Archive for the ‘Uncategorized’ Category

GET OFF MY WIENER (not political)

Tuesday, June 14th, 2011

That was fun right? Everybody is making lots of jokes about Rep. Anthony Wiener (D-NY,) his eponymous body part and other photos. Comedians, joke-tellers, pundits, pontificators and others are having a great time with this situation and making good money out of it.

Now, I said that this is non-political and it is but, of course, politics gets involved because he’s a politician. So, besides all the jokes and wise-cracks, there’s also plenty of call for his resignation from both sides of the aisle. His colleagues are suddenly stepping away from him as if he fell into the muck-tank and managed to climb out and is now sitting on their collective porch. Even President Obama couldn’t resist making a comment, stating that he would be personally embarrassed. Somehow he couldn’t say that Wiener has been given a leave of absensce by the House, has entered treatment, and let it go at that. Or just said that he’s got nothing to say on the matter. Everybody acts as if Anthony Wiener, one of the House gadflies, suddenly stinks like a large, dead, beached whale.

Why is this? What’s wrong here? The man has said he’s got a problem, admitted to God, himself and (several/many) other human being the exact nature of his wrongs. He’s said he’s going to get treatment and has done that. Why is he a pariah? What horrible thing did he do?

I don’t know. What I know is that the man sent some revealing photos of himself to people to whom he was not married. As far as I know the photos weren’t viewed by the recipients as “harassment” or unwelcome.  The people to whom he sent the photographs weren’t underaged, as far as I know. What I’m saying is that these were acts between, or among, consenting adults.

So what did he do? Why should he resign? Beats me. He said he has a problem and has begun treatment for that problem. I thought that was the American way. I can think of any number of people in public life who’ve had problems, have sought help for those problems, and we’ve embraced them for having the courage to face their demons. Betty Ford & Robert Downey, Jr. come to mind pretty easily. Shrub (OK – not so embraced by all.) How many times did Lawrence Taylor get busted for using drugs & get sent to rehab without his team mates and members of opposing teams screaming for his ouster? What about the Mick? Mickey Mantel (or Mick Jagger, for that matter.) Loads of men and women in the Arts go to rehab & then capitalize on the story (see my earlier blog entry “Anonymity A Quaint Idea? Not Really” for how I see that bit of stuff.)

Yeah, yeah. I get it. All those worthies went into treatment for drug & alcohol abuse, not a sex scandal. Well, get over it. It’s all poor impulse control kiddies. It’s not even about “poor judgement” and, if it was really about being some kind of “role model” then Mickey Mantle and Babe Ruth would have been dragged through the mud instead of being The Mick and The Sultan of Swat.

It’s all about learning to face those demons, however they choose to attack. It’s no less moral to send a picture (to someone who is willing to receive it) than it is to go driving drunk on the freeway on a regular basis and is certainly less dangerous to life and limb. We’ll celebrate the singer who goes to rehab umpty-nunkle times for booze & blow, but not the politico who sent someone a photo of his (oh, really. Don’t make me say it, Okay?)  Let’s get over it. The man has a problem. He’s taking care of it. Done.

Any questions? Comments? Rebuttals? Post a reply to this (or any other of my posts) on this site. I promise I won’t bite and I’ll even try to mount an intelligent response. No promises about the intelligence or intelligibility of the response, but I’ll try. I’ll even make a special effort to be civil. Let me know what you think.

Thanks – Jay


You’re Going To Charge Me For Missing A Session?

Thursday, May 19th, 2011

Yeah. I am. Can we reschedule? Let’s talk about that later.

I hear ya. Yer doctor just lets you call and say you’re not going to be there and everything is fine. Same thing with the dentist and some other health professionals. Everything is jake. You call up, say you’re not getting there, they cancel your appointment and then you reschedule when you get the chance or whenever what’s bothering you kicks up again.

So what’s this about? Making sure that I don’t lose income? I’ve heard that before and the answer is, “Yes, but that’s not the main reason.” Some people stop at “Yes” and don’t hear the rest. Unfortunate. I do own up to it being, in part, about my income. Your fee is my income. I can’t double book the way physicians and dentists do so, when you don’t show, I don’t get paid for that period of time that I’ve reserved for you.

Ah, there’s another part of the “…not the main reason.” I’ve reserved the time for you. In most cases I can’t rebook the time. I realize this isn’t your problem, except that you want me to keep this time open for you every week, right? If you want me to release the time to someone else, I can do that, but then it’s that person’s if he’s willing to pay for it on a regular basis. Then you & I have to decide on a new schedule and, guess what, it’s still a regular appointment and, you guessed it, you’re going to pay for that missed session.

“Missed” session. Hmmmmm. Yeah, about that. If you don’t show up and you don’t pay it’s not a “missed” session. It becomes a “missing” session. What’s the difference. “Missing” sessions don’t exist. They didn’t happen, there’s nothing to note their passing and there’s nothing to talk about. I know you think there’s nothing to talk about if you miss a session, but that’s not true. There’s plenty to talk about and that’s why it needs to be “missed,” not “missing.” I’ll go further with that another time. Please just take my word on this one for now. If you want to think about it and tell me the difference please feel free to post a comment.

Now, about that rescheduling of our appointment. What are you asking of me with that request? Your asking me to fulfill your wish that you get a Mulligan. The “caring one,” as Harry Stack Sullivan labeled the infant’s primary care giver (often mom but not necessarily,) will do what is wanted. Your wish to be taken care of will be fulfilled no matter what the cost to anyone else. What are you asking of me? You are, in effect, asking me to cut my fee in half by giving you another session (the one you missed plus the”rescheduled” appointment) for the price of one session. Two for one. You’re presuming that I have the open time that will match yours and, maybe, that if I can’t match your time you won’t have to pay because you can’t reschedule and it’s my fault.

That doesn’t answer the question about rescheduling a session. That answer is, if I have time open and it matches your availability then, yes, I will reschedule. Once. Please.

Long ago in a galaxy far, far away I dated a woman who said, in response to my saying I felt “used” about something “Everybody uses everybody. Don’t abuse anybody.” Please.

Comments? Please feel free to post them below.

Anonymity a Quaint Idea? Not really.

Wednesday, May 11th, 2011

The subject of an article in last Sunday’s Style section of the New York Times (“Challenging the Second ‘A’ in AA“) was the idea of anonymity within and outside of Alcoholics Anonymous. The article begins with the author stating his name and that he’s an alcoholic. With that in mind, and in a similar spirit, I offer you this piece of information:

My name is Jay E. Korman. My status of being, or not being, an alcoholic is not on the table, nor will it be contained in this article. I am anonymous, even to the extent that my anonymity is about whether or not I have anything to be anonymous about. How’s that grab ya?

See, it’s real simple. I’ve worked with substance users for years and continue to do so. Some are still using, some quite comfortably, some struggling, some not using (also some comfortably and some not.) The times article puts forth the idea that the principle of anonymity “…at the level press, radio, and screen,” contained in the eleventh tradition from AA’s book of essays about the Steps and Traditions, commonly referred to as “The Twelve and Twelve, was necessary when the organization was a few alcoholics struggling to stay sober and alcoholism carried a heavy stigma. Carried, as if there’s no stigma today. Therein lies the rub.

The people I work with aren’t authors, big name musicians, or artists. They’re working folk (sometimes not-working folk because they’ve lost jobs, families, apartments, etc. to the economic and social effects of alcohol) who aren’t out there in the realm of the creative and are expected to be more solid and reliable (artists, etc. please note: I’m not saying you’re not reliable. I’m saying that there’s an image that exists of how an artist’s life is somehow different from a factory worker’s in terms of being self-indulgent.) Being a drunk, drug user, gambler, or and other addiction-er (or an ex-whatever) isn’t celebrated the same way in a middle manager or a factory worker as it is in artistic circles. There’s still quite a stigma against someone who’s had “a problem.”

Also note: There is still the problem of what happens when a recovered celebrity who has gone public falls off the wagon. That too is public and for every person who says that the celebrity was at fault for not “working his program” there is at least another (usually someone who was looking for a reason not to join a recovery group) who says that it’s the fault of the program and therefore won’t be joining it because “it doesn’t work. We won’t discuss, in this paragraph, that the problem may have been that the celebrity was “working his program” but not “working the program.” There is a difference. What I’m saying here is that a public failure by a celebrity is a failure for the fellowship of recovery because, as the Twelfth Tradition states:

“Anonymity is the spiritual foundation…ever reminding us to put principles before personalities.” The Times article puts forth the idea that “no one ever talks about it” much. Maybe that’s the problem of why people think it’s OK to out each other or themselves in a public way. The tradition says “principles,” not “principals.” It ain’t about the players, it’s about the game, youse guys. When it becomes about the principals  recovery becomes dependent on the strength of the people representing it on a (very) public level. AA doesn’t advertise (except the occasional PSA) because another tradition states the tradition of “…attraction rather than promotion.” When a celebrity outs himself about his recovery from his “disease” he’s promoting himself, sometimes his latest creation, and a program of recovery for saving his life, career, whatever. Wonderful. Tell it at your next meeting to your fellows. You’re supposed to be telling it to save your ass and “carry the message to the alcoholic (addict, whatever) who still suffers.”

Is AA going to disappear because the author of that article, other authors, musicians, artists have outed themselves (and others in the process)? Not immediately. What disappears is the spirit of service to the fellow who still suffers without any reward other than saving your own ass in a way that no one else ever could. Is AA harmed by the celebrity who engages in public disclosure? To some extent it is (here’s that stuff I didn’t talk about in that earlier ‘graph) because it acts as negative publicity just as sure as ________ __________ (fill in your favorite recovering performer’s name) being a success in recovery will act as positive publicity. As the spirit of service disappears so does AA, or at least “good AA. (see the web article about Gresham’s Law and Alcoholics Anonymous to see what I mean by “good AA.”)

Don’t kid yourself about this: being a substance user, even a former substance user still carries plenty of stigma, especially among the working classes. It’s considered a failing, whether moral or character or personal strength or…. It’s nice to be able to have a cavalier attitude because you and your cohort celebrate your new-found freedom (and your continued years of freedom.) See if they weep with you or walk away from you when that freedom is lost. Better yet, take a look around at the rest of the people who aren’t part of your cohort. See what effect their actions have on their ability to live their lives.

So, to repeat: My name is Jay E. Korman. I don’t tell patients whether or not I’m in recovery, or drink (drug or whatever) because it’s probably not going to help them, and I’m certainly not going to tell you because that’s not going to help you, either. What I will tell you is that I have a profound respect for the disOrganization of Alcoholics Anonymous, both for the work that it’s members, service committees, etc. do for themselves (and others,) and for the fact that the organizational structure truly works for its members in a way that very few others do for theirs. The members control the board, not the other way around, to make sure that the needs of the members (on an organization wide level, not an individually punitive or aggrandizing level) are met, have been met, and continue to be met.

Maybe instead of doing away with, or ignoring, the traditions the “breakers” could spend more time discussing the benefits of them. I’ve heard it said that the steps are a “suicide list,” because they keep the (ex) drunk from killing himself, and the traditions are a “homicide list” because they keep others from killing the (ex) drunk. That alone sounds like a good reason to keep them.

As for anonymity within AA, that’s just silly and was never supposed to be the rule. How else can you go visit one of your fellows in the hospital if you don’t know a last name? It’s not about being anonymous to each other. Members of the fellowship don’t wear masks at meetings so they can hide their faces from one another. Can you think about what you’re doing and saying when you stay anonymous to each other and saying “that’s the tradition?”

“Hallelujah. Hallelujah. Throw a nickel on the the drum….” I heard Judy Henske sing it years ago when I was a teenager. Don’t proclaim it. Be it.

Coffee and fellowship is in the anteroom immediately following the closing. For all those who care to join….

Consumer, Client, Patient, Analysand: What’s in a Name?

Thursday, April 28th, 2011

Willy Shakes asked the question in Queen Lizzie’s time (the first one, not the current monarch.) At that time he was asking because, to the questioner, a name was something that made no difference in the person to whom it was attached but made lots of difference as to how the person was perceived and accepted by others.

Insurance companies have renamed everyone who is receiving health care services. No longer are we “patients,” “clients”or, in the case of psychoanalysis and or psychotherapy “analysands.” We’re now “consumers,” according to the insurance companies. Those of us who are delivering health care services are no longer “doctors,” “analysts,” or “psychotherapists.” We’re all lumped under the title”provider,” again by the insurance companies. What does this mean? Don’t we still get treated the same as we did when we were patients and therapists, Analysts and analysands, etc?

Well, no. Not really and, on top of that, I don’t like being called a consumer when I’m on the receiving end of health care, nor do I much care for being called a provider when I’m on the giving end. Why? I’m gonna tell ya (with a nod to Dino. RIP.)

A consumer is someone who uses/purchases a good or service, which is considered a consumable. Very general. Doesn’t separate someone who is in treatment from someone who’d buying a toaster. Are you using my service? Yes. Does that make you a consumer? No. Our relationship is more personal than that, or, at least, is intended to be more personal than the relationship between someone buying a toaster and the salesman at an appliance store.

“OK. So I’m not a consumer,” you say. “Then I’m your client, right?” I’m not so sure. The dictionary on my e-reader says that a client is “a person…using the services of a lawyer or other professional person or company” (New Oxford American Dictionary.) I guess that sounds closer to the mark. I am a professional. Are you “using” my services? Well, yes and no. You have engaged me in my professional capacity. Maybe client does work but it seems to me that it misses something. It’s like chicken soup without the parsnip and dill weed. It’s may be good but it’s missing that geschmeck that makes it delicious.

What’s missing? You got it? No? Sure you do. The helping relationship. The (hopefully) healing relationship. So what’s the word now? Patient, right? Same dictionary gives the first use of the word patient as a noun to be “…a person receiving or registered to receive medical treatment.” Woah! Shazaam!, as Gomer was wont to say.) Shazoom!, as Captain Marbles said. “That’s it,” I hear you say. Well, yea and nay. Far better than consumer,  more better than client but still….

Analysand? What the hell is that? A person undergoing the process of psychoanalysis with a trained psychoanalyst. A very specific word that honors the relationship that exists in the room between us.

As for “provider….” Dad (in the stories of how family life used to be) is the “provider.” “Your father’s a good provider.” Can we talk about transference and countertransference here? I thought so.

So, what do you prefer to be called? What do the implications of “consumer” and “provider” mean to you? Add a comment and let us know. Keep those ol’ cards & letters rollin’ in (Dino, we miss you. Lots.)


“Yeah, but what’s my diagnosis?”

Tuesday, April 12th, 2011

Patients invariably want to know what diagnosis I’ve given them or the papers from somewhere else say they’ve been given. Some don’t ask. Many do. To those who do I’m really, really tempted to say, “What’s it to ya?” but I’d just be dismissed as being flip or, even worse, that I’m with holding some secret that will help do something, though I’m not sure what. Most of the time patients don’t know what that information is going to help either. I do tell patients that I’ll tell them but first I’d like to know what having that information is going to do for them. Most of the time the answer is something vague, like, “I just want to know what you’re writing about me,” or “I want to know what I’ve got.”

I know, you’re looking for an answer. You want to be told you’ve got Bi-Polar Disorder or Schizophrenia, or something, anything, as long as it has a name. Giving your condition a name explains what you have and then explains a course of treatment, right? That’s how it works when you go to the doctor. He says you’ve got Bronchitis, you take this prescription for antibiotic to the pharmacy, take a pill x number of times a day for y number of days and “you should feel better. If not, call me. Be sure to take all the pills.” OK, the doctor doesn’t say most of that, it’s written on the bottle the pills come in but it’s doctor (some doctor) who tells the druggist to put those labels on the bottle.

OK – you don’t really want to know you’ve been diagnosed with Schizophrenia or Bi-Polar Disorder because those are serious problems. So how about some depression or anxiety? Better? OK. Still, what does that tell you? There are clinical interpretations of those two words but I don’t really think that’s what you’re looking for because: there’s no antibiotic that you take for y number of days and it goes away. Medication can bring some relief, or so the pharmaceutical companies claim (more on that another time – I’m not anti-medication, just anti-miracle drug,) psychotherapy/psychoanalysis can bring some relief, the combination of psychotherapy/psychoanalysis and medication can bring more relief but, if you want real relief from what’s troublin’ ya (“What’s the matter bunkie? You say your brother hid your homework in the washing machine and now you algebra stuff is all over your underwear and the teacher is asking you to hand it in….”) you’ve got to change the things that are causing the condition, because that’s what your condition is a reaction to and a defense against.

We diagnose across five Axes (that’s acksees, not the things that have strings and make music), I-Clinical Disorders; Other Disorders That May Be a Focus of Clinical Attention II. Personality Disorders; Mental Retardation III – General Medical Conditions IV – Psychosocial and Environmental Problems and V – Global Assessment of Functioning.

When you ask me what is your diagnosis you’re usually asking me for the top item on the list. I hesitate to tell you because it doesn’t tell you anything about what’s going on. It barely tells me what’s going on. What it tells me is that your symptoms, your reactions to your General Medical Condition added to your Psychosocial and Environmental Problems, have been given this or that name and number by the taxonomists who need to track these things for statistical and other informational purposes, like whether you can have coverage under the new parity law or not (another post another time.) Same thing about Axis II except that’s more pervasive, more of a character style, than just a bunch of symptoms.

What you’d be asking if you knew what to ask is what do I see as the things that are pushing and pulling on you that are causing you to be this way. You’d be asking me ” How do I increase my GAF (Global Assessment of Functioning) so I can _____ (insert desired result here.)

Doesn’t matter. I’m still going to hear “What’s my diagnosis” or its variant “I took a test (looked it up, whatever) online. I’ve got this. Do you agree?”

I don’t know.  Please tell me more about it.

Hand Movements May Give Clues to ADHD Severity – MedNews

Tuesday, March 8th, 2011 recently posted an article about ADHD that – wait – you don’t get news from How else are you going to find out about new drug approvals by the FDA, breaking information about recalls & lots of other useful stuff? Where else are you going to get articles like the one about which I’m commenting?

OK. So they posted this article about studies involving hand movements and ADHD which had some interesting points. One study found that children with ADHD weren’t able to perform the finger-tapping exercise without extraneous movements that weren’t as apparent in “typical children.” Another demonstrated that magnetic pulses caused movements in ADHD children to a greater degree than “typical children.” They said something about myelination of the left/right brain connective nerve tissue, the brain’s “braking mechanism” on movements, and a demonstration of why ADDers have a problem with keyboards and fine hand movement tasks.  The article also said that there wasn’t a clear “clinical” application for the outcomes of this study or these tests.

Whoa! That’s a lot of stuff there, compadre! First of all, does anyone other than me have a problem with comparing ADDers to “typical” children? Typical? What are they saying? Who are they stigmatizing? How about calling those “typical children” as having “Attention Surplus Disorder” (thank you Thom Hartman.) Typical indeed. Read Harte’s anthropological & historical view of ADD in “Think Fast: The ADD Experience,” T. Hartman & J. Bowman, 1996, Underwood Books,(link to Amazon page for the book,) a book of excerpts from the Compuserve (remember that) ADD forums. Typical! Poppycock!

Next: What do you think of a parent that allows his/her child to be subjected to “magnetic pulses” as a form of testing without knowing the outcome? Even with knowing the short-term outcome.  I realize that it’s hard to test pediatric effects and dosages but, really…. “God said, ‘Abraham, kill me a son.'” (“Highway 61,” B. Dylan, as if you didn’t know) but Abraham was spared from having to do that by the substitution of a ram at the last minute (insert computer and RAM joke here.) How do you feel about parents submitting children to experiments in the name of science? Me, I believe in things between consenting adults being permissible (within limits) but how does a parent consent for his/her child to be subjected to “trans-cranial magnetic pulses” – zapping the kids brain with magnetic charges – to observe if his/her arm jerks in response.

Finally, and this is the big one for me, and the whole point of this post: No clinical application? Are you ferreal? How about the simple “clinical” value of a piece of psychoeducation? Being able to tell a frustrated parent that the fidgeting child doesn’t have anything wrong with him, that it’s just the way his brain works and let’s find things that will help him learn instead of beating him down for not being able to sit still. How about being able to tell the child who doesn’t have the same fine motor skill as some of his buddies that, believe it or not, that will develop with time but, in the mean while, what can you do that they can’t because that’s what makes you special. How about using the information to educate teachers so they can learn that the kid who gets up from his seat to watch the squirrels running in the ivy on the side of the school building is also learning something, probably already finished the assignment, and is preventing himself from being bored (and getting in trouble for fidgeting.)

How about forgetting this ADHD vs “Typical.” Treat a child like he’s defective and you get a problem child. Treat a child like he’s a member of the family and you get a member of the family who can use his gifts.  ADDers aren’t defective. Just different. If  you think they frustrate you, you have no idea how frustrated the ADDer is – but that’s for another post.

Bullying and Popularity and Brain Damage and Prosecution and, and and…..

Tuesday, February 22nd, 2011

Bullying. It’s the cause du jour. It’s the new disease, the new focus. We’re off of childhood depression, past social phobia and onto bullying, which we’re criminalizing as well as stigmatizing, theoretizing, and philosophizing. We do everything but empathizing (with the bullies.) Of course we also point out that being the victim of bullying leads to depression, social phobia, and stigma. We don’t look at what being the perpetrator of bullying leads to except that it should lead to correctional facilities and straightening out.

There’s an article in the New York Times (02/14/11) by Tara Parker-Pope  about, well, what’s the title up there? Bullying and Popularity .” Web of Popularity, Achieved by Bullying” . There’s also an article in the Boston Globe, “Inside the Bullied Brain” that speaks about “damage” and differing formations that occur in children who are bullied that appear similar to children who are subjected to sexual and physical abuse.

The basic argument in the Times article is that the teasing and jockeying for position and popularity that goes on is only different by degree from the Bullying that gets lots of attention in the press. These cause stress as high schoolers vie for status. The Boston Globe article is a bit more honest, saying that although these differences are seen on scans it’s not clear whether the bullying causes the differences or the differences cause the bullying. The Globe does say that showing that there’s a physical effect could make it easier to prosecute bullies.

As unpopular as the view I’m about to express might be, I’ve got to disagree with these findings and this urge to label all “aggression” on the part of students as harmful and prosecuting bullies (even at the school level) unless there is real, physical damage like broken bones, just like any other case of battery.

We are over-reacting towards trying to correct a situation in which some individuals have an exaggerated and inappropriate response to the beating down that they’ve received, including the lack of support from the schools and parents.

I’ll be very clear – I’m not condoning bullying. I’m condemning the reactions we have to it. Most of the methods used to stop bullying just give the “bullies” more power and get them sympathy from their fellows, rather than shunned. Labeling someone a bully is labeling. Period. Having the school intercede and tell the “bullies” to stop rarely works.

Brain scans look great but, honestly, do we really know what we’re looking at when areas of the brain “light up” in reaction to a stimulus? Is it glycolization, blood flow, or pixies? We really don’t know. We can just guess. I can safely say that somebody getting hit in the head will cause some form of brain damage but I don’t know about the verbal alternative to “sticks and stones.” An aside to the bullies: if they’re only calling you names, don’t tell them that names will never hurt you – it doesn’t pay to hip the squares.

What’s missing in every one of these studies is the support given by family and school to build up the ego strength of both the bullied and the bullies. Just labeling someone a “bully” is also a form of bullying, but it’s OK because it’s us doing it, right? We’re on the side of good, yes? NO! The so-called bullies aren’t criminals (until they commit battery, rape, etc.) As Izzy Kalman points out in his Bullies to Buddies website & a past newsletter if we have to legislate against bullying we are admitting that we are failures as psychologists.

Before we look at brain scans, before we decide that schoolyard squabbles for pecking order are just another example of behavior we need to stamp out, lets look at the family systems involved. Let’s look at what is being done to help the victims and the perpetrators. Let’s look at what we’re doing to help the families, the schools, the society to deal with the situation. Without stress steel doesn’t become forged and strong, but it also needs to be quenched and tempered, all by a guiding hand. Without stress children don’t strive to become better, people don’t strive to be more than they are, but without support the stress can break a child or an adult.

Let’s not rush to judgment and condemn the bullies without looking at what we’re doing that feeds the situation.

Are Psychoanalysts Ever “Off-Duty?”

Tuesday, February 8th, 2011

First, a disclaimer. I don’t go around listening in to conversations at nearby tables, on the street, the bus, or anywhere else. Maybe I should say I don’t try to listen. I can’t help it if you’re going to speak loudly enough for everyone in the general area to hear you. This isn’t about why people think others need to hear what they’re saying, so enough of that. It’s just a disclaimer. Period. Done.

OK – so why the disclaimer? The other night I was walking home after getting off of the bus and there was a group of three people on the street ahead of me, two men and a woman. As I was approaching I heard a part of the conversation. One of the men said to the woman,”You’ll like him. He’s a psychoanalyst.” She responded by asking something about are psychoanalysts always analyzing everybody or do they ever turn it off. She also said something about it being tiring to always being “on.”

Do we ever turn it off? You betcha!  Tiring to always be”on?” Jeez. Probably even more tiring for everyone around than it is for us. Can you imagine that? Why would I, using myself as the example I know best, want to constantly be confronting people with their “hidden motives” for doing things? Where would my respect for my friends and neighbors be if I did that?

The people who come to me for psychotherapy are asking me to use my skills to help them.  They expect me to “listen with the third ear,” as Langs put it, to attend “with free-floating attention,” to quote Uncle Sigmund. They pay me to do this. My friends, family, neighbors and total strangers aren’t paying me for my time or my skills. They aren’t asking me to listen to their free associations and make an interpretation. I’m expected to be just another person in the room and not invade the privacy of why they do what they do.

Yeah, I’m a curious guy. Uh, maybe I should rephrase that. I’m curious about a lot of things in this world. I’m curious about what makes people tick, including me (especially me,) and seriously hope, as the old, sad joke says, that it’s not a time-bomb. That doesn’t give me the right to pry into what’s going on in someone’s psyche and, contrary to what some believe (and/or have done) it’s not a parlor game where I can (or will) look at people in the room, talk with them for a couple of minutes and then give a psychoanalytic profile.

I like my friends, family, neighbors (trust me on this.) Why would I want to piss them off by telling them why they’re doing what they’re doing or trying to manipulate them by analyzing them without their knowledge or consent. Ah, there it is – perhaps the real point of the question (OK – this is analyzing but it’s me thinking about what I might be trying to accomplish by that seat-of-the-pants analysis) is whether I would be “using my powers” for my  own nefarious purposes. To manipulate things & people.

What do you think? Do you think we ever “turn it off” other than when we sleep? Do we manipulate people? Let me know – leave a comment. I won’t analyze what you’re saying or how you say it – promise.

Therapists Behaving Badly

Wednesday, November 24th, 2010

This one’s gonna be touchy. I’m not all that clear about putting this post up there. It could be nothin’ but net, could be a brick. I’m sure this is going to make some people unhappy on both sides of the couch but, I gotta say something & so, as Wellington said to his mistress when she threatened to make his letters to her public, “Publish and be damned,” though I probably already am. It’s a professional liability.

This is written in part for patients, in part for therapists, and in part to get it off my chest ’cause its been there for a while & it’s startin’ to feel like a 10-ton safe. Here goes and if it bends you out of shape, so be it.

I was in the elevator going up to my office a few weeks, maybe a month and-a-half ago with 3 other people. Two were therapists, one was, I think, a patient. One therapist asked the other about his next patient & the comment came back something along the line of “He’s a real borderline.” The other said something like “yikes,” and then followed with a comment about being told by some mentor that you shouldn’t have more than one on your caseload. The one who made the comment in the first place said something about that being right.  If you’re reading this and you recognize yourselves, I’m not picking on you. I’ve picked you as an example. If you’re offended you can take it up with me. Leave me a comment. Please. If you have an opinion about what I’m saying here, please, leave me a comment.

The whole time this exchange was proceding I was uncomfortable because I wanted to say something to this pair. The other guy in the elevator (remember him, the patient looking guy?) was looking decidedly uncomfortable and unhappy.  I wanted to tell this pair to pipe down, that there’s other people on the elevator. Mind you, they didn’t say anything that might identify the patient (other than that he’s a he.) The behavior broke no privacy or confidentiality rules, HIPAA was certainly not violated. So, what’s my beef?

That’s easy. It makes patients uneasy when they hear this. They already think we talk about them when they’re not present. They have wonderful imaginations and are very sure we talk about them. There’s no need to prove them right. It doesn’t make them happy and gives them a not great opinion of us because, they think, it tells them what we think of them.

We’re not even going to talk about the categorizing of a patient with an unflattering label. We all know what borderline means, and that includes patients. It means difficult, explosive, unmanageable, right? Too bad it didn’t mean that when it was first proposed, but that’s what it’s come to mean. But I digress….

My point here is this: I was fortunate. My first internship was, in part, at the James A. Peters Veterans Medical Center in the Bronx where there were signs on the two side walls of each elevator reminding the staff to not discuss patients in the elevators because staff, patients and patients’ families all share the same elevators. Good signs to post because people forget.

What I’m saying to therapists – pipe down! If you must talk about patients, and I’ll be generous and say that you’re “consulting” with a colleague, do it in your office or your colleagues office and do it with the door closed. Not in the hall. Not in the elevator. Not in the toilet. Let’s show them the respect they deserve.They come to us in pain and we’re not here to add to it by hearing us talk about patients (in the pejorative) in public. We’re not carnies and our patients aren’t Rubes. If you can’t pipe down, and you’re in a public place with me, expect that I’ll ask you to hold it for when you’re alone. I invite any other clinician to do the same when they hear another of us doing this.

By the same token I’m saying to patients that it’s OK to tell the therapists who are having this conversation in front of you that they should zip it. Tell them not to have this discussion in front of the kids. Tell them that you feel disrespected. Tell them that they’re treating you like you’re not there. They may get huffy. Let ’em.

You, Your Insurance and Privacy of Our Work, Pt II

Wednesday, October 13th, 2010

OK, where was I before I started brewing my tea – a nice Oolong with lots of flavor, good aroma & gentle bite? Oh, yeah, about codes and privacy. This section gets a little technical but hang in there, fans – it’s worth it.

I said that those codes don’t leave much of an artifact (footprint, trace, record) that’s going to make any difference, right? Wrong! There’s a procedural code for every procedure that goes on a claim form, whether it’s medical, dental, surgical, psychotherapeutic, etc. The procedure performed becomes part of your permanent medical record in your insurer’s database. “So what” I hear you say. So this: it’s not just in your insurer’s database. It’s in their insurer’s database. They’ve gotta lay their bets off somewhere. That’s with a meta-insurer (think AIG or similar.) Someone who does risk-management and determines how much they can back the bets your insurers make. Think of it as the insurance company has sold your marker to someone. You said it was Jake for them to do that when you signed the line that said that your information could be disclosed for the purpose of obtaining payment. And you thought it was just between you, me, and your insurance company. Have another thunk because there’s more.

Anytime there’s a procedure code there’s a diagnosis. Again, this is whether the work is medical, dental, surgical, psychotherapeutic, or whatever. Now we’re beginning to where it gets sticky. Diagnosis is a serious word. It means that, based on criteria established by the Taskforce that created the Diagnostic and Statistical Manual of Mental Disorders-IV TR, you get labled with a disorder. You are no longer “the worried well,” or someone who just feels anxious. You now have a recorded disorder. This is part of that marker. The fun doesn’t stop there….

Anything that is contained in the DSM-IV is contained in a book called the ICD-9 (going on ICD-10) – “The International Classification of Diseases” published by varoius publishers all putting out the same book (it’s used world wide – International, right?) This means that where ever your record is read they all read the same diagnosis. Great, right? Maybe if the people reading that record were also psychotherapists, psychiatrists, or some kind of mental health professionals, but they may not be. Yes, some insurance companies do utilize us for review but not all the reviewers are. This means that your case is being reviewed by a clerk of some sort. This clerk gets to decide (among other things) how many sessions we can have during a given year for a particular disorder, if any at all. They can also decide that treatment has gone on long enough based on the tables they have and what instructions they’ve been given. At this point it involves more work; usually for me and for which I don’t get paid but, again, even though I mention the do-re-me it’s not about the bucks. It’s about the time it takes to appeal the decision & meanwhile the treatment and who’s going to pay for it is in Limbo (which is often somehow contiguous with Hartford, CT or someplace in Texas, maybe offshore. Who knows?)

These clerks aren’t under the same constraints about the privacy of your information (remember, that’s what this is about) as I am. They are allowed to bundle it for research as well as developing their actuarial tables and other statistical purposes. Your personal information (PHI – Protected Health Information) is not as protected anymore.

But wait, as they say on the infomercials, there’s more. See part III, coming up shortly….