tag:blogger.com,1999:blog-247815772024-03-07T13:43:41.220-05:00Just Noticeable DifferencesThe science and practice of clinical psychologyFree Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.comBlogger80125tag:blogger.com,1999:blog-24781577.post-68845259469476969832010-03-28T12:24:00.002-04:002010-03-28T12:26:24.938-04:00Conflict within the Autism Community<div xmlns="http://www.w3.org/1999/xhtml">President Obama has nominated Ari Ne'eman (pronounced AH-ree NAY-men) to the National Council on Disability, and in the process has inadvertently highlighted a split in the Autism advocacy community. Ne'eman is an interesting guy. He apparently has <a href="http://www.aacap.org/cs/root/facts_for_families/aspergers_disorder" target="_blank">Asperger's disorder</a> and is the Founding President of the <a href="http://www.autisticadvocacy.org/" target="_blank">Autistic Self-Advocacy Network</a> (ASAN). They argue that autism is a form of "neurological diversity." By conceptualizing autism in this way, ASAN sees autism as a form of diversity, not an illness. <br /><br />ASAN argues that the main focus on autism expenditures should be on providing supportive services and thus finding ways to include autistic persons in society. It shouldn't be on finding a cure. In contrast, the largest advocacy group on autism in the US, <a href="http://www.autismspeaks.org/" target="_blank">Autism Speaks</a>, still sees autism as an illness that needs to be cured. They want to see an emphasis on research on causes and cures. The New York times <a href="http://www.nytimes.com/2010/03/28/health/policy/28autism.html?ref=health" target="_blank">just published</a> an article on the controversy.<br /><br />From my perspective, as a clinician who has worked with persons with autism, the controversy is overblown. The reality is this: <br /><br />First, advocates of the neurological diversity hypotheses about autism should remember that the vast majority of mutations occurring in the natural environment are maladaptive. There is no reason to assume that all diversity is good and this is the case with autism. The social and economic costs of having a child with autism in the family are tremendous and we should not idealize autism. Families are disrupted. There are divorces, because parents are depressed and guilty about the child. Siblings often feel left out and lost in the family while parents devote most of their energies to the disabled child. Autism can be a terrible disability. We have found that early intervention does have a positive impact on autism, but we are still a long way from a cure.<br /><br />Second, there is a wide range in the functioning of autistic persons. People like Ne'eman can function fairly well and be remarkably successful. However, they are the exception to the rule. Most autistic individuals are unable to function independently and--if they can work at all--can only do manual labor. While there is nothing wrong with manual labor, people with autism simply do not have the social skills to function adequately in those kinds of situations. I know. I work in an county that still has a lot of factories. A person who is "different," perhaps in appearance, ethnicity, or functioning, gets horrible harassment, especially if they don't have the social skills to stop it. A factory or construction site is not a place for people with autism. There are few jobs out there for them in the community.<br /><br />Finally, our current commitment to housing and social resources for people with autism is pitiful. <a href="http://www.pawaitinglistcampaign.org/" target="_blank">It takes years</a> to be placed in supported housing in Pennsylvania. I assume it is the same in other states. Care providers in group homes are terribly underpaid and there is a tremendous turnover in employees. The greater the turnover, the less the experience of the average care provider, and the worse the care is.<br /><br />Ultimately, given our limited resources, we have no choice but must divide them:<br /><ul><li>We need basic research to better understand the causes of autism, which we hope will lead to either a cure or prevention or both.<br /></li><li>We need treatment research to improve our current assessment and treatment protocols.</li><li>We need more social services to provide more support so that we do not abandon persons with autism.</li></ul>Obviously, I'm arguing that both sides are right and I don't apologize for that. Advocates of each side can deny the legitimacy of the other side. But in the long run, treating autism is an overwhelming task and no amount of denial will make it less overwhelming. Compared to the need, our resources are very limited. Is it hopeless? No, but solving the whole puzzle of autism will take much time and many more lives are going to be impacted by it before then.<br /><br />There is a book of Jewish wisdom, entitled Pirke Avot, which is variously translated, "Ethics of the Fathers," or (more modernly), "Teachings of the Sages." One of my favorite teachings comes from <a href="http://en.wikipedia.org/wiki/Rabbi_Tarfon" target="_blank">Rabbi Tarphon</a>, who said, "You are not required to finish the job, but neither are your free to abstain from it." He was talking about religious study, but his advice has also been interpreted as applying to doing good works. As a society, we need to live by that wisdom, especially as it applies to all forms of disability.<br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com2tag:blogger.com,1999:blog-24781577.post-84357016662995516692010-03-22T18:02:00.003-04:002010-03-22T18:31:41.487-04:00We Won! (For the Time Being)Last night, the Democratic Party won it's fight to reform health insurance. You'd think it was over, but it's not. The Republicans have sworn to repeal this legislation.<br /><br />So, first, there will be another endless round of parliamentary maneuvers in the Senate to delay passage of the budget reconciliation bill. That will eventually fail, but in the meantime the Democrats will go through another round of shooting themselves in the foot by arguing over the bill.<br /><br />Then comes the November congressional elections. At this point, the whole electorate will be fed up with the whole thing. This, however, won't stop the Republicans from lying about something else and continuing to stir up the pot. If the Democrats play true to form, they won't anticipate what the Republicans are going to do and will get caught flatfooted. They'll have to say such things as, "No the new health plan won't require you to get your nose pierced," while Fox News will swear up and down that it does. So, here's what I recommend:<br /><ul><li>First, by the November, some of the provisions will be in place. Democrats should spend the next seven months all over the news showing people what is really happening. Point out that if you like your insurance, nothing's changed. Point out that people in the high risk group have finally gotten insurance and can breathe easier.<br /></li></ul><ul><li>Second, the Democrats should immediately and loudly and repeatedly portray Republicans as people who are perfectly happy with millions of Americans being without insurance. Put the Republicans on the defense for a change.<br /></li></ul><ul><li>Third, don't throw numbers like "40 million" around. Instead say, "<a href="http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx">one in six</a> Americans are without health insurance." Think about what that means the next time you're in McDonald's.</li></ul><ul><li>Finally, make them out to be the obstructionist, sore losers they are.<br /></li></ul>Make the debate about the Republicans and you'll win in November. Make it about health insurance and you'll lose to their next round of lies.<br /> <div style="margin-top: 10px; height: 15px;" class="zemanta-pixie"><a class="zemanta-pixie-a" href="http://reblog.zemanta.com/zemified/51a52614-d171-48b7-a5ce-7f69805cf363/" title="Reblog this post [with Zemanta]"><img style="border: medium none; float: right;" class="zemanta-pixie-img" src="http://img.zemanta.com/reblog_e.png?x-id=51a52614-d171-48b7-a5ce-7f69805cf363" alt="Reblog this post [with Zemanta]" /></a><span class="zem-script more-related more-info pretty-attribution paragraph-reblog"><script type="text/javascript" src="http://static.zemanta.com/readside/loader.js" defer="defer"></script></span></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-57536809609057540702010-03-06T13:00:00.003-05:002010-03-06T14:36:29.231-05:00Health Care Hangs in the BalanceWell, here we are again, wondering what will happen to health care reform. It is amazing that we're still watching the Democrats fumbling around when there is a clear path to success.<br /><br />Before Howard Dean took over as chair of the Democratic party, I used to say that Republicans are a bunch of vicious hypocrites and Democrats are a bunch of fumbling incompetents. Then Dean launched his 50-state strategy. I watched Obama run a great campaign and the Democrats in congress got majorities in both chambers. So I stopped saying it. Unfortunately, now that Dean has completed his tenure, the Democrats went back to their old ways.<br /><br />So, in the hope that Democrats still have some potential, here's my message to those of them who are still on the fence about health care:<br /><ul><li><span style="font-weight: bold;">This is why you became a Democrat.</span> Democrats believe in the ability to government to help people. Democrats believe that government should help everyone, not just the wealthy. Here's your chance to act like a Democrat.<br /></li></ul><ul><li><span style="font-weight: bold;">Failing to pass health care reform will make you look inept.</span> That's what the Republicans are counting on. Don't worry about people voting against you for passing health reform. They didn't vote for you in the last election. Worry about people who will vote against you for your legislative incompetence.</li></ul><ul><li><span style="font-weight: bold;">You'll show Republicans they can lie and get away with it.</span> Do you think they'll stop lying if health care reform goes away? NO, YOU IDIOT!! THEY'LL SEE LYING WORKED AND LIE MORE!!</li></ul><ul><li><span style="font-weight: bold;">Don't be afraid of Republican lies.</span> They lie because the facts are against them. Otherwise, they wouldn't have to lie. Don't be afraid to call out the Republicans on the their lies and don't be afraid to answer their lies with the facts. Just learn to make the facts understandable. Say it over and over and people will get it.<br /></li></ul><ul><li><span style="font-weight: bold;">I promise I'll vote for you if you support health care.</span> I know I'll regret this, but I mean it. I dislike both my senators (Specter and Casey) immensely. But I'll vote for them in the primary and general elections if they can deliver on health care. Screw this up, and I'll vote for Felix the Cat first. This is especially true for you, Bob Casey, if you get sucked into the anti-abortion mess.</li></ul><ul><li><span style="font-weight: bold;">The Senate bill is imperfect but it is still better than nothing.</span> I'd be happy to see the public option in there. Hell, I'd like to see a single payer system, but I know it can't happen in the US. But since you can't make a perfect bill now, this will do. You can make the system better in the future, even without a single payer system, and maybe without a public option.<br /></li></ul><ul><li><span style="font-weight: bold;">Don't be afraid to use the budget reconciliation process.</span> The Republicans used it to pass their tax cuts for the wealthy. You can use it, too. Make the Senate bill better with it. The fact that Republicans are yelling (and lying) so hard about it tells me they're scared. GO FOR IT.<br /></li></ul><ul><li><span style="font-weight: bold;">Don't worry about Republican hand wringing over the deficit.</span> Instead, counterattack. It was Republicans who ran up the deficit with unwise tax cuts and two unfunded wars. They were the ones that created the economic mess we're in with their opposition to effective regulation of Wall Street. Economists will tell you that the deficit is not out of control, especially because interest rates are so low. Answer Republican lies with the facts.</li></ul><ul><li><span style="font-weight: bold;">Health care reform is good for the economy.</span> From reducing lost wages to reducing illness-related bankruptcies, better and more affordable health care is good for the economy. More affordable health care means more small business start-ups. Small business almost always fuels economic recoveries.<br /></li></ul><ul><li><span style="font-weight: bold;">Don't be afraid of a Republican filibuster on this or any other bill.</span> Make the Republicans do it. Let voters see the spectacle of them staying up all night holding up the work of the Senate.</li></ul><ul><li><span style="font-weight: bold;">Stop trying to get a bipartisan bill.</span> In AA, they define insanity as doing the same thing over and over again and expecting different results. Get some sanity. The Republicans aren't going to help you.<br /></li></ul><span style="font-weight: bold;">And pass the damned bill!</span>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-45791899429453117542009-08-01T16:33:00.005-04:002009-08-01T18:32:19.992-04:00Is Health Care Reform Going to Fail Again?I've been watching the debate over health care reform and I'm losing hope that it will happen. People of good will can disagree about the best way to deliver health care to all Americans. But, we're not seeing that. Instead, the debate is about nonsense. Things like:<br /><ul><li>You're going to substitute socialized medicine for my Medicare! (No, Medicare IS socialized medicine and nobody is trying to mess with it.)</li></ul><ul><li>You're going to make health care elitist, so only the wealthy will have good health care! (No, the way it is now, only the better off can get good health care. Obama wants to make it less elitist.)</li></ul><ul><li>The government will withhold health care and let old people die! (No, nobody has proposed that and nobody would tolerate that.)</li></ul><ul><li>An anonymous bureaucrat will control my health care! (What do you think is happening now? With public health care, you can write to your congressman. Under the current system, you get to write to the company that denied you coverage.)</li></ul><ul><li>It's going to be too expensive! (No, doing nothing is too expensive. Nobody has argued with <a href="http://www.nytimes.com/2009/07/22/us/politics/22obama.transcript.html?pagewanted=4&sq=obama%20press%20conference%20health%20care&st=cse&scp=3">President Obama's point</a> at his last press conference, that doing nothing will double our health care costs in ten years, while further reducing the number of people covered.)</li></ul><ul><li>I won't have the freedom to choose my health plan! (You don't have that freedom now. Your employer selects the plans you get to choose from. If you're lucky, the plan you can afford is adequate. If we have a "public option," that plan will be available to everybody, actually increasing choice.)</li></ul><ul><li>I won't have the freedom to choose my doctor! (The way it is now, you have to choose a doctor who takes your plan. If your employer decides to change your plan, you might have to change doctors. That won't change unless regulations require insurance companies to accept all willing providers. Fat chance.)</li></ul><ul><li>I won't be able to keep my current plan! (Yes, you will. There is nothing in any of the current proposals to keep you from doing that.)</li></ul><ul><li>I'll be forced to buy insurance when I don't want it. I should have the right to go without insurance! (No, we're all in this together. You never know when you'll fall down the steps, get bitten by a mosquito carrying Lyme disease, or be diagnosed with cancer. Just like with car insurance, you pay into the system so you can get the benefits when you need them.)<br /></li></ul>The health insurance companies like the system the way it is. They're making money hand over fist. They don't want any changes and they are throwing money at both parties (<a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/07/05/AR2009070502770.html">1.4 million dollars a day!)</a> to defeat reform.<br />Worse yet, the Republican Party has decided that <a href="http://www.politico.com/blogs/bensmith/0709/Health_reform_foes_plan_Obamas_Waterloo.html?showall">defeating Obama is more important than helping US citizens</a>. They have been actively feeding this nonsense through their usual media outlets. They ought to be ashamed of their lies, but I don't think they have the moral fiber.<br />There is no reason we should be holding to the current system. It's a social and economic mess. People are going bankrupt with medical bills, while others have no coverage at all and only get treatment at an emergency room when they are really sick. Furthermore, we cannot compete internationally if we continue to throw good money after bad for health care.<br />Every other western nation has managed to provide health care for all its people. Why can't we? There's only one reason we can't: We've got Republicans and they don't.<br />Blue Dog Democrats are bad enough, but at least they're willing to vote for something. If health care reform fails it will be on the Republicans, and they will happily take the credit. But, while they are celebrating, they should know there will be a lot of us who will remember what they did.<br />I guarantee you, if health care reform fails, the only time I'm going to vote Republican is for dog catcher. Then I'll get the meanest, nastiest dog I can find and set it loose.<br /><div style="margin-top: 10px; height: 15px;" class="zemanta-pixie"><a class="zemanta-pixie-a" href="http://reblog.zemanta.com/zemified/02533a92-19ca-4c76-8ee0-ea2ae62c9c3b/" title="Reblog this post [with Zemanta]"><img style="border: medium none ; float: right;" class="zemanta-pixie-img" src="http://img.zemanta.com/reblog_e.png?x-id=02533a92-19ca-4c76-8ee0-ea2ae62c9c3b" alt="Reblog this post [with Zemanta]" /></a><span class="zem-script more-related more-info pretty-attribution paragraph-reblog"><script type="text/javascript" src="http://static.zemanta.com/readside/loader.js" defer="defer"></script></span></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com2tag:blogger.com,1999:blog-24781577.post-5490696929692791392009-06-30T12:06:00.018-04:002009-07-08T12:00:48.692-04:00How Health Care Reform can Save MoneyHealth care reform is near and dear to my heart, both as a provider and as a patient. The national situation, where 40 million Americans either have no health insurance or bad health insurance, is an abomination. Under Obama, it looks like some kind of reform is going to happen now. I've been wondering about some more obscure aspects of the system.<br /><br />The Senate Health, Education, Labor, Pensions (HELP) committee has released an outline of its latest proposal for for health care reform. I just found the <a href="http://help.senate.gov/BAI09A84_xml.pdf">bill on their web site</a>. It's 615 pages, so I don't think I'll be reading it between clients. I skimmed over it, and didn't see what I was looking for.<br /><br />I was specifically looking for reform of programs that have health insurance components, such as:<br /><ul><li>Worker's (or Workman's) Compensation insurance; </li><li>Motor vehicle insurance; </li><li>Medical malpractice insurance; </li><li>Homeowner's, renter's and business liability insurance; and </li><li>Product liability insurance.</li></ul>You could probably come up with some additional examples, but these seem to be the major insurance programs. All of them deal with injuries which are attributed to the fault of another person or entity. Under these plans, medical costs attributable to the accident are not paid through the person's medical insurance. They are paid by the appropriate liability insurance company.<br /><br />So, for example, a worker injured on the job is compensated by the employer for his or her injury through Worker's Compensation. Injuries from slipping on a wet floor at the supermarket are paid by the supermarket's liability insurance. An injury caused by a defective product is paid for by product liability insurance. Here's the critical thing: While the person's initial claim may be covered quickly by the insurance company, escalating costs are fought vigorously. The only thing an injured person can do is hire a lawyer.<br /><br />Universal health care can reduce some of these costs, but my reading of the bill says it won't. This is a shame, because one of the goals of insurance reform is to reduce costs to businesses. Let me show how it can do this. First, as an example, consider worker's compensation:<br /><br />An employee is hurt on the job. He goes to the emergency room as instructed by his employer and gets initial treatment. Then, he goes to other physicians or therapists as appropriate and takes some time off to recover. Ideally, Worker's Compensation would cover the medical costs and the lost wages.<br /><br />"Ideally" is the operative word. Worker's Compensation insurance will cover the employee's claim only if they are convinced that the injury is genuine and a direct result of the employee's accident. They fight the claim if there is any ambiguity in the diagnosis or if there is any reason to suspect a preexisting condition. There is always ambiguity and there are frequently preexisting conditions, so a large number of Worker's Compensation claims end up in litigation.<br /><br />The whole thing can take years to resolve. During this period, the employee is subjected to extensive harassment and intimidation. I have heard all of the horror stories, and I've heard them repeatedly. The first time you hear them, you think the person is paranoid. But then you hear the same stories again and again, and it no longer seems delusional.<br /><br />For example, a person receiving Worker's Compensation benefits finds that, with no good reason:<br /><ul><li>The person goes to a pharmacy to refill prescriptions. The prescriptions, which were covered a month ago, suddenly aren't being covered. There's a $500.00 bill to be paid before they get their pills.<br /></li><li>The monthly check covering lost wages stops coming without warning.</li></ul>Frantic phone calls go unanswered until the person retains an attorney, and then magically the benefits start up again for some period of time. Then, other things start happening:<br /><ul><li>The person is followed and videotaped by private investigators to find evidence they're not disabled. Investigators are allowed to videotape through the person's windows and show the tape in court.<br /></li><li>The person is sent to a physician, sometimes far away from their home, whose sole job is to review the claim, perform an examination, and proclaim they are ready to go back to work.</li><li> Hearings over eligibility for Worker's Compensation are scheduled far in the future and then continued for no good reason, often leaving the person without a check or without medical care.<br /></li><li>Needed treatment is denied after a long decision-making process. Often this means that more extensive and expensive treatment, with poorer results, has to follow after the claim has been resolved.<br /></li></ul> I would rather find out that a nuclear cruise missile has been launched directly at my rectum, than to go through this. Of course, that's the point.<br /><br />For Worker's Compensation companies, there is no downside to this level of harassment. The more they harass you, the more you get worn down, and the quicker you are to settle. It's expensive, but the costs are just passed on to the employer, who is reassured that they are really saving money because none of their employees are (God forbid!) getting over on them.<br /><br />My experience has been that Worker's Compensation has been the worst of these systems, but this can happen anywhere when liability for medical care is involved. I've seen it with motor vehicle accidents, and have heard about it with medical malpractice and product liability cases.<br /><br />We all pay for this crazy system. We don't pay it up front, and the costs are hidden, but they are there. When you buy a car, a refrigerator, or a can of soup, part of that cost covers workers compensation and product liability insurance. Similarly, when you pay your car insurance premium, part of that premium pays for health care costs for injuries others have sustained in an accident. The price you pay for food or for a swing set partly covers these costs. Your health insurance premium partly pays for medical malpractice and workers compensation for health care workers.<br /><br />So here's my question: If health care is a right, not just a perk provided by your employer, why not just include the treatment of all injuries under it, regardless of origin? That way treatment is administered in a timely manner and without difficulty. There will still be litigation over lost wages, pain and suffering, and lost capabilities, but at least health care will be out of the picture.<br /><br />I can hear the demagogues bellowing, "I don't want my health insurance to pay for someone else's mistakes!" Well, as I just indicated, you pay for it anyway. You just pay for it with a different check. And you pay more for it because you have legal fees attached to it. We can streamline the process and reduce costs by eliminating the adversarial system as it covers health treatment.<br /><br />Will people try to run up health costs to appear more disabled than they really are? Of course they will. But however health care reform works, there will be cost controls in place to handle unnecessary treatment. Those cost controls are much less expensive than litigation.<br /><br />How much less expensive is an open question. I haven't been able to find statistics on how claims break down into medical vs. non-medical payments. One site I found wanted $500 for access, so I'll leave that issue to others who have better library access than I do. I would love to hear from you if you do have that data.<br /><br />By removing medical coverage from worker's compensation and various liability insurances, we reduce costs to employers and manufacturers. We have heard about tort reform for years and it is usually a code for "let's screw the little guy." This is a simple tort reform that has the potential to significantly reduce costs and will benefit the little guy at the same time. It makes our products more competitive on the world stage and that cannot be a bad thing.<br /> <div style="margin-top: 10px; height: 15px;" class="zemanta-pixie"><a class="zemanta-pixie-a" href="http://reblog.zemanta.com/zemified/0fcca4b3-34db-40ef-8dcb-1e7966ab2ab5/" title="Reblog this post [with Zemanta]"><img style="border: medium none ; float: right;" class="zemanta-pixie-img" src="http://img.zemanta.com/reblog_e.png?x-id=0fcca4b3-34db-40ef-8dcb-1e7966ab2ab5" alt="Reblog this post [with Zemanta]" /></a><span class="zem-script more-related pretty-attribution"><script type="text/javascript" src="http://static.zemanta.com/readside/loader.js" defer="defer"></script></span></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com5tag:blogger.com,1999:blog-24781577.post-69694437461897110932009-04-26T12:53:00.002-04:002009-05-27T22:40:36.377-04:00Grieving for our Parents<div xmlns="http://www.w3.org/1999/xhtml">This week's New York Times Magazine has a fascinating article by Christopher Buckley about the deaths of his parents, Pat ("Mum") and William F. Buckley ("Pup"). The article, excerpted from his upcoming book, is about his ambivalent relationship with them. Christopher is a wonderful and compelling writer. He tends to write in a style we clinicians call, "rambling, but goal-directed." He often digresses, but there is always a purpose to it, and returns to his main point quickly. He is an apple that didn't fall far from his parents' tree.<br /><br />Christopher's mother died 11 months before his father. He relates seeing her in the ICU. At a point when she may have already been dead, he found himself saying, "I forgive you." Like so many essential things we say, his words surprised him. Then, a few months later, with his father facing death, they had this interaction:<br /><blockquote><p>I had planned to leave mid-July on a trip to the West Coast. One night as we watched the first of three — or was it four? — movies, he said apprehensively, “When are you leaving for California?”</p><p>“I’m not, Pup. I’m going to stay here with you.” </p><p>He began to cry. I went over and patted him on the back. He recovered his composure and said, somewhat matter-of-factly, “Well, I’d do the same for you.” </p><p>I smiled and thought, Oh, no, you wouldn’t. A year or two earlier, I might have said it out loud, initiating one of our antler-clashes. But watching him suffer had made my lingering resentments seem trivial and beside the point. </p>I wondered, while keeping this vigil with him, whether to bring up certain things and talk them out so that, when the end came, nothing would be left unsaid between us. But each time I hovered on the brink, I found myself shrugging and saying, Let it go. Perhaps it was another way of saying “I forgive you” — as I had to Mum that night in the hospital — on the installment plan. I felt no need for what is called, in other contexts, the “exit interview.” I was able to love him now all the more, and actually laugh (inwardly, anyway) at that “I’d do the same for you.” Oh, yeah? Ho, ho, ho.<br /></blockquote>We come to terms with a loved one's death by accepting them as they are. It is at best unnecessary, and sometimes counterproductive, to try to leave everything said, or to "talk things out." Instead, we need to understand that in the face of death, "my lingering resentments seem trivial and beside the point."<br /><br />When we grieve for our parents, we grieve for them as they were, and we grieve for what we have wished they were. As we come to terms with that discrepancy, we come to terms also with our own lives. We do not have to be perfect to be valuable human beings. Our past mistakes and our current faults do not make us despicable; they make us unique and human. In some ways, Buckley is telling us, our faults are just as precious as our our assets.<br /><br /><div class="zemanta-pixie"><img src="http://img.zemanta.com/pixy.gif?x-id=8dafc3e3-55b4-806a-8439-a0c973dec453" class="zemanta-pixie-img" /></div></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com1tag:blogger.com,1999:blog-24781577.post-79773541098387095712009-04-18T18:48:00.002-04:002009-04-18T18:53:47.938-04:00The Psychology of Jealousy: Guest PostI recently had a request from <a href="http://radiographyschools.org/">Sarah Scrafford</a>, to post on JND. As I haven't been posting lately, I welcomed her offer. Below are her thoughts on the psychology of jealousy.<br /><br /><big><b>The Psychology of Jealousy</b></big><br /><br />Relationships are complicated, even when things are going smoothly. You never know when you’re going to be overcome by emotions like anger, sadness, and the worst of them all, jealousy. It’s an evil, green-eyed monster that makes your life miserable; it eats away at every shred of happiness you have until you’re a bundle of nerves and an emotional mess; and it makes you do things you would never do when you’re in your right senses. We only have to look at the female astronaut who put on a diaper and drove all through the night to attack a rival for her beau’s affections to see the truth of this statement.<br /><br />A close friend and I were discussing a couple whose relationship had hit the doldrums. He wanted in, she wanted out; and the more she wanted out, the more he wanted in. My friend was of the opinion that that’s the way human beings are – when we know that we cannot have something, we somehow seem to want it even more. So when someone close to us withdraws and retreats into a shell, we seem to crave their company and affection in the worst possible way. It’s worse when there’s a third person involved, when you know that someone else is getting what you think you deserve. Jealousy comes rushing in and takes over your life, making you incapable of rational thought or reasoning.<br /><br />While I’m no psychologist, here’s what I know about the psychology of human relationships – the best way to attract someone’s attention is to pretend to be totally unaware of them. This works really well when they know you’re interested in them and when they’ve rebuffed your advances at least once. The moment you stop hanging around them or trying to get them to show an interest in you, they’re going to wonder why you changed your mind, why you’re not as into them as you seemed to be before. And this hits their ego, the one that you helped inflate with your undivided attention.<br /><br />If they’re the mature kind, they realize this hurt ego for what it is and let things go; after all, they’re really not interested in a romantic relationship with you. If not, they’re definitely going to hang around you more, check if you’re looking at them from afar, tease you a little with a text message or a mildly flirtatious email, or invite you out for a cup of coffee. But before you jump for joy at this new attention, let me warn you that this interest, the one that’s riding solely on a hurt ego, will disappear the moment you begin to reciprocate, unless your beau is really into you by this time. <br /><br />Yes, as Shakespeare rightly said; it’s a tangled web we weave, when we first practice to deceive. The psychology of relationships is complicated, more so when we have to play games to win over the people we really want.<br /><br /><br /><b>This article is contributed by Sarah Scrafford, who regularly writes on the topic of <a href="http://radiographyschools.org/">online radiography schools.</a> She invites your questions, comments and freelancing job inquiries at her email address: sarah.scrafford25@gmail.com.<br /></b><br /><p class="MsoNormal"><span style="font-family:sans-serif;"><span style=";font-family:";font-size:14;" ><o:p></o:p></span></span></p><br /><br /><div class="zemanta-pixie"><img class="zemanta-pixie-img" src="http://img.zemanta.com/pixy.gif?x-id=31f00b18-305a-8c3a-abac-b0d58e0d2f7d" /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com4tag:blogger.com,1999:blog-24781577.post-61846217090127224012009-01-28T09:37:00.002-05:002009-01-28T09:40:06.542-05:00Traumatic Brain Injury and Football<div xmlns="http://www.w3.org/1999/xhtml">Almost exactly two years ago, I posted a <a href="http://justnoticeabledifferences.blogspot.com/2007/02/sports-rant.html">sports rant</a> focusing on the effects of repeated concussions on football players. Here it is Superbowl time again, and <a href="http://www.sciencedaily.com/releases/2009/01/090127165938.htm">another story</a> has surfaced on the topic. (Also see <a href="http://www.eurekalert.org/pub_releases/2009-01/bu-cft012709.php">here</a>.) I assume these stories are released at Superbowl time to get more play.<br /><br />The study of the brains of former NFL players is being conducted by the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. Credits are as <a href="http://www.eurekalert.org/pub_releases/2009-01/bu-cft012709.php">follows</a>. I added the parenthetical clarification of the acronyms:<br /><blockquote>CSTE (Center for the Study of Traumatic Encephalopathy) is a collaboration between SLI (Sports Legacy Institute) and USM (Boston University School of Medicine). SLI was founded by former Harvard football player and WWE pro wrestler Chris Nowinski, and neurosurgeon and concussion expert Robert Cantu, MD, chief of Neurosurgery and director of Sports Medicine at Emerson Hospital in Concord, Mass, and clinical professor Neurosurgery at BUSM. The work at BUSM is being led by McKee, an associate professor of Neurology and Pathology, director of the Neuropathology Core of the BU Alzheimer's<br />Disease Center, and the director of the brain banks of the Framingham Heart Study and the Bedford VA Medical Center, and Robert Stern, PhD, associate professor of Neurology and co-director of the BUSM Alzheimer's Disease Clinical and Research Program. The CSTE received initial funding for their research from BUSM and subsequently received a $100,000 grant from the National Institute on Aging to support their work. This past week, the group of researchers learned that they received a $250,000 grant from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).<br /></blockquote>According to the story, players have been asked to donate their brains for study under the "88 Plan," named for John Mackey who wore jersey 88 for the Colts and now has severe dementia. So far, 7 NFL players have been evaluated, an 6 have been diagnosed with chronic traumatic encephalopathy. Trauma refers to damage. Encephalopathy refers to brain pathology. Hence, traumatic encephalopathy is a technical term for brain damage caused by head injury.<br /><br />One can diagnose encephalopathy through brain imaging, psychological tests, and by clinical signs and symptoms. However, in this case, the diagnosis was made the most reliable way, by autopsy, so there is no mistaking the severity of the problem. Interestingly, the players' brains had some similarities to Alzheimer's patients. Most of the players showed signs of memory loss, impaired thinking, depression, and impulsive behavior. They also may have abused substances. Two died of suicide and a third died of a self-inflicted gunshot wound ruled accidental.<br /><br />This is pretty scary data, but I want to add two cautions to interpreting the data. First, these are people who have died early, between 25 and 50, so they had severe and repeated injuries. If we examined players who lived a full life, we would certainly see a different picture. This is why the authors have carefully avoided claiming that most NFL athletes have brain injury.<br /><br />Second, the players with traumatic encephalopathy played at a time when concussions weren't taken seriously. The NFL has developed procedures for managing concussions and when to allow a concussed athlete back onto the field. The NCAA has supported <a href="http://www.neuroskills.com/pr-footballconcussions.shtml">studies </a>of concussions. The American Academy of Family Physicians has a <a href="http://www.aafp.org/afp/990901ap/887.html">nice summary</a> of how to manage concussions in high school athletes. As mentioned above, the quality of the equipment is also being evaluated. So, now that concussions are being taken more seriously, the pervasiveness of traumatic encephalopathy should be declining. But we don't know that for sure.<br /><br />As someone who spends most of his time in his head and others', I question why we accept this risk at all. Remember the old commercial, "A mind is a terrible thing to waste"? When a child or a young adult athlete is concussed, the rest of their life is at risk. And for what?<br /><br /><br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com7tag:blogger.com,1999:blog-24781577.post-43456619875484218422008-12-20T15:35:00.003-05:002009-04-26T13:11:41.954-04:00Controversy over DSM-V<div xmlns="http://www.w3.org/1999/xhtml">This week, I finally got a reprieve from numerous reports and paperwork, so I can dust off the old blog and have some fun again. There is no better place to begin than the controversy over DSM-V.<br /><br /><b>Background</b><br /><br />First, some background. DSM-V stands for Diagnostic and Statistical Manual--Fifth Edition. Of course, in psychiatry, numbers can be misleading. DSM-V will actually be the seventh revision, as DSM-III was revised once (DSM-III-R) and DSM-IV was also revised (DSM-IV-TR. TR stands for "Text Revision.") It's published (and jealously guarded) by the American Psychiatric Association.<br /><br />When I started out in the 1970's, DSM-II was the manual we used, and it was awful. Definitions were vague, and you could diagnose the same person with anything from depressive neurosis to schizophrenia without much difficulty. DSM-II was generally denounced as irrelevant and unnecessary by behaviorists and humanists. At the time, diagnosis had little to do with treatment, so it really was unnecessary. In hospitals, physicians would argue endlessly about a patient's diagnosis, with no change in treatment after they had differentiated what kind of schizophrenic they were dealing with.<br /><br />DSM-III changed all that, as diagnoses were made on the basis of behavior. Specific symptoms were identified and you had identify a certain number of symptoms in order to diagnose depression. This was a great advance in two areas. First, research could be focused. If you wanted to research a treatment for depression, there was now a clear operational definition for depression. That means that we could compare different studies without comparing apples and oranges.<br /><br />Second, DSM-III gave us the ability to communicate what we were treating to third parties. It was published when insurance companies were beginning to pay for psychotherapy. Unfortunately, many therapists didn't know an adjustment disorder from major depression. Consequently, managed care used DSM-III to refuse to pay for many treatments. We had to learn to say, "Here are the symptoms that show the client is depressed and here is the progress I am making on them. Once we learned to do that, managed care stopped refusing psychotherapy and we now generally get as much time to treat clients as we need.<br /><br /><b>The Controversy</b><br /><br />DSM-IV has been a small improvement over DSM-III, but it's still controversial. Now DSM-V is on the horizon and it's generating more heat. A <a href="http://www.nytimes.com/2008/12/18/health/18psych.html?ref=health">recent article</a> in the New York Times picked up on the controversy. There are a number of points of controversy.<br /><br />First, there is no real understanding of the causes of mental illness. We're still not even sure if there is such a thing as a mental illness. Psychiatry has been moving toward a neurobiological model of mental illness, but is still far away. If you ask a psychiatrist what causes depression, you'll hear one of two answers. You might hear, "We don't know," which is the honest answer. However, more likely, you will hear some mumbling about serotonin and biochemical imbalances. Those guys are just blowing smoke. Just ask them to define a healthy biochemical balance; their response will be entertaining. Unfortuantely, more than half of the members of the task force writing DSM-V <a href="http://www.cspinet.org/integrity/watch/200805051.html#4">have drug company connections</a>, so you know they will remain committed to a neurobiological model.<br /><br />Second, diagnoses are often points on a continuum. Consider what is now called Attention Deficit/Hyperactivity Disorder (ADHD). Our ability to pay attention falls along a continuum from fleeting to intense. When we diagnose someone with ADHD we are saying that their attention <i>on the average, </i>falls below some imaginary point on that continuum. That imaginary point is also arbitrary. Do we abandon children who fall just to the normal side of that point? How about children who fall mostly to the average side of that point, but occasionally their attention and concentration crash and burn?<br /><br />Third, the inclusion of a diagnosis in the manual has always been unsystematic and has many social implications. Why is repetitive handwashing considered obsessive compulsive disorder, while repetitive shopping is not? Is binge eating a disorder, or does the person just need to grow up and get some self control? In DSM-II, homosexuality was considered a diagnosable mental illness. In DSM-III, homosexuality was removed as a diagnosis. There is a straight line from deciding homosexuality is not a mental illness to deciding gays should have the right to marry.<br /><br />Fourth, how open should the process be? The APA has had the members of the DSM-V task force sign conficentiality agreements. Dr. Robert Spitzer, a member of the APA task force on DSM-V has <a href="http://pn.psychiatryonline.org/cgi/content/full/43/14/26">raised concerns</a> about it. (More about the controversy can be found <a href="http://www.latimes.com/news/opinion/commentary/la-oe-lane16-2008nov16,0,5678764.story">here</a>.) Given the social implications for some diagnoses, there's a lot at stake here. But, it's difficult to balance the need for open, scholarly discorse, with the risk of being personally attacked by one pressure group or another.<br /><br />Who gets treatment is affected by diagnosis. When I diagnose a child with autism, that child becomes eligible for a wide range of services that a child with plain old "mental retardation," would not get. Interest groups in a lot of areas would like to see their own diagnoses included, so more services become available. A battle is raging over whether or not transsexuality should be included in DSM-V as a mental illness. Some would like it to be normalized; a person should be able to cross dress if they want to. However, others would like to have insurance cover sexual reassignment surgery. You can't cover a procedure if it isn't treating a diagnosis.<br /><br /><b>Conclusions</b><br /><br />DSM-V will almost certainly move closer to a neurobiological model and away from a psychosocial model. That will lead to less emphasis on psychosocial treatment. I don't hold that against psychiatry; they treat mental illness biologically. However, psychotherapy still has much to offer. Psychotherapy is still the best (or at least a competitive) treatment for personality disorder, post-traumatic stress disorder, and some depressive and anxiety disorders. Generally, psychotherapy reduces the risk of relapse. Yet, if we structure our diagnoses around neurobiolgical models, psychotherapy will be marginalized. Already, family and marital therapies are extremely difficult to justify using DSM-IV. Somehow, diagnoses should also be there to allow for psychosocial treatment and to encourage more research in that area.<br /><br />Despite these problems, we still need a diagnostic manual. Psychiatric diagnoses, for all their arbitrariness, give us a way of organizing research and communicating therapeutic information. At some point research will give us a handle on the nature of mental illness, and a clear diagnostic system will emerge from that. In the meantime, this is the best we've got, and none of the critics have given us a good alternative to the writing of a new manual.<br /><br /><br /><br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com3tag:blogger.com,1999:blog-24781577.post-44353796502804343102008-09-17T18:18:00.003-04:002008-09-17T18:18:56.686-04:00APA Passes Resolution Passes on Psychologists' Working in Detention Settings<div xmlns='http://www.w3.org/1999/xhtml'><font face='sans-serif'/><strong/>The American Psychological Association has just issued a <a href='http://www.apa.org/releases/petition-result.html'>press release </a>stating that the membership passed a resolution forbidding work in settings where "persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the US Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights." <br/><br/>The full text of the petition is <a href='http://www.apa.org/releases/petition-result.html'>here</a>.<br/><br/>If I read this right, there are no significant loopholes. Psychologists should either work for detainee's well being or not at all.<br/><br/>It's about time!<br/><br/>I think some people thought that there was room for psychologists to work within the system to better the detainees' situation. I don't believe that's possible. While it's enticing to think of the heroic psychologist fighting the system, human nature (not to mention Solomon Asch and BF Skinner) tells me that the psychologist would just be co-opted into the system.<br/><br/>It was also particularly galling that the AMA had done this long ago while the APA wimped out. So, as I often teach my clients, time only goes forward. It would have been better for APA to have done this sooner, but doing it today is better than doing it tomorrow.<br/></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-23320980138595917052008-08-16T13:17:00.003-04:002008-08-16T16:19:49.567-04:00JND in Top 100 Mental Health and Psychology Blogs<div xmlns="http://www.w3.org/1999/xhtml">Just Noticeable Differences has been mentioned in the <a href="http://www.universityreviewsonline.com/2005/10/top-100-mental.html">Top 100 Mental Health and Psychology Blogs</a>. It is an interesting site, and I found some good stuff there. I appreciate the mention, especially when I haven't blogged since May. My goal this year was to blog weekly, and I haven't come close.<br /><br />I have been extremely busy. Work has gotten chaotic and I have been spending all my free time at home either working on the house or, more often, writing reports. After you've spent several hours on a weekend writing such deathless prose as, "On examination, Mr. Johnson was alert and oriented in three spheres," blogging isn't high on the list.<br /><br />There are several reasons work has gotten chaotic. First, as I've said <a href="http://justnoticeabledifferences.blogspot.com/2006/07/new-psychology-advocacy-group-is.html">elsewhere</a>, fees for psychotherapy services are static. I will get a 3% raise soon, but with <a href="http://www.nytimes.com/2008/08/15/business/economy/15econ.html?scp=3&sq=inflation%20dollar&st=cse">inflation about 5.6%</a>, I will still still have to work more hours to stay even.<br /><br />Making matters worse, there has been a lot of conflict in my office. I think it's due mismanagement, but hey, nobody listens to me, anyway. At this point, I'm so disgusted that I'd like to leave and restart my private practice. Unfortunately, I am the source of health insurance in my family and I would have to purchase insurance separately if I resigned. I calculate that if I and my wife were lucky enough to qualify for it, we would pay through the nose. There is also no guarantee that if we got sick and tried to use it we would be able to keep it. So, isn't this great? I get both ends of the health insurance mess at the same time.<br /><br />I've learned one critical lesson from this. Republican opposition to national health insurance has nothing to do with taxes or small government or any other nonsense. Republicans oppose national health insurance because it makes employees more dependent on their employer. Because I can't just pick up and start a private practice, my employer has more control over me.<br /><br />Like many Republican policies, this is at best penny-wise and pound foolish. At worst, it is self defeating. Opposing national health insurance helps the large corporations, but it hurts the US economy. The lack of national health care almost certainly hinders small business formation. Small businesses are an important part of our economy. It is small businesses that bring innovation into the marketplace.<br /><br />So, I'm watching the campaign very closely this year. Having a Republican in the White House will probably mean 4 more years of this nonsense. Unfortunately, Obama has apparently inherited the Dukakis strategists: McCain is beating up on him and he's on vacation.<br /><br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com1tag:blogger.com,1999:blog-24781577.post-89488093251023282282008-05-20T00:02:00.004-04:002008-05-20T00:13:13.178-04:00Net NeutralityA few years ago, an idea was floated by the large ISP's that they should be allowed to prioritize the access to different web sites. The initial plan was focused on providing faster access to users for a fee. While that idea sounds logical, the devil is in the details.<br /><br />High volume users, such as Google, have <a title="objected strenuously" href="http://www.google.com/help/netneutrality.html" id="osez">objected strenuously</a>. It will certainly make their operation more expensive, but more importantly, small content providers who rely on Google will be affected by it. After all, the little guys get their start blogging on Blogger and similar sites. It will be those users who will be affected by increased costs to Google and other providers like them. So, little guys like me could be forced off the net.<br /><br />Now, I know that losing me wouldn't be a great loss. I'm not controversial and I don't blog much. But losing me, means that you could lose someone more important. Why not, for example, make life more difficult for <a title="Daily Kos" href="http://www.dailykos.com/" id="bm_x">Daily Kos</a> (who just happens to be <a title="blogging on this" href="http://www.dailykos.com/storyonly/2008/5/19/104552/353/446/518242" id="cizy">blogging on this</a> on May 19, as I am)? This is something that we need to be very worried about. The New York Times, <a title="in an editorial today" href="http://www.nytimes.com/2008/05/19/opinion/19mon2.html?ref=opinion" id="fcru">in an editorial today</a>, commented that the ISP's <blockquote id="lezn0">have realized that they could make a lot of money by charging some Web sites a premium to have their content delivered faster than that of other sites. Web sites relegated to Internet “slow lanes” would have trouble competing. <p id="ese90">This sort of discrimination would interfere with innovation. Many major Web sites, like eBay or YouTube, might never have gotten past the start-up stage if their creators had been forced to pay to get their content through. Content discrimination would also allow I.S.P.’s to censor speech they do not like — something that has already begun. Last year, Verizon Wireless refused to allow Naral Pro-Choice America to send text messages over its network, reversing itself only after bad publicity.</p></blockquote>So, there is a risk that non-neutral access to the web could result in limiting access to sites that express ideas the corporations don't want. Do you think that will be left-wing or right-wing ideas?<br /><br />I'm going to share an idea that I've held for a long time. It's a little crackpot, but no one I've mentioned it to has been able to punch holes in it. As I look back over the last century, it seems to me that liberal/progressive ideas flowered at two times: the 1930's and the 1960's. I believe it happened because both eras were marked by inexpensive and decentralized media, allowing the left to reach its audience.<br /><br />In the 1930's, there was excess printing capacity as newspapers and publishers failed during the Great Depression. Radio was a new medium and small radio stations slowly started up. During this period, the Socialist Party flourished. Labor unions started to take off. Roosevelt's New Deal was inked. But then, during World War II, small newspapers and radio stations fell by the wayside. Both the draft and the defense industries needed bodies, and small radio stations and newspapers were a luxury that couldn't be afforded. After World War II, the remaining radio stations and newspapers started folding into ever larger corporate bodies. Since corporations are politically conservative, outlets for left-wing messages were closed down. Not surprisingly then, the 1950's was a politically conservative era.<br /><br />In the 1960's, new legislation and regulations readjusted the radio spectrum and required that AM radio receivers also receive FM. This allowed FM radio to come into its own. Small family-owned FM radio stations started gaining listeners. The stations found new content in the music and the left-wing politics of the times. As a result, people heard messages that they would otherwise have missed. Left-wing politics bloomed. But in the 1970's, corporations began buying the small stations, and with centralization, left-wing politics again fell by the wayside.<br /><br />If I'm right, Ronald Reagan was the Teflon President, not because he was the Great Communicator, it was because he was the Only Communicator. George II similarly got a free ride until the internet really matured. He could hide the coffins coming back from Iraq from television. But now he can't stop pictures of the war from being posted on YouTube and things are looking bad for the Republican party.<br /><br />The Republicans understand this dynamic. Previously, they make no effort to hide their view that Public Broadcasting is a left-wing voice. They've worked hard to harass public television and have tried repeatedly to shut it down. They have also worked hard to relax the rules against corporate ownership of multiple stations in the same market. With the development of the internet, of blogging, of podcasts, of YouTube, and so forth, communications are again being decentralized. If we, who consider ourselves liberal or progressive, want to keep our lines of communication open, we need the internet.<br /><br />"Net neutrality" refers to protecting the internet from prioritized access. The Times editorial indicates that several net neutrality laws have been proposed to Congress, but they have gone nowhere. Why am I not surprised? The Republicans don't want net neutrality and the Democrats are too stupid to realize how important it is to them.<br /><br />Learn more about net neutrality at <a title="Wikipedia" href="http://en.wikipedia.org/wiki/Network_neutrality" id="miz1">Wikipedia</a> and at <a title="Common Cause" href="http://www.commoncause.org/site/pp.asp?c=dkLNK1MQIwG&b=1421497" id="xyuz">Common Cause</a>. There are petitions to sign at <a id="koce2" href="http://www.savetheinternet.com/=act">SavetheInternet.com</a> or <a id="koce3" href="http://civic.moveon.org/save_the_internet/">MoveOn.org</a>.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com5tag:blogger.com,1999:blog-24781577.post-51055302767174362092008-03-09T12:14:00.003-04:002008-03-09T12:27:40.265-04:00Autism and Vaccines<div xmlns="http://www.w3.org/1999/xhtml"><a href="http://www.nytimes.com/2008/03/08/us/08vaccine.html?ref=health">The New York Times has a story</a> on a lawsuit over vaccines and autism. It opens as follows:<br /><blockquote>Study after study has failed to show any link between vaccines and autism, but many parents of autistic children remain unconvinced. For the skeptics, the case of 9-year-old Hannah Poling shows that they have been right along.<br /><br />The government has conceded that vaccines may have hurt Hannah, and it has agreed to pay her family for her care. Advocates say the settlement — reached last fall in a federal compensation court for people injured by vaccines, but disclosed only in recent days — is a long-overdue government recognition that vaccinations can cause autism.</blockquote><p></p><p></p><blockquote> “This decision gives people significant reason to be cautious about vaccinating their children,” John Gilmore, executive director of the group Autism United, said Friday.</blockquote>The government argued that it did not cave in to anti-vaccine hysteria:<br /><p></p><blockquote>“Let me be very clear that the government has made absolutely no statement indicating that vaccines are a cause of autism,” Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said Thursday. “That is a complete mischaracterization of the findings of the case and a complete mischaracterization of any of the science that we have at our disposal today.” </blockquote>So, why did they settle? It's not clear from the news stories, and I don't have access to the settlement. Given the attitude toward science in our government, decision-makers may have decided not to let the facts bother them when their minds were made up. Or, maybe they just decided that they didn't want to put this one in front of a jury that might be controlled by sympathy, rather than science.<br /><br />To understand the science, you have to understand some background. There are two reasons why people began worrying that vaccines may be causing an "epidemic" of autism. The first is that autism rates have been rising along with vaccination rates. The second is that symptoms of autism emerge at roughly the same time as vaccinations occur. So, it seemed like a logical hypothesis. Thimerosal quickly became the culprit.<br /><br />Thimerosal is a vaccine preservative, and it contains ethylmercury in very low doses. There had been general consensus that the doses were low enough to be of no concern. However, the safety standards were based on methylmercury exposure, and it was thought remotely possible that there could be greater risk with ethlymercury. Alternative preservatives had been developed and it seemed prudent to eliminate thimerosal. Beginning in 1989 thimerosal levels were reduced in vaccines. The process was completed in 1992.<br /><br />Because Thimerosal levels have been reduced over the years, a good way to track the effects of Thimerosal exposure is look at rates of autism as they correspond to Thimerosal exposure. A number of these studies (<a href="http://www.immunizationinfo.org/immunization_science.cfm?cat=1">summarized here</a>) have looked at this. Of particular interest is the <a href="http://www.immunizationinfo.org/immunization_science_detail.cfv?id=134">California study</a>. They looked at autism rates in California from 1989 to 1992, when Thimerosal was being removed from vaccines. Had Thimerosal increased risk of autism, rates of autism would have dropped over the course of the study. Instead, there was no change in the frequency of autism. Since they were relying on practitioner's diagnoses, there was no room for bias (by massaging diagnoses) in the study.<br /><br />Hannah, the autistic girl in the lawsuit, was a member of the age group in the California study. According to the story, she got 5 immunizations at the same time, but still, she would have been getting lowered doses of Thimerosal, because she was getting them after 1989. Again, overall, Hannah's age group showed no change in it's rates of autism over the course of the study.<br /><br />As an alternative to Thimerisol, there has also been concern about the measles, mumps, and rubella (MMR vaccine) itself causing autism. Here, the evidence is even weaker. Studies purporting to show a relationship usually involve smaller numbers of cases. They often rely on investigating groups of autistic children and try to relate the emergence of autism with receiving the MMR vaccine. However, as I said before, vaccination occurs at the same age that autism emerges, so you're bound to see a correlation. The only way to identify a relationship here is to examine individuals both with and without autism who have both received vaccinations.<br /><br />The data just doesn't support a relationship between vaccines and autism. The best explanation for rising autism rates comes from two sources. First, there have been marked changes in diagnosis. We used to see autism as a single entity. You were either autistic or you weren't. Today, we see autism as a spectrum of disorders; you may be more or less autistic. So, people previously diagnosed as mentally retarded are now seen as autistic. High functioning autistic individuals used to be diagnosed with "childhood schizophrenia." Today they're diagnosed with Asperger's disorder, which is considered a form of autism.<br /><br />Secondly, and perhaps more cynically, diagnostic labels determine access to some services. There are a large range of services for people who are called autistic. If someone's "just" mentally retarded, they may not have access to the same services. Hence, providers may say, "This kid needs Day Training Program A. If I call him 'autistic,' he'll get it. If I call him mentally retarded, he won't." I can't prove this happens, but it wouldn't surprise anyone in this business.<br /><br />My first professional position after graduate school involved working in an institution for people with mental retardation. I was involved in the group of professionals who made it possible to clear the institutions and get people with cognitive and developmental disabilities living in the community. So, over the years, I've seen a lot. What I've seem mostly, is parents struggling with their disabled children.<br /><br />As late as the 1960's, the conventional wisdom was to tell parents to put their cognitively disabled children in an institution and try to forget about them. Parents who followed that advice were often consumed by guilt. Today, thankfully, disabled children live and are educated in the community. But it's a terrible strain on the parents and on other family members to have a disabled person in the house. Behavior modification, the best treatment for autism, requires an incredible amount of time and effort. Even so, the guilt hasn't been completely eliminated.<br /><br />Parents wonder if they caused their child's autism. Was it that drink I had when I was 3 months pregnant? Or that I smoked, or that I chose to have a child at 38? Maybe it was a toxin I was exposed to at work? Maybe I shouldn't have worked? Maybe I should have taken better care of myself?<br /><br />Wouldn't it be nice if autism was caused by the doctor, and not me?<br /><br />My heart goes out to parents of disabled children. Their desperation leads to all kinds of ideas; I've seen them come and go. Megavitamin therapy was big for a while. Give lots of vitamins to your autistic child and he won't be autistic any more. Didn't do a thing. Remember assisted communication? The idea was that autistic children had only impaired communication skills and if we helped them communicate they would be just fine. It turned out that the people that helped them communicate were really doing the communication themselves. It's hard to find a good reference to it now on Google.<br /><br />This doesn't mean we should throw our hands up in despair. As Rabbi Tarphon, a Jewish sage remarked, "It is not required that you complete the job, but neither are you free to abstain from it." We cannot cure or prevent autism yet, but as a community we can support autistic people, their families and other caregivers. We cannot give support by pretending there is an easy cure or an easy explanation for their children's illness.<br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com2tag:blogger.com,1999:blog-24781577.post-62078081617784204582008-02-09T22:21:00.000-05:002008-02-09T22:41:47.478-05:00Ken Pope Resigns from APA<a href="http://www.counterpunch.org/pope02082008.html">This story</a> was just emailed to me on the PsyUSA mailing list. Ken Pope, long active in the American Psychological Association, just resigned. His reason for his resignation was the unwillingness of APA to take a clear stand against torturing detainees. I won't bother quoting his letter at all. Ken makes his stand very clear.<br /><br />I support Ken Pope completely in this. I resigned from APA several years ago because I felt that I was paying too much money for an organization that seemed to have no clear agenda. Ken makes it clear that APA has also lost its moral compass.<br /><br /><a href="http://www.dailykos.com/story/2008/2/8/13432/26171">Some commentary</a> on Ken's resignation also popped up on Daily Kos. Some of the commenters have questioned why more psychologists haven't resigned. In fact, others have. We don't know how many; they just didn't send out announcements. Other commenters questioned the value of withholding dues as a protest. Personally, I think it's a valid response. They are making their protest known, but they are still part of APA and still have the ability to influence it.<br /><br />I hope that Ken's action will inspire others to withhold dues or to resign. Maybe APA will finally get the message and follow the lead of the AMA which has forbidden it's doctors to participate in interrogations.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-18719402050371144682008-02-09T17:10:00.001-05:002008-02-09T17:12:41.529-05:00Questions about Psychotherapy<div xmlns="http://www.w3.org/1999/xhtml">A <a href="http://jop.sagepub.com/cgi/reprint/22/1/3">recent editorial in the Journal of Psychopharmacology</a> by David J. Nutt and Michael Sharpe raises questions about the efficacy and safety of psychotherapy. It's currently available free of charge, but will be placed behind a pay wall 90 days after initial publication.<br /><br />Clearly, an editorial in a psychopharmacology journal is not going to be sympathetic to psychotherapy and this article does not disappoint. I'm going to discuss four of their points.<br /><br /><b>1. Is Psychotherapy Effective?</b><br /><br />Nutt and Sharpe begin by questioning the effectiveness of psychotherapy. They say, "few psychotherapy trials have complied with the standard regulations that are required of all drug treatments." This is both true and not true. Psychotherapy cannot be evaluated in the same way as drug therapy. It's a different treatment and there are different issues in evaluating it. Psychotherapy is a procedure, and as such, it is more akin to surgery, than it is to pharmacotherapy.<br /><br />Nevertheless, psychotherapy has a rich and diverse research base, going back over 50 years. In particular, cognitive behavior therapy (CBT), always grudgingly acknowledged as an empirically based therapy, is based on a large body of literature involving operant conditioning, classical conditioning, rational emotive behavior therapy, self control and self-management. There are large numbers of outcome studies available. While few are large-scale studies, the accumulation of the data through meta analysis still shows fairly robust and positive results.<br /><br />This research base has given us a good understanding of how CBT works. See the <a href="http://www.amazon.com/Bergin-Garfields-Handbook-Psychotherapy-Behavior/dp/0471377554/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1202525597&sr=8-1"><i>Handbook of Psychotherapy and Behavior Change</i></a> for some excellent reviews of the research. In fact, we have a better idea of how CBT works than how drug therapy works. We have a pretty good idea about how changing thoughts change mood, and how exposure changes anxiety. In contrast, we still haven't been able to define that "biochemical imbalance" that allegedly causes depression. If you think we have, ask a psychopharmacologist what the balance is, or ask why one SSRI works and another doesn't.<br /><br />Nutt and Sharpe also raise the issue of whether or not psychotherapy has been evaluated with double blind studies and placebo controls. I'm going to leave that issue for another day. I think they're wrong, but that's going to require more research than I have time for tonight.<br /><br /><b>Is Psychotherapy Safe?</b><br /><br />Nutt and Sharpe question the safety of psychotherapy. They begin by arguing that psychotherapy can, in some cases, worsen outcomes. In particular, they identify suicidal patients and manic patients as being at risk. However, <i>any</i> treatment can cause problems in these patients. We have all heard of the worsening of suicidal ideation in adolescents on SSRI's (Nutt and Sharpe minimize this, but the black box is still there). Less well known is that SSRI's can also cause a manic episode in people with bipolar disorder. One advantage of psychotherapy is that the individual is seen more frequently and can be managed if they deteriorate. In contrast, people receiving drug therapy may not have any contact with their physician for a month or longer.<br /><br />Another issue they raise involves an old technique called flooding. In exposure therapy, we deliberately expose people to feared stimuli, but in gradual steps. Flooding therapy involves fully immersing the subject in the feared situation all at once. Here is what Nutt and Sharp say about it:<br /><blockquote>When taken to its logical extreme [exposure therapy] becomes flooding therapy, which was once popular. The anxiety induced by flooding can be extraordinarily distressing and there are well recognised examples of patients escaping in fear from their treatment andrefusing further sessions. David Nutt runs a specialist anxiety disorders clinic in which we have seen a number of patients who could be considered as suffering from a PTSD-like syndrome as a consequence of failed flooding treatment for phobias and OCD. (p.4)<br /></blockquote>I can believe that a "PTSD-like syndrome" could occur as a result of premature termination of flooding. In fact, I never thought I would have the intestinal fortitude to keep a client in a feared situation long enough to make the procedure work. So, I never did any flooding, and, in fact, I've never met a therapist who ever did any flooding. They must have been out there, but I never traveled in their circles. So, I can't believe it was "popular."<br /><br />Besides, isn't this an example of the pot calling the kettle black? Shall I now list the now-rejected medical procedures that have hurt people? Ever read the book, <a href="http://www.amazon.com/Lobotomist-Maverick-Medical-Genius-Illness/dp/0470098309/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1202526573&sr=1-1"><i>The Lobotomist</i></a>? We who help those in pain often feel the need to "do something," to help people and we often wind up hurting instead of helping.<br /><br />Nutt and Sharpe then raise the "false memory syndrome" canard. According to advocates of this syndrome, questioning people about past trauma can cause people to develop false memories of events. In reality, experimental evidence for false memory syndrome is weak. Ken Pope has a good discussion of the problems with false memory syndrome <a href="http://www.kspope.com/memory/memory.php">here</a>.<br /><br />Nutt and Sharpe unwittingly provide an excellent example of how badly false memory syndrome is abused. They say:<br /><blockquote>One young adult patient of David Nutt’s with severe OCD (obsessive-compulsive disorder--F.O.) was quizzed by a therapist about the possibility that she had suffered sexual abuse by family members. This led to her developing chronic ruminations about the possibility that she might have been abused by her father, <i>even though she knew this had not happened</i>. As a consequence for years she was unable to tolerate being in the same room as him, which markedly exacerbated her problems and caused great distress to the family. (emphasis added; p.4)</blockquote>The section I italicized is the key. The patient knew full well that her father never abused her, so this could never have been an issue of false memories. Instead, this woman was struggling with an obsession. No big surprise. She had OCD. The woman obsessed over the possibility of her father abusing her.<br /><br />There have clearly been some therapeutic abuses in the name of uncovering a history of trauma. This ain't one of them. A therapist who doesn't consider the possibility of trauma in a severely ill patient isn't doing his or her job.<br /><br /><b>Are Effective Treatments Withheld?</b><br /><br />Moving on, Nutt and Sharpe argue, "Another proven potential risk of psychotherapeutic treatment is that effective drug treatments are withheld either because the therapist does not believe in their efficacy or because the patients are not introduced to the possibility of their being useful in their condition (Klerman, 1991)." True, but this is not a risk of psychotherapy. It's a risk of being a true believer. How many times have patients not been referred to psychotherapists because the physician doesn't believe in it?<br /><br /><b>Therapist Misconduct</b><br /><br />Finally, Nutt and Sharpe bring up the risk of sexual misconduct. They site a 1986 study showing 7% of male psychiatrists and 3% of female psychiatrists have engaged in sexual contact with their patients. I am assuming these are psychiatrists who are providing psychotherapy. But this data is over 20 years old and since then, laws have been enacted, and licensing boards have been aggressive in enforcing a ban on so-called dual relationships. In Pennsylvania, it's a felony to sleep with a client. Yes, I know it still happens. But overall, this isn't a problem with psychotherapy. It's a problem with power relationships. Professors sleep with their students. Business people sleep with their secretaries. This kind of sexual misconduct occurs everywhere there's a power imbalance between men and women. Thankfully, my profession has been aggressive about stopping this.<br /><br /><b>Conclusions</b><br /><br />After all this, I'm not willing to just write off Nutt and Sharpe as a pair of physicians with an axe to grind. I agree that psychotherapy is not as closely regulated as pharmacotherapy and I'd like to see greater quality control over psychotherapeutic services. But like other hands-on treatments, such as surgery, physical therapy, occupational therapy, and others, much of the effectiveness of treatment relies on the skills of the provider. This comes from training. One of the great disappointments to me has been the unwillingness of the leadership in psychology to improve training and accountability.<br /><br />Psychology defines itself as the science of behavior, and we often research psychotherapy. But, when it comes time to say, "Yes, I believe the data. We should do A and not B to treat depression," we back down and run away. Too many people view any effort to develop treatment guidelines as an attack on psychotherapy. It's a shame that papers like this are so poorly drawn that they reinforce this belief.<br /><br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com3tag:blogger.com,1999:blog-24781577.post-65838243522927167132008-01-13T12:18:00.001-05:002008-01-13T12:23:26.345-05:00Treating Depression in the Elderly: Medication, Psychotherapy, or Both?<div xmlns="http://www.w3.org/1999/xhtml">An <a href="http://www.psychiatrictimes.com/showArticle.jhtml?articleId=202602110">article in Psychiatric Times</a> discusses the status of treatment for elderly people who are depressed. Written by Mark Miller, it opens with this observation:<br /><br /><span class="articleBody"> <p></p><blockquote> There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.</blockquote></span><br /><a href="http://www.nimh.nih.gov/health/trials/practical/stard/index.shtml">STAR*D</a> (Sequenced Treatment Alternatives to Relieve Depression) was a massive set of studies, conducted under grants from NIMH, in which they attempted to replicate real world treatment of depression. In the real world, depression often--if not usually--coexists with another disorder, such as anxiety. In most studies, the subjects have uncomplicated depression. That makes it easier to interpret the results, but raises questions about applicability of the results to the real world. In most studies, the subjects were given one medication and evaluated for depression after a set period. In the real world, if the patient isn't responding to treatment, the treatment is changed.<br /><br />In STAR*D, the subjects were more heterogeneous and they were given sequenced treatment. Hence, the treatment was more applicable to the real world. The results, which Miller summarizes in one sentence above, are, I think, consistent with what all of us practitioners know. Treatment effects are significant, but there is no<br />predictability in response to treatment. Not everyone gets better easily.<br /><br />In the real world, psychotherapy is often added to medication management. In STAR*D, there were a number of studies of psychotherapy. Here is <a href="http://www.nimh.nih.gov/science-news/2007/in-second-try-to-treat-depression-cognitive-therapy-generally-as-effective-as-medication.shtml">one report</a> of adding cognitive therapy to the mix. NIMH summarizes the results as follows:<br /><br /><blockquote>Switching to or adding cognitive therapy (CT) after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve.</blockquote>I believe also, that either this study or another study had evidence that showed that the subjects, when given a choice of medication change or psychotherapy, often opt for medication change. There are two reasons for this. First, taking medication is easier and less anxiety-provoking than going once a week for psychotherapy. Second, all of the television ads for drugs give the impression that they are the way to go. Yet several types of psychotherapy, most notably cognitive therapy and interpersonal therapy, have very good track records.<br /><br />All of this is equally true with the elderly. Miller argues that psychotherapy is particularly important for the elderly:<br /><p></p><blockquote><br />Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:<br /><ul><li>Be able to restore a state of homeostasis or balance by lessening the severity of the depression (and any comorbid anxiety).</li><li>Maximize the coping ability of the patient.<br /></li><li>Foster a more positive outlook of remaining strengths and opportunities.<br /></li><li>Solicit external supports to foster not only a sense of being "backed up" but also a sense of having valued and purposeful integration into a social network.</li></ul></blockquote><br />Working with the elderly is different from other types of psychotherapy, because there is more emphasis on coping with problems in the real world. Therapists often worry that elderly clients will be too rigid to benefit from therapy. However, that rigidity is often outweighed by a strength not possessed by younger clients. Elderly persons have been through a lifetime of problems and usually have a well-developed repertoire of coping skills. The trick in therapy is to identify them and encourage the client to use them again.<br /><br />So, the answer to the question, medication, psychotherapy, or both? is "It depends." It's frustrating that mental health professionals have not been able to identify who will profit from what kind of treatment. It's still very much a trial-and-error process, despite a significant amount of science in both medicine and psychology. By combining psychotherapy and medication, we can often bring out the best of both treatments. Miller illustrates this by paraphrasing Kay Redfield Jamison<span class="articleBody"> (<a href="http://www.amazon.com/Unquiet-Mind-Memoir-Moods-Madness/dp/0679763309/ref=si3_rdr_bb_product">An Unquiet Mind</a>): "Lithium diminishes my depression, but psychotherapy heals."</span><br /><br /></div>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com13tag:blogger.com,1999:blog-24781577.post-21374852794986807902008-01-03T09:26:00.001-05:002008-01-27T18:36:19.947-05:00I'm Having FlashbacksI just discovered <a href="http://www.phdcomics.com/">Ph.D. Comics</a>. The <a href="http://www.phdcomics.com/comics/archive.php?comicid=959">most recent comic</a> is giving me flashbacks to grad school.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-58116533263243818712008-01-01T15:28:00.000-05:002008-01-03T09:24:57.456-05:00Happy New Year and a Return to BloggingOnce again, I'm back; this time after a 5 month hiatus. I've been away for several reasons. I just finished some remodeling work in my house, which took a lot longer than I thought. My house is almost 100 years old, so there's always something to be done, and it's never as simple as it starts out to be. Then, too, I had to enjoy the summer. But, it's the new year, and it's time get back on the horse. I do enjoy blogging. It just takes so much energy.<br /><br />The New York Times has an interesting article entitled, "The New Year's Cocktail: Regret with a Dash of Bitters." It's about New Years Day descent into regret about choices not made:<span style="font-size:100%;"><br /></span><blockquote><span style="font-size:100%;">An opportunity, that is, to forestall the traditional morning-after descent into self-examination, that lonely echo chamber of what should and could be.<br /><br />Ghosts roam around down there, after all, and they are the worst kind — alternate versions of oneself. The one who did not quit graduate school, for instance. The one who made the marriage work. Or stuck with singing, playwriting or painting and made a career of it.<br /><br />Lost possible selves, some psychologists call them. Others are more blunt: the person you could have been.</span></blockquote><p><span style="font-size:100%;"></span></p> This is a lyrical, but a-grammatical passage, which is somewhat surprising for the Times. But I like the metaphor of the ghosts. Looking at those ghosts may make us say, "If only I had done this differently, my life would have been WONDERFUL!!"<br /><br />Ecch. When I start thinking that way, I always get in contact with my inner H. L. Mencken. Yeah, I could have stuck with singing. And today I could be living in a dump asking myself why I didn't go to grad school.<br /><br />Life is about choices. Every time we make a choice, we cut off one universe of possibilities and embrace another universe of possibilities. I think of these possibilities as paths, and we walk along the path set by our previous choices. The great joy of life is how those paths take us to unpredictable places. Sometimes the places are enjoyable, sometimes they're not. When we find our path taking us to a place we don't want to be, all we can do is make new choices.<br /><br />Because of this idea, I've been trying to stop referring to good or bad decisions. A decision puts us on a path which itself is infinite, so it never “turns out.” It simply opens up some choices and closes off others. I can make a decision very carefully, by considering all the options, seeking advice, and carefully selecting a plan of action. It can still put me on a path that takes me to a bad place. Once I see that I'm coming to a bad place all I can do it make new choices. But I will never know what would have happened if I had made a different choice and not taken that path.<br /><br />Ultimately, our lives are the totality of the choices made and the paths taken. When we take a path, we make it real. The paths not taken exist only in the realm of imagination. So, if you ever find yourself wondering, "Why was I so stupid as to make that choice?" just remember the old line. "It seemed like a good idea at the time."Then go and make more decisions and make some new paths real.<p><span style="font-size:100%;"></span><br /></p>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-64839641553740121392007-07-25T13:32:00.000-04:002007-07-25T14:30:10.079-04:00In Memory of Albert EllisThe New York <em>Times</em> <a href="http://www.nytimes.com/2007/07/25/nyregion/25ellis.html">reported today </a>that Albert Ellis has died. Ellis is the founder of what he originally called "rational therapy," then called "rational-emotive therapy," and most recently called "rational-emotive behavior therapy," or REBT. He was a tireless lecturer and writer. He was also a shameless self-promoter and total character. He was known as the Lenny Bruce of psychotherapy.<br /><br />Ellis started writing and lecturing in the 1950's and continued his work until his death. This year, he was giving seminars from his bed in a nursing home. He founded an institute, currently called the<a href="http://www.albertellis.org/aei/index.html"> Albert Ellis Institute </a>in New York. In many ways, he has been at least as influential as Freud.<br /><br />Ellis's great contribution was the recognition that our feelings do not come from what happens to us. Instead, our feelings stem from what we tell ourselves about what happens to us. For example. Imagine you get a B on an exam. First, imagine telling yourself, "Oh, God, I'm such a fool! I only got a B. I'll never get into a good school. I'll never accomplish anything. My parents will be disappointed in me!" You can easily see how upset you'll get.<br /><br />In contrast, imagine yourself saying in response to the B, "Oh, boy. Only a B. I was hoping for an A. What did I do wrong? What can I learn from this?" Here, you might feel disappointed, but not crashingly depressed.<br /><br />Finally, imagine yourself saying, "Boy am I proud of myself! This was really hard. I didn't think I could do this well!" Then, you feel good.<br /><br />Ellis's point is that the B didn't make you feel anything. Your thoughts about the B--what you say to yourself--affect your mood. So, you can't tell your spouse, "You made me angry!" That's an unrealistic--Ellis would say irrational--belief. Your spouse may have done something you don't like, and you have every right to object to it, but you made yourself angry.<br /><br />I saw Ellis speak several times over the years. He always said the same things. Sometimes he would change names, or refine previous ideas, but he never deviated from this basic message. His lectures were always the same. First, he would talk about his approach, then he would demonstrate therapy with volunteers from the audience. He always peppered his speeches with obscenities.<br /><br />The last time I saw him, he was in his late 70's, still going strong. I often tell my clients about this, because he managed to explain his approach in two words.<br /><br />After explaining how thoughts affect mood, Ellis began talking about how to change what you tell yourself. He said,<br /><br />"There are two words you can tell yourself that will get you through any situation, no matter how bad it is."<br /><br />You can imagine, this whole room, overflowing with clinicians. We all thought to ourselves, "Oh, boy, we're going to get some wisdom from the Master!" We all leaned forward, and Ellis said,<br /><br />"TOUGH SHIT!"<br /><br />Broke up the joint.<br /><br />Ellis's whole life was a tribute to those two words. He started his career at the time that psychoanalysis and humanism were the dominant clinical trends. Everyone thought he was crazy, and the criticism was whithering. Ellis didn't care, basically saying, "They don't like what I'm saying, tough shit. I know I'm right." He outlived all his critics and has been revered as the last of the Grand Old Men of psychology. Today, with variations, an awful lot of us are doing therapy his way.<br /><br />For about the last 25 years, Ellis was somewhat eclipsed by Aaron Beck's "cognitive therapy." Yet, Beck openly admits that he based his approach on Ellis's ideas. Beck was successful because he was more dignified, if less interesting, than Ellis. He made for a better face for psychotherapy. But, I doubt that cognitive therapy would be where it is today, were it not for Ellis and his willingness to be such a character.<br /><br />If we live well, we touch the world in some way; we usually don't know how. But Ellis died knowing that the things he believed in were now part of clinical psychology's mainstream. That's an incredible legacy.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com5tag:blogger.com,1999:blog-24781577.post-81961727567538715052007-07-04T12:03:00.000-04:002007-07-08T17:48:14.809-04:00Psychoanalysis Evolves: Freudian DissentersThis is the second post in my series on psychotherapy. I know, I've been gone a long time. My stats show it, too.<br /><br />When Freud published <span style="font-style: italic;">The Interpretation of Dreams,</span> he became a very controversial figure because of his emphasis on sexuality. He went through a brief period where he worked in isolation, but, by 1902. he began to gather a group of physicians around him. By 1908, the group had grown into the Vienna Psychoanalyic Society. Two early members of the Society eventually split from Freud: Alfred Adler and Carl Jung.<br /><br /><span style="font-weight: bold;">Carl Jung</span><span style="font-weight: bold;"></span><br /><br />Jung and Freud were very close and Freud saw Jung as his successor. This relationship soon fell apart, however, as Jung began to diverge from Freud's views. There are many accounts (some of them scandalous) of their final split, which, fortunately, are irrelevant to my goals for this series.<br /><br />Jung's theory, like Freud's, is extremely complicated. A good summary of his ideas can be found <a href="http://webspace.ship.edu/cgboer/jung.html">here</a>. Jung became fascinated with symbols, and began to see a cross-cultural pattern in them. He argued that there are "archetypes" among those symbols which relate to common human heritage, not just the individual's experience. Thus, each of us has a set of common symbols within us, which Jung referred to as the collective unconscious. The collective unconscious coexisted with the personal unconscious.<br /><br />For Jung, neurosis, or mental illness in general, resulted from attempts to cut off elements of both the collective and personal unconscious from the conscious experience of the individual. Humans have an innate need for "self-realization," which involves understanding and integrating all of the material from the collective and personal unconscious. Proceeding with self-realization results in "individuation," the process of becoming a unique and unified individual.<br /><br />Psychotherapy for Jung was less structured than psychoanalysis. He did not use free-association the same way Freud did. Rather, he relied on the spontaneous discussion of the individual. Like Freud, he analyzed dreams and verbalized symbols. He was less concerned with uncovering trauma and more concerned with tracing the relationships among symbols. He also understood symbols more in terms of common human experience and less in terms of sexuality. Through therapy, individuals become more centered and more comfortable with their own contradictions.<br /><br /><span style="font-weight: bold;">Alfred Adler</span><span style="font-weight: bold;"></span><br /><br />An early member of Freud's inner circle, Adler was the first to break with Freud. A good summary of his ideas can be found <a href="http://ourworld.compuserve.com/homepages/HStein/principl.htm">here </a>and <a href="http://ourworld.compuserve.com/homepages/HStein/aaisf.htm">here</a>. Adler anticipated much of modern psychology and psychotherapy. He dispensed with Freud's instinctive psychology and focused instead on the goal-oriented nature of human behavior.<br /><br />Adler saw individuals first and foremost as social creatures, forming goals and striving to meet them. Where Freud talked about the superego managing our behavior, Adler conceived of the role of values. This is an oversimplification, but essentially Adler saw mental health in terms of (a) having healthy values, which affect what goals we try to achieve, and (b) having both the confidence and the ability to achieve those goals.<br /><br />This means that analysis was very straightforward. The analyst encourages the patient to overcome feelings of insecurity, develop more rewarding and meaningful relationships, and to pursue healthy life goals. Insight and exploration of the patient's past occur early in the relationship, but later on, there is more emphasis on behavior change.<br /><br />There were two critical differences between Adler and Freud. First, Adler emphasized the role of empathy in the therapeutic relationship. For Freud, the analyst was supposed to be a blank slate. This encouraged the development of transference. The interpretation of transference was critical for psychoanalysis. In contrast, Adler argued that the analyst should develop an empathic relationship with the patient, stimulating hope and commitment to the process. Second, while Freud encouraged the analyst to be quiet and allow the patient to free associate, Adler encouraged the analyst to engage in <a href="http://gandalwaven.typepad.com/intheroom/2006/11/ask_any_cogniti.html">Socratic dialogs</a> to help the patient achieve insights.<br /><br /><span style="font-weight: bold;"></span><span style="font-weight: bold;">Conclusions</span><br /><br />Jung and Adler are really polar opposites. Adler was much the realist, while Jung was much more mystical. Together, Jung and Adler moved analysis off the couch and put it across the desk. This changed the dynamic between the patient and the analyst, making it possible to create the modern collaborative relationship. <br /><br /> Both Jung and Adler continue to be influential, and there continue to be institutes (e.g., <a href="http://ourworld.compuserve.com/homepages/HStein/homepage.htm">Alfred Adler Institutes</a> and <a href="http://www.junginla.org/">C. G. Jung Institutes</a>) devoted to their ideas. While Jung is better known, it has been Adler whose influence has been most pervasive in modern psychotherapy. He anticipated the more active approaches we use today and was the first analyst to downplay the emphasis on probing the unconscious. We will come back to him briefly when we discuss cognitive-behavior therapy.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com2tag:blogger.com,1999:blog-24781577.post-66493924481174883172007-05-20T20:16:00.000-04:002007-06-03T21:18:03.681-04:00A Brief History of Psychotherapy: FreudWhen I originally conceived of this series, I thought it would be a brief set posts. I can already see that I was overly optimistic. There's an awful lot of material here. So, at this point, I'm not sure of how many posts it will take to complete this project.<br /><br /><span style="font-weight: bold;">Freud, Charcot, and Hysteria</span><br /><br />Most people believe that psychotherapy began with Freud. Actually, Freud himself (Himself?) began as a student of the French neurologist, <a href="http://www.pbs.org/wgbh/aso/databank/entries/bhchar.html">Charcot</a>, who was investigating the phenomenon of hysteria. In this disorder, patients, mostly women, would manifest symptoms of physical disorders (such as paralysis or blindness) with no known physical causes. (Space prevents me from dealing with the feminist issues here.)<br /><br />Charcot discovered that hypnotizing his patients and encouraging them to talk about their symptoms would result in their remission. Freud was very impressed with this and began trying Charcot's technique on his own patients. He began a brief collaboration with Josef Breuer, and in 1895, they published <span style="font-style: italic;">Studies on Hysteria</span>, probably the first book ever published on psychotherapy.<br /><br />Freud apparently was either not a very good hypnotist or not a very enthusiastic hypnotist and soon abandoned hypnotic induction. He kept everything else in place; the patient would lie down on a couch in a dimly lit room and begin talking about her symptoms. There is an apocryphal story that Freud initially used to question his patients to clarify what they were talking about. On at at least one occasion, the patient said, "Don't interrupt me when I'm talking," and Freud learned to be quiet and listen during free association. This is the form of classical psychoanalytic practice: a period of free association followed by interpretation of the material by the analyst.<br /><br />Freud's initial work led to the publication of <span style="font-style: italic;">The Interpretation of Dreams</span> in 1899. (The publisher later dated the book for 1900, probably to identify it with modernity.) This book, along with his later book, <span style="font-style: italic;">An Outline of Psychoanalysis</span>, (published in 1940) contain the best material on Freudian psychoanalysis.<br /><br /><span style="font-weight: bold;">Personality and Behavior</span><br /><br />Psychoanalytic theory is highly complex and was constantly evolving under Freud; I cannot do it justice here. Nevertheless, to understand why Freud did what he did, you have to understand some part of his theory of personality.<br /><br />For Freud, personality reflected the interaction of forces inside the psyche. These intrapsychic forces interacted and opposed each other. The healthy psyche was one where the forces balanced each other out and energy was expended in rational behavior. These forces interacted within and between three major structures in the psyche: The id, or unconscious mind; the ego, the conscious, rational part of our minds; and the superego, essentially our conscience, although Freud thought of it as the internalized parent.<br /><br />The id is driven by instincts to either create or destroy. The basic physiological instinct associated with creativity is, of course, sexual reproduction. Aggression is the basic physiological instinct associated with destruction. Because the id is the only source of energy, it is always the central player in our behavior.<br /><br />The ego and the superego obtain energy from the id through symbolization. The id is unable to tell the difference between reality and the symbol; that is the job of the ego. Hence, the ego would direct the individual to engage in behaviors symbolically related to these instincts. Anything, from playing a musical instrument, to telling a joke to a friend, to doodling on a piece of paper would accomplish this.<br /><br />It is the job of the superego to control the impulsive, reckless, and immoral behavior of the id. In the healthy individual, the ego is the negotiator between them; in the unhealthy individual, the ego is the battlefield between them. When the superego is in control, the individual is rigid, compulsive, and intolerant. In this three-way interplay, the symptoms of mental illness emerge.<br /><br /><span style="font-weight: bold;"></span><span style="font-weight: bold;">Treatment</span><br /><br />It is important to understand that treatment actually evolved before the theory did. Freud thought that his treatment worked. After being analyzed, symptoms of hysteria seemed to go away. Hence, psychoanalysis is really an explanation for why treatment worked.<br /><br />Treatment, for Freud, was a matter of balancing intrapsychic forces. For doing this, he had three primary tools: Free association, dream interpretation, and analysis of the transference relationship. Free association gives us the classical image of the patient on The Couch.<br /><br /><span style="font-style: italic;">Free association. </span>Free association, as described above, provided the primary data for analysis. It was assumed that if the patient was talking about it, it was important. The juxtaposition of different ideas gave a clue about unconscious connections between them. Symbolization was manifested both in free association and in dreams, and proper interpretation was crucial to treatment.<br /><br /><span style="font-style: italic;">Dream interpretation.</span> Freud regarded dreams as the "royal road to the unconscious." He found that patients often discussed dreams during free association and became convinced that dreams represented unconscious processes. By analyzing the dream symbols, the analyst developed insight into the patient's problems.<br /><br /><span style="font-style: italic;">Transference.</span> Transference refers to the manner in which the patient responds to the analyst. Does the patient idealize the analyst, or does the patient "forget" about appointments? Freud concluded that the patient "transfers" his or her feelings about the parents onto the analyst. This, of course gives clues about early family relationships that are so critical to the development of the individual. To this end, Freud argued that the analyst should be as bland as possible.<br /><br />Countertransference is the other side of the coin and refers to the feelings of the analyst toward the patient. While this gives insight into the analyst's state of mind, it also helps the analyst understand how the patient affects other people. If, for example, the analyst feels angry at a patient, it may suggest that the patient is behaving in a hostile manner toward the analyst. That provides much data for the analysis.<br /><br /><span style="font-style: italic;">Analysis.</span> Using these tools, Freud investigated the unconscious life of the individual. By uncovering unconscious conflicts and developing insight, Freud believed that he could strengthen the ego and redirect the emotional energies in a healthier manner. This always involved understanding the internal symbolic world of the individual, and the symptom was always linked symbolically to the underlying trauma. If, for example, a patient complained of hysterical blindness, Freud assumed it was because they had seen something awful. Hence, it was necessary to uncover the traumatic event the patient had seen, to relieve the symptoms. Generally, for Freud, the traumatic event involved childhood trauma.<br /><br />By developing insight and uncovering repressed trauma, energies attached to inappropriate objects can be released and appropriately redirected by the ego. Freud used the term, catharsis, to refer to re-experiencing the emotions related to the trauma. Release of the tensions associated was called "abreaction."<br /><br /><span style="font-style: italic;"></span><span style="font-weight: bold;">Conclusions</span><br /><br />For those who know something of Freud, you will note that I have said nothing about his theories of development. I have done that deliberately. I am more interested in focusing on psychotherapy than on personality development or psychopathology. I will only say in passing that Freud was very right to observe that a child is not a small adult. His scheme of development was very wrong.<br /><br />Freud remains a controversial figure today. We continue to argue about his strengths and weaknesses. (A good discussion of the strengths and weaknesses of classical psychoanalytical theory is contained <a href="http://www.personalityresearch.org/papers/plaut.html">here</a>.) In relation to psychotherapy, I think it is safe to say, he made several significant errors.<br /><br />First, Peter Kramer, in his book, <span style="font-style: italic;">Freud: Inventor of the Modern Mind</span>, argues that a great error of Freud was his belief that the symptom is a symbol. For Freud, the symptoms were always related to the underlying psychodynamics of the individual. We know now that is not true. Depressed people show similar symptoms regardless of their underlying dynamics. So, for example, if a person experiences panics when out of the house, Freud would have assumed that the person experienced some trauma outside of the house. The goal of treatment would involve uncovering that trauma and unlocking the emotions associated with it.<span style=";font-family:Verdana;font-size:10;" ><i><a id="lnx0" name="evtst|a|0060598956" href="http://www.amazon.com/gp/product/0060598956?ie=UTF8&tag=californialit-20&link_code=as3&camp=211189&amp;amp;amp;amp;amp;creative=373489&creativeASIN=0060598956"></a></i></span><br /><br />Freud's second error was that he didn't understand the role of the situation, and saw behavior as a function of the internal dynamics of the individual. Freud did not recognize that individuals acquire maladaptive behavior through experience. A child growing up in an abusive environment learns to be a perfectionist because it helps reduce the abuse. It's not because of a rigid superego.<br /><br />Third, Freud did not understand the influence of culture. We know that as culture changes, symptoms of mental illness change. Freud saw a lot of hysterical blindness and paralysis. We see almost none of it today. In fact, I have been in practice for over 30 years, and I have yet to see an individual with hysterical blindness. Similarly, Freud saw the role of women as being biologically, not culturally determined. He would be amazed to see women working along side of men, much less fighting in the military.<br /><br />Finally, Freud hoped that someday psychoanalysis would be subjected to scientific evaluation. But, psychoanalysis is not a scientific theory, especially as science is practiced over 100 years after <span style="font-style: italic;">The Interpretation of Dreams</span> was written. Psychoanalysis is too complex and it makes too many conflicting predictions. There is also a paucity of systematically collected data. But, that does not mean Freud has nothing to offer us.<br /><br />As I said <a href="http://justnoticeabledifferences.blogspot.com/2006/06/who-was-freud.html">previously</a>, Freud was a visionary. His ideas are so ingrained in us today, that we cannot conceive of a world without the idea of unconscious motivation. For me, Freud, beginning with almost nothing, made three significant breakthroughs.<br /><br />First, through his concept of transference, Freud uncovered the therapeutic relationship. Today, we understand that the relationship between the therapist and the patient is the primary vehicle for change. The therapist and the patient must have a relationship of mutual trust and respect if the patient will explore material that is potentially shameful and anxiety-provoking. The modern view of the therapeutic relationship is broader than Freud's, but there is no doubt that he originated the idea.<br /><br />Second, Freud recognized that something is going on in people's minds that they are unable to talk about. Most modern therapists do not talk about investigating the unconscious, but they do recognize that there are things going on the person's head that are relevant but difficult to identify and change.<br /><br />Finally, and most importantly, Freud recognized that speech is a very powerful tool. The term, "talking cure" came from one of Freud's patients, and it is a very apt description. Without Freud, there would be no psychotherapy today.<br /><br /><span style="font-weight: bold;">Coming Soon</span><br /><br />Today, it is safe to say that there are few orthodox Freudians left. In fact, early in the twentieth century, contemporaries of Freud began to elaborate and diverge from his thinking. By the 1950's psychoanalysis had evolved significantly from it's roots. My next post will trace that change.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.comtag:blogger.com,1999:blog-24781577.post-52000791321589351622007-05-13T09:09:00.000-04:002007-05-16T22:45:26.923-04:00A Series of Posts on PsychotherapyI'm going to begin a series of posts on psychotherapy, which are long overdue. When I started blogging, I anticipated writing a lot about the science of psychotherapy, but I haven't followed through with it; I've been having too much fun with other things.<br /><br />Two events have come together to get me started. First, at Aardvarchaeology (on <a href="http://scienceblogs.com/">ScienceBlogs</a>), there was a recent post entitled, <a href="http://scienceblogs.com/aardvarchaeology/2007/05/is_psychotherapy_superstition.php">Is Psychotherapy Superstition?</a> in which the author, Dr Martin Rundkvist, seemed to be confused about what psychotherapy is. Furthermore, some of the commenters on the blog seemed totally unaware of the evidence for the effectiveness of psychotherapy.<br /><br />Second, I put off a post on a story in last week's New York Times Magazine by Bruce Stutz, who decided to <a href="http://www.nytimes.com/2007/05/06/magazine/06antidepressant-t.html?ref=magazine">withdraw himself from Effexor</a>. Stutz initially went on Effexor after becoming depressed during difficult period in his life. He stayed on the drug for several years, and was advised to stay on it the rest of his life. He decided that he didn't want to and weaned himself off, but experienced severe withdrawal symptoms in the process:<br /><blockquote>Over the next several days they (low doses of Effexor<span style="font-style: italic;">--F.O.</span>) came in handy, especially at night, when I would wake up feeling dizzy, almost seasick, disoriented and in a heavy sweat, the pillow soaked. One night, awake and not eager to go back to lying restlessly in bed, I went online, typed in “Effexor withdrawal” and found bulletin boards full of pained, plaintive and sometimes angry posters who had quit taking their medication and were suffering a broad but surprisingly consistent range of symptoms: dry mouth, muscle twitching, sleeplessness, fatigue, dizziness, stomach cramps, nightmares, blurred vision, tinnitus, anxiety and, weirdest of all, what were referred to as “brain zaps” or “brain shivers.” While there were those who went off with few or no symptoms at all, others reported taking months to feel physically readjusted.</blockquote>Stutz eventually did wean himself off Effexor, and has not had a recurrence of depression. He puts his finger on the issue:<br /><blockquote>If my psychiatrist had told me, “I think you can do this without taking any drugs,” would I have done just as well? If I had been told how difficult it would be to get off the drug, would I have so readily started on it? Even the doctors and researchers who most believe in the effectiveness of antidepressants acknowledge that the “chemical balance” paradigm, the magic-bullet paradigm, makes things seem simpler than they actually are. For some, these drugs may be a lifesaving treatment. But for most of us troubled or even temporarily anguished by life’s difficulties, does our long-term reliance on these drugs become more of a convenience than a cure, allowing us to simply keep going in the midst of very difficult circumstances? And once we start taking them, how do we find the wherewithal to stop? </blockquote>To make a decision between drugs alone, psychotherapy alone, and both combined, patients need to understand what psychotherapy is. It is not a panacea, as it was once advertised. It's not for all people, or even for all depressed people. Prospective clients of a psychotherapist need to understand what they are getting into. So, there are three topics I want to address in this series.<br /><br />First, I'll talk about what psychotherapy is and is not. To do that, I have talk about the history of psychotherapy and how we got to where we are today. Next, I'll give a brief description of research in psychotherapy, and finally, I'll talk about how therapy and medication work together in treatment.<br /><br />I hope this will give readers a better idea of what to expect if they seek psychotherapy and a better ability to understand some of the stories about the effectiveness of therapy that emerge in the press. All treatments for physical and mental illnesses involve decision making. The more you understand the options, the better.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com4tag:blogger.com,1999:blog-24781577.post-39368009167274271072007-05-06T19:09:00.000-04:002007-05-07T21:43:42.751-04:00The Tyranny of the ShouldsI was reading the New York Times, as usual, and stumbled across two articles I knew I should blog about. The first was <a href="http://www.nytimes.com/2007/05/06/magazine/06antidepressant-t.html?ref=magazine">Bruce Stutz's account of his withdrawal from Effexor</a>, an antidepressant drug. Effexor is a very popular drug, especially among primary care physicians, and it can be very hard to get off. His story is, at points, gruesome. But it speaks for itself, and right now I have nothing to add. I will soon, though, so stay tuned.<br /><br />The second story is much funnier and more enjoyable. It's an article in the Book Review, entitled, <a href="http://www.nytimes.com/2007/05/06/books/review/Queenan.t.html?ref=books">Why Not the Worst?</a> In it, the author, Joe Queenan, writes about his love of bad books and compares himself to others who are obsessed with quality:<br /><blockquote>Most of us are familiar with people who make a fetish out of quality: They read only good books, they see only good movies, they listen only to good music, they discuss politics only with good people, and they’re not shy about letting you know it. They think this makes them smarter and better than everybody else, but it doesn’t. It makes them mean and overly judgmental and miserly, as if taking 15 minutes to flip through “The Da Vinci Code” is a crime so monstrous, an offense in such flagrant violation of the sacred laws of intellectual time-management, that they will be cast out into the darkness by the Keepers of the Cultural Flame.</blockquote>Queenan goes on:<br /><blockquote>Some people would identify a passion for bad books as a guilty pleasure, but I prefer to think of it as a pleasure I do not feel guilty about, even though I probably should. Bad movies, bad hairdos, bad relationships and bad Supreme Court rulings merely make me chuckle. Bad books make me laugh. And if they ever stop writing books with lines like “Being a leader of the Huns is often a lonely job,” I want to stop breathing on the spot. </blockquote><nyt_author_id></nyt_author_id>So, what does this have to do with psychology? <br /><br />Queenan is attacking what <a href="http://en.wikipedia.org/wiki/Karen_Horney#Theory_of_neurosis">Karen Horney</a> (pronounced HORN-eye), an early neo-analyst, called "the tyranny of the shoulds." In this, Horney anticipated the cognitive-behavioral therapies of <a href="http://www.albertellis.info/">Albert Ellis</a> and <a href="http://mail.med.upenn.edu/%7Eabeck/">Aaron Beck</a>.<br /><br />Horney recognized that we carry around many beliefs about what should or should not be. Some shoulds are about what happen to us. We believe, "I should be successful," or "My spouse should know what I want without my saying so." Unfortunately, that's just not realistic. <br /><br />We have every reason and right to want things. But, "should-ing" is based on the unrealistic belief that the world must grant us what we want, just because we think we're right. When the world doesn't cooperate with that belief, we get angry or depressed.<br /><br />Some shoulds address standards for our own behavior. For example, "I should read only good books." These shoulds make us rigid and rob us of our pleasures. Why not enjoy a bad book occasionally? Queenan's observation, "I prefer to think of it as a pleasure I do not feel guilty about," is a wonderful rejection of those shoulds.<br /><br />When I hear a client bring up their shoulds, it is my job to attack those beliefs and replace them with more flexible beliefs. Some clinicians use <a href="http://gandalwaven.typepad.com/intheroom/2006/11/ask_any_cogniti.html">Socratic questioning</a> to attack peoples shoulds. For myself, I've found that far too often, Socratic questioning turns into the <a href="http://www.answers.com/topic/the-red-green-show">Possum Lodge Word Game</a>. Instead, I like to hit people between the eyes with a one-liner. <br /><br />Needless to say, I'm always on the lookout for a good one-liner. Now, I can't wait to say to a client, "Don't think of it as a guilty pleasure, think of it as a pleasure you don't feel guilty about."Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com1tag:blogger.com,1999:blog-24781577.post-55786772037070662032007-05-04T23:16:00.000-04:002007-05-04T23:19:04.868-04:00Comments are now being moderatedI've been getting spammed by an idiot pushing drug paraphernalia. So, until he or she gets tired and goes away, I'm moderating comments. <br /><br />Sorry for the inconvenience.Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com0tag:blogger.com,1999:blog-24781577.post-88506866058095574782007-04-18T09:38:00.000-04:002007-04-18T22:41:54.823-04:00Virginia Tech School Shootings<span>I have been trying to write a post on the awful events at Virginia Tech. Every time I try to talk about the psychological issues involved, I sound horribly intellectualized, so I've left that post for another day.<br /><br />Instead, I will just express my compassion for the victims and their families. I was in college in Ohio when the Ohio National Guard shot several students at Kent State during a demonstration. So, although it was a long time ago, I can imagine how it feels to students to have their security ripped away from them. I can understand why people living and working at other institutions have been affected. The college campus will never again seem like an idyllic place to them.<br /><br />As a parent, I can barely imagine the families' grief. Losing a child to violence is a parent's worst nightmare. If it were my children who were shot, I would be experiencing overwhelming rage. If my children hadn't been shot, I don't know if I could let them return to school.</span><br />One thought keeps going through my head. I think of Mr. Cho's parents. I cannot imagine the guilt, shame, and grief that they must be feeling. I look for news stories about them, and so far, they are absent, thankfully. When they finally get dragged out in front of the cameras and pontificators, it will be awful.<br /><br />My heart reaches out to all who have been touched by this awful tragedy. I think of Harold Kushner, in his book, <em>When Bad Things Happen to Good People.</em> In it, he grapples with the randomness of tragedy:<br /><br /><blockquote>Some people will find the hand of God behind everything that happens. I visit a woman in the hospital whose car was run into by a drunken driver running a red light. Her vehicle was totally demolished, but miraculously she escaped with only two cracked ribs and a few superficial cuts from flying glass. She looks up at me from her hospital bed and says, "Now I know there is a God. If I could come out of that alive and in one piece, it must be because He is looking out for me up there." I smile and keep quiet, running the risk of her thinking that I agree with her (what rabbi would be opposed to belief in God?), because it is not the time or place for a theology seminar. But my mind goes back to a funeral I conducted two weeks earlier, for a young husband and father who died in a similar trunk-driver collision; and I remember another case, a child killed by a hit-and-run driver while roller-skating; and all the newspaper accounts of lives cut short in automobile accidents. The woman before me may believe that she is alive because God wanted her to survive, and I'm not inclined to talk her out of it, but what would she or I say to those of the families? That they are less worthy then she, less valuable in God's sight? That God wanted them to die of that particular time and manner, and did not choose to spare them?<br /></blockquote><br /><span>Kushner's ultimate answer to this question is that it is the wrong question. The definition of an imperfect world is that bad things happen to people who don't deserve it. So, t</span><span>he more important question is, "What do we do now that bad things have happened?" </span><br /><span></span><br /><span>For him and for me, it is humanity's job to help all people heal from these terrible wrongs. We need to give up the blaming and finger-pointing and instead give strength to all the survivors. We do that with kindness and understanding.</span>Free Operanthttp://www.blogger.com/profile/01213177543015935126noreply@blogger.com1