Social Skills

For some children good social skills come naturally, but for many, not. What some children just seem to know, others must be taught.  Therapy, whether done individually or in groups, has its limits.  Some things are best learned when modelled and taught by parents.  Once upon a time, here’s what I told those parents:

·         Remember to teach your child the basics of self-care including appropriate dress, grooming, and personal hygiene.

·         Play games with your child, especially board games and card games.  Rehearse taking turns, being patient, being observant, following rules, being a gracious winner, and being a good loser.

·         Have lots of conversations. Have your child practice attentive listening and responding. Teach your child to ask socially appropriate questions.

·         Teach your child how to tell a joke.

·         Understand that while having a few good friends enhances the quality of life, popularity doesn’t predict outcome.  What matters is the ability to steer clear of the bad ones.  Children struggling to belong tend to gravitate to marginal peer groups that are willing to offer some measure of acceptance. Children rise or fall to the level of the peers that surround them. A true friend makes you better. Teach your child how to recognize a true friend.

·         Identify with your child a potential friend, and then set up a structured play date. Plan an activity.  Make it time limited.  End it on a positive note.

·         Encourage your child’s participation in adult-supervised structured peer activities, such as Scouts, 4-H, church youth groups and camps.

·         Choose sports according to your child’s ability to cooperate and participate.  Don’t put a child in a situation where they are likely to be ostracized.  If your child can’t throw and catch, don’t put them in baseball.  Consider signing your child up for martial arts, swimming, golf, or tennis where success can be self-paced.

·         Identify, encourage, and support your child’s talents, interests, and hobbies. These can become entrees for interaction with peers.  These can also, on occasion, become marketable skills.

·         Someday your child will need job skills—interviewing skills, customer skills, skills working with supervisors.  Start with the basics.  There is a right and a wrong way to shake a hand.

·         Encourage good work habits, including chores and schoolwork.

·         Set appropriate expectations and boundaries regarding the use of electronic social media.  Remember, for a child lacking in social common sense, there are people out there who prey upon the naïve.  Social media, used judiciously, can break down some of the barriers of isolation, but beware the hazards.

·         Discourage excessive use of electronics.  Recreational electronics easily turns into time taken away from other, developmentally more important, activities.

·         Your child needs protection from bullying and exploitation.  A child who struggles with social skills is often the first to be singled out and the least able to act in self-defense.  Whenever possible, work closely and in partnership with your child’s school.

·         Remain calm and patient.  Maintain a sense of humor.  Don’t take your child’s inevitable social miscues personally.  Turn them into learning opportunities.

·         Embrace the journey.  You can do this!

Democracy

“The best argument against democracy is a five-minute conversation with the average voter.” (Winston Churchill, 1874—1965)

Our country was invaded, attacked, and weakened. Covid killed more than 800,000 citizens. More die each day.  We failed to coordinate a unified counterattack to Covid, and we responded to this invader with neither common purpose nor common sense.  We argued about vaccines and masks.  For too many, conspiracy theories prevailed.  Rational discourse did not. In the past, we rallied together to defeat the common enemy. This time, we did not. We are more deeply divided now than ever. Our democracy, if not terminally ill, is in desperate need of intensive care. 

When a patient is admitted to the Intensive Care Unit a list of problems is identified.  If democracy is the patient, then here’s a list of the problems:

1)      COMPLACENCY—The apathy of a centrist majority empowers the enraged and disenfranchised few, the right-wing and left-wing zealots, those who would willingly exchange our two-party system of democracy for single-party autocracy.

2)      IGNORANCE—A failing system of public education graduates too many students who are taught too little civics, science, and critical thinking.

3)      TRIBALISM—No longer the melting-pot that honored our commonality, we are a nation of differences; blue and red, black and white, us and them.

4)      MISINFORMATION—Under the protective umbrella of ‘free speech’ lies and falsehoods compete on equal footing with truth.

5)      BUREAUCRACY--Rules, regulations, threat of litigation, and red tape have replaced judgement, discretion, and common sense.

6)      EXCUSES—Blame has replaced leadership and responsibility.

7)      ENTITLEMENT—Civic responsibility is a thing of the past.  We no longer ask, “what I can do for my country.”  Instead, we ask, “what my country can do for me.”

8)      MORAL TURPITUDE—We remain a nation of laws, but no longer a nation of principles. There is no guiding moral compass. Sworn oaths mean nothing. Political careers are guided not by principle, but by the quest for reelection and power.

9)      GREED—Capitalism’s Achilles heel, the accumulation of vast wealth and power by the very few, has led to a declining middle-class and a society of haves and have-nots.

10)  WASTE—National wealth has been squandered and misspent. We are trillions of dollars in debt. 

Whether it be information or misinformation, I read that a significant minority of Americans, 28%, still believe that the last presidential election will be overturned. Some even believe that armed resistance should be used to overthrow the current government.  Biden flounders, Trump lurks in the background, and too few have the courage to fight on behalf of democracy.  

“No one pretends that democracy is perfect or all-wise. Indeed, it has been said that Democracy is the worst form of Government except for all those other forms that have been tried from time to time.” Churchill was the defender of democracy in a time of rising fascism.  His words remind me why, despite the daunting list of problems, I pray the patient recovers.

Cheating?

“Cheating is a choice, not a mistake.” (anonymous)

I just got back from a quick trip to Colorado.  I was able to spend one day in the mountains fishing with my brothers-in-law.

On a gorgeous morning, temperature in the 50’s, aspens at the height of their color, we drove to a beautiful little lake.  However, after 3 hours of fly-fishing I had hooked only 3 fish, which was 3 fish more than either of my in-laws. We paused for lunch and shared our frustration.  So, we decided on a plan in order to make sure that the afternoon would be more rewarding

We went to a trout farm off of Interstate-285 and paid to fish. Yes, a trout farm, the kind of place you take your children when you want to guarantee that, for a price, they will catch a fish. The price we negotiated for 2 hours of fly-fishing was not so unreasonable. We agreed to use barbless hooks in order to minimize harm to the fish. We agreed with the owner that we would catch-and-release any of the fish that we hooked. 

For 2 hours we caught (and released) fish after fish, big fish and little fish, rainbow trout and brown trout.  They bit on dry flies. They bit on terrestrials. They bit on nymphs. They bit on streamers. In fact, at one point I got so bored with catching trout that I tried to find a lure that they would not bite.  After unsuccessfully trying half-a-dozen different lures, I finally found the lure that caught no fish. Trout don’t go for hot-pink marabou jigs.  No longer bored, I went back to the business of catching more trout.

When we got home and described our day of fishing, the wives seemed to think that going to the trout farm was cheating, like going to the zoo to hunt for big game.  Assume they were correct.  Assume that catching fish at the trout farm was sort-of cheating.  It doesn’t change the fact that the afternoon was a whole lot more fun than the morning.  So, shame on me, I cheated. Who says that cheaters never prosper?

Interdependence Day (or Parenting the Strong-Willed Child)

A strong-willed child can be oppositional, challenging, and at times exasperating.  Here's my advice to parents of a strong-willed child:

Avoid win/lose battles.  When possible, avoid the attitude of, “I’m going to make you”, which is inevitably followed by your child’s, “Oh no, you’re not.”  Instead, there is a concept I suggest you and your child discuss, the concept of interdependence.  Families are interdependent, “We depend on each other.” 

An engine has many interconnected parts, big and small, but if even a small part is not working properly then the whole engine does not run right. In every family there is work to be done.  Some jobs are bigger, and some are smaller, but everyone has a job and everyone's cooperation is needed.  If one person refuses to do their job, everyone pays a price.  The work is not always fun.  If it was, it wouldn’t be called chores. But the burden is shared. Grown-ups will do their grown-up chores.  Children will do theirs according to age and ability.  The expectation is to help one another.  That’s fair. That’s what families are supposed to do. That’s interdependence.

When your strong-willed child misbehaves, and they will, you may find yourself reflexively pondering the next punishment.  Frankly, I’ve never been particularly impressed with the benefits of spanking, grounding, or other creative punishments.  I’ve never yet seen the child who, as a result of their punishment, had a sudden epiphany, saw the light, and changed their ways.

An overly punished child is a discouraged child. Whereas the child who misbehaves needs to be encouraged to do better. The over-arching goal is that your child learns from mistakes. Misbehavior is an opportunity for you to teach. Children must learn both to apologize and to repair.   What your child has damaged must be repaired and restored.  What your child has broken must be paid for and replaced. 

Consequences are different than punishments. All behavior has consequences. Add to the discussion of interdependence an example of consequences, the rule of reciprocity.  “If you don’t do your job and make things hard for me and others, then don’t come to me asking for favors.” Conversely, “When you do your part and help out others, I will happily go out of my way to help you.”

Strong-willed children want autonomy.  They resist being told what to do.  They react to your requests as-if each request was a test of wills.  You all must begin to think of your day-to-day interactions not as a tug-of-war, but as a journey together, working hand-in-hand. Remember, that, while your child may disagree with your means you share a common goal, your child’s future success in life.

Make sure you always keep a perspective. Know what matters . . . your child’s character. Know what doesn’t matter . . . the small stuff.  Keep a sense of humor and enjoy your child’s quirks and idiosyncrasies.  Build good memories. Have some fun together.  Be sure to model for your child what you expect from them in return: flexibility, caring, compromise and cooperation.

"We need each other."  "We help each other out." That's what families are supposed to do. That's interdependence.

Redemption

As I understand a Jewish perspective, there is the belief in a messianic age when peace will prevail throughout the land.  This world can be made holy.  Despite all its cruelty and craziness, the world can be redeemed through Tikkun Olam, repairing this broken world.  Furthermore, though everyone is born with both an inclination for good and an inclination for evil, no one is beyond redemption.  Teshuva, re-turning towards good, is always possible. 

The seminal event in the origin of Judaism was the exodus from Egypt, from slavery into freedom, from homelessness into a promised land. Despite all the subsequent history and evidence to the contrary, Judaism has remained essentially optimistic.  There is still hope for this world.

As a Jew I will try to articulate a Christian perspective, as I understand it.  The world is filled with corruption.  Everyone comes into this world in a fallen state of sin.  This world is beyond redemption.  Only through faith in Christ and the grace of God will a select few find salvation in a better world to come.

The seminal event in the origin of Christianity was the crucifixion and resurrection of Christ.  Christianity emerged in a historic time of great cruelty and suffering, symbolized by the cross.  Christianity, to me, appears essentially pessimistic and justifiably so.  The world’s a mess. From a Christian perspective, this corrupt world is just a brief stop before life eternal where many will be damned, and a few will be saved.

I know too little to reflect intelligently on the Muslim, Hindu, or Buddhist perspectives.  But what about the scientific perspective?

As I understand the scientific perspective, words like redemption, salvation, corruption, and sin would not factor into any conversation.  From a religious perspective, these words mean a great deal.  From the scientific perspective these concepts can not be objectively observed and measured, therefore any discussion focusing on these words is not considered meaningful.

From a scientific perspective, there is a belief that science and technology are the pathway to a better world, though it is unclear what that ‘better world’ might look like.  Less suffering, longer life, and survival of our species are some of the goals of science, though it remains unclear whether science and technology will ultimately save us or destroy us. From the scientific perspective, the world will continue on for a few billion years, more or less, with or without us.  We can hope for longer and more comfortable lives, but ultimately our existence or nonexistence is of no matter in an otherwise indifferent universe.

I am trained in science, but I try to resist the spiritual nihilism of the scientific perspective.  In my times of pessimism, I can’t help but think that the Christian perspective may be correct, this world appears to be hopelessly corrupt.  I remain a Jew, but a troubled one. I look around and believe that we have been largely unsuccessful in the task of Tikkun Olam. The world remains broken. Why are we failing?  What must we do better?

Oppositionality

Forget the diagnosis ‘Oppositional Defiant Disorder’, commonly abbreviated to O.D.D.  Dare I say, I find this diagnosis to be 'odd'.  Something’s not quite right, taking childhood rebellious and defiant behavior and turning it into a mental disorder. My office was once filled with very oppositional children . . .  oppositional but otherwise healthy children.

Not all oppositionality is the same. Some oppositionality is found in children who have difficult and irritable temperaments.  About 10% of all children are born with such a difficult temperament.  This is not considered to be abnormal or pathologic, just difficult.  These kids are often edgy, rigid, and inflexible. They adapt poorly to change and inconsistency.

When children have difficult temperaments, parents and teachers should provide a calm, reassuring, and consistent environment.  Occasionally interjecting some fun and humor goes a long way helping these children to interact more positively with the grown-ups.

Some oppositionality occurs in children who are asked to do what they cannot.  Sometimes teachers and parents have expectations that exceed the child’s physical or mental capacity. In response to the miserable, poorly tolerated, and passive state of “I can’t”, these children change their interactions to the in-control and active state of, “I won’t.”

It is unfair, even cruel, to expect children to do what they cannot.  Sometimes expectations have to be revised.  These children should be evaluated and provided supportive services when needed. Parents and teachers need to identify these children’s strengths and assets. Give them opportunities for success, not for additional frustration.

A great deal of oppositionality arises when children interact with authoritarian, obedience-obsessed adults, grown-ups whose over-arching expectation is, “Do as I say.” When obedience is demanded, a child has only two choices, to obey or to disobey. Many choose the latter.

When obedience is demanded, it can lead to a test of wills. “Do as I say.” “You can’t make me.”  “Oh yes I can.”  Oh no you can’t.”  This is a win/lose battle.  The problem is, in the long run, the child will always lose.  If the child wins the battle, then defiance is rewarded, and the behavior escalates.  If the child loses the battle, they do so with accumulating resentment. No one likes to lose and, in the future, they will learn to fight the battles longer and harder.

It’s not always easy, but authoritarian adults need to learn alternatives to win/lose interactions.  The absolutes should be few in number:  no hitting, no stealing, no running into the street, etc.  But battles need not be fought over the small things.  If a child wants to wear plaid and stripes together, so what? Let ‘em.

Some degree of oppositionality is developmentally normal.  Children challenge rules and boundaries, especially with their parents.  A child who is oppositional around the house but goes out into the world and interacts appropriately with teachers and other adults, is of far less concern than a child who acts defiantly outside of the home.

Some degree of oppositionality is even normal in adults.  Matter of fact, I’ve been called oppositional, but I’m not.

Modernism

 “In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing “messes” incapable of technical solution.  The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or to the larger society, while in the swamp are problems of greatest human concern.”  (Donald Schon, 1930--1997)

Modernism, the prominent philosophic movement of the late 19^th and early 20^th century, embraced the promise of science and technology.  Science was believed to be the path to all meaningful knowledge.  Technology was believed to be the means to a better world for all.

In the day-to-day ethos of Western European culture, Modernism largely displaced religion, leading the German philosopher Nietzsche to pronounce that, “God is dead.”  The existentialist Nietzsche, though an avowed atheist, did not declare God’s death with joy, but with trepidation.  With the collapse of traditional religious values, he anticipated a great void, a void that science and technology could not fill.

Then came the horrors of a modernized 20^th century: two world wars, genocide, nuclear weapons, and environmental devastation on a global scale.  The world felt the void that Nietzsche had feared and prophesized.

For most of my career I worked in an academic, science-oriented milieu. Where I worked was committed to the values of Modernism, devoted to the belief that a better world, including better mental health, would come from science, research, and applied technology.

During my career as a child psychiatrist, I witnessed an exponential increase in scientific knowledge about the brain, about genetics, and about mental illness.  Some of what we learned was of great importance. We learned that autism is not caused by cold and rejecting parents.  We learned that schizophrenia is not caused by double-bind communication and schizophrenogenic parents.

However, along with the increased knowledge came an increased number of possible diagnoses and an increased number of children being diagnosed.  Unfortunately, a diagnosis doesn't necessarily translate to a better life.  It used to be rare to have 1 or 2 children in a school on Ritalin.  Now it is common to have 1 or 2 children in a classroom on stimulants or other psychotropic medications.

ADHD, autism, gender confusion, depression and suicide, drugs and alcohol, trauma and abuse; despite increased scientific knowledge the mental health challenges for children have only gotten worse. But why?

Modernism has fallen short of its promise. Science alone is not enough.  There is a piece missing. There is a game in academia called, "publish or perish." But much that gets published in the professional journals, though sounding quite erudite, is in reality quite trivial. Too much science and research pursues technical minutiae, all the while failing to wade into the "swampy lowland where situations are confusing." However, before we can discover better solutions, we must first learn to ask better questions, questions that address the "problems of greatest human concern."

The Clinician

“I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”  (Abraham Maslow, psychologist, 1908—1970)

In the arena of mental health care, there are three types of providers: the theoretician, the technician, and the clinician.

Sigmund Freud was theoretician.  His theory was psychoanalysis. Psychoanalysis was the tool he used to understand and treat patients.  Freud described his patients according to their ids, their defenses, and their superegos.  He placed patients on his couch and asked them to free associate. He would then make interpretations, trying to make the unconscious conscious. Psychoanalysis was Freud’s hammer.

B.F. Skinner was a theoretician.  His theory was behavior modification (specifically, operant conditioning). Behavior mod was the tool he used to understand his subjects, both human and animal.  Skinner described his subjects according to stimuli, rewards, and responses.  Skinner tried to modify the behavior of his subjects by reinforcing desired behavior and extinguishing undesired behavior.  Behavior mod was Skinner’s hammer.

In the mid-20^th century, psychoanalysis and behavior modification were the prevailing theories informing mental health care.  Each theory had its adherents, some of whom became theoreticians in their own right, expanding and rewriting the works of Freud and Skinner.  Some went on to develop novel theories, viewing mental health through new lenses, creating new and improved hammers.

There are only a few practicing theoreticians. There are far more technicians. A technician works with neither the depth of the theoretician, nor the breadth of the clinician (which I shall get to shortly). The technician works from one model, trying to implement and imitate the work of the theoretician. An informed technician reads journals and attends conferences. A skilled technician may be a warm, genuine, and imminently relatable individual.  Often aided by manuals and algorithms, many technicians are effective therapists.  However, the technician ultimately relies upon the theoretician’s hammer.

 In contrast to the theoretician and the technician, the clinician uses a broad array of lenses in order to explain, understand, and ultimately treat the client.  A clinician first listens, unbiased by any one theory, and then customizes a therapy suited to the unique needs, strengths, and challenges of the presenting client.  The clinician is a pluralist.  The clinician knows that no single theory is sufficient to understand human complexity.  The more theories that are understood, integrated, and utilized, the clearer the understanding of the client.  The clearer the understanding of the client, the better the chances for a successful outcome.  For any one theory, the clinician may not have the theoretician’s depth of understanding.  However, the clinician has a breadth of understanding and a range of tools that the theoretician often lacks.

Whenever I taught psychotherapy, I wanted to inspire future clinicians.  I taught multiple psychological and behavioral theories, believing that each model taught was another tool added to the student clinician’s toolbox. With multiple tools in the box, the student was less apt to enter into practice seeing only nails and using only hammers. By providing them with multiple tools, I tried to prepare students for the craftsmanship of clinical care.

Psychotherapy 101

“The harvest of psychotherapy is not cure—surely, in our field that is an illusion—but instead change or growth.” (Irving Yalom, 1931--)

While on faculty at Washington University School of Medicine, I developed and taught a two-year introductory course on Child and Family Psychotherapy. My students were residents and fellows, M.D.’s and D.O.’s in their 4^th and 5^th years of post-graduate psychiatry training.  Coming into this course, these students were well trained in biological psychiatry, psychiatry as a medical specialty. Now, it was their time to be introduced to a wide range of behavioral and psychological theories and techniques.  This blog is about day-one of that course, the basics. On that first day five questions were asked and explored.

1) What is psychotherapy?  Perhaps it would be more accurate to ask, “What are psychotherapies?”, for there are many models and theories of psychotherapy.  However, with the input of my students, we arrived at the following definition that captures the common and quintessential nature of most, if not all, of the psychological and behavioral therapies.  “Psychotherapy is a process of guiding change in a patient or client, undertaken within a theoretic framework, by a therapist trained in the application and implementation of that theory.”

2) What are the goals of psychotherapy?  There are as many goals as there are theories of psychotherapy:  making the unconscious conscious, strengthening the ego, working through problems, expressing feelings, clarifying goals and beliefs, reducing symptoms, resolving conflicts, improving self-esteem, empowering, growing, finding meaning, improving relationships, self-actualizing, extinguishing negative behaviors, reinforcing positive behaviors, correcting distorted cognitive schema, etc., etc., etc.  Yet, however otherwise stated, the common purpose and goal of psychotherapy is constructive change; behavioral, psychological, cognitive, and/or emotional change.

3) How does change occur?  In medicine, change occurs either by altering structure (anatomy) through surgery, or by altering function (physiology) through the use of medication.  In psychotherapy, change occurs when someone’s way of thinking, or someone’s way of behaving, are modified through use of one or more techniques associated with psychological and behavioral therapies.

4) What skills and characteristics are found in a good therapist?  A good therapist is well-trained and well-informed. A good therapist is genuine and warm.  A good therapist is a good communicator.  A good therapist is cognitively flexible, able to tolerate uncertainty, ambiguity, and subjectivity.  A good therapist is ethical, adhering strictly to professional boundaries and standards.  A good therapist possesses a sense of humility, understanding the limits of psychotherapy or what has been called by some ‘the impossible profession’.

5) What determines good outcome in therapy?  Outcome in therapy may be less determined by the specific type of therapy and more determined by the experience, quality, and personality of the therapist.  Theory is important, but relationship is even more so.  Outcome also depends upon the attitude of the patient coming into therapy. Good things happen when a patient comes to therapy ready to learn and to change.

It reminds me of an old joke.  How many therapists does it take to change a lightbulb?  Just one, but the lightbulb has to really want to change.

Amor Fati

 “. . . amor fati—that one wants nothing to be different—not forward, not backward, not in all eternity.  Not merely bear what is necessary . . . but love it.”   (Friedrich Nietzsche, 1844-1900)

I have type II diabetes, have had it for the past twenty years. My initial reaction to the diagnosis was, “Why me?” I have no family history for diabetes. Sure, I was overweight, but not that overweight.  Sure, I sat at my desk sedentary for much of the day, but I was not that out of shape.  I was indignant and angry, wrestling with the unfairness of it all.  I felt sorry for myself. I felt scared about my future.  However, none of that lasted long. I had to accept the reality of my diagnosis. I had to change my diet.  I had to lose weight. I had to exercise.

For several years, I was able to manage my diabetes through diet alone.  After a few years, oral medication became part of my management regimen.  For the past few years, I have had to take shots of insulin with each meal.  Nevertheless, with diligent management I remain relatively free from the sequelae of diabetes. I still have good kidneys, good eyes, and no neuropathy.

Loss comes in many forms. Receiving the diagnosis of a chronic illness was experienced by me as a loss, and with every loss there is a process of grieving. At some point in time, I probably experienced each of Elisabeth Kubler-Ross’ five stages of grief:  denial, anger, bargaining, depression, and acceptance.

Recently I learned that contemporary French philosopher Andre Comte-Sponville suggested that there is a sixth stage of grief:  gratitude.  “Gratitude does not abolish grief, it completes it. . . the grateful recollection of what has been. . .”  In other words, the work of grief is complete when one can recall a loss and be able to say, “But for having had that experience my life is richer.”  Gratitude does not negate the loss and grief. It gives meaning and value to some of life’s hardest experiences.

I am not happy to have diabetes.  But without my diabetes, there is every chance that I would be in poorer health today.  Because I have diabetes, I eat a healthier diet. I keep the pounds off.  I exercise regularly. Despite the demands and inconvenience of diabetes, I am grateful that I have made lifestyle changes and can say that I feel well.

Grief is an on-going process.  There are still days I slip back into the anger and sadness of ‘why me?’  I get tired of shots and checking my glucose. There are days when I resent having to count carbs, while watching others casually eating their bread, pasta, and dessert.  However, it was my fate to get diabetes, and but for a few momentary lapses I can usually embrace that fate.  From the hard experience of diabetes, my life is better, and for that I am grateful.

Sued

During an otherwise normal workday, I was served a subpoena.  I was being sued for malpractice.  The trial itself took place eight years later and lasted for two weeks. The ordeal ended with the jury deliberating for 20-minutes, finding me and my two co-defendants free of any liability.  All allegations of neglect and malpractice were dismissed.

When it was done, my lawyers and the plaintiff’s lawyers shook hands, smiled, laughed, and joked as-if this had all been a grand sports event.  No hard feelings.  For me, it had been no game.  To this day I detest the plaintiff’s attorneys who knew they had a weak case, who hoped for a quick out-of-court settlement, and who, in court, had twisted and distorted facts in an attempt to win the game, at any cost.

My initial reaction in the aftermath of the trial was to deny any significant psychological sequela.  I was prepared to return to work and carry on as-if nothing had changed.  But work did change, subtly.  I became a little more obsessive with each of my written notes.  I became a little more cautious with patients, second-guessing my decisions, wondering in the back of my head, who might be next to sue.  I began to enjoy work less and less.  And while the lawsuit was not the only factor in my retirement, it was a significant factor.

Malpractice and medical neglect occur.  Patients need protection and redress of grievances.  But sometimes bad outcomes occur despite good medical care.  Given the nature of the work, healthcare providers also need protection.  There must be a better way.  The lawsuit hung over my head for eight years.  I estimate that the total cost of the legal defense was in excess of one-million dollars.  Not added into the cost were the many hours of lost clinical productivity. In the meantime, until and unless there is a better system, we all bear the significant burden of cost in an already cost-burdened health care system.

I think about being on the witness stand.  Remembering my lawyer’s advice, I tried to not be provoked to anger.  Under the plaintiff attorney’s accusatory and seemingly mocking attack, I mostly recall feeling numb.  At one point, the plaintiff’s attorney stooped to a bit of courtroom theatrics yelling at me, “Dr. Boxer, are you prepared here and now to apologize to this family!”  The judge quickly interrupted the proceeding, instructed me not to answer, scolded the attorney and called for a brief recess.

Even to this day, I repeat the answer I wish I could have made.  “Yes, I am sorry that bad illnesses happen to children.  I am sorry that, due to a serious illness, your child had many years of hardship and suffering. I am sorry that good doctors and good nurses who devote their lives to the care of sick children must defend their competence and integrity in these adversarial arenas. That said, I am, in good conscience, unapologetic about the care I gave your child eight years ago.”

Debate

“Deliberation and debate are the way you stir the soul of our democracy.” (Jesse Jackson, 1941--)

I used to judge High School debates.  I did so when my son, and later my grandson, were debaters.  As a judge, I recognized some very particular characteristics and skills shared by all of the really accomplished debaters.

A good debater was a good researcher, prepared with the facts. In my son’s time, debaters carried large and sometimes multiple boxes filled with articles and information, sorted and filed, pertaining to all aspects of the debate question.  Good debaters understood the value of thorough documentation. By the time my grandson was in debate, file boxes were no longer needed. Instead, files were downloaded onto much easier to carry personal computers.

A good debater was a good critical thinker able to use facts effectively, as building blocks to a logically constructed argument.  Reasoning, backed by solid information, sustained their case.  A good debater could distinguish logic from fallacy.  Perhaps the worst, and certainly the most offensive, of the fallacious arguments was the Ad hominem argument. Only an unskilled and unprepared debater resorted to personal attack and insult.

A good debater was a good communicator and an effective persuader.  A good debater spoke clearly, made good eye contact, used humor judiciously, and mixed raw data with illustrative stories and examples.  I would describe a good debater’s demeanor as calm and confident, assertive but not aggressive.

A good debater not only had to speak . . . a good debater had to listen.  An opponent’s argument had to be heard and understood.  A good debater then had to follow-up with an effective rebuttal.  A good rebuttal often required the debater to be a quick and flexible thinker, able to adjust to new and unexpected twists and turns.

A good debater, going into a meet, had to be prepared to argue either side of the debate question, both the affirmative and the negative.  Debate questions were typically complex, requiring the debater to examine the question from multiple perspectives.  I suppose that a good debater even learned to appreciate that, in life, the most difficult questions often lack definitive answers.

Those who learn debate learn invaluable skills. Personally, I believe that debate should be part of the required High School curriculum.  Debate teaches skills of critical thinking along with skills of good communication. All students could benefit.

I think that many students would be shocked to find out that debate, as taught in High School, is something vastly different than “debate” as practiced and modelled on T.V. by our public servants.  When Trump and Biden were running their campaigns, we did not see a debate.  We witnessed a spectacle.

I recently heard in the news that Rep. Marjorie Taylor Greene has challenged Rep. Alexandria Ocasio-Cortez to debate the Green New Deal.  I doubt this debate, or spectacle, will occur.  But should it happen, I would love to come out of retirement and judge once more. I know the characteristics and skills necessary for a good debate. But do they?

D-Day

It will soon be June 6^th, the anniversary of D-Day.  As I understand history, not all Americans agreed with entry into World War II.  There was a significant isolationist sentiment.  There was even a small pro-German sentiment.  But as a country under attack we came together, resolved to defeat the Axis powers. Three years into the war, there was not unanimous agreement regarding the best strategy for defeating Germany.  But leadership stepped forward and agreed upon a coordinated plan to storm the beaches at Normandy. In World War II, Liberals and Conservatives, Democrats and Republicans came together unified in purpose and resolve. America was united and America was great.

Of all that I found disheartening this past year, it was the politization of the Covid pandemic.  How different this country would be today if Liberals and Conservatives, Democrats and Republicans had put aside partisanship, stood together, and acknowledged that we were at war with an enemy that, as it has turned out, has taken almost 600,000 American lives.  We should have been united in purpose and resolve, each of us soldiers battling an invisible and invading enemy.  Tragically, there were no FDR’s and no Eisenhower’s to unite us and lead us through this Covid war.

Recently, I saw what I think is the most insipid and stupid T-shirt I have ever seen.  “Wearing masks is slavery.”  Not surprisingly, the T-shirt was worn by an angry looking white guy. Slavery . . . really?  More recently, Representative (sadly) Marjorie Taylor Greene topped that with her ignorant and offensive comparison of wearing masks to the holocaust in Nazi Germany.

Prior to D-Day I don’t imagine that all the generals were in 100% agreement. The battle plans were imperfect and sometimes required revision and improvisation.  I doubt that every foot soldier agreed with their officers, but I doubt that any wore T-shirts of protest while landing on the beaches.  I doubt that any suggested that the decisions on the battlefield should be left to the good judgment of the individual, and that the orders of battle were an impingement on civil rights, let alone a form of slavery.

The battle against Covid should have been fought with a sense of unity, patriotic duty, and willingness to sacrifice.  Obviously, that did not happen.  And now that we begin the process of unmasking and resuming a semblance of normal, the squabbling continues.  The directions for how to proceed remain confusing and contentious.

America, during World War II, exemplified the potential greatness of this country.  Ironically, for all the pro-Trump bluster about making America great again, the opportunity to do so was lost this past year. Unlike WWII, we failed to meet the Covid challenge with unified purpose and resolve.  We tragically lost more of our countrymen to Covid than to battle deaths in WWII.  In 2021 we are an angry and disgruntled nation, a nation at low ebb, our democracy teetering on the edge. That was the great tragedy of 2020.

Time

 “The only reason for time is so that everything doesn’t happen at once.” (Albert Einstein, 1879--1955)

Without a doubt, the best Star Trek episode of all time was “The City of the Edge of Forever”, in which Dr. McCoy inadvertently travels back in time to New York City in the 1930’s.  There, he saves the life of social worker Edith Keeler, and all of history that follows is changed. We learn that after her life is saved, Keeler becomes a spokesperson for the peace movement, causing the United States to delay its entry into World War II. Nazi Germany develops the bomb first and wins the war.  Captain Kirk and Spock must travel through a time portal and (despite Kirk falling in love with her) prevent McCoy from saving Edith Keeler’s life, so that the original course of history is restored.  Needless to say (SPOILER ALERT), they are successful in their mission.

As an often-explored subject of writers and movie makers, thinking about time travel is fascinating . . . but, is it really possible?

Physicists ponder the paradoxes and problems of time travel in theoretic constructs and mathematical formulas that are beyond my capacity to fathom. It is my understanding that physicists consider time to be the 4^th dimension, forever linked to the three dimensions of space.

Einstein said that, “The distinction between the past, present, and future is only an illusion.” Trafalmadorians, agree.  Theses aliens of Kurt Vonnegut’s imagination are able to travel with impunity through the 4-dimensional space-time continuum.  For them past, present, and future are one and the same. 

Here on Earth, we move forward, backward, up, down, and sideways through 3-dimensional space, but unlike Trafalmadorians, we are stuck in the elusive present moment.  I can remember the past.  I can imagine the future.  But I exist only now.

What is time?  A series of metaphors comes to mind.  Time flows.  Time marches on. Time flies. Time passes (quickly or slowly).  Time can be lost, wasted, or even killed.  Time can be filled.  Time can heal.  It can catch up to you.  It can run out (but not run in). Time is precious. Time is money.  But metaphors don’t define time.

There is a circle of time.  In the Autumn leaves fall, birds migrate, and bears hibernate.  “. . . there is a season and a time for every purpose under heaven.” Every 365 days, Earth returns to where it started. The circle is once again complete, and another cycle begins.

But it is the arrow of time that penetrates our awareness. We ride this arrow towards a time when, for us, time will cease.  With aging, the mind fills with memories, witness to a past that was and never will be again. With aging, the body shows its wear and tear, witness to the cumulative effect of time gone by. On the arrow of time, we bear witness to our past as we progress into our future.

It may be true that time has no beginning and no end, but life and this blog does. So . . . do I believe that someday time travel will not just be science fiction, but a reality?  Probably not. Time will tell.

Stephen Jay Gould

 “Coincidence is God’s way of remaining anonymous.”  (Albert Einstein, 1879—1955)

Stephen Jay Gould died in 2002.  During his lifetime he achieved a status obtained by few other scientists.  In addition to his scholarly work in evolutionary biology, he became one of the most popular science writers of his time.  Gould had national visibility as an expert witness defending evolutionary theory in court and contending with fundamentalists’ intrusion into school science curriculum.  He testified that creationism was religion poorly disguised, masquerading as scientific inquiry. 

Gould defined a relationship that he felt should exist between science and religion.  “Science tries to document the factual character of the natural world, and to develop theories that coordinate and explain these facts.  Religion, on the other hand, operates in the equally important, but utterly different realm of human purposes, meanings, and values.”  Gould concluded that science and religion must be acknowledged and respected as separate domains, each equally important, neither intruding into the other’s realm.  There is Darwin and there is Job.

Gould’s grandparents fled religious persecution in Eastern Europe.  They began their new lives in the sweatshops of New York.  His father became a middle-class worker and a left-wing political activist.  Gould went on to complete a doctorate in paleontology and became a professor at Harvard.  He was a self-professed skeptic, liberal, agnostic, and a life-long Yankee fan.

In 1988 Gould wrote “The Streak of Streaks,” an essay about his hero, the Yankee Joe DiMaggio who in 1941 hit in 56 consecutive games.  Gould, armed with hard-to-dispute statistics, predicted that DiMaggio’s streak was one record, so improbable, that it is likely never to be broken.

Gould, too, had a streak of his own.  Without a single interruption “for cancer, hell, high water, or the World Series,” he authored 399 consecutive monthly essays for Natural History magazine, an improbable feat, and a record likely never to be broken.

Among scientists Gould is best known for his theory of “punctuated equilibrium.”  Gould argued that life evolved not only from ‘survival of the fittest’, but also by coincidence and dumb luck.  By chance, 65 million years ago, Earth crossed the path of an oncoming meteor and as a result dinosaurs became extinct.  Had Earth and the meteor not been in the same spot at the same time, dinosaurs might have survived.  And if they had survived, they might easily have dominated the smaller, weaker mammals.  But for that random collision of Earth and meteor, intelligent life on earth might have been reptilian.

As one who spent a career writing about chance occurrences, it was ironic that six months prior to his death, Gould wrote about “the most eerie coincidence that I have ever viscerally experienced.”  Gould possessed an English grammar book that his Grandpa Joe carried on the boat, coming into America.  His grandfather, upon arriving at Ellis Island, had written a note in it.  “I have landed.  September 11, 1901.”  Gould was on route to Ellis Island to commemorate his family’s one-hundred-year journey in America on the morning of September 11, 2001.

C.U.D.S.--A.

CIGARETTE USE DIAGNOSTIC SURVEY--for ADOLESCENTS (CUDS--A)

INSTRUCTIONS:  Check all appropriate boxes:

 

_____I do not smoke cigarettes.  (If you’ve checked this box, go no further.  You’re done.)

 

_____I smoke cigarettes because:

            _____I’m too dumb to believe that smoking is a health hazard.

_____I’m too narcissistic and grandiose to believe that smoking is a hazard to MY health.

_____I’m so depressed I don’t care if smoking is harmful to my health.

_____I’m so self-destructive that I’m counting on smoking being harmful to my health.

_____I’m so totally insecure I believe that if I don’t smoke nobody will like me.

_____I’m a passive, helpless victim of the cigarette advertising industry, hopelessly addicted to smoking.

_____I’m a self-deceiving liar who says, “Cigarettes taste good.”

_____I’m a total wreck, unable to cope with stress, who needs to smoke in order to calm my nerves.

_____I’m a mindlessly rebellious adolescent who smokes, as one way of many, to aggravate my parents and other authority figures, and to prove to them that I am really grown up and nobody can tell me what to do because I know best, and all adults are full of shit.

_____I’m a shallow, hedonistic, impulsive, and immature adolescent, who lives according to the belief, “if it feels good, do it now.”

_____Other creative rationalizations for smoking:

  

 

Upon completion of this survey, consult DSM-5 for your diagnosis.

 

(April Fools)

 

Lost and Profound

“What Paul says about Peter tells us more about Paul than about Peter.” (Baruch Spinoza, 1632--1677)

“There are no facts, only interpretations.”  (Friedrich Nietzsche, 1844--1900)

“. . . the philosophy which is so important in each of us is not a technical matter; it is our more or less dumb sense of what life honestly and deeply means.”  (William James, 1842—1910)

 

I enjoy philosophy, thinking about “what life honestly and deeply means.”  Recently, I have read biographies about two philosophers that intrigue me, Spinoza and Nietzsche.

On the surface they seem to have little in common.  Two centuries separated their lives.  Spinoza lived in the Netherlands, Nietzsche in Germany.  Spinoza was born and raised with a traditional Jewish education.  Nietzsche’s father was a Lutheran pastor.  Temperamentally, they were quite different.  Spinoza lived a quiet, modest life of contemplation.  Nietzsche was a wanderer, often tormented by a plethora of physical ailments.  Spinoza declared that his philosophic task was to seek a path escaping the ‘human bondage’ of unwanted emotions while finding sustainable happiness through reason.  Nietzsche approached the trials and torments of existence as our fate to embrace, amor fati . . . and to rise above. We must transcend suffering in order to be the overcoming person, the ubermensch.

Though in many ways different, there are similarities. Both Spinoza and Nietzsche rejected their religious upbringings.  Both were harshly critical of established religious institutions.  Both questioned the nature and existence of God.

For Spinoza, there was no personal God.  God does not observe, judge, or intervene in the world.  For Spinoza, God is nature and the world, and we exist within God.  Spinoza was a rationalist, meaning he believed that for everything in the world there is an explanation.  Our human capacity to explain is finite and limited.  God alone encompasses the totality of order and rationality. Spinoza believed that morality can be discerned within the logic of nature.  Skipping the many intermediate steps that led him to his conclusions, I can report that Spinoza advocated for a society that cares for those in need, a religiously tolerant society, and a society that protects free thought.

Nietzsche famously announced, “God is dead,” meaning that we, who in our need had once created God, had now outgrown and killed God.  Whereas before, the belief in God was the basis of traditional morality, we were now adrift, both compelled and free to define a new morality. Nietzsche’s focus was not political.  He disdained nationalism.  His interest focused on the individual’s capacity to overcome, to rise above the ordinary, achieve greatness, and say yes to life.

I was talking to my wife about Spinoza and Nietzsche, trying to explain their philosophic systems.  She immediately wanted to know more about their lives.  Did they marry?  Did they have children?  No . . . neither of them ever married or had children.  She thought both of them sounded somewhat narcissistic and self-serving. She found it ironic that two men, uncommitted in relationships, detached from children, and professing to know about God, should presume to understand “what life honestly and deeply means.”  I think she heard their stories and judged them to be more lost than profound.

 

Money

 “There are only two things wrong with money:  too much or too little.”  (Charles Bukowski, 1920-1994)

Growing up, I had no allowance.  I was not paid for grades or chores.  Those were expected.  My parents were not wealthy, but money for expenses was generally available to me as long as requests were reasonable. I don’t remember my parents ever using money as a means to threaten, to punish, or to reward.

I was expected to work hard at school and get good grades, but as long as I was working hard at school, I was not expected to be earning money. I was expected to work during the summer, but how much I made was not an issue, so I was able to work at low-paying summer-camp jobs.

In my office conversations with parents, about their children and money, I usually heard more questions than I had answers.  Parents wanted to know. Should children have allowances?  If so, beginning at what age?  How much?  To be used for what expenses?  Should allowances be given automatically or should allowances be earned?  Should children be paid for doing household chores?  Should children be paid for getting good grades?  Should allowances be withheld for poor grades, not doing chores and breaking rules? At what age should children get jobs?  Should children work during the school year?  Should parents continue to provide financial support for children 18 and older?  If so, for how long and under what circumstances?

As psychiatrists often do, I typically responded to these questions by asking more questions.  How were the parents helping to prepare their child for the future and eventual emancipation? What did the parents want their child to know and understand about money?  I didn’t feel strongly, one way or another about allowances, but I did feel strongly that money should not be used coercively, to threaten or to punish.  When a teenager was doing poorly and not working hard in school, I would tell parents that it was time for their child to get a job and start earning some money.  Conversely, if a child was working hard in school, I encouraged parents to be as supportive as possible of their child’s education.

Now I come to the point in this blog where I get stuck.  I've already spent many hours writing and rewriting the ‘so what’ of this article.  I know this is an important topic. Money is undoubtedly a critical piece of well-being, yet the genre of parenting manuals offers little guidance. Children need to enter into the adult world prepared to earn and manage money.  But somehow, this seems to me to miss a more important point. Children also need to enter into the adult world with the right attitude towards money.

Money, too much or too little, can effect self-esteem.  Money, too much or too little, can bring out the worst in us, becoming the catalyst that fuels envy and greed. It is important to earn money, but how do we teach children that it is important not to obsess about money?  What is enough money and what is too much? How do we teach children to value money but not to worship money? How do we teach children to balance the necessity of earning, with generosity of giving?  How do we, as adults, model for our children what we try to teach?

So many questions. I'm still trying to figure it out.

12 Months of Covid

Eerie, unreal, crazy . . .  one year ago those were my words to describe the abrupt and unanticipated changes that occurred early in the pandemic.  Now, what was once hard to fathom has become a way of life.  Problem is, what has become a way of life is about to change.  With the change, I must again recalibrate what is safe and what is unsafe, what precautions remain necessary, and what precautions are no longer required.

I’ve gotten my two doses of the Pfizer vaccine.  Easy enough.  No side effects.  Not even a sore arm.  I’ll trust the scientists and assume the vaccine will protect me from any significant Covid-caused disease.

I am venturing out a bit.  I have been in a couple of stores to buy clothes.  I have taken the cars into the shop.  I have browsed the bookstore.  I now go into the grocery store.  My wife just gave me my final home haircut.  Through this past year she did a commendable job, but next month it's back to my barber.

I expect to do some limited travelling in April to visit family. The CDC has just given the okay to hug the grandchildren.

I thought that getting out and going into stores would feel liberating.  Instead, it has been a bit of a letdown.  I go into the stores wearing a mask and sanitizing my hands. I notice that inventories seem low. I realize that there is still a long way to go before life is ‘normal’. I wish otherwise, but the pandemic is not over.

I am not yet ready to eat inside of a restaurant, but drive-throughs and outside dining are now possibilities.  I suppose, when I get back together with friends there will be few handshakes and we will sit farther apart.  I miss live theater and concerts, but it will probably be a while before I’ll venture into a large and confined crowd of people.  An Alaskan cruise used to be on my bucket list. That won’t be happening any time soon.

I have acquired some behaviors during the pandemic that I expect will continue. For now, I will continue to wear a mask in public buildings. I will continue to regularly wash and sanitize my hands.  I will continue to carefully wash fresh produce. I will continue to Zoom, to bank on-line, and to shop on Amazon.

Some pandemic inspired behaviors I will gladly discontinue.  No more hoarding paper towel and toilet paper. No more obsessively watching the daily Covid news.  No more jigsaw puzzles (at least for a while).

It was 70 degrees outside today and sunny.  I took a long walk through the park. Most everyone I passed smiled and said hello. The playground was filled with children.  My first reaction was a small gasp.  Children have not yet returned safely to school, yet here were so many children without masks, crowded together, sharing playground equipment.  They were running about, laughing, playing and for a fleeting moment life seemed wonderfully back to normal.