ShrinkTalk.net

The Times They Are A-Changin'

ShrinkTalk.Net's host company, Rudius Media, is going to be closing up shop very soon. This site (and me, assuming I don't die from the flu that is currently coarsing through my erstwhile healthy body) will continue to exist, but plan on some aesthetic and practical changes to the format in the immediate future. Once those changes have started, I will fill you in on everything that happened and, at least as far as I know, why. Until then, please pray for my health if you are a religious person. If not, become one now.

A Critical Error in Parenting

My mother told me that I'm no longer allowed to say negative things about her on this site. I believe the exact words were "stop humiliating me you ungrateful...ingrate!" I don't think it's fair to say that I've bashed her - see here as evidence - but she threatened to post pictures of me as a child on her new, as yet un-launched website, UngratefulRob.Com. Apparently she has photos of me as a toddler going through toilet training and such, so I'm going to at least consider her wishes going forward.

All that said, I would like to point out just one parenting mistake she made when I was a young boy. Recently I was sitting in a restaurant at a small table with a friend. Next to us was a family of five: two parents and three very loud, boisterous and, quite frankly, annoying little kids. The parents seemed mildly embarrassed by the whole scene but not to the point they were going to leave or do anything about their children's behavior. I'm guessing that parents in such a situation don't get to go out all that much, and they weren't about to have this rare opportunity go to waste.

My mom, while not a strict disciplinarian, taught me at an early age that it's important to be polite and, more importantly, reasonably soft-spoken when you're in any restaurant that isn't Chuck-E-Cheeze's. It's a good rule to live by, especially when you consider the negative stares these parents were getting from all the other adults in the restaurant. But while it was paramount to be a good patron, my mother stressed another but dangerous and erroneous concept: make sure you eat everything on your plate.

Apparently this was a pretty common philosophy in the 70's and 80's, before obesity became one of America's biggest, or at least most noted health problems, and lots of parents employed it. I remember times when I ate beyond satiety to win praise from my mom and even the waitress. "Oh, what a good boy you are!" the server would say in that patronizing way kids are often addressed. "You're just so, so good, aren't you?"

"Oh yes," my mother would agree as I stared at the waitress with contempt. "He's very good. You did such a great job. A good boy eats all his food."

Why is praise of this nature a bad thing? Shouldn't children be commended for their actions?

Her words promoted a direct link between global self-esteem and a highly specific behavior (in this case, a very unhealthy one). The message is "you need to do this to be a good person." And so what if I didn't eat all of my food? Did that make me a bad person?

Kids who grow up with these conditional messages often become adults who are validation seekers, those who consistently need the approval of virtually everyone. They become people pleasers with an all-or-none life view. When they do positive, pro-social or successful things, they see themselves (and others) as "good." And when they screw-up, they are "bad." This is a very difficult way to live life because it doesn't allow you to be fallible and still be a person of worth.

In Alcoholics Anonymous they ask family members to separate the illness from the person. It's a medical model that promotes the notion that a person is not simply the cumulative behaviors associated with drinking. Whether you believe this take or not regarding alcoholism, I ask you to consider a life philosophy where all people, no matter what they do (or do not do), are worthwhile simply because they exist.

This was the approach advocated by the late, great Albert Ellis and he was one of the happiest people ever. He asserted that while behaviors can be either pro or anti-social, the person is not the sum of those actions and deserves unconditional acceptance, simply because he lives and breathes. In other words, he judged the behaviors of both himself and others, but not the people themselves. This allowed him to hold people accountable for their actions, but his philosophy dictated that they were always viewed as people of worth. And so if he had actually believed that a child should eat all of the food on his plate, he would have said, "Rob, you boy genius, you are wonderful. It would be great if you ate everything on your plate. That would be excellent and, if you do not, there may be consequences. But no matter what, you are a person of worth." What kid wouldn't feel good about that?

I was lucky that my mother clarified her position about self-worth over the years, allowing me to focus more on my homicidal rage instead of my own esteem. But many people never get those messages and can only see self-esteem as a product of action, something that has to be earned. Whether you are millionaire or poverty-stricken, educated or ignorant, pretty or ugly, you don't have to earn anything regarding self-worth. It's a right that comes with living.

Most of you who read this site are under 25 and don't have kids of your own as of yet. But when you do, consider the mistake my mother made. Don't repeat it, because your kid may become a blogger who writes a little bit about his family. And you know how that can turn out...

A Russian Doctor Hates Me

Years ago I got branded as a racist for refusing to treat a client whose primary language was Russian. Apparently this was a woman who was depressed and could have benefited from therapy, but her command of the English language was considered only decent at best. The physician who wanted the woman to get treatment from me was also Russian and had little tolerance for being told 'no.' I later learned that she had been discriminated against by American doctors upon her arrival in the states and was therefore very sensitive to the needs of the Russian community.

"You hate Russians!" the doctor yelled into the phone before I could explain why I refused to see her patient for treatment.

I immediately considered all the things Russian that I enjoy: Black Russians, Ivan Drago, Beef Stronganoff, even Communism, at least in theory. Therefore I rejected her nefarious claims about me.

So why would I not take on a client who could clearly use help but not speak English well?

Back in the day when I was still considering being a religious person, I was walking out of church after service with a friend. The pastor was at the end of the line of exiting people, waiting to say good-bye, and I stood near the end of the queue for my turn to shake his hand and bid farewell for the week. As we slowly approached him I noticed my sneakers, which I had thrown on my feet in haste after having overslept for probably the 30th Sunday in a row. The shoes were blue suede, almost like boating shoes that would normally be seen at some yuppy regatta. Given that my friend worked in the field of fashion, I decided to ask for her take on my footwear.

"Hey, do these shoes make me look like a jerk off?" I said.

She looked somewhat horrified. "What?"

"The shoes," I repeated, as we got to within about 10 feet of the pastor. "Do they make me look like a jerk off?"

A look of relief came over her and then a huge giggle that she needed to stifle. "Oh! I thought you said, 'these shoes make me want to jerk off.'"

I laughed. "Oh. No. I mean, I didn't say that. And also, I mean, they don't make me want...you know..."

"Right, I know," she said, probably creating a mental list of my potential fetishes. "And yes, they look pretty stupid, especially with plaid shorts. Just wear normal sneakers like everyone else. Perv."

How does this anecdote of sartorial idiocy relate to therapy? Notice in the exchange with my friend how a change of just a few words completely altered the meaning of the sentence. In the first, I'm asking her if I am engaging in a fashion faux-pas. In the latter I'm sharing masturbation fantasies just before saying farewell to a man of the cloth. Subtle changes in language drastically change meaning. This issue actually handicaps a patient, because providing her services in a fairly unfamiliar language will invariably lead to missed nuances.

Both self-talk and open conversation can strongly impact emotions. When a client who has been curt with a co-worker tells himself, "I'm such an asshole to people, no one likes me!" he's likely to feel a strong depression. Contrast that with the client who says, "I acted like an asshole, but that doesn't mean that no one likes me." This second person is likely to feel remorse or regret or guilt, but is unlikely to get depressed. In fact, this client, simply by changing a few choice words, is more likely to apologize to the co-worker and be done with it, whereas the former is inclined to withdraw and perpetuate the problem.

In couples' work, most therapists discourage the use of extreme terms. For example, a wife would be challenged when she says, "he never spends time with the kids," unless she can prove that the term never is factually accurate. More often than not such a term isn't entirely on target and, moreover, it often generates defensiveness on the person toward it is directed. If the wife makes a slight change and says, "he doesn't spend nearly as much time with the kids as I would like him to," not only is she conveying a likely more accurate statement, but she's setting up a productive, problem-solving dialogue with the husband.

Many say that English is one of the hardest languages to learn. Is it fair to ask a woman who has only a marginal understanding of the subtle nuances of the language to engage in therapy with someone who can't translate to her native tongue? Hell, I've spent multiple sessions teaching monolingual Americans the difference between "assertive" and "aggressive." How can someone who may not even have heard either of those terms be expected to grasp their subtle differences?

So a small medical office in New York City thinks that I now hate everyone who is of Russian descent. I can deal with that, especially since the office was able to find a therapist who speaks her language, and I was told that the woman is doing quite well. So all's well that ends well, I suppose.

The morals of the story:

1) Don't hate Russian people
2) Only conduct or engage in therapy in your strongest language
3) Wear normal shoes
4) Do not have sexual discussions of any sort in church.

I know, I know. What pearls of wisdom will I come up with next?

Football Coaches Suck at Discipline

Earlier this year, Oregon football player LeGarrette Blount was suspended for the entire season for sucker punching an opposing player in the face. Given that this was his senior year, LeGarrette's college football career is over. This is particularly relevant because he is/was considered a decent professional prospect, and his lack of playing time this year could drastically impact scouts' impressions of his abilities.

Apparently LeGarrette has shown extensive remorse and a deep desire to return to the team. So much so that the head coach is considering reinstating him before season's end. From a football standpoint it makes perfect sense, as few doubt that he improves the team. It also gives him an opportunity to showcase his talents to pro scouts. From a psychology standpoint, however, this is a mistake. Why?

It is well-documented that reward systems are superior to punishment models for changing behaviors. If you want your child to do household chores, you are much more likely to get results by offering extra time with the Playstation than you are by hitting him or even withholding dinner. If you want better results on your next exam, you will increase the likelihood of that happening by buying yourself that new album you've been wanting for positive results than if you socially isolate as a penalty for poor performance. People generally respond better when there is something to be gained rather than to be lost.

There are times, however, that punishment is a necessary tool. In clinical settings, you'll see this employed when therapists work with autistic children. When the children are banging or screaming, clinicians will often look away and refuse to acknowledge the child's presence. This withholding of attention (punishment) can sometimes serve to engage in the child in more productive interactions.*

Punishment was required in the LeGarrette case. As bizarre as it sounds, you will statistically get better outcomes if you reward players for each game that they don't get into a physical altercation than you will for punishing those who do. Most scoff at the idea of rewarding what is considered a social norm (e.g., not hitting people) or the way people should behave. However, we've seen that just because society dictates behavior, doesn't mean it occurs.

So under the assumption that punishment is sometimes necessary for behavior modification, there are two ingredients to make it work effectively: immediacy and severity. The coach's action met both criteria. He didn't wait very long at all to lay down the suspension and, barring the athlete's removal from campus altogether, the punishment was pretty intense. We're told that the impact on his professional draft status from not playing could cost him millions of dollars in contract money. That would be enough to stop me from punching people, and I have that urge on an almost daily basis.

The problem is that the coach is considering not following through on what was an iron-clad ruling. There wasn't a "you can get out of this for good behavior" addendum on this punishment. It was fixed. And when you open the door on what you've claimed to be closed, you're begging for trouble.

Good shrinks invariably tell their clients that behavior modification requires consistency. If you need your child to stop screaming in the grocery store and threaten to take away his toy at home (punishment), but then don't do it, you're done. It's over. Your 3 year-old now owns you. Everything you say after that will be an empty threat until you consistently demonstrate otherwise. And if a toddler knows this, there's no doubt the athletic world does too.**

The coach's punishment, however, wasn't simply to change LeGarrette's behavior. In fact, the negative media attention alone might serve as enough punishment to prevent recidivism on this one player's part. No, part of the penalty was to create vicarious learning; not just at the University of Oregon, but throughout college athletics. We know that there were a boatload of players who are prone to violence on the field who said, "Out for the year? That's a long time. Millions of dollars? I better keep my cool." If LeGarrette comes back early, however, they'll know. They'll know that the message has changed from 'you will lose your rights to play this year,' to 'you may lose your rights to play this year.' And that small question mark, that bit of doubt, that one moment where someone says, "I could possibly get away with this," is when the behavior re-emerges.

There are plenty of people who are set free from punishment after demonstrating good behavior, sometimes with excellent results. But for maximum effect you want to make that possibility crystal clear before the official punishment is handed down. Behavior change works best when all parties are fully cognizant of the rules and all grey areas are eliminated. This didn't happen here, and because LeGarrette may not serve his full sentence, vicarious learning is compromised. This is not to say that suddenly we will see sucker punching running amok throughout college football. No, far from it. It's not a common offense anyway. But if the goal of the suspension was to impact other players from engaging in behaviors that even resemble what LeGarrette did, then from a statistical, scientific standpoint, the coach will have failed.

* There are strong arguments that punishment, while effective in altering certain behaviors, doesn't necessarily eliminate them altogether. It simply suppresses them in certain milieu and time frames. In the above example with autistic children, better results are obtained if rewards (e.g., a huge smile and praise when the child stops screaming) are paired with the punishment.

** Yes yes, I know one could make a joke here about a football player's intelligence level as compared to that of a child, but that's not very nice and you should be ashamed of yourself for even thinking it.

Reminder Calls

Dr. Rob, I read your recent post on how you hate it when new clients don't attend their first appointments. As usual, you pulled the 'woe is me' card and tried to paint the world as unfair and cruel to you. Instead of getting on your soapbox like a fucking cry baby, why don't you just make reminder calls to these people the night before their appointment? If they are feeling better maybe they'll just tell you that they won't be coming in. For someone with a Ph.D. you're pretty fucking stupid.

Anonymous

This is actually a pretty good question, and I'd thank you for writing in if you weren't such a seething bag of hate. And of course you're anonymous, because you're such a clever wit that everyone would be banging down your door to hear your very next word if they knew who you were. For funnier hate mail directed at me click here.

There are two reasons why reminder calls aren't in my calendar, one practical and the other philosophical. While reminder calls are not particularly labor-intensive, when I'm not fielding calls from current clients, setting up appointments or actually doing my job as a Psychologist, one of the last things I want to end my day with are multiple calls to people to remind them of an appointment that they themselves sought out. I'm my own secretary for budgetary reasons and there are only so many hours in the day and so many administrative tasks that can be taken on by the business owner and his employees (especially when the number of employees is zero).

For those of you going into the self-employed, small business world, there are decisions you will have to make about how you conduct your interactions with your clients. In Psychology this entails how much phone contact you will have with clients (versus face-to-face); what, if anything, you will charge them for those calls; how you will handle cancelations or non-payments and the like. Most graduate programs in Psychology teach you nothing about these types of situations and you are forced to learn as you go, or ideally get advice and tutelage from a more seasoned person in the field. While Dr. Steve and I don't agree on most issues regarding being a private practitioner, he did teach me an invaluable lesson that is relevant to any business: determine your rules and boundaries for your work and only deviate from them for special circumstances. Know, however, that even if your business model is more than fair, you will most certainly anger clients at times (e.g., charging them for canceling with less than 24 hours notice) and you will also lose clients who will move to other, "more flexible" providers. That being said, more often than not patients will respect you for your consistency and fairness. This will make your work with them not only more efficient, but more enjoyable, simply because each party will feel respected. In other words, having firm rules in place at the risk of losing clients and money is better than compromising your model to make sure every person walks through the door.

The second reason is much more important. Western medicine is, broadly speaking, a very passive experience. You fill the script, pop the pill and wait for the drug to do its thing. This isn't inherently bad, but that is what it is. Psychiatry/Psychology (especially therapy) is, ideally, something you do for yourself. It is intended to be a very active experience, one in which you choose to engage. And while no one is required to enjoy the idea of coming to session - in fact, the very nature of the experience, which demands a person sit with intense, negative feelings, can be aversive at times - there should be a level of need present. Something should click, your inner monologue should say, "something isn't right, I need help and maybe, just maybe, the appointment with the shrink will steer me in the right direction." If that isn't happening, if that urge to improve your life isn't there, and someone has to call you to remind you to be an active agent in your own life script, then perhaps you shouldn't be there in the first place. That's really an unfortunate place for people to be, and unless they move off of that spot and choose to have greater control of their life, no amount of therapy will help.

I'll get off the soapbox now, Anonymous. You really should consider moving your rants to Twitter, though. With your snarky tongue I'm sure you'd have more followers than Ashton Kutcher.

* Exceptions to this would include patients who are court-mandated for treatment, people hospitalized against their will, and minors who are there at the insistence of their parents.