument any more exposure than it already has. Since, unfortunately, she is a guest-poster to a site I used to have in my blog roll and some of you may have read her already*, I am posting my response, verbatim, here:

[Poster] claims that AA is anti-treatment. This is totally not my experience, not as a recovering alcoholic 24 years sober, not as a psychotherapy patient, and certainly not as a psychotherapist with 29 years in clinical practice.

Alcoholics Anonymous (the Big Book) states quite clearly that medical professionals and medications have their place. Other officially-sanctioned AA literature includes brochures and pamphlets on mental illness, medications, and recovery. What is discouraged is medication that merely replaces (by mimicking the effects of) the alcohol/drug of choice (e.g., Valium, Xanax). In meetings it's called 'taking your alcohol from a prescription bottle' or 'taking your alcohol in pill form'. It is the abuse of prescription drugs and the naïveté of physicians who keep handing them out that AA sponsors worry about, not appropriate treatment.

Alcoholics and addicts are experts at obtaining prescriptions that they don't need and which may interfere with recovery to the point of precipitating a relapse to the drug of choice. Old-timers recognize this drug-seeking behavior when they see it because they spent many years doing it themselves, and warning against it is not "bad advice". It may save a life.

My professional and personal experience is that very few groups will tolerate the handing out of advice. It's one form of "cross-talk" when it happens within the meeting itself, and is actively discouraged if not forbidden outright. Sharing in meetings is supposed to include our "experience, strength, and hope". When we tell our stories we share "what it was like, what happened, and what it is like now". This basic instruction is read aloud at the beginning of every meeting. It means that when a topic is introduced, we share how we use the Program to deal with a given issue--not how you should do it. "Take what you want and leave the rest" is an oft-repeated slogan in 12-Step groups.

In the context of fellowship outside the meeting, telling another member what she should or should not do is considered to be working the other party's Program instead of your own, a sign that you at a stuck point in your own recovery process, and is similarly discouraged. While we will point it out if we think a person we are sponsoring is engaging in (pre-)relapse behavior, rarely, if ever, would a member with good quality sobriety tell another member not to take their medication or not to see a given professional.

Even so, of course some members will dispense bad advice. We're only human! The Program offers a built-in protection against that, as members periodically remind themselves and each other that for successful recovery one must place "Principles before personalities". In other words, keep the big picture in mind. Don't let one person's bad attitude or general wrong-headedness get you off track.

[Poster] is right about one thing, though: Of course nobody wants to hear about your diagnosis at meetings--because that's not what meetings are for. AA members recognize that they are not professionals and are not equipped to treat mental illness. AA can be independent, primary, or supplementary, to mental health treatment, but is not in competition with it. Meetings are for getting clean and sober. They are for talking about the solution rather than living in the problem.

The whole point of working the Steps is to learn to live life on life's terms, which is to say, clean and sober regardless of what happens to you inside or outside of your body. Got a funeral to go to? A divorce to get through? The Steps teach you to handle it sober. Talking about how you can't handle it will not. (That, by the way, is a basic principle of Cognitive-Behavioral Therapy--not anti-scientific at all!) Depressed? Working a good Program will get you through this episode sober. Sitting around talking about your depression will not, and anyway, you can (and should) do that in therapy.

This may sound cold, but it is not. It is practical. Raise your issue in the meeting then take the cotton out of your ears, put it in your mouth, and listen to how people who are happily sober many years longer than you handle similar situations in their lives. You may learn something. Again, far from being anti-scientific (or even lacking in common sense), modeling is a basic principle of learning theory, intuited and put into practice by recovering alcoholics decades ago. AA is like dust-bowl empiricism: We use what works.

Old-timers hold newcomers accountable because they ARE accountable for their behaviors, as is everyone else trying to live life as a mature adult responsible member of family/society. Relapse is a behavior, a decision, a choice. Alcoholism is not. It is a disease. But now that you know you have this disease, you are responsible for your recovery. AA does not hold people responsible for their mental illnesses any more than they hold them responsible for being alcoholics.

"Think before your drink" and "the time to call your sponsor is before not after" are no different than our expectation as therapists that a cutter or suicidal patient be responsible for her recovery by picking up the phone to call us before she picks up a razor blade or a gun.

Nor does AA apply consequences for relapse. When your patient returns to his home group to pick up another white chip (think behavior therapy tokens) after a period of 'going back out to improve on his story', he will be greeted with a chorus of "Welcome back!" and hugs, not punishment. Relapse has its own natural consequences--another basic learning theory principle intuited by Bill W. and the other originators of the Program.

Most, if not all, AA members have struggled with symptoms of anxiety and depression at some time, if not chronically, and many may qualify for formal diagnoses. Child sexual abuse survivors, for example, are heavily represented in women's meetings. I believe you would be hard put to find a home group that has not lost at least one member to suicide. So the old-timers know exactly what it's like to suffer from emotional pain. The Big Book from the First Edition addressed the dual-diagnosis issue directly in the Promises, where it reads that even the severely mentally ill can achieve sobriety if they are capable of being honest. But old-timers also know that drinking when you are feeling blue or antsy not only will not help, it will inevitably make symptoms worse: Statistics show that alcohol is directly involved in a significant proportion of suicides, and AA members are more aware than most of this connection. The quip heard in meetings is that "I never had a problem that was made better by pouring liquor on it".

Because of AA's acute awareness of the consequences of untreated mental illness/addiction, "hitting bottom" does not mean abandoning a person to his own self-destruction. AA members fully appreciate the dangers therein. However, just as in therapy, the person needs a certain amount of motivation to succeed in recovery. All "hitting bottom" means is becoming sufficiently "sick and tired of being sick and tired". Members compare it to being on an elevator going down: You can get off on any floor. But sobriety is not something you can impose from the outside in: It's an inside job. AA members reach out to the suffering alcoholic as part of their 12th Step work, but at the same time recognize that the newcomer has to "want what we have and [be] willing to go to any lengths to get it" in order to resist the siren call of alcohol.

In short, AA as a whole--completely unlike Scientology--is hardly anti-treatment, never mind anti-science or lacking in common sense. C.J. Jung had a lot of input into the early development of the Program. As noted above, a lot of common-sense psychological principles are incorporated into it.

Many members come to the Program through treatment, because it's the rare addiction program that does not incorporate required attendance at AA meetings as part of the treatment plan. AA, NA, CA, and other groups meet on treatment-facility campuses. Off-campus groups send representatives to host meetings in hospital facilities, serve as temporary sponsors, or meet one-on-one with patients. Many, if not most, of the staffers in these facilities are recovering alcoholics/addicts.

I have personally seen a pair of old-timers bundle a newcomer into their own car and drive her directly from her first meeting to a treatment facility, recognizing as they did that she was in withdrawal and needed professional attention, STAT. Members routinely refer each other to their own psychotherapists and psychiatrists, many of whom are in recovery themselves.

Real world, then, the overlap between mental health and addiction "cultures" is nearly 100%. Setting up a false dichotomy like treatment-vs-recovery tears a great hole in the safety-net fabric for alcoholics/addicts to slip through, potentially falling to their deaths. It does this by providing them with an excuse not to participate in real recovery, to wit, "My therapist says it's a cult". Just going to psychotherapy alone is a softer, easier way, and if we enable people to do that, the choice is a no-brainer for the active alcoholic/addict. And it won't work. We can practice our empathic listening skills, pretending we are doing something to get them clean and sober and feeling good about ourselves, until we coddle our poor victims of mental illness right into the grave.

"Poor me, poor me, pour me a drink" is not just a slogan, it's a real and deadly phenomenon.

My professional experience over three decades is that I cannot get patients clean and sober without their active 12-Step involvement. In all that time I have never once found either the Program or its members to interfere with someone's mental health recovery. I have, of course, often had clients engage in splitting between the therapy and the Program, and I am reasonably certain they employ the same defense in reverse when they are at their meetings. Seasoned therapists in possession of a deep familiarity with personality structure, the dynamics of addiction, the process of good psychotherapy, and with how 12-Step programs work, however, will recognize that for what it is and work through it with the patient to the latter's ultimate benefit.

AA has succeeded in helping many people who were formerly considered hopeless causes, and they've done it in a completely transparent manner, from the publication of the Big Book (probably the original manualized treatment!) forward. Furthermore, they do it entirely through the efforts of volunteers who wish only to give of their time and energy to share what they have found with the still-suffering alcoholic. It is a gross insult (not to mention, a false analogy) to compare AA to a secretive cult that charges its members each hundreds of thousands of dollars over a lifetime for a completely bogus process. All AA asks of you is that you put a buck in the basket if you have it, and that you stick around to "pass it on". You do your patients a grave disservice when you compare individual A.A. members to a manic, over-paid actor who publicly insults people who seek treatment for emotional problems. You do them a disservice when you dismiss all the people over the past six decades who have found sobriety and a new life through the Program as lacking common sense.

*Also, because it is so ridiculously long (longer than the original post!) that it may not make it through moderation.

I guess I'm just a sentimental old fool

2010-04-05T19:11:00.000-04:00

Image by George Eastman House via Flickr

"I'm a dog person," I told my client. "I'm going to cry right along with you." And I did.

I have cried with clients before. I have cried with women whose fathers were dying, couples whose children died, and once even at a wake for a client who died. But mainly, I cry when people's dogs die.

I can only hope that it's therapeutic. Because I really have little choice except to proceed. I mean, what am I gonna do, say, "Sorry, I don't 'do' dogs"? Because really, I do dogs. I am, after all, a dog person.

I feel your pain.

I have always had dogs. There was a dog in the house before I was born. I got a puppy of my own for my seventh birthday. Starting with her, I count six who have blessed my life with their love, companionship--and in some cases, sense of humor--over the years. They have, variously, served as playmates, bed-warmers, bodyguards, co-therapists, physical fitness trainers, and travel companions. I loved every one, each in her or his own way. I have grieved the loss of five, and I can tell you that it never gets any easier.

We're supposed to be objective professionals. But lose your dog? I will lose all objectivity.

Huzzah, anyway

2010-03-27T09:43:00.000-04:00

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.

Huh?

2010-03-19T21:59:00.000-04:00

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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.

Therapeutic Texting

2010-03-19T19:17:00.000-04:00

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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.

#7: Patience is a virtue

2010-03-13T18:38:00.002-05:00

Image 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.

The Carlat Psychiatry Blog: WebMD's Big Lie

2010-02-28T10:40:00.000-05:00

The Carlat Psychiatry Blog: WebMD's Big Lie

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Just Who the Hell Do You Think You Are?

2010-02-27T13:22:00.010-05:00

In which Dr. Phil scolds a family, and I scold him

I came home early from work Friday, and caught a snippet of an ad for Monday's episode of Dr. Phil. I must say, the experience was a bit like coming home early and finding one's partner in bed with someone else. What I saw, however, was not Mr. Wood in flagrante delicto, but Dr. Phil verbally abusing a patient.

I caught Philip Calvin McGraw shtupping my beloved profession. And I have a few things to say about that. (You knew I would, didn't you?)

But first, the disclaimer: I do not watch the show. I do not believe that work around such personal, private issues should be done on national television. We are ethically bound to work exclusively in the patient's best interest, and this is in no one's interest that I can make out other than Philip Calvin's. I could not bear to watch another psychologist exploiting people's pain for money, or to get his narcissistic needs met. It would make me physically ill. And because I don't watch, I have no idea what is clinically indicated in this case.

Here's what I do know. You don't yell at patients. Never. Not for any reason. It's abusive, it's incompetent, and it's unethical.

Among the basic Principles that form the foundation for our Code of Ethics are the following:

Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally . . . .
Principle B: Fidelity and Responsibility
Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct. . . .
Principle E: Respect for People's Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. . . .

Back when I was a young grasshopper just starting out in the profession, some of the elders in the therapeutic community here liked to distinguish between two groups of therapists--huggers and hitters. Generally speaking, women were said to be huggers (literally and figuratively speaking) and the male therapists mostly tended to be hitters (not literally, ok?). I'm a hugger. McGraw obviously considers himself a hitter.

Even allowing for differences in therapeutic style, the man is going too far now. This is beyond Reality Therapy (anybody here besides me old enough to remember William Glasser?), beyond tough love. This is verbal abuse. "Who the hell do you think you are?" and calling a female client "Sister" in that tone of voice is inexcusably disrespectful. Telling her "It's time to grow up!" is not therapeutic, it's insulting: He might as well have told her that he thinks she's being childish. She's sitting there frozen, wide eyes fixed on him, tears rolling down her face. And speaking of hitters, if she'd ever been hit in her life I'd be willing to bet that at that moment she was physically afraid of him.

It's incompetent. Everything a patient does or does not do, and I do mean everything, is grist for the mill. All behavior has meaning, and the single best tool we therapists have in our armamentarium is the analysis of behavior. Part of what he was yelling at the patient for was not showing up for appointments and walking out of a session. After, and only after, he analyzed his own behavior for technical errors, McGraw could have gained a lot of mileage in the therapy by helping her analyze her own feelings, thoughts, and actions.

Any time we offer an observation, an interpretation, or some other intervention, we pause, observe the patient's response, and adjust our next move accordingly. The patient's response is the measure of whether we've got it right or wrong, so that if I were to say or do something that resulted in a patient getting up and leaving the room, I would have to automatically consider first that I screwed up somehow. This is so obvious I can't believe I have to say it.

So I look at myself first. Have I made the patient believe it's no longer safe in my office? Maybe I triggered overwhelming anger in her which she does not feel ready to handle yet. Regardless of the exact nature of what just happened, most likely the power differential between therapist and client prevents her from thrashing it out with me one on one. Whatever, she's not being bad. I have made an egregious therapeutic blunder of some sort, and she's taking care of herself the best way she can.

If I can get her back in the room, it will be my job to make this a safe space again to start the process of analyzing what happened, to apologize if necessary, and to help the patient learn from it something that is useful to her. Telling people to be different than they actually are is not therapy. Also, it doesn't work. You might as well yell at the weather for all the good that it will do you.

It's disrespectful, too. To be a good therapist, you have to believe that everyone has in themselves the potential to grow into their own best selves. Imposing what you think is a person's best behavior upon them not only ignores what they want for themselves, it discounts their own abilities to get it. McGraw is telling this woman by his behavior that he knows what's better for her than she does (she's stupid) and not only that, he's going to do it for her because he doesn't believe she can (she's weak). McGraw even talks on his website about "giving" people tools, as if they were his to give.

On the other hand, helping a client see that she can use words to deal with feelings instead of acting them out, that she has the power thereby to make changes in a relationship, helps her find within herself a capacity she has always had but has lost touch with. She will never again believe that when she runs into problems in a relationship that she has only Hobson's Choice between staying and taking abuse/neglect, or walking out. A good therapist can in this way turn potential therapeutic disaster into personal growth for the client.

If she's truly responding to something internal--especially likely in a trauma survivor--then my job is still to get her back in the room any way I can and help her analyze it. This probably happens elsewhere in her life and by understanding herself better she can get some control over her reactions and learn some better tools for handling them. She will only do that if she feels safe with me to explore her internal reality. That won't happen if I'm busy yelling at her.

Yelling, getting angry at a patient, is not about the patient's therapy any more. It is about using the power inherent in your professional role (and perhaps also in gender, racial, class, and other differences) to gain control of another person's behavior. It's now about the therapist and the therapist's needs, not the patient's ultimate welfare. What we have in McGraw's clip is an older male authority figure yelling at a younger, female client. This is a flagrant abuse of power, and as in any abusive relationship, it is about controlling the victim's behavior.

McGraw also yells at her that when he asks her a question, she'd better 'tell the damn truth'. This reveals a total lack of understanding of the patient's experience of psychotherapy and of the process of therapy. It's the kind of incompetence you might expect from a first-year graduate student in the first weeks of his therapy practicum. Clients don't tell the truth. Any lawyer can tell you that, without the first bit of training in clinical psychology. In the first place, clients don't always know the truth. That's what they're here for, ~~dumbass~~ Doc, to learn the truth about themselves.

In the second place, they are afraid to tell the truth. They are afraid that we will think they are crazy, or evil, or stupid. They are afraid we might yell at them for it. They are afraid that they might scare us, disgust us, anger us, and then we might refuse to work with them any more. Which of course is exactly what happened here: McGraw acts out the patient's worst fears instead of working through them.

You see, Philip Calvin, whatever we think or act or feel (or don't) is also grist for the mill, except we don't just blurt it out in the session. We analyze it privately or in supervision--which I think Philip Calvin could really use--and then and only then decide if we want to use it in the hour and how we might best do so. If a client makes us angry, for example, or renders us impotent (as seems to be the issue in this case) by not showing up or not getting better or whatever, first we need to check and see if this is our issue. Did my mother make me feel like that? My Dad? My boss?

If so, I need to let that one pass on through me and get myself back to the reality that is the client in front of me. If it's not primarily an issue from my past, then my next best bet is that the client makes a lot of people feel this way. Will I help her understand her impact on other people if I scream at her? No. Will I help her change her behavior by telling her to cut it out, or else? No. If it were that simple, she'd have done it already. But if, on the other hand, I can help her look at what just happened in the session and the feelings and intentions behind her behavior, then she has a chance of learning something that will help her in the future to behave in a way that works better for her.

Instead, McGraw takes the no-shows and the lying and the walking out of sessions personally, as if it were about him and not the client. Which of course by now it is, due to his ham-fisted attempts to exert control. If the only way she can retain some of her power and dignity is to not show up or to leave when he's ~~being an asshole~~ overbearing, that's what she's going to do. He's so contaminated the therapeutic field that by now it's going to be nearly impossible to sort out what's hers to work on and what's his. If I were his employer, I would assign the family to another therapist at this juncture, because it's not the family's job to help him sort out his stuff. They're here to get help for themselves, and they aren't getting it.

Don't get me wrong: There are times you have to fire a patient. If you are working in the patient's best interest, though, you don't yell, "You do that again, Sister, and we're through!" and "Don't try me!" The sacking is a therapeutic process, handled properly. McGraw, again, is trying to control another person's behavior with threats--in this case, as if he were a parent threatening to withdraw the father's love if the she doesn't do what he wants. He's attempting to get his needs met in the therapy, and if he does fire them in the coming weeks, it's going to do damage.

While we are on the Daddy thing, by the way, you may have noticed that I have been speaking about this case from the standpoint of individual psychotherapy. The reason for that is that I don't practice couples or family therapy--I don't have enough training or experience in it. I'm guessing McGraw might not either, because one thing I do know is that the therapist's job in family therapy is most emphatically not to step in and be the Daddy. If I'm right, he's practicing outside the boundaries of his competence (Standard 2.01, Boundaries of Competence) and that's not only unethical, it's dangerous. Do the wrong thing in family therapy and you have the power to not only permanently disrupt vital relationships in people's lives, but even to get someone killed.

Specifically, that Standard states in part:

(a) Psychologists provide services. . . only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

Philip Calvin wrote his dissertation on rheumatoid arthritis. Make of that what you will.

But I digress. The way to handle this is to point out the reality of the situation to the client, to wit, therapy cannot happen if you [fill in the blank]. We need to find a way to help you stop [whatever it is that's undermining your treatment]. How can we best do that? Or is it possible that your behavior is your way of saying that you are not ready to be in therapy yet? Or perhaps just not in therapy with me? In this way, you are helping the client see that she is making a choice--to engage herself at the next higher level in her therapy or to stop treatment for now. It's her choice, to make with integrity. McGraw's approach is punishing her for being herself, for doing the best she can with what she's got. The method suggested here challenges her to to make a conscious decision, and that's growth for her no matter which way she goes with it.

According to Wikipedia, McGraw is no longer licensed, and presumably he's not a member of the American Psychological Association (APA) either. If correct, he does not subscribe to and is not bound by the Code. Also according to Wikipedia, he claims his show is entertainment, not the practice of psychology. Assuming a judge would accept that distinction, he's therefore not practicing psychology without a license, which otherwise would subject him to possible legal sanctions. His website is a bit fuzzier on this latter point, listing as it does his academic credentials and talking about helping people, so somehow I seriously doubt that either his ~~victims~~--dang! I did it again!--patients, I meant to say, or his audience fully understand these fine distinctions.

It makes me sick to see something like this on television. It is exactly the reason that people do not come to therapy, or if they come they can't fully engage--they are afraid that the therapist is going to judge them. Our job is not to judge. It is to act as guide to the client's inner life. One three-minute tirade like McGraw's, and 6.7 million people will be frightened off forever.

I'm telling you, it just makes me sick.

Welcome to Rape Culture, Joe

2010-02-19T22:42:00.002-05:00

Image via Wikipedia

Valdosta State University's remarkably inept recent posting of Rape Prevention Tips for Women triggered a number of blog posts on Rape Culture in which the bottom line was as follows: There is only one cause of rape, and that is the presence of a rapist. Tips for preventing rape, therefore, should be targeted at rapists. (Anna posted a great one in the Comments section, here.)

Personal Failure at Forever In Hell was one of the bloggers responding to the VSU gaffe. In response she got, perhaps inevitably, the usual mansplaining troll who took her to task for her "tone", among other things. He criticized her for being angry and anti-male. Fannie, of Fannie's Room took him on, and her post is so right on that I feel compelled to reproduce a goodly chunk of it, verbatim, here. (The last time I asked someone to attempt such a flip-flop, I got totally flamed. I hope she does not, because seriously, this is really good.) I would ask every man who does not believe that we live in a Rape Culture to try this one on for size:

"A good flip-flop comparison would be to imagine a world in which women routinely kicked men in the balls really hard for no reason at all, so much so that men wore protective cups on their genitals at all times and, if they didn't, they knew full well what they were asking for. One wonders, how would men react if the ball-kicking led to the formation of Ball-Kicking Prevention Tips that advised men to never walk alone at night, to avoid dangerous neighborhoods (especially where groups of women congregated), and blamed men for Getting Their Balls Kicked if they chose to move in the world like how people got to move?

It's not so much that the tips are not useful. Some of them are. But wouldn't the men rightly be angry about living in a culture that seemed to focus more on all the ways men could limit their lives to avoid getting kicked in the nuts, as opposed to how we could make women feel less entitled to attack men in the first place?

. . . .

Welcome to Rape Culture, Joe."

Right on, Fannie! There's really not much I can add to that.

Always Be Aware of Your Surroundings

2010-02-07T09:31:00.001-05:00

Do you monitor the internetz for potential rapists? Perhaps you should.

I myself have one of those automatic Google thingies set up to scan for variations on my name and report links to me in a weekly e-mail ('course that's not why I do it, but never mind). Perhaps that's how this rape victim discovered a Craigslist ad in her name asking for a partner to act out a rape fantasy. Or not.

In any event, by the time she found out about it and got Craigslist to take it down, a real-life rapist had already seen it and was happily on his way to her house to fulfill some of his deepest fantasies.

Turns out she was set up by her ex-boyfriend.

So if we are responsible, as so many rape-prevention experts advise, for maintaining a constant awareness of our environment, now I guess we are to not only acquire eyes in the backs of our heads (this would be especially tricky if, whether for religious reasons or simply because it is raining cats and dogs, you cover your head when you are out in public), figure out how to see around corners and through parked cars and tree trunks, but also be aware of every transaction on the internet around the entire world in every language all the time! Because you will have nobody to blame but yourself if you get raped because you were unaware of your surroundings.*

My goodness. When will I ever find the time to wash my hair?

*Nobody in the original article--not the reporter, Ben Neary (AP), or anyone interviewed, implied any such thing--but wait for it. It's only a matter of time. I'll bet you a guest post that someone, somewhere, will at least say that once the victim found the ad she should have taken extra precautions. Any takers?

You CAN Prevent Your Own Rape, You Know

2010-02-05T23:26:00.000-05:00

Image via Wikipedia

I heard it from an expert.

I've been at an otherwise pretty good two-day workshop that was supposed to be on the neurobiology of trauma, but turned out to be a whole lot about treatment. The seminar leader is a genuine nice guy, a brilliant researcher and clinician who has devoted his career to helping people recover from trauma.

In some ways, I think, that makes what happened today even worse.

He was telling us about a case of a martial artist who was raped, and suggested that women like her get raped because they are unaware of their surroundings and/or are frightened into immobility due to past trauma. He clearly could not think of any possibility other than something about the victim. And I gotta give it to him, maybe she was spaced out--trauma survivors often are. Maybe she did freeze--trauma survivors often do. But still. Why be trying to puzzle out what it is about the victim that gets her raped? That makes me want to set my own head on fire.

Maybe it was a "blitz attack", which of course by definition would mean she wouldn't have known she was even being attacked until she was already down. Or maybe her rapist had a weapon: I have to ask--do men really believe that a martial artist can kick a gun out of an attacker's hand like good ol' Chuck Norris on the teevee? And then there's the rapist who comes in through the bathroom window in the middle of the night and has you under his control before you even wake up. Now how you gonna karate-kick his ass outta bed with your legs all tangled up in the kivvers? And then there was the woman I knew whose attacker told her if she cooperated, he wouldn't harm the children sleeping in the next room: All the martial arts training in the world won't trump that one.

And seriously, even assuming a normal (i.e., non-traumatized) level of awareness, how far can tracking your surroundings possibly take you? You can only watch your back-trail so closely before you get a crick in your neck--or worse, stumble into traffic. A guy who's determined to sneak up on you will. Or jump out from behind something: Can you see through tree trunks, around corners of buildings? I can't. And how aware can we be when we are sleeping in our own beds?

The expert thinks it is empowering to teach a woman to kick the shit out of a model in pads and a helmet. He noted her proud stance after the class and said something to the effect of, 'Now she's in control of her own destiny.' The sheer illogic of this is stunning when a lifetime of training in martial arts didn't protect her. (I've seen this from a women's self-defense expert, too, who repeatedly tweets that it is up to you to be appropriately assertive--in control--so you don't get raped.)

Let us note that one in every six women in the U.S. will be assaulted in her lifetime. Maybe it's just me, but I think that's frequent enough to suggest that we are not, in fact, in control of our own destinies--at least not when it comes to rape. Indeed, that kind of thinking sounds to me like a form of privilege: The not-raped can believe they did/do something to earn/deserve that status ("I kicked the shit out of him!" or "I'm always aware of my surroundings." Always? Really?). That kind of thinking allows the not-raped to feel safe and secure in the fantasy that "it will never happen to me" and to look down on victim/survivors as people who screwed up somehow.

But I digress. I'm sure beating up on that guy in class was fun for her. And maybe all women should know some self-defense. But shouldn't anybody think that's going to necessarily prevent a rape (see above). Heck, it might get her hurt worse or even get her killed, because some rapists escalate when you fight back, either because it angers them or because they are excited by it.

These are all reasons why it is both cruel and ignorant to blame women for not paying sufficient attention to what every potential rapist within arm's reach might or might not be doing, or for not fighting off a dude who outweighs her, has a longer reach, has got the drop on her, or who is carrying a weapon--or all of the above. I'm sure the presenter didn't mean to blame anybody, but that is, precisely, victim-blaming.

My stance has always been (and I learned this at Grady's Rape Crisis Clinic back in the '70s, by the way--I don't get original credit for it) that whatever the woman does and survives is the correct thing. I wasn't there. You weren't there. The expert wasn't there. She was. She read the situation and handled it instinctively--and survived. That right there gets her a grade of A+.

The scary part, again, is this guy is a recognized expert who amply demonstrated a high level of sensitivity at other times during a career spanning decades. If he can have a mental lacunae like this. . . well, I just despair sometimes.

And of course he's not the only professional to do this, nor is it always a man. A recent report of a "female" getting raped in a park caused a female psychologist to nearly throw herself onto Twitter to warn "girls" not to go to parks alone or after hours. I clicked on the link and found that the original news article had never specified the victim's age, the time of day, or whether she was alone. Never mind that none of these things is in the least bit relevant anyway, because rape, dear readers, is caused by rapists.

Trust Means Letting Go of Control Over the Outcome

2010-01-22T21:46:00.003-05:00

Vigil for Dr. Tiller Image via Wikipedia

What is Blog for Choice Day?

Each year, NARAL Pro-Choice America poses a question to pro-choice bloggers before the anniversary of Roe v. Wade, and then asks them to blog their answer on January 22.

In honor of Dr. George Tiller, who often wore a button that simply read, "Trust Women," this year's Blog for Choice question is:

What does "Trust Women" mean to you?

Ironically, I was inspired to this post by another disabled feminist blogger's expressed opinion that abortion is just another way for upper-class Caucasians to get rid of "bad babies", which is to say, fetuses who might already be defective in some way or who have the genetics for a future disability.

The blogger is right when she points out that we have such a prejudice against the disabled in this country that we often disapprove of either disabled women having children, or women in general having disabled children. For example, she points out that we even frown on older women conceiving because of the mere risk of problems. The gist of her post is that no, she does not trust women: She thinks we are all out to kill her and her kind.

She notes that people who think that raising a disabled child is a terrible burden are making a basic logical mistake: It's not the child's disability that is the biggest problem. It's the lack of affordable health care, accessible child care, and so forth. In other words, that baby is facing all the societal prejudices against disability from day one. And by extension, the miserable lives that the able-bodied envision for those of us with disabilities is premised on the same logical error: It is often not our disabilities that are our biggest problem, but the attitudes of others (including the unwillingness to hire us at comparable pay), the lack of accessibility everywhere we wish we could go but can't get in, the lack of decent health care in this country, and the ignorance of our health care providers about our specific needs.

About all this my sister blogger and I are completely in agreement. But also, and unfortunately, there is little social support in the United States for any woman to raise any child. If she is a single, young, unemployed woman of color? Fuggedaboudit. No support. Indeed, she is likely to be punished in any number of ways, large and small but equally cruel, every day for the entire dependency of that child. And this, my dear readers, is why most women seek an abortion. Not because the child is going to be disabled but because the woman in question simply cannot have and raise a child. Any child. Maybe especially not a disabled child, and maybe especially not if the woman herself is disabled, but the bottom line is that any woman may find herself unable or unwilling to carry a fetus to term.

Find me one case of one of these mythical Caucasian upper-class women with, say, a hereditary crippling disease, selectively aborting pregnancies until she gets a "good" one, and I'll buy you dinner. I can safely make that bet because the fact is that "abnormalities in the fetus" is the least-frequent reason cited, world-wide, for seeking an abortion.

The able-bodied aren't the only ones making logical errors here. Sometimes disability advocates and pro-lifers do, too: pro-choice is not synonymous with pro-abortion, but some people have an annoying habit of conflating the two. I am not personally acquainted with any pro-choice folk who think that there is any circumstance in which a woman should have an abortion. What we want is for women to never again be forced to carry every pregnancy to term, irregardless of her personal circumstances.

Which brings us to what "Trust Women" means to me. The dictionary definition of trust is, "reliance on the integrity, strength, ability, surety, etc., of a person or thing; confidence." You will note that there's nothing in this definition about outcomes, only about process. We, as women, if we trust each other, must rely upon each other to make our own best, ethical decisions about our own bodies. Pro-lifers do not trust us: They have one specific outcome in mind and that's what they want come hail or high water, whereas people who are pro-choice by definition express confidence in each woman's strength and integrity, in her ability to make the right decision. Pro-life is a paternalistic approach that treats women as children; pro-choice respects us as the adults that we are.

To me, "Trust Women" means just that. Trust us. Trust each other.

Stupid EOBs, Edition 1

2010-01-22T18:42:00.004-05:00

Mount Aetna Image via Wikipedia

An EOB, for the unitiated, is an Explanation of Benefits. More often, they are better described as Obfuscations of Benefits.

This one is from Aetna. It purports to explain why they did not pay me for a session:

"The member's plan provides benefits for covered expenses at the plan's recognized percentile level of charges received by Aetna for the same service."

I feel like I need a shower now

2010-01-20T23:00:00.000-05:00

A recent thread on a professional listserv I belong to has taken up the topic of using client/patient testimonials on psychotherapy websites, in brochures, and for other marketing materials. A couple of people responded to the original poster that he should not do it. And then this:

My [partner] is an attorney and we looked into this before I obtained my testimonials. It is true that in [State] testimonials are not allowed regarding current clients. However, clients that you have terminated with are fair game.

"Fair game"? Egad. What a way to look at one's patients. Would you want to see a therapist who looks at you as the marketing equivalent of a deer in his crosshairs?

The commenter goes on to say,

Some of my clients fill out a form. . . and some I speak with over the phone. The phone interviews are much more productive because you can discuss what may be relevant to your marketing needs, e.g., getting them to talk about specific results that have come from our work together rather than just praise about me.

Finally, the commenter refers the original poster to the website of a practice coach who says, and I quote:

. . . through the course of your work together perhaps a client spontaneously expresses how he or she is benefiting from seeing you.

When this happens, you should write down what the client said about how he or she benefited from your service and then ask permission to use these statements in your promotional materials.

Seriously. I need a shower.

As the commenter notes, certain states' licensure laws do not expressly prohibit soliciting testimonials from former clients. Our ethics code does not specifically forbid it either. However, it is my position that ethical behavior ought to consist of more than simply not doing what is expressly forbidden. Striving to be as ethical as we can should include having our clients' best interests at the forefront of our minds at all times, acting like a professional (as opposed to, say, a used-car salesman), and maintaining our professional objectivity in any given case. It is a vital part of our professionalism and essential to our objectivity that therapy is about the client's needs, not ours.

Taking notes during a session with an eye to posting clients' statements on your website is hardly keeping your eye on the therapeutic ball. Even if you wait until a client is "former" to ask permission to use a quote, how can you help but think in terms of that client's potential effect on your bottom line rather than doing your best work at the moment? Sometimes our best work is going to make the client uncomfortable--anxious, sad, even angry. We may hesitate to say what they need to hear, as opposed to what they want to hear. What if a client wants us to violate a boundary in some way? We may give in, gratify that wish for them instead of helping them work it through, so we can get a good ad out of it. We're only human: If we walk into that consulting room with any agenda other than the therapy, we are at risk for skewing things to get our needs met at the client's expense.

Waiting until the client is no longer a client to ask for a testimonial does not keep it from being an issue with active clients. Clients who found you through promotional materials using testimonials know perfectly well, even if you haven't mentioned it yet, that this is on the table. How will this affect their work with you? Will they use criticisms for leverage? Will they worry that if they don't give you a testimonial that you will not write as good a letter for their probation officer, or give them whatever else they are needing from you? Conversely, will they spontaneously offer testimonials in order to win your good will? Clients know we're only human.

Clients who form strong, long-term relationships with their therapists are particularly desirous of pleasing us. Might such a client be even more reluctant to hide relapses if they have the extra, added pressure of knowing we need a success to bolster our practices? Could they feel pressured to look like they are getting better than they are, faster than they are, to help us out? Nobody knows the answers to these questions, because nobody's researched it. It would be unethical. But we can make educated guesses, and our best guess is that any or all of these things could happen; our best guess is that this testimonial business is bound to affect the work. It can't not.

Our ethics code and state law do prohibit soliciting testimonials from "persons who because of their particular circumstances are vulnerable to undue influence." Many therapists think that this latter category includes former patients. We are uncomfortable with the legal and ethical distinction between current and former patients that allows certain behaviors toward the latter. Psychodynamic therapists argue that transference, the displacement of feelings from parent to therapist, lasts forever. To them, "once a client, always a client" is the rule. Even if you aren't psychodynamic in orientation, it is difficult to define "former." I've had clients return after a hiatus of as long as 10 years, and probably these folk considered themselves my clients even when they weren't active in therapy.

Contact after a brief period is very common. Perhaps the client you just saw for a 5-session Employee Assistance Service (EAP) assess-and-refer gives you a testimonial--or refuses one--and six months later needs you to testify to your work in court. Will you be squeamish about testifying to things that will hurt your client's case? Will you not want to go if they wouldn't give you a nice sound-bite for your website?

Even if they never come back or need you again for anything else (like court), on what magic date do you stop having most of the power in the relationship such that a client would truly feel free to refuse you? There is no research that I am aware of which would tell us how many days, weeks, months, or years it takes after therapy ends for us to stop being an authority figure to our clients. On what magic date would we no longer be using our position and prestige to get our "marketing needs" met by the client? By the time we get done with a course of therapy, we know things about a person, things we can use to get what we want. On what magic date to we un-know these things? I think the commenter above intuitively recognizes, even as she fails to consciously consider, that power when she recommends telephone interviews: We can exercise a lot more influence, due or otherwise, on the phone than we can through the mail.

The American Psychological Association (APA) ethics code also forbids dishonest or misleading public statements, in which they include your advertising. There is plenty of research to show that, psychologically, humans want things to work. We are hard-wired to believe that a treatment or a product did work for us, and the more time and money we put into it, the stronger is this bias. Asking a client if something was helpful is not going to get the same kind of objective information as, say, before-and-after psychological testing might. Plus, presumably, if a client tells you, "Heck no, you bite," are you going to post that on your website? No. For these reasons, your promotional materials are apt to be misleading, if not downright dishonest, in direct proportion to your dependence upon testimonials.

Bottom line? Just because we can do a thing doesn't mean we should. What we should do is strive to go as far beyond the minimum standards outlined by legal and ethics codes as we possibly can. I simply do not believe that we can do our very best possible work if we are thinking about how what we are doing is going to look in a brochure, and I do not believe for one minute that clients will have the freedom of action or sense of absolute privacy that are the sine qua non of productive therapy if they know they will be used in an ad. There is a risk throughout the therapy and well after it that we will be using our position as the client's therapist, and the power and insider information that goes with it, to get our needs met. Finally, testimonials are not an honest means of advertising.

I tell my ethics students that, "There's illegal, unethical, and just plain tacky." Testimonials may not be illegal, and they may not be unethical, but they are surely tacky. In fact, I would go so far as to say that they are downright sleazy.

Just sayin'.

Haiti Earthquake: Stress Management Tips From The APA

2010-01-15T11:50:00.001-05:00

Haiti Earthquake: Stress Management Tips From The APA

No time to blog it right now--just wanted to put the link up for you.

50% success rate for New Year's Resolutions

2009-12-28T08:37:00.002-05:00

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.

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.
Set a series of small, measurable goals instead of one giant one.
Keep records of your progress.
Enlist support: Go to Alcoholics Anonymous meetings, or tell your family what you're doing, or get an exercise buddy.
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

2009-12-27T13:42:00.000-05:00

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

About those New Year's resolutions. . .

2009-12-26T08:09:00.000-05:00

APA Statement on Senate Passage of Health Care Reform Legislation

2009-12-25T10:34:00.001-05:00

APA Statement on Senate Passage of Health Care Reform Legislation

Abortion

2009-12-24T12:51:00.001-05:00

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

as stated above, the risk of carrying an unwanted pregnancy to term and the risk of a legal abortion are about the same
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
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)
most women do not regret the decision to terminate.

What?

2009-11-30T21:02:00.004-05:00

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?"

2009-11-12T10:28:00.032-05:00

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

2009-11-11T12:06:00.005-05:00

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

2009-11-01T12:33:00.010-05:00

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

2009-10-24T10:39:00.000-04:00

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

2009-09-12T10:16:00.015-04:00

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

2009-09-10T12:43:00.004-04:00

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

2009-09-10T07:20:00.003-04:00

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

2009-08-20T08:05:00.004-04:00

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

2009-08-18T20:17:00.001-04:00

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

2009-08-18T20:03:00.002-04:00

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. . .

2009-08-01T14:57:00.061-04:00

. . . 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 education 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)

2009-07-24T18:44:00.010-04:00

"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

2009-07-20T12:35:00.014-04:00

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

2009-06-30T09:44:00.047-04:00

Sally Kristen Ride, Ph.D.

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!

2009-06-27T11:47:00.032-04:00

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

2009-06-26T07:32:00.002-04:00

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?

2009-06-23T08:43:00.002-04:00

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,

2009-06-14T20:55:00.007-04:00

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

2009-06-12T20:50:00.018-04:00

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!

2009-06-11T19:09:00.022-04:00

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

2009-06-06T18:27:00.010-04:00

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*

2009-06-02T19:24:00.013-04:00

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.

New rule

2009-05-31T17:15:00.001-04:00

There oughta be a rule about moving, but I'll be durned if I can think of one. Unless it's, "Don't do it unless you absolutely, positively have to."

2009-05-28T07:31:00.002-04:00

A nice little essay on ending therapy

I have been thinking lately about reinstituting my old rule about requiring three weeks' notice from clients who wish to terminate so that we can do the review described in this essay.

In which Dr. Wood attempts to work without Larry

2009-05-26T18:24:00.002-04:00

Every single time I came through that door I wanted to say something to My Little Green Man. I never realized before how much and how often I talk to him. I missed him today!

Wonder what, if anything, that says about my mental health.

In which Larry Bird is happily settled in at home

2009-05-24T20:15:00.005-04:00

Today was moving day for Larry Bird. I had to net him, because of course he wouldn't step up, and that was pretty traumatic for both of us. He had to ride home in the truck in his travel cage, and we heaved his big condo into the back. We brought him in just ahead of the rains this afternoon, and before long he was back in his home cage eating and playing with his toys and chortling softly the way he does.

I am going to miss having him at the office this week, but I think he'll be happier here in the long run. He won't be alone on the weekends, for one thing. And for another, he has a big double window right next to his cage, which we open in good weather. So, as he did today, he can look out over the garden instead of a parking lot, and he can listen to the rain and the songbirds and enjoy the fresh air.

I will just have to find another way to figure out when clients are suppressing their anger.

The basics

2009-05-21T08:43:00.003-04:00

I am reading Jane Hall on Deepening the Treatment. It's a book for beginners (she teaches technique at an analytic institute). I didn't realize it was for beginners when I bought it, otherwise I would not have.

Liv Ullman wrote in her memoirs that the book you need comes into your hands when you need it. I picked this one up the other day because every time I walked past my bookshelf it called out to me.

So far, and I'm a couple of chapters in, I haven't read anything I didn't already know. But I'm hanging on every word, nevertheless, partly because Hall says what she says so well, but mainly because she is reminding me why I became a therapist in the first place.

Managed care and training as a psychologist exert a powerful pull. Hall reminds us all of our roots.

Does your school have one?

2009-05-13T09:08:00.003-04:00

Lance Helms sent a message to the members of Safe Schools for All, a Facebook group, and I am pasting it in here.

Subject: Summer reading: GSA 101

Friends,

Whether you're a student, parent or concerned community member, one of the ways you can support safe schools for all is to support the formation of GSA's, or gay-straight alliances, when school is back in session next fall.

Not limited to gay students by any means, GSA's are commonly inclusive of lesbian, gay, bisexual, transgender, queer/questioning students and their allies.

Supporting GSA youth is as simple as asking any student you know whether their school has a GSA. If not, maybe they'd like to consider starting one next fall, when most student clubs get formed.

For any student who'd like to know more about how to start a GSA in their school, Lambda Legal has an excellent GSA resource that's part of their "Out, Safe & Respected" toolkit for LGBTQ students. Here's an excerpt:

"A gay-straight alliance, or GSA, is a club for lesbian, gay, bisexual, transgender, questioning students and straight allies.

"There are lots of different kinds of GSA's. GSA's can be social clubs (some GSA's host dances and movie nights), support groups (some GSA's provide a safe place for LGBTQ students and their allies to talk about problems), educational outposts (some GSA's organize guest speakers or create displays for National Coming Out Day) or advocacy groups (some GSA's participate in GLSEN’s National Day of Silence or push for sexual orientation and gender identity to be added to their school’s nondiscrimination policy).

"Talk with your friends, reach out to other students and decide what you’d like your GSA to focus on. There are more than 3,000 GSA's in schools nationwide, and there is lots of information available about forming a GSA. No matter what its focus is, your GSA can play an important role in addressing homophobia and anti-transgender discrimination and can help create a safe space for LGBTQ students."

So start the conversation today! Chances are, whoever you start the conversation with will be glad you did.

Lambda Legal's "So You Wanna Start A GSA":
http://www.facebook.com/l/;http://tinyurl.com/qbxbma

Lambda Legal's "Out, Safe & Respected":
http://www.facebook.com/l/;http://www.lambdalegal.org/publications/out-safe-respected/

PFLAG's Safe Schools / Cultivating Respect homepage:
http://www.facebook.com/l/;http://community.pflag.org/Page.aspx?pid=1011

Yours in community,

Lance Helms
PFLAG Gulf Regional Director
Atlanta

Hoo, boy

2009-05-09T09:30:00.008-04:00

John Best, over at Hating Autism, has started a bit of a blog war with his latest post, "Ask Newsweek to kill Ari Ne'eman." Called to task for the inflammatory title, he then commented:

I believe that everyone associated with Neurodiversity should be put to death for the propaganda they perpetrate against curing horribly disabled children. They are part of the lies told by vaccine makers and politicians who continue to cause autism intentionally.

I believe that autism is the greatest crime in the history of the planet and that anyone who has been involved with it in any way deserves to die, preferably slowly and with great pain. So, while I don't suggest that anyone should shoot Ari Ne'eman in the head, I do think he deserves a trial for his role in this atrocity. I hope the outcome of that trial would be death.

Hard to know where to start with this one. My heart goes out to Mr. Best (and Mrs. Best--I assume there is one) for the tragedy of their son's illness. I have no sympathy, however, for this kind of bitterness and hatred, never mind the irresponsible talk of killing people.

If Mr. Best wants to talk about atrocities, perhaps he should point his finger not at politicians and vaccine-makers, but at all those folks who won't vaccinate their children: The anti-vaccine movement in the long run has the potential to cause many more illnesses and deaths than autism ever did. Or at the health-care system that is going to make it impossible for his son to remain at home.

But I digress. It's a human trait to look for someone to blame. Accepting that stuff happens is hard. It's easier and more emotionally satisfying (in the short run) to be angry at God, the government, another person, or a minority group. But in the long run, all that rage isn't going to change our conditions one whit. And realistically speaking, it won't prevent another case of our disorder, either. Given that stuff happens, and we all have to deal with it when it happens to us, the best course is acceptance. That is the road to inner peace, in the long haul. It is what is is: Now what are we going to do with it?

If there is somebody to blame, then of course they should be held responsible. But Mr. Best is incorrect in his claim that vaccines cause autism, as has been scientifically demonstrated. He is also incorrect that Asperger's is not autism, or that persons (like Ne'eman) diagnosed at 12 can't possibly be autistic. Autism exists on a spectrum, with Asperger's at the high end. And people with high-end autism most certainly do go to college--and to grad school. High-end autism cases do go undiagnosed until people reach certain developmental stages and start hitting a wall. This is true of several disabilities which first manifest in childhood, such as Attention Deficit Disorder Without Hyperactivity.

Best is also wrong about the neurodiversity movement's goals. The movement isn't about not curing disorders. It's about not othering us.

More changes

2009-05-07T15:20:00.003-04:00

The House Wrens are building a nest this week in the box out back of the office, and the House Finches have started a new nest on top of one of the porch columns (having presumably lost theirs in the Great Leland Cypress Massacre). But we won't be here to see them raise their little families as we are moving at the end of May.

I am relocating to Cherokee Counseling and Psychological Associates, LLP, effective June 1st. And Larry Bird is relocating to our house.

A client's view

2009-05-06T22:10:00.002-04:00

Like most psychologists, I collect shrink 'toons. A customer contributed this one.

2009-05-05T15:20:00.001-04:00

I don't even like Leland Cypress, but when I came to work Monday morning and found that ours had all been chopped down, I thought I would cry.

Maybe next year

2009-05-03T08:48:00.003-04:00

I didn't find out about this until today, but it seems like a cool idea. Now in its 4th year, it happens every May 1st.

In the meantime, here's a great link to a post about the language of disability.

2009-05-02T17:42:00.004-04:00

what I look like when I'm grading

Mental Retardation

2009-05-01T19:42:00.003-04:00

Not my area of expertise. But seems to me it would be cool if the next version of the Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association, changed the language. In the meantime, I'm working at trying to change my habits.

Souter retires. . .

2009-05-01T19:24:00.005-04:00

. . . and we have an opportunity! The National Organization for Women is circulating a petition on the internet that you can sign asking the President to appoint a woman to the Supreme Court.

Women lack role models at the highest levels of government, business, and the professions. We lack voices at the highest levels of decision-making in government, business, and the professions. The Supreme Court, like most corporate boards, Congress, or any other high-profile group you care to name, does not reflect the diversity of our population.

This is a chance for the President to rectify that situation just a little bit. It would be good for women everywhere to see a woman on the bench! So let's all go to NOW's website and give The Man a shoutout!

This flu thing is gettin' outta hand

2009-04-30T08:51:00.001-04:00

We're open today, and I'm goin' to school in a coupla hours, but seriously folks, if you are sick--or if you've even been exposed--for heaven's sake stay home!

So Sad

2009-04-22T21:34:00.003-04:00

He beat her to death with a fire extinguisher.

During the trial, prosecutors played recorded jail conversations where Andrade referred to Zapata as "it" and said it wasn't as if he "killed a straight, law-abiding citizen."

"His own statements in the jail call betray the way he values Angie's life, the way he thought of her as less than, less than us because of who she was," Chief Deputy District Attorney Robb Miller told jurors."Everyone deserves equal protection under the law and no one deserves to die like this," Miller said.

[The defense attorney] said Andrade's statements were jokes made by a man who knew he was innocent.

Suicide

2009-04-18T18:58:00.054-04:00

'Cause suicide is painless,

It brings on many changes,

And I can take or leave it if I please

-The theme from M*A*S*H,

by Johnny Mandel & Mike Altman

I've never tried it myself, but I really doubt that suicide is painless. Yes, I know--it's just a song. But there are lots of songs out there that imply the same thing, and the sentiment corresponds with what more than a few of my suicidal clients have as much as said. The truth of course is somewhat different.

The time leading up to the decision is certainly emotionally painful, and of course sometimes the person is motivated by chronic physical pain to consider suicide in the first place. And finally, suicide is ugly, so that no matter how you do it, it is going to be traumatic for whoever finds you.

It's not at all romantic

Suicidal people are in a world of pain. They do not feel loved, or even lovable. Waldowski, the suicidal dentist in M*A*S*H, couldn't get a girlfriend, and that was his central motivation for wishing to die. But most suicidal people (I would except folks like Hitler in his bunker) are loved. If you are depressed enough to kill yourself, you can't feel the love, but it's there. Both fictional scenarios, M*A*S*H and Tom Sawyer, are accurate in that regard. People will go to great lengths to keep you alive if you give them the chance (witness the ritual the whole M*A*S*H unit puts on to help Waldowski get laid), and they will certainly grieve you if you don't.

People die because they have given up hope. It is one of life's greatest tragedies that a laughing baby, a beloved toddler in his new white Stride-Rites, a snaggle-toothed teeny-bopper with her braces and pigtails, and a grinning teenage boy can grow up to be so hopelessly miserable that they end up blowing their brains out under a tree in the park one night, swallowing pills and putting bags over their heads in lonely motel rooms, or swerving their cars into oncoming traffic. Or like my friend back in '85, stuffing towels under the garage door and sitting in her car with its engine running, her favorite music on the radio, and a Moosehead in her hand, waiting for the Reaper.

Seasons don't fear the reaper
Nor do the sun, the wind, or the rain
We can be like they are...

We'll be able to fly...
Redefine happiness...
We can be like they are

-Don't Fear the Reaper
Blue Oyster Cult

No, you can't: You can't be like the elements, you can't fly. (The last verse of the song makes suicide sound like the Darling children following Peter Pan out the nursery window.) You'll be dead. Suicide doesn't redefine happiness, or bring on many other changes, either, other than that you are now dead. I once heard a workshop presenter liken people's fantasies of suicide to the scene in which Huck and Tom watch from their hiding place as the townsfolk drag the Mississippi for their bodies, grieving the boys' presumed deaths and regretting every wrong or injury done them, however slight. I'm not sure suicidal people really understand that they will not be here somehow to see that their loved ones or the bosses or whoever "will be sorry." That relationship can't change after you are gone. The people you leave behind may well wish they could have a do-over, but will be too late for that. If you want things to be different, you have to be here for it.

Some folks, like teenagers, or persons with Borderline Personality Disorder, tend to give up hope when the problem situation is clearly (at least to the dispassionate outside observer) a temporary one. This was, of course, the case with Romeo thinking Juliet had really died. But they over-react, they believe that they way they feel now is forever, always has been, and always will be. They cannot remember that they actually have felt better recently, and most likely will again soon. They see no solution to their situations. Such folks are particularly prone to impulsive, lethal attempts. This is perhaps life's greatest tragedy, because such people do not have to die. Many, if not most, suicides don't, but these people really don't. Unfortunately this is a decision that, once made, cannot be un-made: As the old line goes, it's a permanent solution to a temporary situation.

I'm not sure what I'm trying to say with this rambling missive. Perhaps I just want you, if you are feeling this way, not to give up hope. I want you to believe that the love is out there, even if you can't feel it right now. I want you to believe that you can find happiness again, or maybe for the first time, but you can find it.

In case you doubted that animals have personalities

2009-04-06T19:33:00.004-04:00

Friday night, when I started getting sick, my dog Io started sticking pretty close to my side. By the time we decided I needed to go to the ER, she was curled up on the foot of the bed watching me closely and sniffing at me with what I swear was a concerned look on her face.

My husband had taken migraine meds before bed so he could not drive me, plus I was so sick I was going to need help getting to the car, so we called our neighbor Russell to come help. Io wouldn't let him in the bedroom: She stood on the foot of the bed and barked and growled, effectively holding him at the bedroom door. This is particularly remarkable in light of the fact that Russell is her babysitter when my husband and I are away.

What makes this interesting to me is that she was already two years old when we got her, and we've only had her about four months. By comparison, her predecessor, Rosie, was born into my waiting hands. I towelled her off and gave her back to her mama to lick and nurse. I took great pains to build a one-on-one relationship with her when she was tiny, but despite the fact that I adored her and she me (to the extent that she would not eat if we were separated from each other), she never seemed to take any particular notice when I was sick or upset. Io is a far more sensitive dog in that regard.

Interesting.

Anonymity and other matters

2009-03-31T18:52:00.006-04:00

I was going to tell "Anonymous" that he can't have it both ways--either I'm an stereotypical histrionic female or I'm dogmatically scientific. (In fact, I am neither.) But then I looked at the writing style(s) a bit more closely and concluded that I may have not one but two Anonymouses (Anonymice?).

It's hard to tell without a numbering system (Anonymous 1, Anonymous 2, . . .).

Be that as it may, one or both of them wants some research citations on affirmative therapies.

Watch this space: I'll get a biblio up soon.

Godbagism and Gays

2009-03-28T13:48:00.030-04:00

"Anonymous," commenting on my previous post, referred Rules readers to a book on results obtained by the Exodus program in converting gays. I would like to thank "Anonymous" for that link, as I was not aware of the book. Following that link--and Googling some people and institutions referred to there--led me to a whole bunch more stuff of which I was not aware. However, I did not discuss religious conversion in that post, and I'm not going to discuss it here, because the topic, as I am sure attentive readers noticed, is the ethics (or lack thereof) of professionals attempting treatment of a core aspect of identity (not a disorder). That's number one.

Number two, I am a psychologist, not an imam, monk, priest or rabbi. As such I am neither interested in nor qualified to speak to issues of sin and redemption. And I certainly make no pretense at knowing what God does or doesn't want, or at having any authoritative knowledge of who or what "God" is. I've never even met Him/Her/It/Them. I have my spiritual beliefs, but that is all they are--beliefs. Not sure knowledge. Beliefs. That's why we call the religions of the world "faiths" and not "epistemologies".

Number three, psychology, albeit with mixed success, historically has sought to explicate the universals of human nature. We seek to help people of all faiths or none to lead happier, healthier, more productive lives, and we seek to do so on a foundation of objective science (insofar as science can be objective). And thus far, science tells us that neither gender identity nor sexual object preference, per se, have any bearing on these goals. (This data would make a whole book, never mind one post, but for starters, see the groundbreaking work of Evelyn Hooker.)

The book "Anonymous" links to was written by a Christian psychologist, a professor at a Christian university, using graduates of a Christian conversion program, published by an evangelical publishing house, and it clearly proceeds from that bias, thus violating every rule of relevance enumerated in the preceeding three paragraphs. I mention it here only because I know a certain proportion of Rules readers are going to follow that link, as I did, and will find that the book purports to be science.

"Homosexual behavior is clearly condemned in the Holy Scriptures, but God always provides a way of escape from the sin that entangles us. I am thrilled there is finally scientific research which compliments the tremendous freedom that I have experienced personally and that I have witnessed in others during my 20 years with Love In Action International. I hope this study will open the door for more unbiased research of this caliber."

Thus spaketh the Rev. John J. "Finding Freedom in Jesus Christ" Smid, President/CEO, Love in Action International, Inc. (an ex-gay group) in response to the book. In case you had any doubt, this makes clear that the book is for people whose bag is one particular version of God, not for those whose bag is objective Science, or for that matter, any other faith. It is religion, not science because it is about sin and redemption in the narrow context of one minority faith.

It is not science also because it is not the norm for scientists to first publish studies in book form, but to use peer-reviewed professional journals to disseminate new scientific knowledge to the scientific community. When one does publish one's work in a book, it is usually in the form of a roundup of not only one's own previously-published peer-reviewed articles, but those of other experts in the field as well. These studies are integrated into a well-rounded summation of the state of knowledge at the time on your topic.

So what we have here is a book on religious conversion, not on psychological or psychiatric treatment, counseling, or clinical social work. What we have here is "data" which has not been peer-reviewed and which may or may not apply to LGBT persons who are Muslim, Catholic, Jewish, or Buddhist, Jain, Baha'i, Shinto, Zoroastrian, Pagan, Sikh, Rastafarian, or Hindu. It will only appeal to people whose bag is this one particular (protestant evangelical) brand of faith.

If that suits you, if you're an evangelical Christian who believes that being gay is a sin, then by all means go buy the book and read it. Just don't be mistaking it for science.

2009-03-26T19:09:00.072-04:00

Homosexuality was removed from the Diagnostic and Statistical Manual list of psychiatric disorders in 1973. On August 14, 1997, the American Psychological Association (APA) Council of Representatives passed, by a vote of 10 to one, a resolution against so-called "reparative therapy" for gays. The first "whereas" makes crystal clear our view, as a profession, of this type of "treatment":

Whereas societal ignorance and prejudice about same-gender sexual orientation put some gay, lesbian, bisexual, and questioning individuals at risk for presenting for "conversion" treatment due to family or social coercion and/or lack of information . . .

And yet.

And yet, more than ten years later, there are still folks out there who think they can and should "cure" people of being gay. Or bi. Or transgendered. Twisty Faster, over at I Blame the Patriarchy, or IBTP for short, has brought to the attention of Blamers worldwide this BBC report on a study just out about some ~~retro~~ Neanderthal types in Great Britain. The journal, BMC Psychiatry, is open access and you can read the entire study here. The study reportedly found that, if asked by the client to do so, 17% of the mental health professionals surveyed would attempt to help a client change her or his sexual orientation*. The authors' conclusion?

Given lack of evidence for the efficacy of such treatments, this is likely to be unwise or even harmful.

"Likely" to be unwise? "Or even" harmful? You think? This lukewarm disapproval is bitterly disappointing, to say the least. Such practices are deemed unethical if not downright abusive (I believe the American Psychiatric Association uses that word) by every major professional group in the United States, Canada, and Great Britain that I know of, and I assume in most other progressive societies. I wish that the authors had unequivocally condemned such behavior, called for more education of the holdouts, and stern discipline of those therapists offering such "treatments".

The authors note that this is a "significant minority" but again, I think they are under-reacting. That one in six British therapists may have attempted to "cure" somebody's sexual orientation is scary. As the writer of a student dissertation on a related topic pointed out, this reveals a really serious problem with these people's training and ethics. It points up serious failings in training programs and in our ethical oversight of our peers. In other words, this is a problem for the profession as a whole, and it is a big one. The estimates of the proportion of therapists who violate sexual boundaries is, by comparison, much smaller, but our profession has generated reams of ink on why they do it, how to stop it, the effects on the victims, and so forth. If this kind of abuse is so much more frequent, how come it's not getting the same attention?

And according to the BBC, another group of researchers is trying to collect "stories" of successful changes via a website. I couldn't track them down, so I can't tell you anything else about it. But lord, lord. Does it never end? How can any ethical psychologist contemplate conducting research into unethical treatments? How can the rest of us, as ethical psychologists, countenance others doing it? And who the hell is funding this garbage?

They just don't get it. Except for one pretty seriously flawed study, there's no evidence that this even works, never mind that it is the right thing to do. Unfortunately, some groups advocating reparative "therapy" have seized on that one. It was published in 2003, by Robert Spitzer, in the Archives of Sexual Behavior. Spitzer asked, "Can some gay men and lesbians change their sexual orientation?" His answer was a qualified "yes," and it sparked a storm of criticism (26 letters to the journal, which is almost unheard of) and outrage.

Spitzer interviewed 200 self-selected reparative "therapy" patients and reported that the majority reported achieving re-orientation to at least "predominant" heterosexuality that lasted more than five years. At what cost to their general mental health? He didn't ask. Besides that little omission, his study was criticized for its sampling method (subjects were self-selected) and for its reliance on self-report.

It has been long established scientifically that there can be extensive differences between potential subjects who do not participate in a study and those who self-select in. It is also long-established fact that people in similar situations are motivated to perceive change in the desired direction. These clients after all have spent money and time in therapy to change, and their views of what they got from these efforts are going to be biased accordingly. Spitzer's data would have been a lot more credible had he studied all the clients of a given treatment program or programs and had he obtained objective before-and-after assessments. In short, it's lame even as pilot studies go.

He's not a bad guy. But I think he exhibited terrible judgment in conducting this study. If we are going to study treatments that have already been declared unethical, of "problems" that have already been ruled not problems, then we need to be focusing our money and our time, effort, and talents on exploring the damage done by those treatments and how, if it's possible, to undo the damage to their victims. But nobody asked me.

That same year, another group published a study of a more general nature, also using survey data. This one, "Predictors of psychotherapeutic benefit of lesbian, gay, and bisexual clients: The effects of sexual orientation matching and other factors," was published in 2003 in Psychotherapy: Theory, Research, Practice, Training. Note that the authors were not specifically investigating reparative therapies, but therapy for LGB clients in general. These authors found that

Negative predictors include having a therapist who is an analyst, who uses reparative therapy, or who violates sexual boundaries (p. 289).

A quick check of PsychLit tonight produced no additional published research, only a how-to book containing "personal testimonies" and one single-case study (by an analyst). In short, no one advocating this practice is producing any real data to say that it works. (Spitzer, it must be noted, is not an advocate. He just thinks we need more data, which is hard to disagree with, except I just have to ask, "Man, if it's not a disorder, why do we give a rat's ass whether you can cure it?") Plus, those advocating this practice are proceeding on the clearly-stated assumption that being gay is dysfunctional, which assumption no professional group of which I am aware accepts.

If being gay, bi-sexual, or lesbian is normal, which the helping professions all now agree that it is, then buying into the client's desire to change it is buying into their internalized homophobia. (I'm not even going into forced treatment of children and adolescents: That's a whole 'nother rant.) It is agreeing with them that a core facet of their very identity is something to be disgusted by and ashamed of. Therapists like the 17% in the Great Britain survey may claim the best of intentions, but in fact are using their power as credentialed healers to do severe damage to suffering individuals who instead need to be relieved of their shame, not their orientations.

One of my absolute favorite clients made her first call to the office to ask The Question: "My son needs a therapist. But he is gay and before I make an appointment with you, I want to know how you feel about that." Usually, that question is code for, "Our kid just came out to us and we're in total panic and want you to fix him/her now, if not sooner." It's a hard question to answer, not because I don't know how I feel--I do--but because I want that teen in therapy with me. The last thing I want for him or her is for ignorant, homophobic parents to keep calling around until they find a therapist who will agree it's just a phase, a fad, or something to be cured. So I took a deep breath, and answered, as I usually do, "That's like asking me how I feel about gravity, or the weather. It just is what it is. May I ask why you want to know?" When the parent(s) tell me that they want treatment for the gay-ness or the trans-ness I do my best to educate them and get them to schedule an intake. Sometimes it works, sometimes it doesn't.

This mom, God bless her, laughed out loud, and said "Good! Because being gay is not his problem and I didn't want a therapist who would assume that it was." And we scheduled an appointment.

We did talk about being gay in that young man's therapy, because his father wasn't quite 100% on board with it, and because his school allowed bullying to continue unabated--even blaming my client for coming out at school (he didn't, he was outed). He was already well wired-in to the gay community, so he didn't need any pointers there. What he was here for was his obsessive-compulsive anxiety disorder, and that is what we focused on.

And that is as it should be. Any therapist who attempts to make a lesbian's or gay man's orientation an issue any more than a straight patient's would be ought to be taken to the ethics woodshed. Same goes for any therapist who would make an issue out of a transgendered person's identity: It should be no more of a factor in the therapist's mind than a straight client's gender identity would be, except for the obvious--that LGBT clients are a harassed, discriminated-against, abused, and not-infrequently-murdered-for-it minority who also suffer internalized homophobia. And those problems certainly should be at the top of a therapist's list of issues to deal with.

*A student at Kennesaw State is conducting a similar study, but asking whether therapists think a long list of practices associated with reparative therapy are ethical. To me, it's not up for discussion (this is Ethics Codes for Dummies) and I'm more than a little uncomfortable with the study for that reason; nevertheless, it will be interesting to see whether his results tally with the 17% of the other study. I'll keep you posted.

Sometimes you feel like a nut!

2009-03-25T18:16:00.001-04:00

Sometimes you feel like a nut!, originally uploaded by wherepineswhisper.

Dear Readers:

It's a cool spring day, but these leaves are warm here in the sun, AND I've got a bone! Life is perfect.

Love,
Io

Editors Note: Dogs know how to live in the moment. And if we will let them, they can teach us. -vsw

Two Things I'm Unhappy About Today:

2009-03-20T21:41:00.003-04:00

1. That the press thinks it's necessary to identify a murderer as a "transgendered wife", and
2. That Mr. Obama thinks it's funny to joke about Special Olympics.

My First Therapist

2009-03-12T20:42:00.006-04:00

My first therapist was a leftist Black social worker with a 'fro out to here. She looked like Angela Davis: Initially I suspected she might even be Angela inexplicably gone to ground in the South. I mention all that not because race per se is the important thing here but to demonstrate the power of social expectations of women to seize hold even of someone like her.

I knew a little about her: The VietNam war was raging at the time, and when her boyfriend's II-S wasn't enough to keep him out of the war any more, she married him to give him a higher deferment. When they started drafting married men, she got pregnant to get him his III-A. I knew that she was not happy being married, and she was not happy being a mother, either: She did it because she didn't want another Black man to die in some godforsaken jungle on the other side of the planet. That's a hell of a personal sacrifice to make for a man, and I have often wondered what she would have done to keep him out of that war if they'd started drafting married men with babies. What else of herself could she give up?

She did me a lot of good. Looking back, I know it must have been hard for her to listen to my middle-class white-chick whine for 45 minutes every week, but listen she did. Unfortunately, she laughed when I told her I intended to keep my own name when I married. She worried that I was emasculating my husband when I dreamed of living in a home that belonged to my family and having a house full of foster kids instead of going to live with him in his house and having his babies. In short, she'd swallowed the gender paradigm hook, line, and sinker--she would wrench her entire life off course to save a man the inconvenience of serving a little jail time or going to Canada. And she would worry more in my sessions about a boyfriend/fiancé/husband I didn't even have yet than about the real (female) me sitting right in front of her.

I don't know why exactly I have been thinking about her today, but I have. And I'm not sure exactly what I'm trying to say here, either. But there it is.

What I'm Reading Over Spring Break:

2009-03-08T19:48:00.003-04:00

Web CT hates me

2009-03-05T20:54:00.001-05:00

Neek, originally uploaded by wherepineswhisper.

According to the Urban Dictionary Online, a "neek" is a cross between a nerd and a geek. I needed one today.

I was happily reviewing and returning proposed bibliographies to my Personality class, when I logged out for something or other. When I tried to log back in, it wouldn't let me! I could get into WebCT, and from there to my Ethics class, but clicking on Personality just got me a blank screen. Not even an error message.

So. I'm proctoring the Ethics exam and so can hardly get on the phone. I go to the Support page and start a Chat. The first fellow tells me my problem is because I am using Mozilla Firefox (not). So, knowing it will do me no good (I mean, it's never been a problem before, and I can get into one class, so how could it be Firefox??), I log off, close Firefox, and open Microsoft Internet Explorer. Of course, it does not work.

So I log back into Chat and get another fellow, who asks me to wait one while he reads the report I just filed. Which identifies me, by the way, as the Instructor for this course. So I wait. And wait. And wait.

And then I get a message from him asking, "We haven't heard from you in a while. Do you still want to talk about this problem?" I answer politely that he told me to wait. I think, what, you want me to whistle or something while I wait?

So I wait some more. Then he asks me if can see the "My Computer" icon. I'm a bit of an impatient person, so I fire back, "What does the 'my computer' icon have to do with anything?" A reasonable question, in my opinion. We exchange a few more lines, and then he asks if I'm sure the Instructor has given me the necessary permissions to access this class! He tells me that it is up to the Instructor to do that.

I'm betting if I had logged on with a man's name he would not have said that.

Again, more polite than I'm feeling, I respond nicely: "I AM the Instructor!" OK. Sort of nicely. I only yelled one word. And I didn't call him names.

We finally got on the same page, as it were, and he had me do something esoteric in Java, and it works fine now. But good Lord!

Question:

2009-03-05T12:00:00.003-05:00

Do you read your student evaluations?

Do you even open the envelope?

2009-03-04T12:32:00.001-05:00

My first job: food service

2009-03-03T19:58:00.001-05:00

My very first job ever was at a cafeteria-type restaurant. I don't even remember the name of it. It was a summer job, and I lasted approximately the summer. I don't remember the name of it, or how much I made, but I do remember that when I got home every night my feet hurt so bad I'd tiptoe into the house so as not to wake anyone up, fill the kitchen sink with water as hot as I could stand it, climb up on the counter and stick my feet in. Then I'd fall asleep leaning against the cabinets. I had fun because my best friend worked there too, but I hated the job qua job.

That's Cynical

2009-02-26T19:40:00.012-05:00

Thanks--sort of--to Twisty for the heads-up on Lay's new advertising campaign. The ad itself is insulting to women. As a psychologist, however, I'm also interested in this neuro-marketing stuff in the New York Times article.

In brief, it seems that women snack a lot, but "61 percent of [our] snacking includes drinks, fruits and vegetables". Stuff that's good for us, in other words. Frito-Lay wants to convince us that we should be eating unhealthy stuff--like their "salty snacks". No surprise there: We know marketers exist to convince us to buy things we don't need, right? But this is so cynical, and so obviously bad for us, that it blew my mind.

According to the Times:

Neurology used for advertising purposes, called neuromarketing, has gained a following among some marketers. Many use it to test their ads, using research firms . . . to show an ad to consumers and see the level of brain response.

One firm "began by researching how women’s brains compared with men’s, so the firm could adjust the marketing accordingly." That is cynical. Worse, it's pop neurology, grossly oversimplifying the research findings. The marketer in question assumes that because

the communication center in women’s brains was more developed . . . women could process ads with more complexity and more pieces of information.

A memory and emotional center, the hippocampus, was proportionally larger in women, so [Marketer] concluded that women would look for characters they could empathize with.
And research [Marketer] read linked the anterior cingulate cortex, which processes decision-making and was larger in women, to feelings of guilt.

Not to repeat myself or anything, but this is a gross over-simplification of the findings. Even if it weren't, I'm not sure how I feel about the ethics involved in using science to people's (women's!) detriment in this way.

Women, as the marketer noted, feel guilty about a lot. One of the things the culture teaches us is to look at what we eat as a moral issue. There are "good" foods and "bad"; on a given day, depending on what we've eaten, we've been "good" or "bad." Some foods are downright "sinful"! When we're not blowing them, we follow our diets "religiously." We see our self-control as a matter of character, of will. So Frito-Lay set out to reframe junk food so as not to "trip [our] guilt."

Part of the strategy was . . . toning down the packaging and showing off healthy ingredients in the snacks.
“She wants a reminder that she’s eating something better for her,” [Marketer] said.

Even thought she isn't.

Baked Lay’s will no longer be in a shiny yellow bag, but in a matte beige bag that displays pictures of the ingredients like spices or ranch dressing. Some of the new Frito-Lay packaging is in stores already.
. . . the packages trumpet characteristics like fiber and calcium and show ingredients like wheat or almonds.

Now that's cynical.

Amazingly, given that we supposedly can handle more complex material, they have developed an ad campaign that involves a bunch of female air-heads kvetching about their diets, their men, and so forth in nasal tones at the upper end of the register. I, for one, find these "characters" hard to identify with. And to add to the irony, the Marketer muses that it's obvious that we are offended by pink packages or prominently featuring the calorie counts: She completely misses how insulted we would be by an attempt to get us to eat crap by giving us a bunch of pornulated airheads to "identify with."

A sample of the print version of the ad follows:

. . . two women are surveying a Baked Lay’s bag. “These things are the best invention since the push-up bra,” one woman says. The other, admiring her bra-enhanced chest, responds, “I wouldn’t go that far.”

Now that's insulting!

And that's it for me and Frito-Lay. We're done.

Boycott

2009-02-24T18:32:00.004-05:00

OK. That's it. I've had it with dude tv. I don't watch much any more, but I still watch a lot of news shows. But I've had it with them, too. I'm getting all my news from the paper from now on.

Why? The pornulated women. Sample: CNN. Wolf Blitzer--suit, tie. very nice. Deborah Feyrick--bony (has she had her molars pulled??), eyebrows plucked, tons of eye makeup, bright red lipstick. Some other guy--suit, tie. very nice. Senior Congressional Correspondent--two necklaces, plucked eyebrows, tons of makeup, capped teeth, bright red high-gloss lipstick on lips that look like they've been shot full of whatever those women plump their lips up with to make them look bee-stung. Next dude--coat, tie. very nice. Female economic reporter--neckline plunges so low that the bottom of it is not even visible on the screen. The division line between her breasts, however, is clearly visible. And so it goes, for half an hour. And that's just tonight's sample.

And why do we have to interview Michelle Obama in the frickin' kitchen?? What's up with that?? She's a Harvard-educated attorney for God's sake. Somebody aired that earlier this weekend, and come to think of it, that probably was really when the balance tipped for me.

On the local news, here in Atlanta, the women all (even anchorwomen) either wear little girl frills, ruffles, and ribbons (our mayor's trademark is a corsage the size of a dinner plate, but that's another story) or they look like they are headed to a cocktail party. One woman tonight, besides the plunging neckline, was wearing a velvet jacket. The guys are dressed for business in (usually) dark colors, while the women are wearing pastels or worse, neon-bright colors.

That's it. I've had it. I'll be back when they start taking women seriously. Or when they start plucking dudes' eyebrows and putting them on the air in Speedos so I can really see what I'm buying.

Excuse me?!

2009-02-22T10:15:00.069-05:00

This month’s issue of Teaching of Psychology, the official journal of the Society for the Teaching of Psychology--ToPs for short--(Division Two of the American Psychological Association) arrived Saturday. And Dear Readers, I am not a happy camper, because it contains an article touting what is to my mind a juvenile, offensive role play exercise for teaching psychodynamic personality theory in a manner “engaging” to undergrads.

In brief, students role-play the part of the professor’s psyche (including his leering id, run amok at the local mall). Roles are "randomly assigned" to id, ego, and superego groups from among student volunteers, which presumably means that some women land in the id group, the instructions for which are as follows:

Welcome to my psyche! Your group is going to be my ID! Imagine that I am at a shopping mall and have just seen an attractive woman walk by. Remember that the ID is driven by the pleasure principle and seeks to have physical needs met immediately--with no regard for consequences. Your group's task is to come up with ideas of what the ID might "say" in this situation (Segrist, 2009; p. 52).

Excuse me?! I got this far before I threw the article on the floor for the first time.

Examples of id comments: "Wow, look at THAT! She's HOT!" "THAT", mind you--not "HER". She's instantly reduced to a THING. And Segrist doesn't seem to see anything wrong with this. Defense mechanisms employed by the ego included denial, as in "she's not really that attractive" (Segrist, 2009, p. 52). What undergrad exactly does this 'engage'? Well, in case you were wondering, as I was, the author reports feedback from his students on the exercise.

Most of the students polled were majors in their junior or senior year.On a scale of one to five (the most positive rating), students rated the activity on average a 4.6 for enjoyment. Segrist did not report the range or quote any negative comments. Since 81.4% of Segrist's students are women, I have a feeling that when I post this blog entry, I will be told that these numbers prove that nobody was offended and that I should get over myself. (How much do you want to bet? I'm thinking of starting a pool.) I contend, however, that the numbers only show how oblivious young women have become to their own objectification.* Either that or how well-schooled, if you'll pardon the expression, they have become at not confronting sexism when they see it. Plus, without knowing the low end of the range, we don't know that nobody was offended. Somebody might have rated the exercise a 1--or worse.

But I digress. Back to the article. Segrist cautions his volunteers not to be "hostile" or "clearly objectionable" in their role-playing. Excuse me?! Is it not "hostile" by definition to objectify, rate, and thereby degrade female passers-by? Apparently not, since he quotes these in an article purporting to show how great his exercise is. Which leaves one therefore to wonder how he defines "objectionable" or what it takes for a comment to be "clearly" objectionable. And would it be ok to be vaguely objectionable? Or only mildly objectionable? Besides which, should not the very fact that you have to caution them be a red flag that what you are doing is not a good thing?

Segrist concedes that "comments generated by the id group in particular have the potential to be offensive to some students and disconcerting to any student who has been sexually victimized" (2009; p. 53). Does he mean the comments that are not "hostile" or "clearly objectionable"? Or is he, without realizing it, conceding that they all are likely to be just that, given the setup for the role-play?

And what does he mean by "potential"? You ask me, offense to any thinking female is guaranteed, not "potential". And "disconcerting" does not begin to cover the impact this exercise could have on a rape survivor (which I presume is what he means by the euphemism "sexually victimized". Future post: euphemisms for "rape"-- submit your favorites for inclusion therein.).

I can’t imagine being a student in his classes–oh, wait, yes I can. I’d feel objectified, threatened, insulted, discounted and disrespected. Intellectually and professionally, I’d feel like I’d just been completely erased. (Remember, this whole exercise is framed as "inside your professor's head," not "inside some dudely jerk at the mall's head".) I would, in short, feel instantly reduced to merely the means of some dude to "have physical needs met immediately--with no regard for consequences" to the "HOT", anonymized, objectified "THAT". As a woman, I would feel that way whether or not I were objectively "HOT". (I'm not--see RateMyProfessors.) Personal hotness is not the issue here: Objectifying and rating women is. I’d be mad as hell and might even walk out of class and go file a complaint.

Nor can I imagine what the editors and publishers were thinking–oh, wait, yes I can. I bet it never even occurred to them that this is not only offensive but also oppressive. Part of the way the game is played, of course, is that the oppressor gets to be in total denial of his oppressive behavior (nota bene, no ego- or super-ego-playing student seems to have pointed out to the id what a sexist pig it was being).

But wait. Maybe it did occur to someone at ToPs that publishing this article would not be a good thing. Of the 21 Consulting Editors, only six are women, but we are otherwise well-represented among the editorial board and predominate among officers of the Society. Maybe one of them did complain about this article, and was told to get over herself. Maybe she's why all those caveats appear in the Discussion section.

Not enough: The whole thing should have been shit-canned.

Dr. Segrist and esteemed members of the ToPs Editorial Board, my lecture on Freud is coming up in a few days. I wonder what the reaction of my students, and of my department Chair, would be if I used that exercise with young men as the target. Would they not see that as totally, unquestionably inappropriate? Not to mention, downright gross? Dudes, can you not see how much more inappropriate it is to target women in such an exercise? I wonder how many of my male students would be embarrassed or offended. How many of them do you think would feel free to say so, even anonymously? I would ask you to consider how much more so that is true for the members of an oppressed class. And then yank the article already.

*In the course of his article, by the way, Segrist notes, "I have a wife" (2009, p. 53)--not, "I am married." Woman as possession (as in, "I have a car, a house, and a dog, too"): I'm not even going to go there today. That is a topic for a whole 'nother post, and I have papers to grade. Maybe after I do the one on euphemisms for rape--don't forget to send your favorites to me at wood_virginia@bellsouth.net

Reference

Segrist, D. J. (2009). What's going on in your professor's head? Demonstrating the id, ego, and superego. Teaching of Psychology, 36, 51-54.

I did not get the memo,

2009-02-11T07:20:00.008-05:00

but I did get the tickets.

(tickets)

Adjuncts never get the memos: It's a Universal Truth.

It seems that some time last fall, the parking police switched from sticker permits (like the one you see in my windshield, above) to a hanger-tag system. I don't know why.

Be that as it may, I never got a memo. I never got an e-mail. No one ever mentioned it casually in conversation. I never saw a poster or found a flier under my windshield wiper. I never even got a warning!

I just came out after 5:00 one day to find the first ticket on my windshield. First I heard about any hang tags. But of course I look wildly about the parking lot and see one on everybody's rear view mirror. Boy do I feel stupid.

Nothing I can do about it now. And the next day, I had clients all day. And the following day I had clients before I had to return to school. When I would, once again, be teaching until five. So I knew I was going to get a second ticket. And I did. It says in the small print that the third time I would be booted or towed.

(sign I park under every day)

So on the third trip, when I knew I could arrange to go get a hang tag, I made myself a little sign that said I was going to Card Services to get the damn thing and please not to ticket me. And it must have worked, because when I got back, there was no ticket.

Now I'm legal.

At least until the next time they change the system.

Academic Integrity

2009-02-09T10:47:00.007-05:00

Or, Are We Having Fun Yet?

I have always prided myself on my relationship with my students. I treat them like, if not colleagues, then junior associates--like the young professionals that they are becoming. And I thought I was getting equal respect in return. I trust them, and I thought that they were living up to the expectation that they would behave in a trustworthy manner. As a result, I have never thought I had much trouble in my classes with cheating.

I also thought we were on the same side here: They are in school to learn, and I am in school to teach.

But then I read a novel in which (have I told you this story already?) two high school kids were texting answers back and forth during an exam, and dissing the professor as naïve because he didn't walk the aisles during the test. Walk the aisles!? Are you kidding me?

But I did watch my class a little closer during the first test this semester, and lo and behold, I think I did see one pair of wandering eyeballs. But I couldn't be sure.

Then, last week I went to a workshop presented by Beth Kirsner, Ph.D., who is doing some research in the area of academic integrity. According to some very preliminary data she has, there's a lot more cheating going on than I had ever suspected. By extrapolation, there's a lot going on in my classes that I'm not catching. In fact, if I'm reading Dr. Kirsner's survey results correctly, every semester at least a few students are copying another student's test paper, letting other students copy their test papers, copying passages from the internet and not citing them, and the like. The only good news in her data so far is that nobody seems to be buying term papers on the net.

So what's really going on, apparently, is that my students and I are on opposite sides in a tug of war. I have the grade, and they wish to take it from me.

In sum, it seems that I have been terribly naïve.

Bear

2009-02-07T20:43:00.001-05:00

Bear, originally uploaded by wherepineswhisper.

Blind Obedience

2009-01-24T11:17:00.095-05:00

or, Some Things Never Change

Umpty-ump years ago, Stanley Milgram, a Jewish psychologist interested in better understanding the Holocaust, began a series of experiments to see just how far ordinary citizens would go in obeying orders to harm another person. In the best-known of these demonstrations, 65% of his study subjects shocked (as far as they knew) another human being clear into unconsciousness and (for all they knew) possibly even death. This, even in a situation in which it was perfectly safe to tell the authority figure where to stuff it. As one of my students put it the other day, "People are sheep."

However, as Miller (2009) notes, over the entire series of experiments (there were 16 in all), 60% of Milgram's 540 subjects disobeyed orders at some point. So not all people are sheep, and some are sheep only up to a point.

Reasons (some) people are sheep (up to a point) include that, in our culture at least, we are socialized to obey authority. Children who mind well are valued, whereas those who don't are punished or taken to therapy or both. We even have a diagnostic code for particularly willful little brats: We label it a mental illness, Oppositional Defiant Disorder. I would also submit that the child who obeys is the child who survives to maturity and reproduces. Children who play with fire, run with scissors, and dart out into traffic do not. It's that simple.

We don't, of course, raise our children to be cruel. This underscores Milgram's point, which was that it is really the situation which is the most powerful factor in producing destructive obedience, not our national character or our individual personalities (Blass, 2009). This also explains why people, you and me included, will predict based on self-knowledge that they would never do something like this, and then most will, if conditions are right. You and I might, too. The trouble is that we don't know as much as we might about what situational variables have what effects. In any event, we can't control situations. We can, at least potentially, control our reactions. But to do that, we need to know more. We need to know what characterological traits enable us to prevail over even the most powerful situations. But let's get back to the list of reasons why we act like sheep sometimes.

Sheep-ish behavior can be induced by degrees. In the Milgram studies, as is often the case in real life, people eased into bad behavior--in this case, 15 volts at a time. What's 45v when you've just administered 30? ...165 when you've just administered 150? Hitler didn't start out saying, "You're gonna personally slaughter 6 million Jews and several millions more gays, gypsies and people with disabilities." No. He started out just talking bad about them, which got people ready to make them wear the Star of David or a pink triangle or whatever on their sleeves, then he took away some relatively minor civil rights, working his way up to Kristallnacht and such. He crept up on rounding them up and killing them, one small step at a time. And the ~~sheep~~--whoops! I mean, people--went along with him. Not everybody, of course, but enough so that he could get the job done.

Sales people are trained in a similar technique: Get the consumer to say "yes" to as many questions as you can ("wouldn't you prefer a car that is reliable? beautiful? American-made?" Well, of course) before you spring the ultimate question ("Will you buy this car?") on him and he will say "yes." It's a tried-and-true technique. Milgram got people to say "yes" to 15v and worked them up 15v at a time until they were administering potentially lethal shocks using this method. Hitler got people to say "yes" to talking ugly about Jewish moneylenders and worked his way up to "yes" to the cold-blooded slaughter of unarmed women, innocent children, and helpless cripples. It was easy. And it only took a few years to talk a couple of million people into this madness.

Which brings us to #3. We tend to do what the rest of the ~~flock~~ group is doing. It's called group think and many, many studies have documented just how distorted (and extreme) our thinking can get when the group not only doesn't offer a corrective point of view but is actually leading us to the fringe. Fourth, when somebody is telling you to do something, you can slough off responsibility. "I was only following orders" echoes down through history as justification for all kinds of moral failings, ethical violations, and crimes against humanity, from Andersonville to Abu Ghraib. "Baaaa," quoth my student. The sheep will follow the goat.

Most interesting, however, is the sloughing off of responsibility onto the victim. Milgram found that subjects who obeyed ascribed twice as much of the responsibility for what happened to the victim, compared to subjects who resisted (Blass, 2009). Milgram thus may have been the first scientist to document the blame-the-victim phenomenon which Hitler so ably exploited in turning his countrymen against the Jews.

In Jerry M. Burger's (2009) replication of the Milgram studies, which just landed in my mail box last week, one variation in the experimental condition was to have a confederate model noncompliance. This had nearly zero effect on rates of obedience among experimental subjects. However, when two confederates modeled noncompliance in the original Milgram studies, experimental subjects also refused requests to shock their victims any further. It seems that if there is a group of people doing the right thing, it becomes easier for us to resist malignant authority--it gives another, perhaps more palatable, group to join. We don't have to give up the safety of the group in order to follow our conscience: The new group presumably offers us more or less the same benefits as the old one.

Unfortunately, in the real world, there may be no effective individual models for resistance, never mind groups. Evil organizations tend to screen those folks out where they don't self-eliminate, so that for the individual at a moral or ethical decision-point the only available behavioral models may all be torturers and murderers who furthermore are skilled at socializing the novice into the group pathology. An example would be a corporation headed by a sociopath. He (and the stats are that it usually is a "he," guys, so don't get your dander up) will intuitively, if not consciously and deliberately, hire like-minded folk. Who will in turn hire more of the same to work in various corporate departments and branch offices. The occasional non-psychopath who accidentally gets hired will either leave on her/his own, get co-opted (i.e., turned into a sociopath), or be run out of the company. Or sit silently by while evil is done (Miller, 2009). So what you will wind up with over any extended period of time is a company full of sociopaths. But I digress.

Evolutionary psychologists would say that we are hard-wired to feel, think, and behave as a tribe, and it has obvious short- and long-term survival value for us to do so. Think about it: There's not much with a lower potential for long-term survival and reproduction than a single hominid alone on the vast African savannas, is there? Indeed, a half a million or so years later, among certain Plains Indians the most severe punishment available was to run an individual out of the tribe--an almost certain death sentence. And of course even today in dangerous professions such as police work or military service, "going along to get along" has immediate survival value. You have to be able to count on your comrades having your back (see Benjamin and Simpson, 2009, for further discussion).

Stage hypnotists know that the very fact of a subject's volunteering, the parameters of which act are defined by the way the invitation is framed and delivered, guarantees better (e.g., more easily hypnotizable or compliant) ~~sheep~~--dang! I did it again--subjects for the show than if one picks them out of the audience oneself. Similarly, rates of obedience in an experiment or an SS unit may be higher than they would be in the population at large. Miller (2009) also makes this point.

Given all this, the wonder is that 35-60% of Milgram's subjects stopped when they did. Indeed, as Lee Ross (1998; cited in Benjamin & Simpson, 2009) wrote, "The Milgram experiments ultimately may have less to say about 'destructive obedience' than about ineffectual and indecisive disobedience" (p. 16).

Of course in Milgram's studies, nobody was really getting shocked, therefore, presumably, no one was harmed. Still, there were ethical concerns: It was pretty stressful for the study's participants, and we just don't do that any more. Consequently, in order to "replicate" the study, one would have to change the procedures pretty drastically.

Burger (2009) has done just that. His study stopped after participants thought they had delivered 150 volts to the confederates, whereas Milgram's study went to 450v. Burger selected this stop point because in Milgram's lab, most people who quit stopped there, while most people who crossed that line continued to the bitter end. Burger also screened out people (the depressed, the anxious, the traumatized) who might be harmed in the study. Alan Elms, who assisted in the original study, calls this "obedience lite" (2009, p. 33), more about which, later.

The question was, has anything changed? Are we more aware of the danger of blind obedience than we were 50 years ago? Would it make any difference if we studied women, too? Burger found that (1) no, it hasn't, (2) no, we apparently aren't, and (3) no, it doesn't. The latter probably will not surprise students of the Holocaust, who know that some of the most notorious concentration camp overseers were women SS. And some of you may recall that the poster child for Abu Ghraib was a girl.

Jean Twenge writes that, according to her research, young people today should definitely be far more likely to defy authority than a bunch of middle-aged white guys would have been in Milgram's day. She interprets Burger's data as showing a trend, albeit nonsignificant, in the direction of increased resistance to authority, and she points out several aspects of Burger's study which may have inadvertently suppressed further evidence of change (Twenge, 2009). Unfortunately for her argument, Blass, (1999, 2004; cited in Blass, 2009) did a meta-analysis of 25 years' worth of studies and found a "near zero" (p. 43) correlation between the time the study was conducted and the obedience rate.

Also, Twenge's analysis relies heavily on the sampling differences, and for Burger to use a sample more like Milgram's would have, in my opinion, rendered it ecologically invalid. We want to know what college-educated, ethnically diverse, gender-inclusive police and army units would do in the face of an illegal order. We want to know what a melting-pot populace like ours, asked to go along with a Guantanamo or a Patriot Act, would do. With the possible exception of corporate boards, exclusively white male groups like Milgram's study sample are, after all, scarce on the ground any more.

Twenge (2009) also argues that Burger's study confounds obedience with violence and lack of empathy. She notes that the increase in narcissism over the intervening generations since Milgram's day and the desensitization to violence from tv and video games may account for part of the "obedience" rate Burger found. The empathy argument won't wash, however, as Burger tested for empathy (and consequently, indirectly, for narcissism) in his subjects and found this trait not predictive of compliance/noncompliance. As for the violence argument, this is splitting some exceedingly fine semantic hairs. Who cares what we call it? The end result is the same. People will still hurt other people when told to and/or given the opportunity to do so. Baaaa. I am sure that from Andersonville to Auschwitz to Abu Ghraib, plenty of narcissists and violent people took full advantage of the opportunity to act out, side by side with sheep-ish folk who were merely "following orders."

A stronger argument is probably that of Elms (2009), who pointed out that by stopping the study at 150v, Burger effectively eliminated the most critical aspect of the original. And as a result, Elms argues, we cannot say whether people would still hurt, injure, and possibly even kill each other under orders. Maybe if the victims were still writhing, screaming, and finally falling silent, the increased independence that Twenge has documented in her work would have asserted itself and Burger's rates of disobedience would have been much higher. Or not: Burger's subjects were still arguably well within their comfort limits, but on the other hand, discomfort didn't seem to slow down many of Milgram's. We may never know, because the likelihood of getting such a study past an IRB these days is just slightly less than nil.

Elms and Twenge both express concerns that screening out people who would be "upset" by the study reduced disobedience. But that dog won't hunt, either. I would argue (again) that first, being upset did not appreciably contribute to disobedience in Milgram's original studies: In fact, one of the most notable findings was the degree to which people could be upset and still continue on with the experiment. Second, police and military organizations take great care to screen out the anxious, the depressed, the previously traumatized. If we want ecological validity in a study predicting what a soldier might do in, say, a My Lai-type situation, then we need to screen out the folk who wouldn't likely make it into an overseas combat unit in the first place. Works for me.

So while the "lite" factor is a big problem, I don't buy the other criticisms. From my point of view, the biggest disappointment is that we didn't learn something more about, to paraphrase Ross, effective, decisive resistance. Elms (1972; Elms & Milgram, 1966; as cited in Elms, 1990) conducted extensive psychological testing on subjects from Milgram's series who had obeyed or not obeyed, in an attempt to discover some differences. He found only nonsignificant correlations between obedience and authoritarianism.

As noted earlier, Burger had thought that maybe the degree of empathy a person generally has for others might make a difference, or the degree to which control was important to them, but neither personality trait proved to be a predictor. Neither were such demographic factors as gender, age, or level of education. The different ethnic groups weren't big enough, statistically speaking, to test.

So we still don't know why approximately 1/3 to 2/3 of people will refuse to obey an illegal order. To me, that would be the most useful information of all, and I hope somebody, somewhere, is working on that. Burger's was an elegant piece of work, and one can only hope that there will be lots of replications with variations intended to tease out what it is that allows some people to "just say 'no'" to human cruelty.

References

Benjamin, L. T., Jr., & Simpson, J. A. (2009). The power of the situation: The impact of Milgram's obedience studies on personality and social psychology. American Psychologist, 64, 12-19.

Blass, T. (2009). From New Haven to Santa Clara: A historical perspective on the Milgram obedience experiments. American Psychologist, 64, 37-45.

Burger, J. M. (2009). Replicating Milgram: Would people still obey today? American Psychologist, 64, 1-11.

Elms, A. C. (2009). Obedience lite. American Psychologist, 64, 32-36.

Miller, A. G. (2009). Reflections on "Replicating Milgram" (Burger, 2009). American Psychologist, 64, 20-27.

Twenge, J. M. (2009). Change over time in obedience: The jury's still out, but it might be decreasing. American Psychologist, 64, 28-31.

A monstrous ethical dilemma

2009-01-17T16:40:00.008-05:00

I just finished reading Stephen White's first novel, Privileged Information (Viking, 1991; 363 pp.). I'm surprised I'd never heard of him before, because I love murder mysteries and I particularly love those written by or about psychologists. But somehow I'd missed this one: A friend, in town for the holidays, turned me on to it. "Be sure and start with the first one," she said, and I did.

At first, I didn't like it. It wasn't all that well-written, in the beginning at least, and I thought the ethical problem was kind of contrived. But it picks up along the way.

Here's the dilemma. The novel opens with the suicide of a patient. The patient unfortunately wrote up her sexual fantasies about her therapist, the protagonist of the novel, in her diaries without identifying them as fantasy. The executor of her estate reads them, and thinking that the protagonist, Dr. Alan Gregory, not only may have been sleeping with his patient but may have precipitated her suicide by doing so, files a complaint.

Gregory certainly is in a bit of a pinch here, because the complaint hits the papers and of course the therapy community is abuzz about it as well. Gregory can say nothing in his defense, publicly at least, due to patient confidentiality. He of course can defend himself before the licensing board, but that is not the problem here. What felt contrived to me was that he seems to think he can't talk to his colleague and business partner, his lawyer, or even his clinical supervisor about the case, which is completely incorrect. He can. And should.

But this is a relatively minor flaw in the book, because as it turns out the privileged information of the title primarily refers to another patient altogether, one whom Gregory begins to suspect of murder. Now he really is in a bind, because he cannot reveal what the patient is up to without a more clear and convincing threat to a specific person. Which the patient is smart enough not to give him. So the rest of the novel turns around how to stop a killing without giving away privileged information.

Along the way, Gregory, who is completely innocent of the boundary violations with which he is charged, does manage to rationalize some other, serious ethical breaches. And his final solution is not ethically perfect, either. It's creative, though, and it does solve the problem.

White is himself a psychologist who practices in Boulder, CO. In his writing he gives a good picture of the life of a psychologist. But ethical issues not addressed in this novel include (1) Gregory seeing 38 people a week when his caseload is its usual size, and (2) Gregory continuing to work while his personal and professional life crumble around him. He also takes on a patient who represents a clear conflict of interest. He should have referred this guy on during the first session--but then, if he had, there would have been no novel, so I guess we're stuck with that.

Gregory makes boodles of money seeing 38 people a week, but my God. When does he do anything else? Like billing, charting, reading, eating lunch, going to the bathroom... He books people back to back, referring once to "my 3:00 and my 3:45" so he's not doing any of this between sessions. I once interviewed for a job with a psychologist who claimed to see 50 to 55 patients a week: My first instinct was to run like hell. That can't be healthy. You can't possibly, in my humble opinion, maintain a high standard of performance at that level.

He is also working with a couple while his own marriage is breaking up, and one has to wonder if how he sees his own relationship troubles is biasing his view of what the couple he's treating "should" do with theirs.

And finally, he takes on a client who had an affair with a former client. I wouldn't touch that with a ten-foot pole. Or as a former colleague of mine used to say, a 12-foot Russian.

So we hope White doesn't practice like that. And while the book gives a better portrayal of the profession than, say, Prince of Tides, I'd still warn you to take it with a grain of salt (it is, after all, fiction). The Alex Delaware novels by Jonathan Kellerman are much better in that regard. I've read them all and the worst thing I can recall Dr. Delaware doing is having a drink at lunch when he has a patient to see in the afternoon.

Rx

2009-01-13T19:04:00.002-05:00

It has happened occasionally in my career that I have wound up holding drugs for a client. Sometimes, a client leaves them locked up in a file cabinet for safekeeping. More often, I have persuaded clients to turn over a "suicide stash," which my pharmacist disposes of for me. But never before have I confiscated meds prescribed to a person who the MD knew abused the drug, overdosed on it twice, and had even been in detox for it. Couldn't believe it.

2009-01-08T21:40:00.001-05:00

My apologies to every student upon whom I have ever inflicted these PowerPoint-isms. I promise to do better in the coming weeks.

It's Called "Assertiveness"

2009-01-04T12:57:00.014-05:00

Reassigned Time: Taking Care of Self = Losing Patience with Others

Crazy's got another great topic going over at Reassigned Time. She's figuring out on the 4th day of this New Year that to keep some of her Resolutions, she's going to not only be saying "yes" to things that are good for her, but saying "no" to other people's requests in order to clear the decks.

She wrote:

Well, I'm going to have to learn to say no more frequently and more forcefully, because if I keep saying yes to idiots, I will end by making a lot of enemies, I fear. So, perhaps the taking care of the body business and putting oneself before other things does actually produce the very results that the goal aims to produce, for it turns out that although I did not resolve to say no more frequently, I'll have to do so if I don't want people to hate me for being a meanie. This is kind of awesome.

-Posted by Dr. Crazy at 8:13 AM

She's learning quickly what I find to be true for women as a rule--to wit, that we tend to say "yes" to everything, and then there's either no time for the things that are really important to us, or we, in trying to do too much, wind up doing none of it very well. We miss deadlines, let people down, resent the hell out of them... and nobody's happy, least of all us.

I disagree, though, that taking care of ourselves means losing patience with others. Probably because I don't define "patience" as meaning doing things for people that they could/should do for themselves, I find that we can learn to set limits/boundaries quite patiently--albeit firmly: It's called "assertiveness." What tends to happen here--and here is where the "more forcefully" part comes in--is that people who are used to you saying "yes" all the time won't like it when you start saying "no." You are violating the unspoken contract you've always operated on with them (this is true of society as a whole, too, by the way). So they will tend to ask again, and again, or ask more forcefully, or start trying to guilt-trip you (see the discussion on bitchiness, below). And then sometimes we lose our patience with them (and start yelling, "What is it about 'no' that you don't understand? Read my lips! NO!!"). This is, as my mother would say, "not attractive."

So here's where the patience part comes in. We have to remember that, human nature being what it is, people are going to resist change in us. If we see resistance, that actually means we are doing something right--that is to say, we are changing, and people are noticing. That is a Good Thing. And we have to remember that we are teaching them something new about us in particular and about the world around them in general, and that takes time. One-trial learning is not going to happen here.

And saying "no" in and of itself doesn't really make us "meanies", either. Men say "no" all the time, unfortunately women aren't supposed to. We will be perceived as meanies if we are assertive about our limits and boundaries, but it is not the same. Years and years ago (back before the Flood, but never mind--I digress) there was an article in Working Woman magazine on the subject of bitchiness. And the author wrote that "bitch" stands for "being in total control of herself". It's a socio-cultural gender thing. It's also a grand manipulation: People individually, and our culture as a whole, both use the B-word on us when they are not getting their way. It's intended to shame us into caving in to whatever it is they are wanting at the moment, or in society's case, into not demanding whatever we are demanding at the moment. It's about some other person or institution or other kind of group taking control back from us.

(By the way, you can't allow that to happen. In terms of the teaching process, it will set you way back with that particular individual/group/institution. You have to be consistent, persistent.)

But getting back to where we were, I believe that what does make us meanies is when we say "yes" and then resent the hell out of it later, becoming cranky or passive-aggressive, or worse, both. Crazy's right-on in perceiving that saying "yes" when you mean "no" is a prescription for angry outbursts and/or building resentments. A trick I learned for avoiding that is to (a) try not to answer one way or the other right away--ask the requester for time to think about it, put 'em on hold, whatever you have to do to buy yourself some time, and (b) when I've already said "yes" and realized that was a mistake, to go back to the requester and say, "I spoke too soon when I told you I would [whatever].... Sorry, won't be able to do that after all. Nope. Not gonna happen. No, sirree." It's bad form, not to say awkward, but it beats being mad or resentful, and you won't have to do it too many times before you learn not to say "yes" in the first place!

And Crazy is also correct that learning to say "no" without biting people's heads off requires practice. I therefore sometimes advise people, just for practice, to say "yes" to three things that they would ordinarily deny themselves, and "no" to three people they would normally accede to, per week until they get the hang of this. Learning how to do this, and do it well, is, as Crazy says, "kind of awesome."

Wounded

2009-01-03T09:32:00.014-05:00

Untitled: © Irina Sidorowicz - Visit NoHappy.com to see additional artwork and photography. The artist studies Graphic Design and Visual Communication in Buenos Aires.

This picture, posted as a writing prompt at Every Picture Tells a Story is powerfully evocative for me. My first reaction was that she is Palestinian, but she quickly became bigger than that. She is Afghan, too, married at ten or eleven to a man decades older than she. Then she became all wounded women.

Inside every battered woman, every woman who was sexually abused as a child, every rape survivor, lives a girl-woman like this. However bright and strong and confident she may look on the outside, and they do, this wounded girl-woman looks out from behind her eyes. I may see a flicker in the first session, or I may not catch a glimpse until she's been here a few times.

If I can earn her trust, sometimes she will come out.