The Secret of Climbing Perception

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It turns out that Tom Stafford, co-author of Mind Hacks, is a rock climber. He wrote a nice blog post about the psychology of perception and climbing entitled Rock Climbing Hacks. In this post he gives some of the neuroscience background to what climbers call 'route-finding', in other words the ability to pick out handholds and footholds as you go up a wall.

I really appreciated this post after this past weekend when I climbed to the summit of some of the best rocks in the Mid-Atlantic. Somewhere midway up the several hundred foot rock I learned that my idea of a 'good' foothold had changed dramatically. Suddenly a good hold was any little nubbins of a protrusion that I could use to balance on my big toe. And a 'good' handhold was one that I could hold onto just enough to stay balanced on my toes. Miraculously, it worked and I didn't fall. Pretty cool.

Who Else Wants To Climb Like An Orangutan?

(See more rock climbing designs from CafePress.com. While you're at it, pick up a My Three Shrinks t-shirt.)

While googling around the Internet I found an article by Steven Kotler on the Psychology Today blog entitled "How We Learned To Walk: The Uneasy Origins of Rock Climbing". Talk about a surefire, catch-Clink's-attention title!

The article reviews anthropology finds over the years and talks about a new theory of human evolution, specifically how humans began to walk upright. Anthropologists once thought humans started walking upright after they came down from trees. Now primatologists are suggesting that walking is a natural offshoot of climbing. They site orangutans who have been observed "tree walking", or walking across branches while holding an upper branch with both limbs (a bit like a toddler 'cruising' while holding on to furniture). This climbing method is energy efficient and stable because it allows for four points of contact at all times---it also happens to be the way a beginning rock climber climbs.

OK, so it's a bit of a stretch (literally) but at least it gave me a chance to link some of my favorite subjects together in one post.

10 Sure-Fire Headlines: Now You Can Have a Thousand Posts in Only Three Years

Brian Clark wrote on Copyblogger back in 2006 about "10 Sure-Fire Headlines That Work." This is a classic article on how to write headlines that make people want to read the article or click on the link.  I came across it just as Dinah was reminding us that Shrink Rap's 3-year anniversary is coming up on April 22, and this post here is our 984th post.

"Wouldn't it be cool if our 1000th post was on our 3rd anniversary?"

So, I came up with the idea that our final posts should have "Sure-Fire Headlines That Work."  So, stay tuned for our final posts in our triennial millenium.

Why I Hate In Treatment

Dinah, I still love you even though you ignore my opinion and write about In Treatment.

A while ago Dinah wrote about why she hates the television show House. I didn't have strong opinions about the show, I had only watched a few episodes and I thought they were OK. If Dinah hated it and wanted to blog about it that was cool with me. So now, I'm taking my turn.

In the interests of full disclosure, I'll tell you first that I've never had cable TV. Not only that, but since about last July I haven't had a television. I really haven't missed it. I've been to places that had cable TV and what I saw just reinforced the idea that there was a lot of content that just wasn't worth watching. I spent more time channel surfing than viewing. So that's my disclaimer. (I watched the first week of In Treatment on the Internet.)

In general I think it's a bit unsettling to be immersed in TV culture. I notice it more now that I'm not part of the American "viewership", but it feels odd to go somewhere and listen to people absorbed by characters who aren't real and life stories that don't actually exist. I mean really, there are earthquakes and wars and important international events going on and we're wondering who is going to get voted off American Idol? Don't we have real issues to talk about?

As far as the show specifically, I don't like it because it's neither treatment nor is it therapy. Face it, the guy's a goofball whether he's a psychiatrist, a psychologist or a licensed angel adjuster. If you're going to be that far off base from reality you might as well write a show around the complicated dysfunctional relationships between an auto mechanic and his customers. (Oh wait, there was that Taxi series---that's pretty close.) It's too laughable to be drama and too self-important to be comedy. Like I said when it first came on, I'd rather have a more realistic series about seriously mentally ill folks making their way in the world than a gossipy pseudo-introspective contrivance like In Treatment. Dinah didn't like House because the doctor was obnoxious and the show wasn't realistic. Oddly enough, the same reasons I don't like In Treatment.

I'd even prefer blog posts about ducks.

In Treatment: Reflections on the First Week of Season Two

I liked it. I really liked it. My attention stayed focused, my blood pressure didn't soar. I didn't rant once (I don't think, can that be? Maybe I'm just starting to age gracefully).

Now that I've had time to reflect, here's what I liked:

In Treatment captured some of the sub-text, the underlying angst, that we, as therapists, might fail to talk about in a unifying way.

So Mia meets her therapist 20 years later: now she's a head litigator in a prestigious law firm and she sports a Prada suit--he's the vulnerable one being sued and she can save him! She was very attached to him, and he left her (to move) in a way she found painful. And he never contacted her. From the shrink side of the couch, that doesn't seem odd--- psychiatrists don't typically continue to initiate contact with former patients. She feels jilted, and she's never really gotten over that or something else. It's easy to see both sides-- she's too demanding, he's too aloof, why is this still lingering for her? It's pulled to the open when Paul says she must like showing him both her success and her pain. This was good.

And there's his frustration with the limitations of the therapist's role--- he wants to DRAG his patient who is refusing cancer treatments to therapy:if she were her daughter. If only Paul's daughter would return his phone calls. What would the CEO in the cashmere coat do? The one who wants to drag his daughter home from Rwanda? Oh, if only Paul's daughter wrote him such lovely, heartfelt emails. The father-daughter issues are upon us. And if that's not strong enough, there's the whole Mother-son issue with Gina that bonks us over the head.

I've criticized the blurred boundaries in the Gina's relationship (friend, supervisor, therapist, have a shot of vodka?) with Paul. But the reality is that when one psychotherapist consults another, the issues can get a little blurry and the lines of when and where the lines lie might well be a bit fluid.

So, I liked it.

In Treatment Season 2, Episodes 3, 4, and 5

Oliver and his parents present for family therapy. Only the family has split and Oliver prefers the company of his over-solicitous mom. There's not much to say about the session-- looks like a family session to me. Paul does nothing too unusual, and family therapy is hard. There are many agendas and many subtexts, often an overwhelming amount of material to deal with.

So far, what we know is that the personalities are all strong and the issues are complex. Mom makes the point that dad is irresponsible. He plays Wii with his friends and parties all night and he doesn't stock the fridge for his son. Dad makes the point that he makes the bucks and Mom is a perennial student--we've already been set up for the idea that the face one puts on may betray the reality of the behavior. Mom hovers, she moves too closely to the boy and doesn't even suggest he carry his own backpack, and Oliver sucks it up and plays the two of them off each other. It will be interesting to see what comes of the family.
-----------------------
Walter is a big-shot CEO in a cashmere coat, or so he tells us. He can't sleep and he wants his problems solved quickly, even if he has to pay more for more intensive sessions. In fact, he seems to magically want Paul to know what the cure is without being very forthcoming about what the problem is. Walter seems to want to spar with his new therapist, and he's quick to be condescending. At some point, he becomes downright angry when Paul doesn't agree that Walter should rush to Rwanda and 'rescue' his daughter who is working in a clinic. Walter begins to leave in a huff-- he came for relaxation exercises and an insomnia cure, not to talk--when he falls to the floor clutching his chest. Paul tells him to breathe (finally!) and gives him some water. No one calls 911, and Walter tells him, in a gasping, pathetic sort of way, that these episodes always resolve.

Walter's persona is too overtly grandiose-- I can't help but wonder if his blowhard narcissism isn't a defense for an underlying insecurity (--there, I'm finally sounding like a real shrink!). What isn't he telling us and what secrets are still to be had. So Walter-- insomnia, panic attacks, is he really as important as he tells us? An edge of paranoia? And, okay, I admit, the 'bipolar' word crossed my mind when he talked about taking a one hour nap and then being good to go for 24. There's energy and there's Energy. Too soon to tell.
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Paul returns to Maryland to see Gina. She's being deposed in his lawsuit. Paul had decided he's going to lose his license and go bankrupt. And, oh, "I've decided I'm sick of sitting in a chair day after day listening to peoples' problems." We find out that Paul's office is in his apartment and he sleeps on his couch and never sees his kids. He's a disaster, and he confesses that by the end of his patient's therapy, he hated Alex. He's come to Gina for clarity. They have a drink and a lot of ground is covered.

Paul and Gina: so like what is this? Sometimes they call it friendship, sometimes they call it therapy, sometimes supervision. They flit in and out of different modes and the conversations are the same, no matter what they call it. He doesn't want therapy, and then he does want therapy. They're sitting next to each other on a couch, sipping vodka, when they decide to resume therapy.

Signed, Sealed, Delivered: Status Update From The Shrink Rappers

Later this month, Shrink Rap will celebrate 3 years and we're coming close to the 1000 post mark. I'm not sure if we can get them to coincide. We have news:

Signed, sealed, and delivered, the Shrink Rappers have a book contract. So far, the tentative name is Off the Couch: How Psychiatry Works and What Psychiatrists Think. It won't stick, no one likes it, but for now, it's a "provisional" title. The book will be published by Johns Hopkins University Press, sometime in 2011. Since it's not written, it's hard to have an exact release date.

When I asked our readers for thoughts about a sample chapter, I got a lot of conflicting feedback, but one theme was voiced by several-- the book is more serious, more dry, not light and witty. The editorial feedback we've gotten when we tried to mimic the blog was clear: we have "weird doctor humor" and there was concern that we trivialize mental illness. Other than that, they loved it and it was approved unanimously, what can I say? So the book will be different than the blog, it will be a look at how psychiatry works, but it will be a serious endeavor, not banter. If you like you Shrink Rap, you may or may not like Off the Couch. If you like Shrink Rap, I have good news: we're staying here in the blogosphere, we're staying free, and we're staying weird-- ducks, chocolate, and all.

And what about our My Three Shrinks podcast? That's a good question, one I've wondered about myself. We have some podcasts "in the can" waiting for production. I don't know when they'll go up, I don't know when we'll resume on a regular schedule. One thing I do know is that we will be resuming My Three Shrinks with renewed enthusiasm, but it may not be until after we finish the draft of the book. That's due in June of 2010, and we're aiming to have it done a few months earlier.

So ClinkShrink is off climbing every mountain. Roy is looking for the next gadget to count gigabytes on. I'm signing on to a year as president of our state psychiatric society and thinking that between that and writing the book, I'll be tired of psychiatrists pretty soon.

We're all excited about the book. Thank you for reading Shrink Rap and for all your comments and insights; our readers really are what fueled our interest in writing about our work.

In Treatment: Season 2, Episode 2

April enters and we're struggling to figure out what she's doing here. She asks a lot of questions, and she offers information, but what's she doing here? Paul reassures April she can't offend him. "I can't?" "Well, of course you can, but I can take it." Oh, can I try? It was a funny thing to say.

April tells us about her last imperfect therapist who told her the same insignificant story twice. April left the treatment without calling and "the woman was borderline stalking me...second of all she was an idiot." April tells us right off that she can't take being pushed. She tells us she wants to be listened to, and Paul's wasting her time asking about her last shrink. Finally, they come to a calmer place and she has to write down her chief complaint, it's just too hard to say. April has cancer, she doesn't want to talk about it, she just wanted to tell someone. Lymphoma.

April is angry at the medical care she's gotten, she feels like a specimen. She hasn't told her parents. Or anyone else. April is angry with the treatment world. She's not sure she wants treatment and she wants to think about alternative therapies. And then Paul says something nice, he puts April's difficult demeanor in to a nice perspective: "You seem to be a very independent person."

He gives her a list of what she should do: talk to her oncologist, tell her parents. She leaves in a huff without scheduling another appointment. "I'll call you." And we think she might not.

There's not that much to say about the session. Paul has a history of pushing patients a little too hard (if you ask me). This is a difficult patient and we don't know if her anger is part of her, or an acute response to a horrible stress. We do know that, at least for now, she's quick to judge and feeling terribly vulnerable. She pushed Paul by asking about his decorating, why he's moved...and this time he crosses no boundaries.

In Treatment Without Boundaries: Paul Gets Sued

Okay, I'm going to try to follow the series. ClinkShrink, please love me anyway.

The season opens-- Paul, now with too-short hair, unshaven and in jammies, opens his door to Alex's dad. Dad is angry that he's lost his son, the pilot, and says Paul should have told the Navy he was unfit to fly. He wants Paul to suffer: here, have a subpoena, you're being sued and Dad is hand-delivering it.

Lawyer's office, Mia in a Prada suit. Paul is surprised, it's not the male lawyer he thought it would be, and we're led to believe this is one of Paul's old girlfriends, he's clearly uneasy. We learn he's 53, now divorced, moved to NY, and he has an MS and a Ph.D-- somehow I thought he was a psychiatrist, but now we know he's a psychologist. Also, I thought his diplomas last season were from the University of Pennsylvania, but those aren't among the schools listed. Oh, and Mia keeps getting disrupted during this very important meeting-- a call from her father is put through where she tells dad he looks great in green, and a colleague bursts in to the session. Nothing feels sacred here.

Paul acts surprised when he hears the term "malpractice" and it's news to him that Alex's death is being construed as a suicide. And now the episode gets interesting. Paul hasn't sent his clinical notes, ah, he doesn't take notes. That could be a problem. Is it better to be a bad therapist who takes notes then a good therapist who doesn't, he challenges Mia. No one's told Paul that it's best to be a good therapist who takes notes. I'm not sure of the rationale for never taking notes (and that is what he says, he Never takes notes). And it gets even more interesting when we learn that 20 years ago he did take notes, back when he was Mia-the-litigator's therapist. Ah, he left her precipitiously when his family moved and she felt abandoned. He's sorry she felt abandoned, and she jumps right on his words...you felt abandoned, and he seems to have forgotten the details of her distress, of the gift she gave him, of how hurt she was that he never contacted her. Therapists do sometimes if the patient is special. We feel her pain, we watch Paul squirm, and the tables keep turning all episode as to who is grilling who. Mia asks Paul some questions that leave him feeling defensive, angry, and like some of thse strings might go pop at any moment. Mia then gives him an earful on the loneliness and pain of her life. It could have been prevented (we're left to wonder why) and while they both agree this is a bad idea (No? ). Mia gets the final satisfaction of telling her long ago abandoning shrink that his time is up and she has another client. Touchée

It's like everyone here is naked. The therapist is thrust in a room with his former patient and it's not what he wants. She reassures him it's okay, but we know it's not okay. She asks how a patient leaves treatment (Alex) too soon, and we hear the pain of a therapist leaving when a patient still needs them. You're left to wonder: can a therapist force someone to remain in treatment (generally, no) . And is there ever a way for a therapist to depart without causing angst. People move, but somehow I have the sense that Paul could have done so with more sensitivity.

Back with the next episode shortly.

Should People With Mental Illnesses Hold Public Office?

After my post Depressed and Running for Governor post, one commenter (MWAK) asked if people with depression should run for governor. Novalis responded with his own post, Uneasy Lies the Head where he says No and gives his reasons for his thoughts.

It got me thinking. As a psychiatrist, we generally feel mental illness should be destigmatized, and life should be more 'fair' for those who suffer from mental illnesses. I have to say, sometimes I struggle with this--- it's nice to be accommodating, but if the symptoms of one's mental illness make one's companionship intolerable, or one's job performance erratic and inefficient, or one's behavior disruptive or dangerous, how much should others be expected to bend?

So Governor or President....in Doug Duncan's case, it seems he personally decided that the campaign itself was too stressful while he was actively symptomatic. Let's suppose that we can agree that we don't want someone with a symptomatic mental illness running our country. Actually, I don't want them driving my bus, train or airplane either, not while they're thinking about how to suicide or dealing with slowed reaction times or poor judgment.

For the sake of argument, let's say our would-be President or Governor, or pilot or bus driver or armed soldier or police officer has a history of mental illness. Let's suppose it was treated with full remission of symptoms and he hasn't been ill for a while.

Novalis says No: psychiatric illnesses are chronic and recurring (and for some reason he thinks hypertension and diabetes are more likely to stay control or be predictable, but I'm not going there), symptoms can be insidious, gradual, and hidden.

I agree, they can be all of these things and I don't want someone in the midst of an episode running a ship if there really are those buttons one can push to blow up the world. Or decisions that need to be made quickly. Here's my sort-of/maybe beef with this logic: people without mental illnesses can : 1) suddenly get them, 2) have bad judgment or make bad decisions in the absence of a psychiatric illness, 3) keel over and die or become disabled with no warning. We need to have provisions for such things, and the fact that it's higher probability with a history of mental illness doesn't change that we need to have perimeters to check on people involved.

One thing seems clear: If you take away someone's job simply because they seek treatment, then you limit the ability of someone to get treatment. I'd rather have a pilot on Prozac who is being closely monitored, then a pilot who's been afraid to tell anyone his dark thoughts about the plane I'm on.

Novalis says, "If or when our understanding of mental disorders progresses to the point where we can more reliably predict and modify their course, then a major mood or anxiety disorder might survive the vetting process."

We can't predict the behavior of anyone (remember that W guy?). If we know someone has a history and an increased likelihood of recurrence, at least it can be openly discussed and some checks can be put into place.

So no answers here. I do wonder why it is that people have been required to have psychiatric evaluations before all sorts of procedures (in vitro, bariatric surgery) and we don't require our presidential candidates to spend a couple of hours being evaluated by a psychiatrist before we let them run.

I will point out that many of our presidents have had serious mental illnesses, including some of the most popular of presidents.

I'm rambling. Hope I didn't say anything too objectionable.

[Edit 4/5/09 11:30: This is Roy. I just wanted to clarify something here. When I first read Dinah's post, I thought "OMG, she's saying people with, say, a history of bipolar disorder shouldn't fly planes or be President." After reading some comments, esp Nonstandard's comments, and then Dinah's reply, I realized that what she wrote does not clearly state what she seems to intend. So, as a way of either clarifying or distancing from what she said, here is what I think : A 'diagnosis' of anything should not -- in and of itself -- prevent someone from taking on a high-responsibility position (IMHO). The question should be about how they are currently functioning. And if a position carries enough high risk (say, the nuclear button-pusher job, prez, airline pilot), then there should be built-in safeguards that require some sort of ongoing assessment of functional capacity, regardless of one's presence or absence of diagnostic labels. Come on, even dealing with, say, a divorce or your daughter's breast cancer could have a negative impact on one's performance in certain positions. I'll put more in the comments, esp asking why the legal system has put us in the situation that Nonstandard Mind points out in the first place. Back to your regularly scheduled program.]
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Dinah's Addendum
Arg From Dinah! See my clarifying remarks in the comment sections.
Regarding pilots: I'm not the one who said they can't fly with a history of bipolar disorder, it's the FAA's idea. And the FAA is pretty picky about what meds pilots can take and still fly, psychotropics in general are not allowed, so this pretty much eliminates anyone with a chronic or recurring mental illness. Benedryl is a no-go as well, so no acutely allergic pilots. What surprised me is that they can be on blood thinners or anti-arrhythmics and people who need those medicines generally have underlying illnesses that make them susceptible to strokes or sudden death.

Suicidal Tweets, Demi Moore, & The Samaritans

RT John Grohol wrote on PsychCentral:

"I’m sorry, but I’m a bit aghast at this story of someone randomly twittering their suicidal thought to Demi Moore, and then a bunch of people who saw it retweeted by Demi called the police. The police found the person who said they were going to kill themselves, and that person is now under psychiatric evaluation.

I guess this is “news” because someone sent it to Demi Moore. Demi Moore is a celebrity, so anything that touches her is defacto “news.” Does this mean the only way we can get attention/help for mental health issues in the U.S. is by tweeting a celebrity? Really, has it come to that?"

Read the rest here.

In Treatment: What the NYTime Says.

To those who wrote in telling me how to get to the right click:

THANK YOU!!!

Everyone is jumping on the bandwagon. First I blog about In Treatment, now the New York Times has to write about it. I couldn't read it all, too many plot spoilers.

I'm going to give it a try, if I like doing it, I'll keep it up. ClinkShrink wants to stuff me in a closet somewhere. I'm trying to teach her to delete things unread.

Oh, and these people I blog with, they talked me into this MacBook thing. I finally figured out how to copy and paste. How do I save a graphic I see on the internet??? I miss my right-click mouse button so much.

April Fools!

It's a Joke, It's a Joke!!
Read Roy's Post.
It's a Joke!!

Oy, I got it, on the Mac it's command C/ command V, not control C....
I'm getting there.

Health Insurance Co's to Stop Listing Dead Docs in Online Physician Directories

All health insurance companies in the US have promised to stop their practice of including in their online provider directories all physicians and other health care providers who have at some time in the past taken one of their patient members.  Instead, they will actually include only those providers who can take new outpatients. 

"This should end the frustration of having to call, say, all 37 psychiatrists in the directory, to find that only 3 are taking new patients, because the rest are either inpatient-only doctors, retired, deceased, moved, or have stopped taking new patient members because of our low reimbursement rates or our burdensome bureaucratic hoops we employ to drag out the payment process," said Lyle Waggoner, president of Big Corporate Business Shield of America, the nation's largest health insurer.

"Of course," he adds, "that means that we now only have 3 psychiatric specialists in our directory, but that's all we really had before anyway."  The American Psychiatric Association has praised BCBSA for negotiating this change in policy, which takes effect starting on April 1.

Industry experts predict that more patients will actually receive treatment, because many used to give up in frustration after the 10th or 15th phone call.  "We were considering adding 'Insurance Frustration Disorder', or IFD, to the upcoming DSM-V," said APA president-elect, Dr. Carol Bernstein, referring to the upcoming fifth edition of the diagnostic manual of psychiatric diagnoses used by insurance companies.  "We may now have to reconsider the diagnostic criteria."

Health care consumers who are looking for new providers are pleased with the change.  "I only had to make three phone calls to get an appointment in 3 months.  I used to have to make thirty calls, causing me to go to the ER for homicidal ideation," said Anna B., a BCBSA member in Chicago.  "I've heard that they may also make it so my doctor gets paid within 3 days after completing a simple online form.  Now that's crazy."

Insurance companies plan to prove the providers in their online directories are taking new patients by including next to their name the number of outpatient claims for new patients submitted in the most recently available 12 month period.

Depressed and Running for Governor

Doug Duncan has a strong family history of bipolar disorder, and during his campaign to become Governor of Maryland, he became ill with Major Depression. Mr. Duncan dropped out of the race, and let the reason be known. In today's Baltimore Sun, there is an article about his symptoms and recovery. Apparently he made a good recovery with the trial of medication and therapy, and is now doing well. Could he toughed out the campaign? This is a personal decision.

So what do you think-- in our efforts to destigmatize mental illness, would Mr. Duncan's history of depression be a reason people would vote for him in the future?

My guess: I think people would not vote for a President with a history of depression ("Will he push the button in a moment of helplessness? What if she becomes depressed after a terrorist attack?") Otherwise, I think he still has an open door. Just my opinion, do chime in.

And I just bought a brand new Mac Book. I can't seem to work the copy/paste (cntrl c/cntrl v) thing for links. Oy.
Try this if my link didn't work: http://www.baltimoresun.com/news/local/bal-md.vozzella01apr01,0,1621279.column?page=1

Oh, and I can't get a graphic in or put labels on the post. ClinkShrink!!!!!!!!