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.