Back to Georgia

Took a brief trip back to Northeast Georgia this weekend. Saw family and an old old friend. But mainly I reconnected with my inner geek as my son and I have started trying to collect the new Marvel Universe figures that have been in stores for a year or so by jaunting across comics shops in Athens and Atlanta. I also (among other more suitable readings) have started reading comic books to him on the IPAD. We have thus far gotten through the entire World War Hulk series and the DC limited series Kingdom Come (I will only read DC graphic novels, refuse to read ongoing series because everyone is basically in the same costume with different colors....plus Wolverine never shows up). Granted he likely has no clue what's going on in these things other than perhaps thinking that if you paint yourself green you are allowed to lay waste to Manhattan, and that Superman might, just maybe be a fascist. We also got the Toy Story interactive children's books for the IPAD, which he loves and we reread several times, and I think probably can follow better.

I used to have a professor that said, to be a therapist you have to be interesting.....and be unashamed of being interesting....in fact "you have to be the kind of person who reads comic books" (J.D. - 2004). At the time me and my cohort didn't quite get that (OK I think I got it, but I know others were thoroughly perplexed), but now that sentiment makes much more sense to me. Not so much about being a good therapist, but being a good human being. No, no you don't have to read comic books to be a good person, but you do, I increasingly suspect, have to unabashed about the things you love and the things (particularly the art, literature, people, philosophies etc.) that constitute your quirks and idiosyncrasies. These are not things to be hidden away and protected from the world, but rather things to be celebrated and cherished. So for me, among those things, is a tendency to completely geek out and suspend disbelief in regards to patently infantile obsessions (as my psychoanalytic supervisor on internship would have referred to them). While comics are clearly a projection of the insecure male adolescent psyche, they're a pretty darn cool projection as projections go. If you must delve into projections they might as well have unbreakable claws, a healing factor and a penchant for cigars. So I find myself worrying whether my son (particularly as he gets older) will realize his father is a complete geek, and I stop and think "Bigger fear - what if he NEVER realizes that...worse what if he NEVER finds his own idiosyncrasies, and never finds anyone to share those with?" --- the horror.

So Simple

Why can't psychiatrists understand the differential diagnosis of Intermittent Explosive Disorder and Conduct Disorder. Remorse vs. No Remorse, not that hard. If you are angry b/c you want my money and hit me over the head to get it and don't feel bad about that until you get punished for the act (CD). If you randomly find yourself hitting people over the head in unpredictable fits of rage with no discernible utilitarian purpose involved (IED). This is not that hard and I can do this well for 1/3 the salary you guys are making. If you are absolutely annoying to most people who meet you and find yourself constitutionally incapable of complying with even the most basic and seemingly innocuous of requests from authority figures - Oppositional Defiant Disorder. Oh and no kid should ever, ever be diagnosed with all of the following in the same assessment: Conduct Disorder, Oppositional Defiant Disorder, Disruptive Behavior Disorder, N.O.S., Bipolar Disorder, N.O.S., Intermittent Explosive Disorder and ADHD - make a darn decision folks! Be a clinician. I know the DSM nosology is not carving nature at the joints but I'm thinking we could at least pick which childhood disruptive behavior disorder best captures the youth's symptom profile and go with that. OK done with rant. 

International Academy of Family Psychology

Just returned from a great professional experience at the IAFP conference. This is an organization that several of my academic mentors from graduate school have been involved in, and which I had my first chance to get some contact with. IAFP meets every 4 years (now 3 years) and has conferences around the globe that focus on "family psychology". This differentiates from family systems and family therapy in that "family psychology" has an empirical and scientific research emphasis and includes both basic science research on families as well as applied/intervention research.

The conference was a great experience, made all the better by having two of my students attend and volunteer to help set up presentations and symposia. They represented themselves very well and I hope enjoyed their experience. I was able to actually get involved in the organization and will be serving as treasurer for the next three years and as a de facto marketing/membership/web presence person. The latter is difficult in that I cannot write code at all, but I will find a good contract person to help I guess.

The highlight of the conference for me was a presentation by Dr. Greg Jurkovic of Georgia State U. psychology dept. on his method for assessing trauma in juvenile offenders through a card sort exercise. Brilliant stuff, and he and his colleagues have found that this is both an assessment method and an intervention given the impact it appears to have upon the teens desire to talk more about past traumatic experiences. The method has within it principles of assessment and intervention with juvenile offenders that I hold dear - methods need to be concrete and interactive, and methods need to involve the youth as a collaborator. I hope to get a chance to apply this method in our project in Mobile in the near future and see what we find. In particular trauma either conceived as formal PTSD or an emerging concept of "complex trauma" has been under researched relative to studying the etiology of juvenile offending, and particularly so in regards to male juvenile offenders. Research shows that boys who are engaging in criminal and violent acts have levels of exposure to vicarious violence and traumatic experiences (when one's life is threatened) at rates much higher than the average person; but we have historically seen trauma as primarily relevant in the case of female juvenile offenders. I think Dr. Jukovic's method opens the door to assessing and intervening with trauma processes in ways that are particularly good for young men.

Beyond that I also got to hear a bit about how issues like school refusal/dropout are being addressed in Japan and a great deal about the role of families in the development and intervention of addictions. Got to meet Dr. Al Mooney whose father started the Willingway addictions hospital in Statesboro Georgia and who has co-written a popular book in addictions recovery. He discussed his work as medical director of a homeless shelter in Raleigh, N.C. and some thoughts on the pharmaceutical industry's role in mental health and addictions (their negative role I should say). He was a dynamic speaker and I really resonated with his passion for the psychosocial aspects of treating mental and behavioral problems.

So all in all a new door opening for me professionally, and a reason to present my team's work in Tokyo in 2013, which is where the next IAFP conference will be held!

Alabama's Regressive Tax System

http://blog.al.com/press-register-commentary/2010/04/editorial_lawmakers_wont_let_go_of_grocery_tax.html

For the first time in a long time our local paper publishes an op-ed that does not seek to prop up the status quo in Alabama. The inability of our legislature to pass a repeal of the grocery tax, or offer a tax rebate for low income families to offset grocery taxes, is a stain on this state. The op-ed makes some great points, particularly the fact that taxing groceries has a disproportionate impact on the poor and stifles economic mobility to some degree. Beyond the pragmatics taxing groceries for the poor is fundamentally a moral issue. The "redistribution" of wealth that would occur from repealing/modifying this tax is infinitesimal and in the current proposed legislation would only effect a small portion of income earners (above $150,000 per year). In Alabama families making above that amount constitutes less than 1% of the state. Add to that the observation over the last 20 years that income inequality has been increasing, not decreasing in the state http://cber.cba.ua.edu/rbriefs/absum01_income.html

Individual Insurance Mandate

I have been asked to do a presentation on the impact of health care reform on mental health practitioners to a group of local health care providers in May. So I've started analyzing this issue in more depth than I had in the recent past. My first befuddlement came rather quickly, namely my inability to understand the resistance to a legal mandate for individuals to own health insurance. Massachusetts, under the guidance of Mitt Romney, enacted the first state law that required ownership of a minimal level health insurance policy. This law subsidizes purchase of health insurance for citizens earning less than 300% above the federal poverty line. Currently for a family of four, this would be making less than $66,000 per year. The Massachusetts system offers a public option for low income families and a pool of private sector policies for those who don't qualify for the public option. They set up a state agency to enforce and administer this law. So there is at least once precedent for mandating people own a health insurance policy.

So one of the most consistent protests I hear about health care reform (which at present is really health insurance reform, we are doing nothing to change how health care is delivered), is the protest against being required to own a policy. Most states require, by law, that if you own a car you own at least a basic auto insurance policy. Home insurance, while rarely required by law, is required by almost all mortgage lien holders as a hedge against their investment. The point being that culturally we accept mandates, legal or otherwise, for for owning insurance that manages our risk when it comes to property. Also, though not required by law, almost all professionals, particularly those who have a legal license to practice their trade, own liability insurance. Again, we readily accept the sense that owning such policies, while not a mandate, is intelligent and tend to laugh heartily and the poor fools who might fore go such coverage. So, why all the hoopla over a mandate to own health insurance. The arguments I've encountered thus far seem to hinge on a) a constitutional argument that the federal government mandating such coverage is not within its federal powers, b) an argument based on the sense of unfairness that young healthy people's civil rights would be violated by making them own a policy that they do not "need", c) mandating such coverage is a boon to the insurance industry, which it certainly is; but may be the only way to get insurance companies to agree to other benefits to consumers, and d) the argument that the combination of mandating insurance coverage while not offering a public option is a recipe for disaster. Briefly the first and last criticisms hold the most water in my eyes. It seems there is little in the constitution that would grant the power to legally mandate health insurance ownership. This is a power that to me seems to clearly reside with the states. Also, the last criticism holds water as well, if I understand the nature of the bill that the senate is now putting forth, i.e. there is no public option for low income citizens. So we are potentially mandating purchase of health insurance without sufficient aid to those among the 33-45 million without insurance who do not have money to purchase it (not all of that number are simply without funds to procure insurance, many willingly fore go insurance through their jobs of state programs that they could otherwise afford).

It seems to me that the constitutional argument could be surmounted by, instead of having the federal government pass a law requiring insurance, to have the feds incentivize state government passage of such laws. This could be done as it was done with drinking age laws (for good or bad). Here the federal government (to my understanding) held federal highway dollars hostage unless state's adopted 21 as the drinking age. Louisiana famously resisted this and saw crappy infrastructure for many years because of this decision. So the feds can dangle carrots for states to pass a Massachusetts type law.

The other issue is one that is more difficult to resolve. How to ensure we aren't try to wring a dry rag, i.e. force people with no means to own any insurance policy to purchase one or face criminal penalties. This may be addressed in the current law proposed (can't find into to clarify one way or another) in that subsidies are offered so people can purchase policies even if they make too little money. Another solution is to do what Massachusetts seems to have done, i.e. expand the availability of public option insurance like Medicaid to any citizen that makes below a certain amount and offer subsidies for purchase of private sector options for those who make too much to qualify for the public option.

The above thinking about solutions ignores the likelihood that the opposition to a health insurance mandate has nothing to do with arguments over policy or funding or civil rights. It is a resistance that I think is rooted in people's attitudes about personal responsibility. People seem to hear individual mandate and immediately conceive of lazy, unhealthy citizens being "given" something by forcing young, sprightly and rugged individualist young citizens to pony up their hard earned cash. If that were the whole story this situation would certainly be an unfair and unjust mandate. To the extent that people are concerned because middle class older adults and families are going to be milked to fund insurance for the have-nots...well that may be true, but that has nothing to do with whether or not we should have an individual mandate. For those older adults in the middle class, like myself, we mostly already have insurance and the imposition of a mandate would not necessarily impose extra costs to us. Interesting, though, because we've decided to go with an insurance reform strategy, whether or not all of this adds costs to the middle class who already have insurance depends not on the government, but on the degree to which insurance companies attempt to squeeze more out of us. However, to the extent that is the underlying view, this ignores the fact that those young sprightly uninsured adults, most of whom are living on the margins, not headed towards the ranks of the college educated, and (if one looks at the typical data from research with this age group) likely to be abusing moderate levels of alcohol and recreational drugs and engaging in other risky behaviors; then one realizes that these young adults are going to be the fat, lazy unhealthy people in 10-15 years. They have just not reached a chronologically point where the scars of their youth are visible or have begun exacting a toll. Making them our noble victims of government mandates for health insurance doesn't make much sense if you consider the above. So forcing those young people into insurance might increase their contact with preventative care, and yes will bring money into either the insurance industry of public sector health care to help defray the cost of offering subsidized health insurance to older adults and their children who are living at or near the poverty level. In summary if we object to the individual mandate simply because if offends our sensibilities about youth and the sense of invulnerability that comes with it, we are biting off our nose to spite our face.

I'll post again after I've looked into the mental health practitioner end of this more, but I just had quite a few thoughts about the resistance to the mandate, a move which makes eminent sense to me.

Thank You, Thank You

I would like to thank the single human being that attended my conference presentation today, even though I got the sense she wanted to leave after the first five minutes. Thank you good lady for pretending to be interested in group counseling for delinquent boys. Let me also thank the other woman who came in the room in the middle of the presentation in order to take a picture of the Mardi Gras beads hanging from the tree outside of the window and then promptly left. Sadly, this is not the lowest attendance I've ever had. In 1998 at the same conference 0 people attended my presentation. I need to work on my marketing strategies. These are the days that having spent 6 years in graduate school makes complete sense.

http://andrewsullivan.theatlantic.com/the_daily_dish/2010/02/what-republicans-believe.html

This is a really interesting analysis by libertarian/conservative and gay commentator Andrew Sullivan. Sullivan's thesis is that much of the conservative reaction to Obama is rooted in their own psychological inability to make sense of modernity (an uncomfortable parallel to the Muslim fundamentalists' dilemma), and their revulsion at Obama because he represents someone who ostensibly has lead a convention and responsible life, but who is still able to  relate to the world with tolerance and pluralism. Sullivan is at his most devastating pointing out the fact that Obama's own personal and family history appears more "conservative" that many, if not most, of his most vitriolic critics (see Sarah Palin, Glenn Beck, Rush Limbaugh, Sean Hannity, Karl Rove, etc). For example I'm always fascinated how faithfully many follow people like Rush, who is a multiple divorce, former drug addict, and college dropout.

But despite my head nodding with Sullivan's basic idea here, and while I think Sullivan's point about how reactions to Obama may be more about the person and less about the president is true, it seems equally important to point out that this phenomenon is not behind every negative reaction to the president. There seems to be legitimate concern about the administration's leadership and policies that seems completely delinked from the processes of repression, paranoia and pining for a mythologized past that Sullivan is noting here. It worries me that critical reactions to the administration that come from an origin of rationalism are not being given voice. Rather, fear mongering by demagogues like Glenn Beck and Sarah Palin is that main critique of the administration we hear. I think there is actually a rational basis for critique that focuses on the wisdom of deficit spending, and the lack of leadership from the president on healthcare (simply allowing congress to craft a twenty-headed monster piece of legislation). The budget that was just presented can be critiqued on a basis that is clearly free of identity politics or right wing wackery, but we're not hearing such critiques. So while Sullivan has a point (that reactions to the president are often originating from a certain type of psychopathology or the right), the presence of rational critiques of the president is a sign of progress that we should not ignore. We shouldn't ignore them both because they represent the capacity for even some conservatives to get beyond identity politics and engage in rational discourse about policy, but also because such rational critiques (in the end) may be important objectives arguments that will lead to true bipartisan policies and outright more effective legislation and governance. For example David Brooks and David Frum are clearly conservatives, but just as clearly free of the frothing at the mouth, tea party, dim witted and reflexive rejection of the administration's policies that Sullivan focuses upon in his piece. At the end of of the day, there are conservative critiques that are rooted in a genuine intellectual analysis of policy and the country's potential well being, and not rooted in identity politics. We should be listening to those voices, while rightfully critiquing and marginalizing the conservative critiques that arise only from self-serving fear and a limited intellectual capacity to grasp the modern world.