Silly Season

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

/sigh/

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

There are three lies in this:

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

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

But I digress.

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

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

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

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

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

GlaxoSmithKline used ghostwriting to promote Paxil - The Boston Globe

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

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

GlaxoSmithKline used ghostwriting to promote Paxil - The Boston Globe

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

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

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

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

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

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

The Carlat Psychiatry Blog: Eli Lilly Posts its Grand Deception

The Carlat Psychiatry Blog: Eli Lilly Posts its Grand Deception

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

This one's for you, T.!

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

With friends like this. . .

. . . who needs enemies?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A couple of interesting sources I found via PsycNET:

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

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

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

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

By Barrett, Kimberly Ann

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

Homophobia in men: A symptom of gender identity disturbance.

By Debiak, Dennis Michael

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

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

By Finken, Laura L.

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

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

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

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

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

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

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

Attribution Style and Public Policy Attitudes Toward Gay Rights.

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

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

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

let's talk. (about ableism)

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

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

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

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

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

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

Please Hold While I Connect Your Call

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

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

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

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

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

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

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

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

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

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

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