Maggie's Farm

Daily rule #1 in life is to answer this question: What have you done today to make your spouse happy?

"We have to face facts."

Do we?

There is a common and normal human capacity to both know and not know something at the same time. Maybe it's politics or maybe some recent patients that got me thinking about the avoidance of reality - a maneuver which falls far short of the defence we call "denial" (which itself can also be entirely healthy at times, but often not).

I notice this in myself. For example, I noticed that I have not opened my last 2 quarterly 401-k statements. I know it's ugly inside those envelopes, but I see that I have avoided facing the facts squarely. It's avoiding the sharp pain, while tolerating the dull, nagging pain in the back of my mind. Besides the sharp pain, it's also avoiding whatever difficult or impossible decisions might or should be made.

I consider it to be a character flaw in myself - a weakness - but not a fatal one. Many of us dodge facing painful, pride-injuring, disappointing, or bias-challenging truths about ourselves or about reality and how reality works. I am in good company, but I do not approve of it.

I am not referring to an unconscious defense mechanism like repression: I am referring to a conscious and deliberate maneuver, like the suspicious wife who refuses to check to see if her husband is really at another very late business dinner. A reality-ducking means of coping.

There is a spectrum from psychotic denial and distortion (anorectics believing they look fat), to ordinary denial (I don't have a drinking problem, or I am not doing anything wrong), to repression (my brain won't permit me to think this unpleasant thought), to seeing but not believing (It just can't be!), to the sort of avoidance I am talking about (I know what is there, but refuse to look or listen because it will upset me), to the gold standard of bravely facing and dealing with facts, problems, and the limits of reality. As I say daily, Reality is the best but harshest teacher of all.

She - or he - is one tough and ruthless SOB.

Slate says that Emily Yoffe is the author of What the Dog Did: Tales From a Formerly Reluctant Dog Owner. Her essay in Slate is What is narcissistic personality disorder, and why does everyone seem to have it?

Not a bad essay for (and presumably by) a non-professional. Fact is, the whole subject is so complex that I haven't even tried to write about it: there would be so many "but"s and "if"s and "except"s in it that it would be dull reading. One quote from Yoffe's piece:

This is the cultural moment of the narcissist. In a New Yorker cartoon, Roz Chast suggests a line of narcissist greeting cards ("Wow! Your Birthday's Really Close to Mine!"). John Edwards outed himself as one when forced to confess an adulterous affair. (Given his comical vanity, the deceitful way he used his marriage for his advancement, and his self-elevation as an embodiment of the common man while living in a house the size of an arena, it sounds like a pretty good diagnosis.) New York Times critic Alessandra Stanley wrote of journalists who Twitter, "it's beginning to look more like yet another gateway drug to full-blown media narcissism." And what other malady could explain the simultaneous phenomena of Blago and the Octomom?

These days, "narcissist" gets tossed around as an all-purpose insult, a description of self-aggrandizing, obnoxious behavior.

The link for the essay is above.

That's the latest cardiovascular recommendation for brisk aerobic exercise. (It used to be 20 minutes three times a week, but new data has changed that recommendation.)

I have not asked whether 30 minutes of vigorous sex five times/week counts, but we hope it does.

For some today, and for just about everybody in the past, medical insurance was something everybody bought, just like life insurance or disability insurance, to cover extraordinary expenses. It is called Major Medical, and it is still readily available.

Over the past 20-30 years, governments, businesses, and union contracts began expanding their coverage by reducing deductibles and covering more routine things. Medicare, of course, was the model for that. During the same time, costly medical technology and new drugs were developed in a near-miraculous way, mostly in the US.

With those changes, folks began wanting "insurance" to cover their routine maintenance medical expenses instead of the things that would financially overwhelm them. When that shift was combined with the CYA style of medicine which results in $5000 work-ups for dizzy spells (fed by the ambulance-chasers), everybody expected everything.

That isn't sustainable, and will never happen. Medical technology has grown to an amazing extent, but those machines are expensive.

I have no idea what the folks in power are trying to plan for us, but I know it will be an entitlement disaster, filled with unintended consequences, that people would not be happy with. It will end up with politically-determined rationing.

Our family bought Major Medical insurance many years ago. It cannot be cancelled. It's more important than a cool car. Why everybody does not do that when they are young and healthy is beyond me, because it would seem like the logical and prudent thing to do. Over the years, we have increased the deductible so that it is quite affordable, and we keep a money market savings account specifically for medical bills to the amount of the deductible. As I recall, we began with a $2000 annual deductible, and now we finally have a dirt-cheap $20,000 2-year deductible on the original policy. It does not cover any routine or preventive medical care, which is as I think it should be. Nobody owes me medical care, in my view, any more than anybody owes me auto insurance.

We have kept this policy whether or not I or my husband had some form of insurance through work, because you never know how long you will want to keep a position - or when you will be let go.

Off-topic: Around 30% of Medicare expenditures occur in the last year of life. In other words, on failing and terminal people. Interestingly and unsurprisingly, when docs hold end-of-life conversations with these patients (as we should), the costs go way down.

If this new study is correct and replicated, I can only wonder why it took so long to notice such a simple thing.

I have always suspected that most mental illnesses are due to hard wiring, not chemistry. The fact that medicine can help says nothing about their causes: it makes no more sense than it would to call headaches a Tylenol deficiency disorder. Given the complexity of the brain, miswiring is a common phenomenon and gives people plenty to cope with - in addition to the ordinary travails of life.

The human brain is an ongoing experiment of nature.

 From a review of three new books about the experience of madness, at New Atlantis:

Elyn R. Saks, in The Center Cannot Hold, brings to light her first intimation of schizophrenic “disorganization,” as she calls it, which occurred when her father reprimanded her for interrupting him while he was working. “Consciousness gradually loses its coherence. One’s center gives way. The center cannot hold. The ?me’ becomes a haze, and the solid center from which one experiences reality breaks up like a bad radio signal. There is no longer a sturdy vantage point from which to look out, take things in, assess what’s happening. No core holds things together, providing the lens through which to see the world, to make judgments and comprehend risk. Random moments of time follow one another. Sights, sounds, thoughts, and feelings don’t go together.” This frightening slippage from normal consciousness first occurred when she was eight, and she knew she could not tell anyone about it.

and

Saks continued to function in the normal world even while she was delusional and hallucinating. “For example, I was getting my schoolwork done, and I vaguely understood the rule that in a social setting, even with the people I most trusted, I could not ramble on about my psychotic thoughts. To talk about killing children, or burning whole worlds, or being able to destroy cities with my mind was not part of polite conversation.” Sometimes she felt so crazy that she would simply lock herself in her room and turn off the lights. The only person in whom she could confide her true state of mind was her psychoanalyst, Elizabeth Jones.

Just reading the review offers a little glimpse in to what the experience of going crazy is like, along with the agonies of feeling defective, alienated from others, and shamefully stigmatized.

I assisted with an abortion one time in medical school, on my OB-Gyn rotation. I went to the bathroom afterwards, shook and sweated, and then puked my brains out. I refused to help with another abortion. Nobody minded. I delivered about 30 babies during that rotation. Scary if you get into a jam, but otherwise good fun.

Knippenberg considers the embryonic stem cell issue (an issue about which I have no particularly strong opinion), and notes the contradiction between the amoral notion of "let science do science" and the political notion of "most people want this."

I guess pols are experts at insulating their decision-making from morality and ethics. In my view, Utilitarianism, like "efficacy," is neither a moral nor an ethical posture. It's a cop-out. It's the easy way.

From Yuval Levin's Obama's False Choice:

Obama (also) chose to repeat the familiar cliché that the Bush policy was a betrayal of science. In his administration, he argued, “we make scientific decisions based on facts and not ideology.” The facts of the Bush administration’s funding of the research, its support for science funding more generally, and the emergence of alternatives to embryo destruction seem not to count. And the fact that every human embryo is a living human being seemed unworthy of mention.

Science policy is not a science: It must seek to use science to the benefit of the larger society, and also to restrain science in those rare instances when it threatens that society’s ideals. In hindsight, it seems increasingly clear that President Bush’s stem-cell-funding policy will stand as a model of how to strike a balance between these concerns. President Obama’s overturning of the Bush approach offers an unfortunate example of how fragile that balance often is.

Ed. note: Krauthammer today: Morally unserious in the extreme

It's about the pathologizing of opinions you don't agree with. Mind you, I have no problem with ending an exasperating disputation with "You're nuts. I can't discuss this with you."

But that's not a diagnosis. While I am fully aware of group and mass psychological themes, I only confer a diagnosis on those who pay me to do so. Even then, I often cannot give them a label because every person is unique.

I have more science under my belt than 95% of the folks I encounter who dispute my skepticism about AGW. But, in the world of science, the only proper attitude towards anything is skepticism. That's how it works. "Proof" is usually very elusive. We have many theories, few truths, and no Truths.

Brendan O'Neill at Spiked reports on the disease of Anthropogenic Global Warming Denial. One quote:

This weekend, the University of West England is hosting a major conference on climate change denial. Strikingly, it’s being organised by the university’s Centre for Psycho-Social Studies. It will be a gathering of those from the top of society – ‘psychotherapists, social researchers, climate change activists, eco-psychologists’ – who will analyse those at the bottom of society, as if we were so many flitting, irrational amoeba under an eco-microscope. The organisers say the conference will explore how ‘denial’ is a product of both ‘addiction and consumption’ and is the ‘consequence of living in a perverse culture which encourages collusion, complacency and irresponsibility’ (1). It is a testament to the dumbed-down, debate-phobic nature of the modern academy that a conference is being held not to explore ideas – to interrogate, analyse and fight over them – but to tag them as perverse.

"Eco-psychologists"? May I conjecture that these people are nuts?

Comments from Common Room:

Moral vices prosper by dressing themselves as virtues. Niceness presents itself as benevolence, but is often merely an evasion of hard decisions that the realities of human nature require. And it has spread throughout our societies because it is often popular with voters. The road to hell, it is said, is paved with good intentions, and so is a good deal of democratic politics.

and

In our compassion, we have confused egalitarian 'fairness' with justice, and we have created a monstrous sense of entitlement.

Wherever standards are destroyed and merit is redefined, a sense of entitlement necessarily follows. This is true in any aspect of society. In the field of education, it manifests itself in the demand by students for high grades when they are not earned.

And this has resulted thousands of defrauded young people who graduate with diplomas they cannot read, apply for jobs they cannot do, and are forced to remain in minimum wage jobs forever, because they cannot read, write, or perform basic computations.

I have heard employers and managers commonly remark that "so and so doesn't have the DNA for this job." It's well-known by now that many, if not most, temperaments, talents, personality traits and tendencies have a genetic foundation. With overdetermined things like political attitudes, one might expect those foundations to be obscured by life experience, education, and personal growth.

But they aren't, entirely. Wilson discusses in City Journal. A side point he makes, which I feel is well-taken, in reference to Adorno's famous study of the authoritarian personality and Bouchard's further work on the topic. He says:

In his study of identical twins reared apart, Bouchard concludes that right-wing authoritarianism is, to a large degree, inherited—but he says nothing about the Left. This omission is puzzling, since as Bouchard was studying twins at the University of Minnesota, he was regularly attacked by left-wing students outraged by the idea that any traits might be inherited. A few students even threatened to kill him. When I pointed this out to him, he suggested, in good humor, that I was a troublemaker.

Yet if you ask who in this country has prevented people from speaking on college campuses, it is overwhelmingly leftists. If you ask who storms the streets and shatters the windows of Starbucks coffee shops to protest the World Trade Organization, it is overwhelmingly leftists. If you ask who produces campus codes that infringe on free speech, it is overwhelmingly leftists. If you ask who invaded the classroom of my late colleague Richard Herrnstein and tried to prevent him from teaching, it was overwhelmingly leftists.

He gets it. I never understood the equation of "Right" with Libertarian/Conservatism either. His essay, The DNA of Politics, here.

It is curious how Darwin, evolution, and inheritance is ignored by the rabid Lefties. Unless God is involved. The wacko Left is ever on the march.

It's the birthday of Charles Darwin. I'd like to highlight this very observant fellow's most original work, The Expressions of the Emotions in Man and Animal.

That book has been a gold mine for students of human behavior, and is the foundation of sociobiology.

I will stick to my decision to avoid pathological labelling of those with whom I disagree. BUT I can never stop wondering that it is that causes people to become passive in the face of a threat to one's way of life - assuming it is meaningful. This is surely abnormal, because our species could never have survived with a "roll over and give up" instinct.

In recent history, we have seen those who were reluctant to stand up to the Japanese, the Germans, the Russian Soviet empire, the North Vietnamese/Chinese - and now the Moslem assault, in its various forms, on the West. I did a post about Better Red Than Dead in the past, but I cannot find it in our archives.

Is it a psychological issue (eg masochism, which implies a sexual excitement in being dominated - or an enacted suicidal impulse), is it plain cowardice, is it a kind of hatred for one's own culture or nation? Or is it really just a unicorn and rainbow dreaminess about life (which I tend to view as a psychological defence based in denial of the hard and often cruel reality that people pursue their interests)? I have seem much of the latter, especially in women and in young men who haven't really worked yet. Cases in point:

Brits to Pakistanis: Please don't hurt us

David Thompson: Assume the position

Psychoanalysis has known for 100 years that our conscious minds aren't in charge most of the time, and writers and grandmothers have known it forever. Indeed, we humans flatter ourselves when we imagine that they are.

For one example, Overcoming Bias discusses how social cues guide our decision making beneath our conscious awareness:

...the MIT group has identified a handful of common social signals that predict the outcomes of sales pitches, the success of bluffing in poker, even subjective judgements of trust. These signals include the `activity level', effectively the fraction of time the person speaks; their `engagement' or how much a person drives the conversation; and `mirroring', which occurs when one participant subconsciously copies another's prosody and gesture. ...

Humans lived in social groups long before language evolved, and the language function presumably exists on top of a more archaic brain system for non-linguistic social signalling. ... Apes, chimpanzees and other primates - our close evolutionary cousins - lack anything like our facility for language, yet still lead sophisticated social lives through displays of power, meaningful noises and facial expressions.

The post correctly concludes:

Our conscious minds are more PR folks than CEOs of our total minds.  We are much better at explaining than predicting ourselves.  So the first step to wisdom is to realize how little we know about why we do what we do, or why we think what we think. 

Around every New Year's Day, or, if I procrastinate, sometime before the end of January, I tend to do a little personal inventory.

I know what I am pretty good at: my work, raising kids, being a wife, being a friend, skiing, shooting, tennis, golf, sailing, reading, and a few other things too. But I force myself to take time to focus on the things I am bad at. I wonder whether they are amenable to improvement, or whether they are hopeless.

As one grows older, more flaws and weaknesses move from the "Maybe Improveable" into the "Hopeless" category. The reality of one's limits sinks in by repeatedly bumping into reality, one's identity clarifies itself, and one's humility deepens.

Here are just a few of the things I stink at, and which have been contemplating this January:

Being a leader. I am a natural born non-leader. Not a follower by any means (in fact, a lousy follower too), but utterly lacking in leadership skills or talents. When I say "Follow me!" nobody follows. And when somebody else says "Follow me!" I say "Wait a minute, and let me think about it."

Being an executive. I am terrible at running things, and the things I get involved with running only work when the others take initiative. I am terrible at making organizational decisions except at the most elementary level, and I am a complete retard with office politics. I care enough, but I can't make things happen. Plus I detest going to meetings. They make me squirrely.

Paperwork. I derive no pleasure or satisfaction from getting it done, and, despite years of determination, I find myself still making excuses to avoid it.

Writing. I give plenty of talks and lectures, and do that well enough to convey information. I have plenty of ideas and things I think are worth writing about, but I lack the talent to write in memorable or engaging ways. I am at my best speaking off the cuff. And it's not that I dislike writing. I like to write things. I just never like the way it comes off on paper. Dull and pedantic, even when I try to write casual. That's partly why I do not post more regularly here. I am never even half-satisfied with what I put on paper. I have written a number of posts for Maggie's, read them the next day, said "That's lame," and pushed "delete."

Phone calls. Unlike most women, I hate the phone. I avoid the phone. Basically, I will not make phone calls except under duress. I cannot get over this flaw. Maybe it's because I spend my days talking to people, but that sounds like an excuse. Anyhow, email is what makes my life function nowadays.

Everybody at Maggie's has seemed too busy to do much writing of his own this past month or so, so we have been throwing up link posts without adding much to them. I am in the same boat at the moment.

Ars Psychiatrica on The Impossible Profession

Eric Kandel on the biology of psychotherapy

Neoneo on long-term psychotherapy.

Photo of Freud demonstrating his tobacco-inspired analytic technique via Neoneo.

I sent an article from Psychiatric Times (which we linked a while ago), titled The Decline of Psychotherapy, to a Psychiatric colleague. He responded "Good timing for me. It will be dead just when I am ready to retire from my psychotherapy practice."

The article says:

The number of psychiatrists who provided psychotherapy to all of their patients declined from 19.1% in 1996-1997 to 10.8% in 2004-2005. From 1996 through 2005 psychotherapy was provided in 5597 of 14,108 office visits to psychiatrists lasting longer than 30 minutes, but the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2005-2006.

People who have never used a good shrink psychotherapist have no idea how helpful we can be, sometimes even very quickly...but sometimes not quickly at all. I wish I could offer examples, but I'm touchy about the confidentiality.

General hospitals are increasingly relying on "hospitalists" to care for inpatients, freeing up office practitioner's time for their (steadily less lucrative) outpatient practices.

I have yet to be a hospital inpatient except for childbirth, but I think that, if and when I am, I'd like to see the face of my own Doc daily. 

This is a new model for medical practice. More time-efficient? Probably. Less comforting? Probably. Overall, better or not? I cannot say.

Internists, and what few GPs still exist, are having a tough go of it these days: Medicare, which is the bulk of their work, compensates them now at a rate lower than a plumber or electrician in Boston.

I feel badly for this young Psychiatric resident at Baylor, who discussed a mutual romantic attraction to a patient with a supervisor (my bolds):

 “I think you need to take this one to Dr Gabbard. I have never seen a resident with this problem before.” “Never!?” I thought, “I’m the only one!?” I worried incessantly about what was wrong with me to feel so incapacitated, unable to feel in control of the therapy in this particular case. I kept thinking in circular fashion, “I should not have this problem. I must stop it. I can’t stop it. I should not have this problem”—and on and on.

Well, I am glad she finally got to Dr. Gabbard, because he is one smart guy. Still, I found her supervisor's reponse deeply disheartening and soulless - if not neutered.

Fact is, as everybody knows, humans are prone to affection, attraction and attachment and there is nothing necessarily different about whether that occurs in a shrink's office, or between a businessman and his secretary, teacher and student, clergyman and congregant, trainer and client, doctor and nurse, lawyer and client, classmates, or business associates and office colleagues.  Romantic feelings in offices (like many other emotions) are ubiquitous. Sometimes it's mutual. The proximity and intimacy of some associations naturally builds more closeness than the usual and more contentless (but sometimes powerful) chemistry of strangers in bars.

When you put people together, things of all sorts happen. Analysts and psychotherapists have the peculiar and challenging task of figuring those things out rather than acting on them.

So rather than viewing this resident's issue as a "problem," I see it as a healthy sign of vitality. Humans are, among many other things, relentlessly sexual machines and attachment machines, and no PC baloney, laws, psychoanalytic exploration, or rules could or should ever change that.

Obviously, acting on such feelings can destroy the doctor's role, potentially ruin a doctor's life, and end a patient's hope for real internal improvement. That's why analytically-oriented therapists maintain various sorts of rules and boundaries. The doc's gratification is meant to come from doing a job and from getting paid for it, but it's impossible and undesirable to remove the human elements - emotions, fantasies, etc. People fall for each other all the time: it's basic biology.

Mr. Spock would not make a good shrink.

I would go so far as to say that a shrink who never has such emotional experiences with patients is too robotic to practice in the field of intense and confusing human emotion. Of course, one must ask oneself about transference and countertransference and transference resistance and acting out and patient seductive manipulations and the state of one's own psychology and all that stuff we analytically-oriented shrinks get paid the big bucks to think about - but sometimes a cigar is just a cigar. The world is full of charming and appealing people.

Can a shrink effectively treat a patient they have lasting romantic feelings about, whether it's mutual or not? Probably not, if a chat with a colleague and a little introspection can't deal with it. Refer them out, same as one would with a patient you strongly disliked or distrusted so you can get back to doing your job.

(If any resourceful reader can figure out how to forward this post to the honest Baylor Psychiatry resident, Dr. Raymer, who wrote the linked piece, I think she might appreciate it.)

Cornell Medical Center's Dr. Richard Friedman on the crisis of confidence for financial workers. One quote:

...the relationship between self-esteem and achievement can be circular. Some argue that that the best way to build self-esteem is to tell people at every turn how nice, smart and talented they are.

That is probably a bad idea if you think that self-esteem and recognition should be the result of accomplishment; you feel good about yourself, in part, because you have done something well. On the other hand, it is hard to imagine people taking the first step without first having some basic notion of self-confidence.

Our interesting Lie To Me post last week failed to mention Paul Eckman's book, Telling Lies: Clues to Deceit in the Marketplace, Politics, and Marriage. It's more of a report of his studies than a how-to book.

Shrinks are interested in lying. I have always viewed lying as a theft of another person's reality. The lies we tell ourselves are another matter entirely.

Your doctor may be so concerned about protecting you from alcoholism that he or she might not tell you that current research indicates that 1-2 drinks per day appears to reduce the risk of heart and arterial disease by 18-30%.

More is not better, however. Details at Medscape.

Ceviche/Seviche/Cebiche.  I used to make it with sliced sea scallops; lime juice, olive oil and salt, marinate it for an hour or so, and serve with thin-sliced onion and red pepper, and a little fresh Cilantro.

Now Ceviche has gone global, and now it only "cooks" in the juice for a minute or two. You have to go to Peru to find the best, says this author.