Maggie's Farm

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.

When I read in the news shallow pop psychology takes on the heritability of specific traits, like conservative voting, homosexuality, and alcoholism, I am annoyed by the scientific ignorance of newspaper reporters.

I have planned, for a year, to put some time aside to write a magnum blopus on the subject, but finally realized it's better just to post something on the subject, and forget about letting the "best" be the enemy of the "good enough". Tempus fugit.

There is no doubt that personality traits are inherited. Every grandma, dog breeder, and parent knows this. And every family knows this: Bill is a true "Smith." Sally is a real "Jones." Ally is a real blend. Ted is a clone of Grandpa.

They call this general field of study "behavioral genetics," but it is actually about personality genetics and the heritability of "temperament." When you see identical twins, separated at birth via adoption, smoking the same brand of cigarettes, having the same IQ,  and driving similar cars on opposite coasts, you can see it dramatically, but the fact is that the underpinnings - the foundations of personality, are surely inherited.

But they are not inherited like eye color. It's complicated.

But what is done with those foundations is what is most interesting. Free will does exist.

Of course we are.

Most of us want to be desirable and desired, and feel terrible if we are not. Obviously, the human species would be long gone if that were not the case. I don't mean just physically, but I do mean at least partly physically. A good lady has many more sources of charm than boobs.

It seems to me that guys tend to outgrow their sexual narcissism - their desire to look physically appealing to females - sooner in life than do ladies. (However, they do not outgrow their interest in females.) On the other hand, guys have, perhaps, more ways of being attractive than ladies have, and they do not have menopause to make them look and feel old.

Why does the subject come up? Because of this report, Why Do Women Have Breasts? That anthropological essay (on pdf) claims that breasts (which are largely absent in the other great apes except while nursing) confer an evolutionary advantage that has nothing to do with sex appeal.

I do not know the answer. I do know that in societies like ours, men love to look at, and to play with, breasties. I have no idea whether that is equally true in the jungle where nobody wears tops.

Today, a Psychiatrist with cancer discusses Two Stories we Tell Ourselves about Cancer - "The Fighter" and "The Hero's Journey." He points out that these dramatic narratives may help some people cope with their fear and pain, but the truth is that having cancer simply sucks and messes up one's life.

I believe it is the people without cancer who enjoy these comforting narratives. Those with cancer know better.

We have posted on statins in the past.

Here's further evidence that statins are helpful, regardless of your triglyceride levels. Maybe all guys should take them (per your Doc's advice, of course.)

What are the odds that a patient you see for an initial Psychiatric consultation will show up for a follow-up second office visit? In my experience, around 90%.

What are the odds that a patient you see for an initial consultation, who has a past (not current) history of drug abuse and alcohol abuse and messy relationships, will show up for their follow-up office visit? In my experience, around 25-30% (unless court-ordered).

Which is why I am free to post this at this moment. People who mess things up tend to mess up getting help, too. But those 25% who do show up tend to be powerfully  motivated to work on things, are highly helpable, and it is a pleasure and a privilege to help them grow up and take charge of their lives.

I can't imagine why our Editor sent me the link to this topic: Researchers claim foreplay overrated. Sexist, no doubt, because the source clearly has little sensitivity to a lady's need to become, um, interested, when we might be contentedly preparing to teach a class on Freud, or perusing House Beautiful or a gardening catalog.

Unless you happen to be Sean Connery, I advise guys to take the time to apply some of those age-old seduction skills instead of acting like a wild animal. Yes, women enjoy being sex objects just as guys do, but a wholesome, red-blooded lady will make it well-worth the effort if you go the extra mile.

And yes, I do know that guys like to be seduced too. Love it, in fact (but they hate to admit it). Licking them on the ear works well, for some reason, and repeating "My big strong handsome man" while unbuttoning his shirt.

Editor's note: I couldn't resist adding that photo from The 6 Biggest Assholes in the Animal Kingdom. I have no doubt that she is "lying back and thinking of England" because he does not appear to be a particularly sensitive male.

This week we had Joe the Plumber in front of his modest home with an old rusty basketball hoop for his kids, burdened with tax debts but uplifted by his aspirations, and we had Sarah Palin stopping the campaign bus to get diapers at WalMart for her baby.

By way of contrast, we had Michelle Obama, a highly privileged Limo Liberal with millions in the bank and a $350,000/yr "administrative" job for some hospital or something, ordering lobster, Iranian caviar, and champagne for a snack from room service - and whining all the while about how mean and tough life is in America if you have two kids, as her husband preaches about taking from Joe to give to...whom?

Those are called "defining moments." We shrinks understand defining moments, because those are the moments when patterns come into focus. Me? I love caviar... if I earn it.

"Good character is made up of three parts," according to a British think tank report released last August: "a sense of personal agency or self-direction; an acceptance of personal responsibility; and effective regulation of one's own emotions, in particular the ability to resist temptation or at least defer gratification."

Why it takes a think tank to figure that those things are foundations of good moral character is beyond me. As Sissy notes in "It's the character, stupid," McGuffey's Reader, if not Socrates, has been saying those things for quite a while.

But those things, in themselves, are not "good character." An effective Mafia Don or a dedicated Jihadist probably has those "three parts" too. What I define as "good character" depends on the code which is placed on those foundations, and the extent to which behavior is consistent with it.

That think tank was trying to come up with a morality-free, "value-free," psychologized concept of character.

Why on earth would they waste time trying to do something like that?

We found Ars Psychiatrica via Dr. X.

He seems like a thoughtful, literate, and kind person - and one of us Psychiatrists who is still willing to regard many human problems as problems of the soul and spirit rather than of "chemical imbalances."

I deeply disagree with his (and Dr. X's) apparent political views, but that's fine with me. Debate is good. Ars P posted a piece on Psychiatrists' coziness with drug companies. He may have a point, but I have never seen this sort of issue in Boston. Furthermore, in my view, Lexapro is manna from heaven for our patients. The guy appreciates Dylan, so he's OK in our book.

On a related topic, Frontal Cortex looks at "rival bits of tissue contradicting eachother." Yes indeed. It's called "conflict," and it's just one more of those burdens of consciousness.

Did you know that identical twins, whether they are separated at birth or raised together, are equally similar in personality, intelligence, interests, and habits? It's a stunning fact, I think.

I have been teaching the essentials of human nature and the related genetic foundations of human differences for years, partly because these things are true, and partly to counterbalance the "blank slate" bias in our society that says that we are all somehow equal until parents and our environment get their hands on us. This assumption lies behind the insidious mid- 20th century idea in psychology that Moms are the cause of everybody's problems. (No, I am not denying that events affect us, but only in the most extreme cases do they shape our basic architecture.)

The blank slate assumption, with its denial of human nature, has a lengthy history, but it was picked up most ardently by Marxists who wished very much to believe that social and psychological experts could shape children in such a way as to create "a new man," better suited to their vision of a utopian society (run by them, of course).

Steven Pinker's 2002 book The Blank Slate: The Modern Denial of Human Nature was one of the first non-technical books (along with books like The Bell Curve) to address the subject. Unlike Larry Summers, Pinker was not run out of town for saying the politically incorrect things he says.

David Thompson has a fine brief discussion of this topic, and posted the short and entertaining lecture below by Harvard's Pinker in which he also touches on the topics of the arts and of parenting:

A piece on the subject in the NYT notes:

The myth is that like magic, preventive medicine will simultaneously reduce costs and improve health.

Read the whole thing. Sadly, except at the margins, there is little we can to to prevent disease. The wishful thought that we can control fate and the gods never quits, though.

Columbia University is lucky to have Simon Schama on board. I have been a fan since I read his rambling masterpiece Landscape and Memory, and I have attended his lectures on Rembrandt.

You can get a lot out of his rambles through history, art, culture and philosophy. The man has been prolific.

I'm fairly sure I don't agree with his politics (but that's not normally his subject), but he does have a new book out: The American Future: A History.

Although he loves his new home in America, I am going to take a pass this time. I don't need immigrants to talk to me about our future. I have Massachusetts Bay Colony and New Hampshire roots that even Simon might not understand.

As a Psychiatrist and Psychoanalyst, this graph of mentions of "psychoanalytic" from Gene Expression (we linked the article in Graphs on the PoMo Fad) pleases me:

Why does it please me? Because Psychoanalytic ideas were hijacked and distorted by Marxists, Existentialists, the PoMo movement, "progressive educators," academics, and other miscellaneous Leftist or anarchic moonbats - none of whomever understood it at all. The less those people talk about it, the better.

Psychoanalysis is about plumbing the depths of human nature and the human soul. It's closer to anatomy and surgery than it is to "critical theory." It's never PC, it's somewhat dangerous, and it's not for amateurs.