Tuesday, September 18, 2018

Goodbye New York

As my current patients know, I'm relocating to California next month.

New York has been good to me in many ways, but I've developed a chronic knee condition that makes taking the subway impossible. I've always loved Northern California, and I have family there. I've been thinking about moving there for several years, and now is the time.

I'm in the process of obtaining the California LCSW license and will be looking for a job. I'm not sure when I'll try to start a private practice, as I want to get some exposure to other professionals and general practice in California first.

Sunday, May 27, 2018

Is Marijuana Safe?

I've long been suspicious about claims that marijuana is harmless. I was interested in this article in the Washington Post, by a neuroscientist. Any drug changes the body's chemistry.

Tuesday, May 15, 2018

College Students and Suicide

Recently The New York Times published an article about a growing controversy: As more college students commit suicide, parents are frustrated by medical and academic confidentiality laws that seemingly have prevented the colleges from contacting them about their children who are having mental health problems. What should be done about these situations?

When new patients come to my practice, I have them fill out a form that includes space to list an emergency contact. So far, no one has refused to name an emergency contact. I've only called an emergency contact once or twice in 16 years, but it is necessary for me to have this information, because someone's life could be at stake.  Why don't colleges and universities do the same? I don't know. Perhaps their administrators believe psychiatric emergencies aren't their purview.

Of course, it's possible that a student would list someone other than his or her parents as emergency contacts, in a university setting. But that's not the point. The point is that there should be someone who can be called who can assist the student in accessing resources--that could include calling the parents, as laypeople aren't bound by confidentiality laws.

An emergency contact person is ideally someone who is willing to escort the person to an Emergency Room or stay with the person until the crisis is over.

In a genuine emergency, confidentiality laws don't apply. If someone in my practice tells me that he or she is planning on committing suicide, I ask to escort them to the Emergency Room, and if they refuse I would call 911. I do not need a confidentiality waiver to call 911, but, I have in fact never needed to call 911, because every time, the person has agreed to go to the hospital. A college counseling center should be staffed by licensed clinicians who are obligated to work with their patients the same way that I am.

What about situations in which a college student is deteriorating, but it's not clear if it's an emergency? The student should be asked to take a leave of absence for a semester and engage in mental health treatment. Then the treating clinician should be asked to sign off on a form stating that the patient is not at risk, before the student can resume classes. Of course, it's possible for someone to relapse--but at that point the parents could not reasonably claim they didn't know anything was wrong. If they are in contact with their child at all, in most cases they would at least  know that their  child was not attending school that semester.

Thursday, January 4, 2018

Some Important Tips About Being in Psychotherapy

Over the past 30 years, the general public's understanding of psychotherapy has declined. This is because of the growing influence of health insurance companies and pharmaceutical companies, which prefer that people take psychiatric medications rather than going to psychotherapy. It's not uncommon for me to hear patients use the verbiage of pharmaceutical companies without realizing they are doing so. This societal change has caused problems for me and other therapists.

Here is a brief summary of some aspects of being in psychotherapy and how therapy works, that used to be common knowledge but are now mostly unknown among persons under 45:

1. You do not have to use normal social rituals with your therapist. You do not have to shake your therapist's hand, ask them "how are you?" or inquire whether they had a good time on their vacation. It's the one type of  relationship that's about you and not the other person, and this is part of why and how psychotherapy cures.

2 Your therapist wants to hear everything. I discussed this in a previous post. Your history of sexual abuse, your porn habit, your poor money management and bad credit--people go to therapy to talk about the things they can't talk about elsewhere--that's one of the reasons why therapists exist. If you tell lies to your therapist or avoid mentioning important information, your therapy will not be effective.

3. If your therapist confronts you on something you did or are doing in therapy, such as repeatedly showing up late, or behavior in the session, such as sexual provocativeness, the purpose is for the both of you to explore what the behavior means. You do not have to say "I'm sorry." Instead, you should ponder the meaning of your behavior and work with the therapist to understand it. Things that other people say that are meant as criticisms are meant by your therapist to prompt self-exploration. (On the other hand, if the dysfunctional behavior continues, the therapist has a right to stop working with you).

4. The reason for #3 above is that an important part of what's called "insight-oriented therapy" (also known as psychodynamic therapy or psychoanalytically-oriented therapy) is a discussion of the dynamic between the therapist and the patient. In longer-term therapy, particularly therapy that lasts more than two years, patients often undergo a regression and start re-enacting childhood behaviors with the therapist. This is a phenomenon known as "transference." In some cases it is very important for the therapist and patient to discuss the interaction between them and what it means, as behavior in the session may reflect long-standing behavioral patterns or relationships in early childhood.

Psychotherapy is about more than learning "coping strategies." A patient could research coping strategies on the internet. Ultimately psychotherapy is about personal growth through a specific type of dyadic relationship. Psychotherapy harnesses the human tendency to grow and develop through interaction with another person. When psychotherapy is effective it is a permanent cure--perhaps not a 100 percent cure, but a cure that does not go away when the therapy ends--unlike medication.

Your Privacy

This morning I read this story in The New York Times. Not to worry--because I'm old-fashioned (as well as verging on old) I don't keep patient records in a "cloud" or even on my computer. My records are written in pen-and-ink and are stored in a locked file cabinet in my apartment in a doorman building.

Tuesday, October 31, 2017


Over the past year I had been experiencing the pervasive sense that large numbers of people in the US were going crazy. From neighbors, colleagues, patients and random persons on the internet I heard statements that sounded extreme in their despair, fear and rage. At times the statements entered the realm of clinical paranoia. I was told by left-of-center persons that America was full of Nazis, and by persons to the right that the "Left" was engaged in a purposeful campaign to destroy the Constitution and install a totalitarian regime. I blamed the media and our two main political parties for the incessant drumbeat of hysterical "news" stories, inflammatory language and demonization of others that fed this mass hysteria. But it turns out that the real story is even weirder: It was the Russians.

Why do people succumb to propaganda and why can't they see that they are being manipulated? There are many factors:

Conformism: Humans are social animals and want to "belong." If a group of people with whom someone wants to associate insists on a shared belief system, many people will adopt the beliefs even though those beliefs have no basis in fact. The strong need to "belong" will override logical thought processes.

Displacement: Persons with histories of abuse or neglect in childhood deal with anxiety, anger and even outrage, but may be unable to connect those emotions with their childhood experiences due to wanting to protect the images of their family members. Instead, they direct their fear and outrage toward public figures or groups or imagined groups. It is emotionally convenient to fear and hate those you don't personally know.

Self-esteem: Many people revel in a belief in their own moral superiority. By aligning themselves with what they see as a virtuous or righteous position and condemning others who disagree, they feel better about themselves.

What can counter these dangerous tendencies? Here are some tips:

1. Learn history. The better educated and older people I know demonstrated less susceptibility to the propaganda, and not just because they don't use Twitter. It's that they (we) have seen it all before, and what we haven't seen personally we have read about. Propaganda and popular hysteria are nothing new. There have been waves of mass hysteria throughout history, often with atrocious, catastrophic or genocidal results.

2. Use logical analysis to assess claims made by groups, including established groups. It doesn't matter who made the argument or published the news story if it doesn't make sense.

3. Listen to your gut instincts. If something seems fishy, it probably is. If you can't put the pieces together, maybe it's because they don't fit. Ask yourself: Is something missing from the story? Does the story seem too bad or too good to be real?

4. Live a healthier lifestyle: Acknowledge your childhood traumas, build your self-esteem in healthy ways and seek friends who don't demand that you agree with their political beliefs. Talk to different types of people and listen to them.

Tuesday, October 24, 2017

Harvey Weinstein Heads to Rehab

Yesterday I read that Harvey Weinstein is checking into a facility for treatment of "sex addiction." Is repetitive sexual harassment or sexual assault a form of sex addiction? 

Sex addiction, like any addiction, is a repetitive, compulsive behavior. The hallmark of any addictive behavior is that it is experienced as being outside of the person's control. A common self-test for addiction is to try to stop the behavior for a period of time. If you find that you are engaging in the behavior after you told yourself you wouldn't, this could be a sign of an addictive disorder. Simply making something a habit is not itself  a sign of addiction. If the behavior is under the person's control, an addiction has not been established regardless of how dysfunctional the behavior is.

Sex addicts typically either frequent prostitutes, pick up random strangers for sex on a regular basis, or spend hours masturbating to online pornography. Some also compulsively attend peep shows and strip clubs. Eventually they start to realize that they are spending enormous amounts of time or money (or both) on their sexual activities, and perhaps endangering their health or even their lives. At this point an addiction has been established, and sometimes, people seek help.

Based on the publicly reported evidence, Weinstein appears to have exercised great control and planning in his harassment activities. Subterfuge and the assistance of allies appear to have been involved in the various scenarios that have been reported. The cost of hiding the behavior appears to have been calculated. This type of planning and execution is rare in addictive behaviors, because, as I said, the hallmark of addiction is that the behavior has spun out of control. In addition, on a deeper psychological level, addiction is about a regression in which the person unconsciously grants power to a substance or behavior, enacting a dominance/submission dynamic in which the addict is the submissive. In Weinstein's case, it's obvious that the dynamic went the other way in his encounters with young actresses and models.

If it's not an addictive disorder, is it possible that Weinstein has a different clinical disorder? It's possible and perhaps likely, but it may be one that it is extremely difficult to treat. Pleasure in exercising control and dominance over others is sadism, a psychological phenomenon that is rarely treated because sadists don't seek help. I'm not aware of any standard treatment protocols for sadism except perhaps psychoanalytic therapy to resolve early childhood traumas and conflicts, but, as sadists are rarely interested in such treatment, there isn't a lot of evidence regarding outcomes. Sadism is often a component of antisocial personality disorder (also called sociopathy or psychopathy) and this disorder is notoriously difficult to treat. Confrontation and limit-setting may be the only ways to address sociopathic behavior. People, like other animals, respond to negative consequences for behavior.