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sidereaI have an attitude about various things which is not, I think, all that uncommon, but which I never see represented, and which seems to confuse people.
It's a kind of two level opinion. On the one level, we can paraphrase my sentiments as "I don't care what the rules of the game are, so long as (1) I get to know what they are, and (2)they're fair I have equal access to them."
On a deeper level, of course I care what the rules of the game are. I have all sorts of opinions as to the goodness of the game, the desirability and suitability of its rules, and all that sort of thing.
It's like, if I'm wind up stuck in a game of "Monopoly", I'm going to play to win, even though I know that "Settlers of Catan" is a better game. (Monopoly fans: sorry, you're just wrong.) I'm not going to roll my eyes, and *tsk* and declare that I'm not going to build any hotels because Settlers doesn't have hotels; and I'm certainly not going to be okay with the bank cheating me on my rents because Monopoly is a boring, poorly designed, unentertaining game. And I will do my best to frack what enjoyment from the flinty experience I can.
In whatever system I'm having to function in, I'm going to make it my business to know the rules well and play to win. (It might, admittedly, be a slightly idiosyncratic definition of "win".) That does nothing whatsoever to inhibit my ability – or inclination – to criticize the system, and, indeed, have a very low opinion of it.
I have this two-level attitude about many things.
Like the DSM, the "bible" of psychiatry. As part of my profession – at least, the part of it that involves working at clinics and billing insurance companies – I'm required to diagnose patients as per the DSM. I take pride in doing this reasonably well. I'm not a huge expert on it, but there has not yet come a point where my supervisor and I have disagreed on a diagnosis that we opened a DSM and it didn't turn out I was right. Other clinicians come to me and ask my help diagnosing patients.
Moreover, I'm into the history of the DSM in a big way, and get very excitable about the topics of psychiatric nosology and the epistemological bases of diagnosis and all that good stuff.
None of which means I believe in the DSM. In fact, quite to the contrary. In my most jaundiced moments – typically ones where I'm sitting at a computer with a blank assessment form open, staring at a pile of assessment notes, and remembering my psychopathology professor, Dr. Elias, quipping, "The problem with the patients is they haven't read the DSM" – I think of the DSM as kind of the psychiatric version of The AD&D Monster Manual, another complicated rule-based taxonomy I became adept at using.
It's not that I don't believe in the reality of mental illnesses. It's that I don't think that the categorization scheme in the DSM actually maps to reality. Often, it doesn't even fail to map to reality in that useful way some epicycle-encrusted paradigms do. It's chock full of epistemological goofiness. It is in rather desperate need of a sanity check and massive refactoring, which it will probably never get. (Guess what my letters to the DSM-5 committees were about.)
So this results in a lot of cognitive context switching. Within the context of the DSM, if the patient presents with a week and a half of depressed mood, being unable to get out of bed, no appetite, insomnia, impaired concentration and morbid preoccupation, that's not a Major Depressive Episode, and doesn't count towards a diagnosis of depression, even if it happens every two months or so: fourteen days of symptoms or it's not an MDE. Outside the context of the DSM – you know, sitting with the patient – of course that's depression, duh. Knowing that it fails to meet the DSM definition of Major Depressive Episode (or anything else in the Mood Disorders chapter except the "Depression, Misc" category that insurers loathe) changes nothing about treatment – for neither me, nor, apparently, most of the psychiatrists I have worked with, who are even faster to jettison DSM categories than I am, thanks to their beautiful, "I'm a doctor, nobody can tell me how to diagnose, not even the APA," attitude problems.
I can totally tell you (or your insurance company) whether some complaint you present with qualifies for a diagnosis against the DSM, and it will be – aside from its utility in building the legal case for you that your insurance company has to pay for you to have it treated – a completely pointless intellectual exercise that contributes approximately nothing to my clinical formulation of your problem or how I'm going to treat it.
But I'm all over pointless intellectual exercises. I love pointless intellectual exercises. Just because it's a pointless intellectual exercise doesn't mean I'm not going to be awesome at it and get really, really into it! If we're going to split non-existent hairs, I am gonna be a non-existent rockstar-ninja-barber.
So one moment I can be having a sincere, in-depth conversation about whether some"thing" "is" "PTSD" based on subtleties of the DSM-IV criteria, and then next I'm explaining why it's all nonsense anyway, due to the PTSD/MDD symptom overlap, DTD, variable definition of trauma, how there's these common symptoms that aren't in the DSM, etc.
This combination of gleeful enthusiasm for the minutia of psychiatric nosology and deep exasperation if not disgust with the intellectual bankruptcy of the whole thing is, apparently, somewhat confusing for a lot of people.
(Honestly, I think the latter is why I can do the former. I am uninhibited by the despair that overtakes any clinician who expects the DSM to make sense.)
People sometimes assume that if I'm so "into" nosology and diagnosis, that I must be in favor of it. This is really disturbing to me, because the list of things I'm also really "into" includes: antisocial behavior, the psychology of criminality, violence, trauma, oppression, the etiology of genocide, and really, just about everything that falls under the rubric of "why people hurt each other even though they espouse the moral value that they shouldn't."
(Much more rarely, people assume that because I have such a low opinion of the DSM, I must not know what's in it or find it difficult to use – that my dislike is a kind of intellectual sour grapes: if I can't get it, I bad-mouth it. They usually get over that misconception pretty fast. And the two chunks of the DSM I truly do not get – the chapters on Sleep Disorders and Dementias – I have no opinion of.)
Here's another example. Different communities, different social scenes have different norms of discourse; this is true online and off. I have participated in social milieus in which cussing someone out aint no thing, and I've participated in social milieus in which asking someone a trivial neutral direct question about their work was an insult. I've participated in online spaces in which the only rule was that you can't say to anybody "you can't say that" and in which the only rule was that nobody will tell you what the rules are, you have to figure them out for yourself. I once participated in a forum, the title of which had the word "flame" right there in it as a caution to the unwary.
I can participate happily and productively in a whole variety of social rule sets. That doesn't mean I like all social rule sets equally. And it doesn't mean that if I do like a social rule set, I think it's in some sense good. After all, there can be rule sets that advantage me over others, and while I might find that enjoyable, I certainly can recognize that as unfair.
People sometimes get confused when they see me operating to two different social standards, in two different contexts. Yes, here I will flag flamers for moderation, and there I will unleash the napalm with the best of them, because here it is against the community norms, and there it is compliant with them. In that forum I will cut-up like a comedian on speed to earn those "+1 Funny" votes, in this forum, I will gently remind you jokes are off topic and keep my witticism to myself. In this place I will be very sensitive and solicitous of people's sensibilities, in that place I will be irreverent and jaded, and will crack wise in the blackest of humor. In that space I am careful not to swear, in this space I work blue.
I whisper in libraries, I shout in stadiums.
This probably doesn't sound all the controversial to you, Gentle Reader, but I keep running into folks who have various troubles with it. One such trouble is leaping to assumption that if I do X in context Y, then (1) I like X and (2) am inevitably going to do it in all contexts A through Z. Neither is warranted. Regarding the former assumption, I have not yet entirely forgiven two of my references, a tech lead and a social worker, who ebulliently told hiring managers that I was great at debugging other people's code and case management, respectively. No, see, if debugging other people's code/case management is part of the job and needs to get done, I will buckle down and do it (after a few procrastinatory rounds of whatever Flash/HTML5 game I'm playing) and I'm kinda down on doing things poorly, so I will try not to phone it in. But that doesn't mean I approve of the Siderea-does-this-tedious-thing scenario.
Regarding the latter, my favorite example to date was discovering that my fellow Pennsic campers at Quacheri (an "everybody does their own thing" camp) were worried, my first year with them, about me because of my past with Crook'd Cat (camp dinners nightly, chore shifts). Eventually somebody admitted to me that there had been a fear that I would "attempt to organize" them. I suspect, though nobody said it, I was expected to explosively decompensate in the absence of structure. Apparently a few minds were blown.
I'm pretty sure this is not a me-specific thing, though. I ran across a lovely example elsewhere, recently. Trans man Jackson Bird, in his coming out video last May, explains why it was that, as his high school photos attest, he once presented as such a glamorous, femmy young woman.
This happens sometimes: a person who seemed to be a particularly manly man or womanly woman comes out as having never have identified with the gender they were assigned at birth and performed to such social approval. The usual explanations offered for this phenomenon are overcompensation – the fear of being discovered to be trans leading someone to take pains so nobody will ever suspect – and obedience – acquiescing to the demands of parents and other authority figures. But Bird described a third experience. He explained that as he hit puberty assigned female, he didn't know about trans people. He figured he was stuck doing girl. But he if was, he was going to do girl right. "It wasn't me," he says in the video, "It didn't feel like me. It felt like a game. A game I was winning – and which gave me a lot of pride to be winning." Not fear, not obedience: competitiveness. If he had to play Girl, he was going to play Girl to win. But just because he played Girl brilliantly – certainly better than I ever have – doesn't mean he liked it or identified with it. What he liked was getting the best possible result from the situation he was (he thought) stuck with.
Just because you play to win doesn't mean you like the hand you were dealt – or game that you're playing.
Which brings us to my third example: capitalism.
I'm a small business owner, by virtue of being in private practice; I'm a self-employed sole proprietor. This means I have to compete in the market for customers (patients) and function as a business in a variety of ways, such as dealing with vendors.
On one hand, I think selling my services as a therapist to the general public for cash is really neat. Basically, my visceral, emotional reaction to the idea of a market for therapy is that it's a contest in therapisting that uses money to keep score. While that's horrifying for a lot of therapists, who as a tribe are often down on competition, I, myself, am a wildly competitive person who loves contests of skill: for me this is... "catnip" isn't a strong enough word.
(I think about this, and the overwhelming association that comes to mind is a sensory memory of when I helped managed the hounds at a coursing event: the way the greyhounds that were oh-so-unwillingly waiting their turn to run pressed against my legs trying to get past me to join the race, their tails whipping back and forth in ecstasy, and their whole bodies literally trembling in joy in anticipation of racing.)
And if that weren't alluring enough, it's a game I can play that, if I'm good enough at it, gets me out of having to have a real job. So: like getting paid for eating ice cream.
On the other hand, I have some serious reservations about capitalism.
For instance, while I think this whole selling my (medical) services on the open market thing is keen like whoa, there's nothing about subjecting me to market forces that makes me a better clinician.
Quite to the contrary, pretty much any financial incentive puts my interests in conflict with those of my patients. The standard business model, payment per session, incents the treater to the extent the patient still requires services. Put it crudely, that system only pays me as long as the patient is sick, so there's an incentive to treat poorly and slowly!
This is a well-known failure mode of that business model, the industry-standard term for which is "fee-for-service". So a lot of people have tried to come up with alternatives – and all have had similarly awful consequences. Payment for constrained terms (time/service limits) results in treaters treating what they think they can in that time, and declaring success, rather than addressing the patient's presenting problems. Payment for treatment success (e.g. fixed price) results in providers discriminating against hard-to-treat cases – the very patients who most need help. Payment for treatment success moderated through an assessment of how difficult to treat a condition is leads to diagnostic inflation and, where third party payers are involved, diagnostic deflation ("You're not really depressed, you are just having a bad day. Eight sessions should be enough for you.") It also marches right into the weeds of breathtaking coordinative communications costs.
As best I can tell, it's my professional responsibility to (attempt to) put money completely out of my mind when treating patients, so my interests aren't pitted against my patients' – because there is no incentive system which doesn't jog my elbow and cause a conflict of interests.
It's funny: the various Codes of Ethics of my profession all(?) have bits in them about avoiding "dual relationships". A psychotherapist may only relate to a patient as a psychotherapist, not anything else, because the very relationship is one of the crucial tools of treatment, and mustn't be warped by other relationship modes. A therapist treating a patient who is a house painter may not hire the patient to paint their house. But we therapists all look the other way about how the fundamental nature of our enterprise is fractured into a dual relationship when we sell our services on the market: if you are my patient, I am your psychotherapist, but you are also my customer, and I am a vendor to you.
We are stuck here in a capitalist society, so there's no helping this. Oh, if I work for an agency and you have insurance, we can let my agency and your insurer sort out the payment behind closed doors so neither of us has to think about it. And that trick works right up to the moment that: (1) your insurance won't pay, (2) my agency decides not to take your insurance any more, (3) anything bad happens involving the payments getting made. Also, when you let somebody else handle your money for you, often their interests don't align with yours, and you can find yourself taken for a ride. Also-also, we both have to pay, literally, for the privilege of this veil of ignorance; the agency and the insurer both get a cut.
No, mostly what we therapists do – especially those of us in private practice – is concede to the inevitable, grimace in distaste, and attempt to squeeze the two relationships together until they fuse into an amalgam. We use the very commercial nature of the enterprise therapeutically. You've heard of music therapy, and art therapy, and play therapy, and animal therapy: well, commerce tends to make it all money therapy. Yeah; there's this whole thing of using conflict in the matter of payment as relational microcosm, in which to work with the patient on interpersonal problems.
Is this good therapy? I dunno. Adequate, I guess. It's the kind of therapy we're stuck doing when the dual-nature of the therapist/vendor-patient/customer relationship is no longer avoidable.
I've never heard whether anybody thinks it's "evidence based practice", that's for sure.
Honestly, one of the things I feel most keenly about selling my services to the public is a little thrill of what I'll call licit wickedness. Fun as it may be for me, in no sane and rational society would I be allowed to do this. Yet, here we are and here I am. I am increasingly certain from what I know of psychotherapy that the incentives that arise from selling it for a living are bad for it, and result in worse psychotherapy. The best case scenario, the one I am always shooting for, is that I manage, by vigilance and assiduousness, to compensate for the biases of financial incentives – thereby diverting my energies and my attention away from the therapeutic work, which is, of it's very nature, extremely demanding of energy and attention. Doing what is necessary to reach the best case scenario deprives me of resources I would otherwise have free to dedicate to doing therapy.
Meanwhile, the thing that market forces are supposed to do is incent the delivery of better or cheaper services, because competition. But that can't actually work in a market where the buyers can't determine whether one vendor's product is actually better or cheaper than another. How is the market is supposed to evaluate the value propositions of different therapists – with their different prices, different credentials, different approaches, different specialties, different skill levels – when all their prior work is confidential and you don't get to examine it, and they're not allowed to give references? Comparison shopping of therapists is essentially impossible.
I described the market for therapy as "a contest in therapisting", but let's be clear: it's not a contest in how good you are at doing psychotherapy. It's a contest in how good you are at running a psychotherapy practice, i.e. a business. That quite possibly has more to do with how good your marketing is than how good a therapist you are.
Also, I think the whole notion of competition leading to improved offerings on the market just flat out doesn't work in the market for therapy. For one thing, there's the problem that competition doesn't reward innovation and improvement and cost-efficiency in therapy, because both quality and price are actually opaque to the market. The world won't beat a path to your door if it can't tell your mousetrap is better. What we see is a lot of marketing claiming that this provider or that type of therapy is wonderful, but a lot of that seems to be empty hype.
And then there's this other problem: I actually suspect that competitive environments just don't produce the sorts of behaviors in therapists that economic models are supposed to incent. As I mentioned, I'm unusual among therapists because of how competitive I am; the therapist nation is a pretty conflict-averse population. Frankly, the typical therapist reaction to having to compete in a marketplace seems to be flinching away from it, like a poked snail darting back into its shell, and withdrawing from the enterprise entirely.
This may, in fact, be why so many therapists do so terribly in private practice, and why an effective intervention for their self-sabotage is explaining the idea of "niches" to them; it frames market competition as a form of collaboration, which they can then emotionally cope with. "It's not that I'm better at therapisting than the other therapists in this town, it's that I do something none of them do. Okay."
Well, that's (some of) my reservations about psychotherapy under capitalism, but as a psychotherapist, I have lots of other reservations about capitalism, itself. One, in a nutshell: I'm increasingly concerned that participating in markets is actually intrinsically unhealthy – both psychologically and physiologically – for some large but not total percentage of people. That's a topic for a separate post, but you can see there are some serious ethical/moral questions about an economic system which is at odds with the necessities of human health, and even more so when those negative health consequences are unevenly distributed.
Then there's all the more standard stuff about exploitativeness.
Then on top of all of that, I'll be the first to acknowledge the fact that capitalism may be, to borrow an expression, "the worst system, except for all the others." It's not like I'm the partisan of some particular alternative. Construe no criticism I have of capitalism as any kind of covert comparison. It is entirely possible – indeed, fruitful – to examine a system and note what ills it promulgates without reference to any other system. If I tell you why I think capitalism sucks, I am not telling you why I think something else is better, I am telling you why capitalism sucks.
So I'm in this weird position: Capitalism: terrible system, detrimental to psychotherapy, possibly pathogenic to many people, may be best of bad choices, love it, love playing it.
Wait, it goes beyond that. I encourage people to play it. Since we're stuck in this system, I encourage people to play it as best they can, to save themselves. Capitalism seems to have this nasty tendency to sort people into owners and owned, and it's clearly better – or at least nicer – to be the former than the latter. There's a saying, "The problem with winning the rat race is that you're still a rat"; this is true. And it is just as true that the losers of the rat race are just as much still rats. Losing the game doesn't smash it any more than winning it does.
And heaven knows, it's a lot more conducive to psychological resilience to play it as a game than to actually believe in it. The whole Protestant work ethic thing is based on the notion that you can tell where you stand in God's eyes (and your neighbors') by how "prosperous" you are, i.e. how good you are at capitalism, or, more accurately, how well you make out under capitalism. It's easier, I promise, not to believe your bank account, your job, your professional prestige, your material goods are representative of your virtue and worth as a human being.
There are sometimes ways to escape capitalism, to at least some degree. All of them, to the extent they involve dealing with the rest of the world, involve dealing with capitalism and its forces. The jam in my fridge was made by Trappists. None of these escapes are very scalable; some are terrible in their own ways. But if you find one that works for you, more power to you. I will cheer you on.
I sit in judgment on no one for either playing the game or finding ways to escape it. How could I? If you are sitting on the train tracks, I will encourage you to get off them before the train comes, even while I sympathize with your discouragement about there being so few train-free places to sit, or how fast they go and how hard they are to catch; whether you leave or ride the train makes little difference to the lay of the tracks or the schedule of the trains.
But that doesn't mean I have no moral judgment on how you chose to play, if you play. Cheating is still cheating; ends still don't justify means. Winning may be delightful and rewarding, but those are different things than ethical and moral.
And it doesn't mean that I counsel surrender to the status quo; it doesn't mean I think it futile to attempt to work towards better systems, or bettering the system. I mean only that playing the game is almost wholly orthogonal from changing the game. Both may be necessary, but we must not confuse one for the other.
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It's a kind of two level opinion. On the one level, we can paraphrase my sentiments as "I don't care what the rules of the game are, so long as (1) I get to know what they are, and (2)
On a deeper level, of course I care what the rules of the game are. I have all sorts of opinions as to the goodness of the game, the desirability and suitability of its rules, and all that sort of thing.
It's like, if I'm wind up stuck in a game of "Monopoly", I'm going to play to win, even though I know that "Settlers of Catan" is a better game. (Monopoly fans: sorry, you're just wrong.) I'm not going to roll my eyes, and *tsk* and declare that I'm not going to build any hotels because Settlers doesn't have hotels; and I'm certainly not going to be okay with the bank cheating me on my rents because Monopoly is a boring, poorly designed, unentertaining game. And I will do my best to frack what enjoyment from the flinty experience I can.
In whatever system I'm having to function in, I'm going to make it my business to know the rules well and play to win. (It might, admittedly, be a slightly idiosyncratic definition of "win".) That does nothing whatsoever to inhibit my ability – or inclination – to criticize the system, and, indeed, have a very low opinion of it.
I have this two-level attitude about many things.
Like the DSM, the "bible" of psychiatry. As part of my profession – at least, the part of it that involves working at clinics and billing insurance companies – I'm required to diagnose patients as per the DSM. I take pride in doing this reasonably well. I'm not a huge expert on it, but there has not yet come a point where my supervisor and I have disagreed on a diagnosis that we opened a DSM and it didn't turn out I was right. Other clinicians come to me and ask my help diagnosing patients.
Moreover, I'm into the history of the DSM in a big way, and get very excitable about the topics of psychiatric nosology and the epistemological bases of diagnosis and all that good stuff.
None of which means I believe in the DSM. In fact, quite to the contrary. In my most jaundiced moments – typically ones where I'm sitting at a computer with a blank assessment form open, staring at a pile of assessment notes, and remembering my psychopathology professor, Dr. Elias, quipping, "The problem with the patients is they haven't read the DSM" – I think of the DSM as kind of the psychiatric version of The AD&D Monster Manual, another complicated rule-based taxonomy I became adept at using.
It's not that I don't believe in the reality of mental illnesses. It's that I don't think that the categorization scheme in the DSM actually maps to reality. Often, it doesn't even fail to map to reality in that useful way some epicycle-encrusted paradigms do. It's chock full of epistemological goofiness. It is in rather desperate need of a sanity check and massive refactoring, which it will probably never get. (Guess what my letters to the DSM-5 committees were about.)
So this results in a lot of cognitive context switching. Within the context of the DSM, if the patient presents with a week and a half of depressed mood, being unable to get out of bed, no appetite, insomnia, impaired concentration and morbid preoccupation, that's not a Major Depressive Episode, and doesn't count towards a diagnosis of depression, even if it happens every two months or so: fourteen days of symptoms or it's not an MDE. Outside the context of the DSM – you know, sitting with the patient – of course that's depression, duh. Knowing that it fails to meet the DSM definition of Major Depressive Episode (or anything else in the Mood Disorders chapter except the "Depression, Misc" category that insurers loathe) changes nothing about treatment – for neither me, nor, apparently, most of the psychiatrists I have worked with, who are even faster to jettison DSM categories than I am, thanks to their beautiful, "I'm a doctor, nobody can tell me how to diagnose, not even the APA," attitude problems.
I can totally tell you (or your insurance company) whether some complaint you present with qualifies for a diagnosis against the DSM, and it will be – aside from its utility in building the legal case for you that your insurance company has to pay for you to have it treated – a completely pointless intellectual exercise that contributes approximately nothing to my clinical formulation of your problem or how I'm going to treat it.
But I'm all over pointless intellectual exercises. I love pointless intellectual exercises. Just because it's a pointless intellectual exercise doesn't mean I'm not going to be awesome at it and get really, really into it! If we're going to split non-existent hairs, I am gonna be a non-existent rockstar-ninja-barber.
So one moment I can be having a sincere, in-depth conversation about whether some"thing" "is" "PTSD" based on subtleties of the DSM-IV criteria, and then next I'm explaining why it's all nonsense anyway, due to the PTSD/MDD symptom overlap, DTD, variable definition of trauma, how there's these common symptoms that aren't in the DSM, etc.
This combination of gleeful enthusiasm for the minutia of psychiatric nosology and deep exasperation if not disgust with the intellectual bankruptcy of the whole thing is, apparently, somewhat confusing for a lot of people.
(Honestly, I think the latter is why I can do the former. I am uninhibited by the despair that overtakes any clinician who expects the DSM to make sense.)
People sometimes assume that if I'm so "into" nosology and diagnosis, that I must be in favor of it. This is really disturbing to me, because the list of things I'm also really "into" includes: antisocial behavior, the psychology of criminality, violence, trauma, oppression, the etiology of genocide, and really, just about everything that falls under the rubric of "why people hurt each other even though they espouse the moral value that they shouldn't."
(Much more rarely, people assume that because I have such a low opinion of the DSM, I must not know what's in it or find it difficult to use – that my dislike is a kind of intellectual sour grapes: if I can't get it, I bad-mouth it. They usually get over that misconception pretty fast. And the two chunks of the DSM I truly do not get – the chapters on Sleep Disorders and Dementias – I have no opinion of.)
Here's another example. Different communities, different social scenes have different norms of discourse; this is true online and off. I have participated in social milieus in which cussing someone out aint no thing, and I've participated in social milieus in which asking someone a trivial neutral direct question about their work was an insult. I've participated in online spaces in which the only rule was that you can't say to anybody "you can't say that" and in which the only rule was that nobody will tell you what the rules are, you have to figure them out for yourself. I once participated in a forum, the title of which had the word "flame" right there in it as a caution to the unwary.
I can participate happily and productively in a whole variety of social rule sets. That doesn't mean I like all social rule sets equally. And it doesn't mean that if I do like a social rule set, I think it's in some sense good. After all, there can be rule sets that advantage me over others, and while I might find that enjoyable, I certainly can recognize that as unfair.
People sometimes get confused when they see me operating to two different social standards, in two different contexts. Yes, here I will flag flamers for moderation, and there I will unleash the napalm with the best of them, because here it is against the community norms, and there it is compliant with them. In that forum I will cut-up like a comedian on speed to earn those "+1 Funny" votes, in this forum, I will gently remind you jokes are off topic and keep my witticism to myself. In this place I will be very sensitive and solicitous of people's sensibilities, in that place I will be irreverent and jaded, and will crack wise in the blackest of humor. In that space I am careful not to swear, in this space I work blue.
I whisper in libraries, I shout in stadiums.
This probably doesn't sound all the controversial to you, Gentle Reader, but I keep running into folks who have various troubles with it. One such trouble is leaping to assumption that if I do X in context Y, then (1) I like X and (2) am inevitably going to do it in all contexts A through Z. Neither is warranted. Regarding the former assumption, I have not yet entirely forgiven two of my references, a tech lead and a social worker, who ebulliently told hiring managers that I was great at debugging other people's code and case management, respectively. No, see, if debugging other people's code/case management is part of the job and needs to get done, I will buckle down and do it (after a few procrastinatory rounds of whatever Flash/HTML5 game I'm playing) and I'm kinda down on doing things poorly, so I will try not to phone it in. But that doesn't mean I approve of the Siderea-does-this-tedious-thing scenario.
Regarding the latter, my favorite example to date was discovering that my fellow Pennsic campers at Quacheri (an "everybody does their own thing" camp) were worried, my first year with them, about me because of my past with Crook'd Cat (camp dinners nightly, chore shifts). Eventually somebody admitted to me that there had been a fear that I would "attempt to organize" them. I suspect, though nobody said it, I was expected to explosively decompensate in the absence of structure. Apparently a few minds were blown.
I'm pretty sure this is not a me-specific thing, though. I ran across a lovely example elsewhere, recently. Trans man Jackson Bird, in his coming out video last May, explains why it was that, as his high school photos attest, he once presented as such a glamorous, femmy young woman.
This happens sometimes: a person who seemed to be a particularly manly man or womanly woman comes out as having never have identified with the gender they were assigned at birth and performed to such social approval. The usual explanations offered for this phenomenon are overcompensation – the fear of being discovered to be trans leading someone to take pains so nobody will ever suspect – and obedience – acquiescing to the demands of parents and other authority figures. But Bird described a third experience. He explained that as he hit puberty assigned female, he didn't know about trans people. He figured he was stuck doing girl. But he if was, he was going to do girl right. "It wasn't me," he says in the video, "It didn't feel like me. It felt like a game. A game I was winning – and which gave me a lot of pride to be winning." Not fear, not obedience: competitiveness. If he had to play Girl, he was going to play Girl to win. But just because he played Girl brilliantly – certainly better than I ever have – doesn't mean he liked it or identified with it. What he liked was getting the best possible result from the situation he was (he thought) stuck with.
Just because you play to win doesn't mean you like the hand you were dealt – or game that you're playing.
Which brings us to my third example: capitalism.
I'm a small business owner, by virtue of being in private practice; I'm a self-employed sole proprietor. This means I have to compete in the market for customers (patients) and function as a business in a variety of ways, such as dealing with vendors.
On one hand, I think selling my services as a therapist to the general public for cash is really neat. Basically, my visceral, emotional reaction to the idea of a market for therapy is that it's a contest in therapisting that uses money to keep score. While that's horrifying for a lot of therapists, who as a tribe are often down on competition, I, myself, am a wildly competitive person who loves contests of skill: for me this is... "catnip" isn't a strong enough word.
(I think about this, and the overwhelming association that comes to mind is a sensory memory of when I helped managed the hounds at a coursing event: the way the greyhounds that were oh-so-unwillingly waiting their turn to run pressed against my legs trying to get past me to join the race, their tails whipping back and forth in ecstasy, and their whole bodies literally trembling in joy in anticipation of racing.)
And if that weren't alluring enough, it's a game I can play that, if I'm good enough at it, gets me out of having to have a real job. So: like getting paid for eating ice cream.
On the other hand, I have some serious reservations about capitalism.
For instance, while I think this whole selling my (medical) services on the open market thing is keen like whoa, there's nothing about subjecting me to market forces that makes me a better clinician.
Quite to the contrary, pretty much any financial incentive puts my interests in conflict with those of my patients. The standard business model, payment per session, incents the treater to the extent the patient still requires services. Put it crudely, that system only pays me as long as the patient is sick, so there's an incentive to treat poorly and slowly!
This is a well-known failure mode of that business model, the industry-standard term for which is "fee-for-service". So a lot of people have tried to come up with alternatives – and all have had similarly awful consequences. Payment for constrained terms (time/service limits) results in treaters treating what they think they can in that time, and declaring success, rather than addressing the patient's presenting problems. Payment for treatment success (e.g. fixed price) results in providers discriminating against hard-to-treat cases – the very patients who most need help. Payment for treatment success moderated through an assessment of how difficult to treat a condition is leads to diagnostic inflation and, where third party payers are involved, diagnostic deflation ("You're not really depressed, you are just having a bad day. Eight sessions should be enough for you.") It also marches right into the weeds of breathtaking coordinative communications costs.
As best I can tell, it's my professional responsibility to (attempt to) put money completely out of my mind when treating patients, so my interests aren't pitted against my patients' – because there is no incentive system which doesn't jog my elbow and cause a conflict of interests.
It's funny: the various Codes of Ethics of my profession all(?) have bits in them about avoiding "dual relationships". A psychotherapist may only relate to a patient as a psychotherapist, not anything else, because the very relationship is one of the crucial tools of treatment, and mustn't be warped by other relationship modes. A therapist treating a patient who is a house painter may not hire the patient to paint their house. But we therapists all look the other way about how the fundamental nature of our enterprise is fractured into a dual relationship when we sell our services on the market: if you are my patient, I am your psychotherapist, but you are also my customer, and I am a vendor to you.
We are stuck here in a capitalist society, so there's no helping this. Oh, if I work for an agency and you have insurance, we can let my agency and your insurer sort out the payment behind closed doors so neither of us has to think about it. And that trick works right up to the moment that: (1) your insurance won't pay, (2) my agency decides not to take your insurance any more, (3) anything bad happens involving the payments getting made. Also, when you let somebody else handle your money for you, often their interests don't align with yours, and you can find yourself taken for a ride. Also-also, we both have to pay, literally, for the privilege of this veil of ignorance; the agency and the insurer both get a cut.
No, mostly what we therapists do – especially those of us in private practice – is concede to the inevitable, grimace in distaste, and attempt to squeeze the two relationships together until they fuse into an amalgam. We use the very commercial nature of the enterprise therapeutically. You've heard of music therapy, and art therapy, and play therapy, and animal therapy: well, commerce tends to make it all money therapy. Yeah; there's this whole thing of using conflict in the matter of payment as relational microcosm, in which to work with the patient on interpersonal problems.
Is this good therapy? I dunno. Adequate, I guess. It's the kind of therapy we're stuck doing when the dual-nature of the therapist/vendor-patient/customer relationship is no longer avoidable.
I've never heard whether anybody thinks it's "evidence based practice", that's for sure.
Honestly, one of the things I feel most keenly about selling my services to the public is a little thrill of what I'll call licit wickedness. Fun as it may be for me, in no sane and rational society would I be allowed to do this. Yet, here we are and here I am. I am increasingly certain from what I know of psychotherapy that the incentives that arise from selling it for a living are bad for it, and result in worse psychotherapy. The best case scenario, the one I am always shooting for, is that I manage, by vigilance and assiduousness, to compensate for the biases of financial incentives – thereby diverting my energies and my attention away from the therapeutic work, which is, of it's very nature, extremely demanding of energy and attention. Doing what is necessary to reach the best case scenario deprives me of resources I would otherwise have free to dedicate to doing therapy.
Meanwhile, the thing that market forces are supposed to do is incent the delivery of better or cheaper services, because competition. But that can't actually work in a market where the buyers can't determine whether one vendor's product is actually better or cheaper than another. How is the market is supposed to evaluate the value propositions of different therapists – with their different prices, different credentials, different approaches, different specialties, different skill levels – when all their prior work is confidential and you don't get to examine it, and they're not allowed to give references? Comparison shopping of therapists is essentially impossible.
I described the market for therapy as "a contest in therapisting", but let's be clear: it's not a contest in how good you are at doing psychotherapy. It's a contest in how good you are at running a psychotherapy practice, i.e. a business. That quite possibly has more to do with how good your marketing is than how good a therapist you are.
Also, I think the whole notion of competition leading to improved offerings on the market just flat out doesn't work in the market for therapy. For one thing, there's the problem that competition doesn't reward innovation and improvement and cost-efficiency in therapy, because both quality and price are actually opaque to the market. The world won't beat a path to your door if it can't tell your mousetrap is better. What we see is a lot of marketing claiming that this provider or that type of therapy is wonderful, but a lot of that seems to be empty hype.
And then there's this other problem: I actually suspect that competitive environments just don't produce the sorts of behaviors in therapists that economic models are supposed to incent. As I mentioned, I'm unusual among therapists because of how competitive I am; the therapist nation is a pretty conflict-averse population. Frankly, the typical therapist reaction to having to compete in a marketplace seems to be flinching away from it, like a poked snail darting back into its shell, and withdrawing from the enterprise entirely.
This may, in fact, be why so many therapists do so terribly in private practice, and why an effective intervention for their self-sabotage is explaining the idea of "niches" to them; it frames market competition as a form of collaboration, which they can then emotionally cope with. "It's not that I'm better at therapisting than the other therapists in this town, it's that I do something none of them do. Okay."
Well, that's (some of) my reservations about psychotherapy under capitalism, but as a psychotherapist, I have lots of other reservations about capitalism, itself. One, in a nutshell: I'm increasingly concerned that participating in markets is actually intrinsically unhealthy – both psychologically and physiologically – for some large but not total percentage of people. That's a topic for a separate post, but you can see there are some serious ethical/moral questions about an economic system which is at odds with the necessities of human health, and even more so when those negative health consequences are unevenly distributed.
Then there's all the more standard stuff about exploitativeness.
Then on top of all of that, I'll be the first to acknowledge the fact that capitalism may be, to borrow an expression, "the worst system, except for all the others." It's not like I'm the partisan of some particular alternative. Construe no criticism I have of capitalism as any kind of covert comparison. It is entirely possible – indeed, fruitful – to examine a system and note what ills it promulgates without reference to any other system. If I tell you why I think capitalism sucks, I am not telling you why I think something else is better, I am telling you why capitalism sucks.
So I'm in this weird position: Capitalism: terrible system, detrimental to psychotherapy, possibly pathogenic to many people, may be best of bad choices, love it, love playing it.
Wait, it goes beyond that. I encourage people to play it. Since we're stuck in this system, I encourage people to play it as best they can, to save themselves. Capitalism seems to have this nasty tendency to sort people into owners and owned, and it's clearly better – or at least nicer – to be the former than the latter. There's a saying, "The problem with winning the rat race is that you're still a rat"; this is true. And it is just as true that the losers of the rat race are just as much still rats. Losing the game doesn't smash it any more than winning it does.
And heaven knows, it's a lot more conducive to psychological resilience to play it as a game than to actually believe in it. The whole Protestant work ethic thing is based on the notion that you can tell where you stand in God's eyes (and your neighbors') by how "prosperous" you are, i.e. how good you are at capitalism, or, more accurately, how well you make out under capitalism. It's easier, I promise, not to believe your bank account, your job, your professional prestige, your material goods are representative of your virtue and worth as a human being.
There are sometimes ways to escape capitalism, to at least some degree. All of them, to the extent they involve dealing with the rest of the world, involve dealing with capitalism and its forces. The jam in my fridge was made by Trappists. None of these escapes are very scalable; some are terrible in their own ways. But if you find one that works for you, more power to you. I will cheer you on.
I sit in judgment on no one for either playing the game or finding ways to escape it. How could I? If you are sitting on the train tracks, I will encourage you to get off them before the train comes, even while I sympathize with your discouragement about there being so few train-free places to sit, or how fast they go and how hard they are to catch; whether you leave or ride the train makes little difference to the lay of the tracks or the schedule of the trains.
But that doesn't mean I have no moral judgment on how you chose to play, if you play. Cheating is still cheating; ends still don't justify means. Winning may be delightful and rewarding, but those are different things than ethical and moral.
And it doesn't mean that I counsel surrender to the status quo; it doesn't mean I think it futile to attempt to work towards better systems, or bettering the system. I mean only that playing the game is almost wholly orthogonal from changing the game. Both may be necessary, but we must not confuse one for the other.
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Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 03:16 am (UTC)DSM
Date: 2015-09-08 04:15 am (UTC)Likewise, all the payment modes for my field produce perverse incentives. Pay me for good outcomes and I avoid the sickest patients and the noncompliant ones. (I hate the term noncompliance, BTW. People usually have what they feel are good reasons for not following my advice, and their reasons often do make sense to me.) Pay me fee-for-service and why would anyone ever get to "well"? Pay me lump-sum per head, and again, I need to avoid the sickest and those who are unlikely to take steps to improve their health, because they will consume a lot of my time.
I just don't know what the answers are. I do like trying to figure out why systems work or don't work, and I love your writing, because you see the same things I do, but are much more eloquent!
DSM Etc
Date: 2015-09-08 04:19 am (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 11:44 am (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-10 02:58 am (UTC)I often feel like the field has unconsciously decided to solve this problem through the insurance/agency "solution" I describe above. But quite aside from the problems I describe above, which are money problems, introducing third (and in this case fourth) parties introduces completely other problems. Like goodbye confidentiality.
This is the other-other reason I am pursuing private practice: there's things about agency practice and dealing with insurers which makes me feel unclean. Ethically compromised. The whole arrangement feels cleaner, and more honest, and lets me do better work, when the patient is the person who pays.
So long as any third party feels like they're entitled to some sort of oversight, some sort of accountability, the confidentiality goes right out the window, and so does patient authority over their treatment.
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 01:03 pm (UTC)Regarding the problem of markets when neither the cost nor the benefit of competing alternative can be easily compared...yep! We have a somewhat similar thing in the basic research market. Costs can be sort of compared ahead of time, but not effectiveness or benefits, except by considering "reputation". But past performance is no prediction of future performance when each research task is quite different, and going by reputation disadvantages new players who may bring extra innovation, and can also discourage the sort of risk taking that produces big results.
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-10 03:00 am (UTC)There's a therapy which is sufficiently based on that, it's in the name: Dialectical Behavior Therapy. Which, interestingly, is very didactic.
I honestly think maybe everybody should just get two years of DBT in childhood. Maybe around junior high.
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-10 03:39 pm (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-11 02:34 am (UTC)DBT for all
Date: 2015-09-11 02:21 am (UTC)(no subject)
Date: 2015-09-08 02:05 pm (UTC)"it's utility"
"an sincere"
"like comedian on speed"
(no subject)
Date: 2015-09-10 03:00 am (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 05:48 pm (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 06:54 pm (UTC)Loved the post.
I get to be out of the rat race because I've got money. I'm lucky, though, not necessarily good. It's not fair.
I'd sure love to see what Siderea would do if all her financial constraints were removed.
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-10 03:01 am (UTC)0) Sleep for two weeks straight.
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 11:02 pm (UTC)While I agree wholeheartedly that Settlers of Catan is better, I am curious whether you have ever played Monopoly according to its written rules. As it is most commonly played, it is little better than Candyland, due to its history as a household game which small children should enjoy. But if you play with the actual complete rule-set, it's a much better game. Still not "good" by modern game-design standards, but not as bad as its rep is, either.
"If we're going to split non-existent hairs, I am gonna be a non-existent rockstar-ninja-*barber*."
May I put this in my quote file? (Attribute to Siderea?)
"This probably doesn't sound all the controversial to you, Gentle Reader, but I keep running into folks who have various troubles with it."
One reason might be that you (and your typical reader here) live within so many *more* different contexts than the average person. One of the defining traits of the Archipelago of Weird is that it is an Archipelago...
"The whole Protestant work ethic thing is based on the notion that you can tell where you stand in God's eyes (and your neighbors') by how "prosperous" you are"
*lightbulb* It's the Fellowship from Ultima 7 all over again! (Makes note to actually write that post I've been thinking about for a while...)
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-08 11:19 pm (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-10 03:22 am (UTC)Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-10 03:05 am (UTC)My primary memory of Monopoly is interminable waits for the interesting parts to come around again. Does the full rules fix that?
May I put this in my quote file? (Attribute to Siderea?)
Sure!
One reason might be that you (and your typical reader here) live within so many *more* different contexts than the average person.
Surely. But perhaps even more so, I live within so many more different contexts because doing so is not quite the trial for me that it is for the more provincial. (My clinic patients, some of them are amazingly provincial.)
Re: Monopoly
Date: 2015-09-14 12:48 am (UTC)For example, suppose I'm sitting on Free Parking and worried about landing on the Oranges with a house each. The owner of the Oranges is licking her lips, but she also knows that there's a less than 50% that I'll land on any of them. We can work out a mutually-beneficial deal in which I get immunity from having to pay rent on those properties on this time around the board, in exchange for a fixed price (in cash, property, a corresponding immunity on my Greens, a promise to buy Mediterranean and give it to her if I land on it unowned, etc.) There are lots of kinds of trades like this that, while not explicitly mentioned in the rules, are clearly allowed by them.
The only thing I recall that's actually specified in the rules but most players don't know is housing shortages. The game comes with a fixed number of houses and hotels, and rather than just saying "if you run out, use squares of green paper," the rules tell you exactly how to resolve the conflict when several people want to buy scarce houses at the same time (basically an auction, IIRC). You can even create a housing shortage intentionally by downgrading a couple of hotels to four houses each, which you can do because that action has priority over anybody BUYING houses.
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-09-28 09:23 pm (UTC)My best cognate on the professional side is probably Patents. I've written several, and might even submit one or two for Querki -- they are how the game is played, and I'm bloody well going to play the game well -- but I will gleefully argue all day why they are fundamentally destructive to the software industry, and should just be legislated out of existence...
Re: Comment Catcher: A Two-Level Attitude
Date: 2015-10-01 01:01 am (UTC)I suspect it does. It does seem to be an... exquisitely INTJ way of seeing the world.
(no subject)
Date: 2015-09-08 04:15 am (UTC)The part about different behaviors in different contexts is so important and **so** hard to teach to "my" technicians, especially in a culturally sensitive and work-appropriate way. Though I really should have expected that since I can't really navigate it effectively in my personal life (hence the reason that my friends from school, church, girl scouts, and a couple other categories were not actually allowed (by me) to interact with me at the same time for most of my childhood).
On being a rat, if employment is the race that comes to mind first, being a stay-at-home parent is as close to not being a rat as I can get.. but then I've just required my husband, one of the handful of people about whom I care most in the world, to remain a rat. Thankfully, he likes his type of rat-house better than I like mine. Thankfully, he is as well compensated (slightly better, actually) than I would be were I full time. But blergh!
And then there's all the different rat races that being a parent involves. So, still a rat, still racing. Still uncomfortable with that, but at least it makes asking husband to stay gainfully employed in a position that has health benefits, a bit less awkward a request.
(no subject)
Date: 2015-09-10 03:25 am (UTC)That was the first one on my mental list, yes.
but then I've just required my husband, one of the handful of people about whom I care most in the world, to remain a rat
Indeed. And, while I hope it never befalls you, many people who married their way out of the race have been widowed or divorced right back in; this is the other gotcha, that our system punishes those who try to escape by spurning them when they return.
(no subject)
Date: 2015-09-10 03:44 am (UTC)money and therapy
Date: 2015-09-08 02:04 pm (UTC)Re: money and therapy
Date: 2015-09-10 03:29 am (UTC)As it should be.
I'm sure she knew that we would soon be replaced by another couple and she would be getting money from *somebody.*
You have no such knowledge. You have no idea how likely she was to have another client couple on deck, nor any idea how confident she was that someone would show up before she ran out of money. And you have no idea because it was her job to make sure you never found out and that you believed exactly that.
Re: money and therapy
Date: 2015-09-10 05:48 pm (UTC)First was group therapy led by two therapists. They weren't very good (in fairly subtle ways). They were clingy-- they had a policy of asking for two more sessions after a client planned to leave. The first time they talked me into staying. The second time I just left.
They gave me an impression of being grabby about keeping clients, but I wasn't sure whether it was about money or emotional compulsiveness.
Second therapist: Definitely interested in money, but didn't seem pathological about it.
Current therapist: Not interested in money, as in willing to let me pay at the next session, and doesn't necessarily remember that I owe her money. I eventually asked her whether she had a backup source of money, and she said she didn't, she just wasn't very interested in money. She's told me a little about her background, but in my opinion, has stayed appropriate.