john s. smolowe, m.d.

affinity

Adriana: You’re engaged? You two must have a lot in common.

Gil: We have the big things in common…or, at least, we have the little things in common…that is, we both like Indian food…well, we both like pita (sic) bread.

— "Midnight in Paris,”  directed by Woody Allen (2011)

 

 From time to time a patient will be talking of the difficulties of dating. This guy is so sexy, but he has no job prospects. The other guy has graduate degrees and and great income, but there’s no chemistry. “yes,” I sympathize, “it’s hard to find someone who’s both reputable and hot.”

 Seeing “Midnight in Paris,” I realize I’ve left out a variable: affinity. 

 Gil, played by Owen Wilson, is a dreamy, easy-going Hollywood screenwriter who would love to move to Paris, where he will take leisurely walks in the rain and write a novel. On the surface the film focuses on his love for the Paris of the 20s. The hero of his novel-in-progress runs a nostalgia store, selling items from the past, and on one of his midnight walks Gil wanders into the actual Paris of the 20s, where he meets such expatriates as Ernest Hemingway, F. Scott Fitzgerald, Cole Porter, and Gertrude Stein in the prime of their lives.

collaboration in psychotherapy

what have you got for us today?

—   don haas, jazz pianist and arranger, as he greeted a student to begin a lesson

 

who’s in charge in psychotherapy? some therapists let the client set the direction: “uh, huh…tell me more…i hear you…so you’re saying.” some therapists are even, famously, silent. at the other extreme, some therapists have fixed protocols. they fill the sessions with exercises and assign homework between sessions. i like to work collaboratively.

collaboration has 2 key aspects. most visible is collegiality. when i ask my friend rob, a professor who runs  multi-center medical studies, how he understands collaboration, he answers, “you have to like each other.”  indeed, when i say, let’s be collaborative, i mean let’s be friendly, respectful, considerate as we work together. if we’re not getting along, i think we’re not collaborative (if i’m mad and blaming, i may think you’re not collaborative). 

more subtly, a collaboration involves a significant contribution to the vision from all parties. john lennon and paul mccartney collaborated to write the beatles songs—even when they were fighting.  they joined to create songs that are, to many listeners, better than the songs each wrote separately after the breakup of the beatles.

hunting scoundrel docs

in mcallen texas, it's hunting season on scoundrels. dr. atul gawande investigates america's 2nd costliest city for health care (miami is #1, but somehow lost this opportunity for notoriety) and finds (the new yorker, june 1, 2009) that doctors are raking in profits by referring to labs and hospitals they own. america of course has so-called "stark laws" against kickbacks and self-referral, but why texas doesn't enforce these laws as strictly as boston, where dr. gawande lives, or the bay area, where i live, isn't a question that interests dr. gawande.

instead he compares the greediest private practitioners in mcallen to salaried staff docs at the best institutional practice he can find, the mayo clinic, and - by golly - the mayo docs are nobler!  then dr. gawande concludes that private practice and what he calls fee-for-service billing (a mis-nomer as the mcallen docs apparently are actually gouging ppo's and medicare, not billing patients directly) are to blame for rising health care costs in america. one infers we'd do better forcing all docs to work in institutions.

hmmm...something's wrong with pitting the best clinic against the worst private practitioner...an unfair fight? non-matching study cohorts? shooting dick cheney in a barrel? apparently dr. gawande's mom was a private practitioner who saw lots of indigent patients for free. how about comparing her costs of service to the costs at the mayo clinic? then we'd have the best against the best; the solo practitioner would look pretty good.  or let's put a mcallen surgeon in the ring against an institutional scoundrel - say richard scrushy of healthsouth. we'd have to hold the fight in shelby county jail, but both fighters would be equally dirty. i'll take scrushy by tko (head-butt) in the fifth round.

mental soundtrack

i love my mental soundtrack. it runs in the background as i go about my day. just before i sat down to write, i ordered a grateful dead t-shirt online, a red one i can wear to stanford women’s basketball games. now “till the morning comes,” from american beauty, is playing in my mind.

i could sing it out loud, and sometimes i do. i could put on the cd - in fact, i did a few minutes ago;  but (uh oh) now we’re on to the next track, “attics of  my life,” which i don’t really want to hear right now. actually i can’t concentrate with that on. it’s too loud, so i’m going to turn it down. hmmm, still doesn't work. maybe it's the wrong song, so i’ll turn it off. ahh, that’s better; now i have, playing in my mind, just the verse i want to hear:

til the morning comes, it’ll do you fine.
til the morning comes, like a highway sign,
showing you the way, leaving no doubt,
of the way on in or the way back out.

at times i hear, looping, only the phrase “til the morning comes.”   it’s just the right volume – loud enough to hear but in the background, not overshadowing the action. most of the time i don’t even notice it’s there. then, occasionally the direction of my awareness shifts, and whoop, there it is! the song fragment accompanies and amplifies my actions and interactions, in the way that a movie soundtrack accompanies and supports the action.

mr. potato head

i am chatting with an attorney, 30-something, married, top schools. he’s recently been laid off and is considering different firms. he’s wearing jeans and a button-down oxford shirt, white with red pin-stripes. as i listen, i’m carried away by the whiteness of his shirt.  as i watch, it changes into a chef’s coat - double-breasted, large white buttons (yes, i know, “whoa, trippy…”).  let’s play mr. potato head (or ken and barbie) and give him a hat. there, a white chef’s hat.

may i mention something random?

“sure.”   he’s up for it.

i don’t know if this is relevant or will go anywhere, but as you were talking, i found myself picturing you in a chef’s outfit.

lost (in thought) and found

"when a warrior learns to stop the internal dialogue, everything becomes possible"

 - carlos casteneda                

i’m standing in thigh-deep turquoise water, the fine sand visible below my feet.  i’m facing jibe city, the windsurf concession at lac bay, bonaire, dutch west indies. the wind is at my back, blowing safely towards shore at about 18 knots. the sky is blue, water temperature 80 degrees, air temperature 85. i’m wearing bathing suit, windsurf harness, gloves, booties, a blue and grey, wide-rimmed, nylon hat, and spf 30+ micronized-zinc-oxide suntan lotion.

it is my first day windsurfing in 2 years.

i’ve walked backwards from the beach holding the mast in both hands, the transparent mylar sail, trimmed blue and orange, floating on the wind, a foot off the water. attached to the mast, the board trails easily behind. now i’ve passed the toddlers with inflated safety rings clinging to their biceps, passed the blond 8-year-olds jumping on and off an orange, hard plastic kayak, passed the local teenager who, every 2 minutes, sails close to shore, jumps into  a perfect 1 1/2 revolution spin, and without pause sails off full speed. boards pass every minute or so, some whizzing, some lumbering. it’s active, but less crowded than a ski slope; there’s plenty of room for them to avoid me.

(thinking) ok, hold the mast with both hands, walk backwards to lift the sail out of the water. check. the board’s facing left and i want to sail to the right, so mast in my right hand, reach under the sail with my left hand to grab the boom, press down and towards me with my left hand.

as i swing the mast counter-clockwise in a small circle, the nose of board crosses left to right in front of my knees. just as the board comes around to  point to my right, the wind pulls the tail end of the sail out of my right hand and flips it 180. thwap! nose and mast now point, correctly, to the right. 

hey, i remember how to do this. now put the boom on the rear of the board, check. grab the boom with the two hands. check, pull back and lift. right, up comes the sail. what size sail do i have? 5.8 meters. too big? nah, try it. ok, duck under the sail. ow! whacked me on the head. lift it higher. now step up on the rear of the board with my left foot. check.... oh, no! the front of the board’s turning upwind.

crash!

a sweetheart like you

25 –year old grad-student, erin, worries that she sabotages her relationships: “my friends tell me no guy’s going to be good enough for me.” that’s not how i take what you’ve told me, i respond. one guy couldn’t hold a job, another was scared of you sexually. and then there’s tomas. you were in love with him; you’d have stayed with him, but he left. i just think that up to now each man has had only part of the package. i think you’d welcome the guy who had it all. hey, now i’ve got bob dylan running in my head. do you know “sweetheart like you,” from "infidels?" "you know, i once knew a woman who looked like you/ she wanted a whole man, not just a half." i'll email you the link.

the lyrics are on google. (the internet is so handy.)

well, the press is down, the boss ain't here,
he gone north, for a while,
they say that vanity got the best of him
but he sure left here in style.
by the way, that's a cute hat,
and that smile's so hard to resist
but what's a sweetheart like you doin' in a dump like this?

dr livingstone, i presume?

chased by a band of renegade indians, the lone ranger and tonto ride into a twisting canyon, which narrows gradually until it dead ends in a cul de sac. above them on the clifftop, dozens of warriors look down from their horses, bows drawn and arrows notched. “well, old friend,” says the lone ranger, “i guess we’ve come to the end of the trail.” replies tonto, “what you mean ‘we,’ white man?”

the joke revolves around a presumption: an assumption, especially a mistaken assumption, about a relationship.  tonto has an alliance of friendship with the lone ranger and an alliance of race with the indian warriors. the lone ranger assumes, without asking, that the friendship takes priority.

presuming often involves a taking for granted, specifically a failure to check. in couples therapy, joanne complains to roger that she had dinner ready at 7 as planned, but he didn’t show up til 8:30. couldn’t he have called? “but you know i hate to work late," counters roger. "i only do it cause i have to. why do  i need to ask your permission?”

defensiveness

“i would advise you against defensiveness on principle. it precludes the best eventualities along with the worst. at the most basic level it expresses a lack of faith.” - reverend john ames, in gilead, by marilynne robinson

jenny hasn’t been sleeping too well. what might be underneath, weighing on you? “well my parents were visiting.” and? “my mom does this thing. when she talks to the baby, she refers to herself as ‘grandma,’ and she calls my dad, ‘grandpa,’ and she calls me ‘mommy,' but she calls jim, ‘jim.’ not ‘daddy.’” was there space for you to speak to her about that? “well, i said something third person, a bit sarcastically, to jim, something like, "mom sure doesn’t include you in the family.’” how did that go over? “my mom raised her eyebrows, but nothing more. i was pretty subtle.” jim appreciated that i acknowledged what was going on, though, even if i didn’t exactly stand up for him.”

any sense why you don’t stand up to your mom more directly? “well, for one thing, it wouldn’t do any good. i’ve tried in the past. i spent many years trying, and she doesn’t change.” if it doesn’t have an impact one way or another, why not just say how you feel? ”well jim would certainly like that. and i’d be glad that jim didn’t get mad at me later for not supporting him. but my mom would hit the roof.”

the remembered

hannah is wating to break up with her boyfriend.  she’s pretty pessimistic: he’s being a jerk, and he won’t talk about it though she’s tried and tried.

she’s not quite ready to give up. he was caring in the past. they still have fun at times. he’s a good lover. she will miss him.

and one more thing: she has met his old girl friends; bringing them around is one of his annoying habits.  he dismisses her jealousy, saying that she has nothing to worry about, they are just old friends. if that is true, she doesn’t look forward to being “just his friend.” and she doesn’t look forward to thinking of him as “just a friend.” it feels diminishing.

in his novel, “the brief history of the dead,” kevin brockmeier starts with an african notion, that there are 2 kinds of dead, those who are personally remembered by the living, and the revered ancestors,  of whom the living have heard only tales. he portrays a city bustling with journalists, beggars, kids playing, sneaky corporate types, café waiters – all going about their everyday business and all remembering their previous time among the living. as the book unfolds, it becomes clear that one neighborhood is peopled by the 50000 to 70000 individuals that one, still-living woman, laura, has met at some point in her life and can still recall. the inhabitants trade memories of laura and wonder what will become of them when laura is no longer alive to remember them.

stance of the therapist

avuncular adj. characteristic of an uncle or aunt, especially in benevolence or tolerance.

when i teach psychotherapy, in seminar or in individual supervision, i often start by recommending that the young therapist speak naturally, with amiable curiosity - as if he or she were speaking to a good friend over lunch. the main difference between my attitude at lunch and my attitude in the office is that at lunch i eventually say, “ok, my turn,” whereas in therapy i don’t expect a turn. i answer questions – not all questions, because some things feel too private with a patient just as some things feel too private with a friend. I offer anecdotes to commiserate or to illustrate a point;  but i don’t insist on my turn.

short takes

  a list of topics that interest me. i hope to write longer essays on each, but while i'm getting around to it, the list grows longer.

defensiveness - why do we hesitate to learn more about ourselves? and can we treat defensiveness with mindfulness - when did the defensiveness start? how long will it last? what preceded it? what helped it go away? can be as primary to the interpersonal arena as aversion is to solo buddhist meditative practice.

the 50% rule - i prefer to hang out with those i respect enough that, when we disagree, i expect to be right half the time and wrong half the time. i ran into my former patient, peter, on the street. we greeted each other, "how're ya doin?" how you doin?" then he offered, " i wanted to tell you that i think the most valuable thing you ever said to me in therapy was that you let your kids be right half the time."

purview

the range or limit of authority, competence, responsibility, concern, or intention

andy describes a fight with his wife leslie. “my father is visiting from new york. i drive out to get lunch for all of us. i come back into the kitchen and there’s dad eating all the left-over chinese food.  so i say, ‘can’t you leave some for the rest of us? and besides, i told you i was going out for food’ and he says, ‘but i like chinese better.’ so later leslie corners me and says, ‘don’t yell at your dad!’ don’t you think it’s ok to tell my dad how i feel?” well, yeah; but it’s probably also ok that she wants to respect the elders. hard to win that argument, whereas your relationship with your dad isn’t really in her purview. wouldn’t you stand on firmer ground saying, “hey, butt out?”

in organizations, clarity of purview can be quite helpful. who is formally responsible? i want a refund on this computer that died after 4 days. who do i talk to? "yes, sir, that would be joe, the assistant manager."  ok!

blurry purview can be annoying. satellite tv installation is scheduled for 8 am to noon; it’s now 1 pm, and no one has shown. “well, i don’t know, sir; i guess they’ll be there soon.” who knows the schedule? “that would be dispatch.” can i speak with them? “sir, i have no way of reaching them. if they don’t come today, i’m sure they’ll be there tomorrow.” apparently, no one is charged with actually connecting the installers to the customers.

as akira kurasawa’s movie, “ikiru (to live)” begins, a group of mothers from a poor neighborhood presents to the city zoning department a petition for a children’s playground. the zoning officer directs them to public works, where the clerk says, “you need a building permit.” they walk to the building department: “ahhhh, for a project like this, you first need approval from sanitation.” sanitation directs them to zoning – where they started.

scrutiny

And I have known the eyes already, known them all--
The eyes that fix you in a formulated phrase,
And when I am formulated, sprawling on a pin,
When I am pinned and wriggling on the wall,
Then how should I begin
To spit out all the butt-ends of my days and ways?
        And how should I presume?

                                                                         T.S. Eliot

an athletic law student feels depressed and self-conscious. "and my parents aren't helping when they call. asking me about my weight and my period (it's been over 10 years since she had trouble with either) doesn't help. they want to know if i should live in a dorm!" you feel scrutinized. "yeah, scrutinized. that's a good word! i don't do that to people!"

Another undergrad complains about his folks: “I called my mom last week and told her how I was feeling, and she said, ‘you’re so stressed, why don’t you drop that quantitative economics class?’ so, when she called this week, I told her I dropped that class, and she said, ‘I thought you liked that class! How much time are you spending in student government? Why don’t you drop that instead?”

we generally think of attention as pleasant. scrutiny is a word for unpleasant attention of a certain kind. what turns attention into scrutiny?

for one thing, scrutiny is an attention that undermines or even opposes:

panic attacks

in his book of case studies,  the search for existential identity, psychologist jim bugental describes the treatment of a businessman whose life is filled with efficient action but short of inner experience: “those panics just might be the only real touch he has right now with his inner aliveness. those panics are the frantic signals of his lost subjective center.”

a college student has a panic attack on an airplane. are you generally afraid of flying? “no, that’s the funny thing. i’ve flown before. and i’m usually fine. well, maybe a little nervous, but nothing big.” what was going on in the hours or days before the plane flight? “about flying?” about anything in your life. "well, i’d just been staying with my dad, and we didn’t get along at all. every time i’d get ready to go out and see friends, he’d go, ‘who are you going to see? what are you going to do? when are you going to come back?' he has this idea that my friends at home are slackers, and they’re somehow going to bring me down. so i thought maybe he’s right, and i stayed home. but then he and my mom are fighting all the time. and he takes it out on me…"

we start out with a problem of severe anxiety or panic. after some investigation, we end up with  a different problem: anger or sadness or embarrassment. what’s the advantage? one is that the uncovered situation is more primary, therefore, more real.