I guess I'm just a sentimental old fool

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"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

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?

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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

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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

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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

The Carlat Psychiatry Blog: WebMD's Big Lie

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Just Who the Hell Do You Think You Are?

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 child 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.