Monday, September 12, 2022

The Restaurant is Down the Street

 In a follow-up to my last post, there's an additional trend in many of the inquiries I've been getting recently. Since I became certified in EMDR therapy and have posted this in my advertising and other profiles, I have been getting a lot of inquiries about whether I am taking new patients "for EMDR." 

I'm not running a restaurant at which people order whatever they like off the menu. Because what I do is healthcare, I have to start with an assessment. Not everyone is appropriate for EMDR. In fact, the more I do EMDR, the more I become convinced it isn't for everyone. It is most appropriate for persons who, despite having had traumas and PTSD, have a good sense of identity and a history of supportive interpersonal relationships. Sadly, many people who come to therapy struggle in these areas. 

There are relationships that are supportive yet dysfunctional. But I also come across some patients who have had no significant relationship of any kind with an adult growing up.  The human personality is formed by a combination of genetic traits and early relationships and interactions. A child who doesn't have some type of significant relationship with a parental figure growing up ends up with what are called "ego deficits." Can these people be helped? Usually. Often, they need long term supportive therapy. Many such people have addictions and often also benefit from the structure and support of a 12 step group or something similar. But I don't believe EMDR is for them--it is too distressing and too stimulating of childhood traumas.

 The goal of EMDR is to help the person process the trauma so that their brain recognizes the trauma as being in the past, and secondarily, to help the person gain insight into self perceptions that have been caused or colored by the trauma. 

Here are a couple of examples (I have changed names and some details for confidentiality): "Alex" had a traumatic childhood in which he was physically and emotionally abused at times. However, his other parent was supportive of him, if weak. The family overall was close and engaged in typical family rituals and events.  "Alex"  did well with EMDR.

"Laura" grew up in a fractured family. Her parents divorced when she was young, and she rarely spent time with the non-custodial parent. Her custodial parent had many problems and not much time for her. Other adults were not significant in her life, nor did she have older siblings who might have partially filled in the parental role. Laura suffered various types of abuse. She was also subject to traumas that are common in victims of neglect, such as exposure to inappropriate material. "Laura" did not do well with EMDR. 

I see more patients like "Laura" than many might imagine. It's one of many types of experiences I've had in my decades-long career that have convinced me that psychotherapy is no substitute for a childhood. I believe the main path to better mental health for our society is to do a better job overseeing who gets to raise a child. I believe it is a privilege and not a right. 

Monday, September 5, 2022

Internet Diagnoses and Incurable Disorders

 I'm restarting this blog because I've been noticing new trends and things to write about. 

I've been noticing a change in how people make initial inquiries to my practice. In the past, people were mainly concerned with whether I was taking new patients and whether I accepted their insurance. They would also sometimes ask me what my "approach" to therapy was--a difficult question to answer informatively to a layperson. They often shared what their main symptom was, such as depression or anxiety.  They rarely discussed previous therapy in their initial inquiries. When I met them, I found that some had seen a therapist for a year or two before, perhaps when they were in college, or had been sent to family therapy as a teenager, or both. 

In the past year or so I've been getting an increasing number of inquiries from persons who say they have already been going to therapy for years, or have been in and out of therapy for a long time. I'll be honest: This information does not make me want to work with the person, because the information  implies  that their condition is chronic--in other words, that it can't be resolved. Like most people, I like to feel successful in what I do. 

There has been a growing misconception about therapy in the past decade--that it's a way of managing a chronic condition.  It's true that therapy can be used for this purpose--in which case, the type of therapy is called "supportive." Other types of therapy, including CBT, psychoanalytic therapy, EMDR etc. are supposed to resolve the patient's problems. Yes, that's right--many psychological problems are curable. This is information that pharmaceutical companies don't want you to know.

But there are conditions that aren't curable. I'm not just talking about genetically based illnesses such as schizophrenia or bipolar disorder. Borderline Personality Disorder and Narcissistic Personality Disorder also can't be cured. These disorders are common. Many people who have struggled with chronic anxiety despite years of therapy actually have Borderline Personality Disorder (the other possibility is that they had bad therapists). A large percentage of persons with chronic depression actually have Narcissistic Personality Disorder and some have Dependent Personality Disorder. Does therapy help these people? A little bit, maybe. 

I've also been getting inquiries from people who go into detail about what their problems are--I don't mean that they give me a lot of information about their lives--risky to put in an email, but at the same time helpful to me--I mean that they give me a plethora of self-diagnoses. They claim that they are "co-dependent," or "perfectionistic," have self-defeating behaviors, etc. Unfortunately, these claims rarely represent actual insight. I find that most people have no idea what co-dependency is, and if someone really understood how they were perfectionistic or self-defeating, they would have made progress already with their symptoms and behaviors. I have come to believe that people are simply picking up labels from the internet. They actually don't have any idea what is wrong with them.

One of the main reasons people used to go to psychotherapy was to find out what was wrong. They trusted the psychotherapist--a professional--to help them find out the answer. When the true answer was revealed, often it cured the patent. To completely explain this phenomenon, I would have to explain psychoanalytic theory and psychological development, and there isn't space here. What many people under the age of 50 might not know is that this knowledge used to be widespread among the educated general public, and psychotherapists didn't have to explain it. It was a phenomenon that was discussed in popular culture, such as magazine articles and popular books (often written by psychiatrists and scholars). Today, popular culture consists mainly of TikTok videos and Instagram. Is it any wonder that so few have any idea what psychotherapy is or how it works? 

Finding the answer that cures is a process that involves discussion of life events--past and present-- emotions, behaviors and interpersonal relationships. Contrary to what your insurance company has told you, it's rarely accomplished in six to eight sessions (although short term therapy can help people who have short-term problems, such as grief or a family problem). When someone tells me they already know what their problems are, it makes me wonder if they are going to be open to anything I say, and it also makes me wonder what type of commitment to the therapeutic relationship and process they might have. I might also wonder how much nonsense from TikTok and Instagram influencers they have come to believe are clinical diagnoses or scientific facts. 

Tuesday, September 18, 2018

Goodbye New York

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

 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.

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.

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 yet 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.

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.

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.

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.

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.