politics

May 30, 2010

War Requiem

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War — the cost of war — seems worth consideration on the occasion of Memorial Day 2010. Perhaps you have seen the movie Brothers. It will be in the same spirit, I hope, that I reflect a bit on the cost that any war brings, however necessary it might be. I will do this by quoting two poems and directing you to some wonderful music using poetry as text.

World War I,  “a war to end all wars” according to President Woodrow Wilson, generated lots of verse. British poets, in particular, found the pity in wartime, and as Wilfred Owen wrote, “the poetry is in the pity.” Owen fought and wrote about fighting, as in a letter to his mother just after his arrival in France:

“I can see no excuse for deceiving you about these 4 days. I have suffered seventh hell.

I have not been at the front.

I have been in front of it.”

The 25 year-old Owen was to die in battle just one week before the armistice on November 11, 1918.

When Benjamin Britten, the pacifist English composer, was commissioned to write music in honor of the reconsecration of Coventry Cathedral in 1962 (which had been destroyed in World War II), it was Owen’s World War I poetry and the Latin Mass for the Dead to which he turned. The piece, for large orchestra (with the addition of a chamber orchestra), three vocal soloists, and chorus, alternately rages against and laments the ravages of wartime.

The War Requiem ends with the Owen poem Strange Meeting, sung at the première by an English tenor and a German baritone, no coincidence as England and Germany fought against each other in both World Wars.

In this poem (excerpted below), the narrator finds himself in the bomb shelter and sleeping quarters below the trenches of the enemy, “down some profound dull tunnel,” as part of a night raid where he encounters dead and dying soldiers. There, he and his enemy recognize their shared human bond:

…Then, as I probed them, one sprang up, and stared
With piteous recognition in fixed eyes,
Lifting distressful hands as if to bless.
And by his smile, I knew that sullen hall
By his dead smile I knew we stood in Hell

“Strange friend, ” I said, “here is no cause to mourn.”
“None,” said the other, “save the undone years, the hopelessness.
Whatever hope is yours, was my life also…
For by my glee might many men have laughed,
And of my weeping something had been left,
Which must die now. I mean the truth untold,
The pity of war, the pity war distilled.
Now men will go content with what we spoiled,
Or, discontent, boil bloody, and be spilled…

I am the enemy you killed, my friend.
I knew you in this dark: for so you frowned
Yesterday through me as you jabbed and killed.
I parried; but my hands were loath and cold.
Let us sleep now…”

The English language changed because of World War I. Phrases and references to the word “trench” became part of common parlance, as in the phrase “in the trenches” which still refers to working at a hard, grinding task; and even the phrase “trench foot,” which led back to a type of frost bite common in the muddy, cold, wet, and verminous condition of those dark places inhabited by the warriors.

Or, how about “trench fever,” a bacterial infection associated with the lice that bred there. The expression “No Man’s Land,” plays back to the space between the trenches — between you and the enemy trench — which could be a few hundred yards. It was the place belonging to “no man” or side in the conflict, and it was the place where no man could easily survive. So too, when one army decided to launch an attack on the other, they had to go “over the top” of the trench and into hostile fire.

But it was to a much earlier use of the trench in warfare that the poet Patrick Shaw-Stewart would refer.

Patrick Shaw-Stewart was born on 17 August 1888 in Wales, and fought as part of the British Expeditionary Force at Gallipoli on the Chersonese peninsula during World War I, not far from the site of the Trojan War.

Gallipoli was a disaster for the British. Shaw-Stewart was on three days leave from the front on the island of Imbros when he wrote the untitled poem that follows. It refers to the Trojan War as represented in The Iliad, so a little background is required to better understand it.

The war began soon after the Trojan prince Paris abducted Helen, the most beautiful woman in the world, but the wife of one of the Greek kings (Menelaus). The Greeks organized their own expeditionary force and followed Helen to Troy so they might retrieve her.

Many years into the conflict, Achilles, the greatest of the Greek warriors, stopped fighting because the leader of the Greeks (Agamemnon) had taken away Achilles’ concubine. Achilles’ rage and his decision not to fight is called “The Wrath of Achilles.” In addition, Achilles knew if he returned to battle he would not survive the war. Despite this, he resumed the fight and turned its tide, with the goddess Athena beside him, both shouting in a trumpet-like, horror-inducing scream to make the Trojans flee.

Achilles and Athena stood at the ditch in front of the wall built by the Greeks to protect their ships. Achilles’ head was surrounded by an aura of flame created by the goddess (to which the poet refers in the heart breaking last stanza), so better to terrify the Trojans, who panicked and ran away.

Shaw-Stewart tells his own Illiad-like war story from the standpoint of his temporary leave from fighting:

I saw a man this morning
Who did not wish to die
I ask, and cannot answer,
If otherwise wish I.

Fair broke the day this morning
Against the Dardanelles ;
The breeze blew soft, the morn’s cheeks
Were cold as cold sea-shells

But other shells are waiting
Across the Aegean sea,
Shrapnel and high explosive,
Shells and hells for me.

O hell of ships and cities,
Hell of men like me,
Fatal second Helen,
Why must I follow thee?

Achilles came to Troyland
And I to Chersonese :
He turned from wrath to battle,
And I from three days’ peace.

Was it so hard, Achilles,
So very hard to die?
Thou knewest and I know not-
So much the happier I.

I will go back this morning
From Imbros over the sea;
Stand in the trench, Achilles,
Flame-capped, and shout for me.

Much like Achilles, Patrick Shaw-Stewart survived the Gallipoli campaign, but not the war.

He was 29 at the time of his death.

May 26, 2010

Fear of Change: the Therapeutic Implications of Japanese Holdouts

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Things change. The question is, do we change with them? Or, do we instead, continue to operate by the same outdated rules of conduct.

I often said to my patients that they seemed to be behaving as if the conditions of their early life still existed. They had long since fashioned solutions to problems that they faced many years ago, and continued to use the same solutions, even though those methods of living didn’t fit with their current life situation. It is as if one were born in Alaska, learned to wear multiple layers of heavy clothing and then moved to the tropics without a change of attire. The warm clothes were helpful up North, but are a disaster down South.

What does this have to do with the “Japanese Holdouts of World War II? The answer is that these men lived by an outdated set of rules with heartbreaking consequences.

If you recall your history lessons, you will remember that the Japanese soldiers of that period were trained according to the principles of Bushido, a feudal fighting code that derived from the period of Samurai warriors. Above all else, weakness was condemned and surrender was disgraceful. Death by one’s own hand was seen as preferable to permitting oneself to be captured, so as to avoid both personal disgrace and family shame.

The Allied approach to the war against these very soldiers in the Pacific was one that involved “island hopping.” The strategy passed over certain islands, both to save men and ensure that the Allies would be able  to capture those islands that were of the greatest strategic value. When the Japanese surrender came in 1945, numerous Japanese troops found themselves stranded on out-of-the-way Pacific islands, cut-off from their command, and without the capacity for communicating back home. These men neither knew the war was over nor could imagine that any honorable soldier, let alone their entire nation, would surrender. Some were in small groups who gradually died from disease or starvation; others were, at least eventually, alone.

While many never surrendered and died still waiting for reinforcements that never came, it was not uncommon in the late 1940s and 1950s to read news accounts of isolated Japanese combatants giving themselves up. The photo at the top of this page is of Second Lieutenant Hiroo Onada, who finally surrendered in 1974, and would not do so until his former commanding officer, by then a bookseller, personally ordered him to lay down his arms.  At that point, World War II had been over for nearly 30 years.

Thirty years. Yes, 30 years dedicated to a war that was over and a life of desperation that was no longer required.

But how many years, if any, have you given up to a thread-bare, bankrupt strategy of living that has long since outlived its usefulness?. And, more to the point, how many more will you endure? When will you realize that your “solution” has now become the problem?

In my psychotherapy practice I saw numerous variations on this theme. People who were abused or neglected  or criticized as children and who continued to live in terror of disappointing others. Those who found substance abuse the only available way of treating the depression or anxiety they experienced when they were young, and who continued to do so. People who avoided challenges because they were scared of failure, having failed many times in the past. Individuals who wore a chip on their shoulder, forever sensitive to insults and injuries that reminded them of long ago attacks, but now were only injurious in their imagination. And those poor souls who expected rejection because of past rejection. Like the Japanese holdouts, the years pass but the fear doesn’t, and the possibility of satisfying relationships and happiness slips away.

If you still are responding to the present as if it were the past, with solutions that solve little (even if they were once necessary), then it is time to change your life. The barricade of your life’s defenses might be protecting you only from the phantom of an enemy who lives within you, not on the other side of the fortification.

A good therapist is likely to be able to help you develop a new way of living, one more appropriate to the world as it is, not the world as it was; to set aside and heal old wounds.

Is it time?

What is the continuation of your old way of living costing you?

The war, your personal war, might just be over and you don’t know it.

April 28, 2010

Two Americas, But Not the Two You Think

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Before his marital infidelity discredited him, John Edwards spoke eloquently about “two Americas.” He talked of differences between the health care, financial stability, education and housing available to these two different parts of our society.

But there is another American divide that has created two other Americas: on one side the fighting men and women in our armed services (along with their families) and the rest of us on the other.

If you are unhappy about the polarization of our society, look no further than the differences that have been institutionalized by the volunteer army. However much good was achieved by the decision to eliminate the military draft, surely the absence of shared sacrifice has contributed to the ease with which we take opposing positions to our fellow-citizens on matters that have to do with national security.

No longer does the USA pull together for the long haul in the way that was possible during World War II. In part, “the Good War” was good because enough people believed in the values for which the USA fought, knowing that their children, husbands, and brothers would defend those same values with their lives; and it was good because the people of this country (regardless of class) shared in the rationing of goods and the sheer terror of having their loved ones abroad and in harm’s way.

If a war is worth fighting, it should not have merit only because the children of other people are fighting it, even if they do so voluntarily.

These thoughts occurred to me as I listened (on CD) to the book Final Salute by Pulitzer Prize winning author Jim Sheeler. This book is about the officers who inform families that they have lost a loved one, and of the families who suffer the unspeakable pain of the death of a son, a husband, a wife, a brother, or a sister; a dad or a mom.

The book takes no sides on the question of the War in Iraq. Yes, you will hear occasional comments in support or opposition, but you will not think as much about these policy questions as about the human beings you meet along the way. Several families will become your acquaintances as well as the warriors — the Marines — who died serving our country. And you will also get to know Major Steve Beck, a Marine tasked to inform the families of their loss, the man who delivers a message nearly as shattering as the projectile that killed their loved one.

Major Beck and the Marines live by the creed that they shall leave no comrade behind. And, consistent with this value, Major Beck leaves no family behind, providing comfort and support long after the knock on their door that changes everything, that creates a “before and after” without end.

I wish I had the words to convey what is in this book. I don’t. But I can say that it is plainly written, eloquent in its simplicity, aching in its beauty, profound in its impact. It does not work to make melodrama of what is already poignant enough. Rest assured that you will think about war, any war, differently after reading or listening to Final Salute; unless, of course, you are a member of the “other America,” the one that fights the wars and sends its loved ones into conflict. If you belong to the bereft group within that group, then there is nothing contained in this book that you do not already know at a level too deep for words.

If you have lost just such a one as the young men portrayed in Final Salute, I can only give my condolences to you and your loved ones. It is thanks to the willingness of the few to serve on behalf of the many that the rest of us are safe.

We — those of us in the non-fighting America, those of us for whom the wars in Afghanistan and Iraq are abstractions — perhaps remain too comfortable, too detached from something of desperate importance: the work done far from home in our name by the children of other people. And too removed and distant from how these “best and brightest” of their families risk and sometimes give up everything they hold dear.

We need to remember that, for these families, the human cost never fully goes away.

They are out there, these inhabitants of “the other America.”

We walk by them unaware every day…

Kafka said that “a book is like an ax, to break the frozen sea within us.”

This is such a book.

—

The maps above are the work of Allstrak, courtesy of Wikimedia Commons.

April 7, 2010

Health Care Reform and Unintended Consequences: A Prediction

Health care reform has been necessary for a long time. But having said that, I’d like to give you an example of how the expected changes might lead to some unfortunate results, as well as some that are helpful.

My example will focus on Medicare. Everyone knows that Medicare is expensive for the government and that it will ultimately suck the life out of the national economy if costs are not restrained. One way to restrain costs is to require physicians to accept lower fees for their services, something that Medicare has struggled to do for a while, even before passage of the recent health care legislation. Providers are already getting paid less than they were a few years ago, but even more extensive mandated annual changes have been regularly rescinded by the Congress. If they are actually accomplished in the future, Medicare would pay out still less to those same MDs, Ph.Ds, and other health care professionals.

What will happen when reduced fees become more significant? Some healers will decide that it is financially unwise to see patients who are covered by Medicare. They will drop out of the Medicare panel of providers. The greater the fee reductions, the smaller the number of physicians available to see Medicare patients, while at the same time the number of individuals covered by insurance is increasing, led by the large expected additions to the rolls of the insured because of recently passed health care reform legislation.

Let’s say you are the following person: someone covered by Medicare who doesn’t have the cash to pay for treatment out of your own pocket, who also has a medical problem or concern that cannot wait very long. The good news in this hypothetical example is that your MD still accepts Medicare. But when you call your doctor’s office, you are told that you can’t have an appointment for four months—again, hypothetically speaking. The problem and the pain aren’t getting any better in this period of time, maybe they are even getting worse. So what should you do?

First, you will probably try to find another medic who accepts your insurance and has a nearer-term appointment for you. But given the anticipated shortage of people who do take Medicare patients, it will be unlikely.

Eventually, however, you will do what any sensible person would do once the problem becomes really acute—and what your doctor’s office will probably advise you to do under the circumstances—go to the emergency room of your local hospital.

Since emergency room care is notoriously expensive and since the condition might be harder to treat because you waited, this will only serve to drive up the amount of money spent on health care, something that the intended reduction in doctor fees was expected to reverse. Whether the decrease at one end will outweigh the increase at the other, I do not know.

And, instead of the growing number of  people who had no health insurance being the impetus for the increased use of the ER, it will now be people with health insurance who are using it more because they have no other readily available alternatives.

I don’t have a handy solution to this problem. My hunch is that there is some amount by which doctor’s fees can still be cut before they start dropping out of the Medicare system in large numbers. It may be that only trial and error will determine exactly how much cutting is possible before producing the unintended consequences I’ve described. The good news, however, is that where there is a high demand for services, eventually supply does catch up, although in the case of producing more docs it will takes years to do so.

Surely, there will be many more unintended consequences of health reform just around the corner. Some might actually be beneficial, but certainly not all. The system we have is not working well for many of our fellow-citizens, so the status quo is not a good answer. Doubtless, once legislators hear enough complaints about problems such as the one I’ve described, they will attempt to alter the system further. How long it takes before we get something that works well is unknown. It is likely that we will eventually have a two-tiered system: a universal, government-run insurance plan on one side, and some number of pretty rich people simply paying for health services out of their own pockets on the other.

In the short run, all of this reminds me of an old joke Woody Allen told at the end of one of his nightclub routines.

It went something like this:

I’d like to leave you with a positive message.

But I can’t think of one.

Would you take two negative messages?

March 26, 2010

Jackie Robinson, Ford Frick, and the National Health Reform Debate

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With even one eye shut and one ear covered it would have been hard to miss all of the acrimony expressed by and toward our elected representatives in recent days. And, some are saying, that this is unprecedented—this loss of civility, this frank hatred, including acts of vandalism and threats of murder.

Many are decrying the failure of some Republican politicians to rebuke the hate-mongers in an unconditional and decisive fashion, as Republican Representative John Boehner has: “I know many Americans are angry over this health insurance bill, and that Washington Democrats just aren’t listening. But, as I’ve said, violence and threats are unacceptable. That’s not the American way. We need to take that anger and channel it into positive change.”

Well, unfortunately, angry words and angry actions are really nothing new in “The Land of the Free and the Home of the Brave.” You will find them on both the political left and the political right within living memory: the violent “Weather Underground” of the Vietnam War era, The Black Panthers, the lynchings of blacks in the period between the end of the Civil War and the passage of Civil Rights legislation, the hate crimes against gays, the gauntlet of verbal abuse shouted at black children trying to integrate the schools of Mississippi and Alabama in the mid-20th century, the bombing of abortion clinics; the Oklahoma City bombing; the assassinations of JFK, Martin Luther King, and Robert Kennedy; and on and on.

But, every so often in the midst of all this angst—this stuff that makes one despair about the human condition—someone stands up and does something remarkable; something that makes you proud to be an American, and hopeful about the future of the human race.

Turn the page of your history book back to 1947 and to Jackie Robinson of the Brooklyn Dodgers, the first black man permitted to play in the Major Leagues in the 20th century. What follows is heavily dependent upon (and quotes from) Jules Tygiel’s Baseball’s Great Experiment: Jackie Robinson and His Legacy.

—

Robinson faced a revolt by some of his own teammates who attempted to organize a petition against him. Kentucky-born Pee Wee Reese, who was to become a great friend and supporter of Robinson, later remembered, “In the park that I grew up in, there were no blacks allowed. Blacks got in the back of the buses, they had a special fountain to drink from. I don’t guess that I ever shook the hand of a black person.” Reese expected Robinson to fail because white people in his part of the country always believed that Negroes had no guts.

“You hear this all your life, you believe it.”

The petition died aborning because most of the players would have no part of it, and because of threats from management. But the bigoted sentiments were still there for Robinson to deal with. His teammate Kirby Higbe was asked on a radio interview how he’d come by such a strong arm. His answer? From pelting Negroes with rocks.

Dodger manager Leo Durocher laid down the law: “I don’t care if a guy is yellow or black, of if he has stripes like a f___in’ zebra. I’m the manager of this team and I say he plays.”

The Philadelphia Phillies were the worst of the race-baiters. Led by Alabaman Ben Chapman, the Phillies showered unspeakable derision on Robinson in their first series with the Dodgers early in the 1947 season.

According to Harold Parrott, “At no time in my life have I heard racial venom and dugout abuse to match the abuse that Ben sprayed on Robinson that night. Chapman mentioned everything from thick lips to the supposed extra-thick Negro skull…(and) the repulsive sores and diseases he said Robinson’s teammates would become infected with if they touched the towels or combs he used.”

Chapman knew that Robinson couldn’t fight back because of the disruption that would cause, the very thing that many predicted and used as an excuse to defend the segregation of the Major Leagues. Everyone soon came to know that Robinson, who received varsity letters in four sports at UCLA, was a sitting duck. “Plenty of times I wanted to haul off when somebody insulted me for the color of my skin,” Robinson later said. “But I had to hold to myself. I knew I was kind of an experiment…The whole thing was bigger than me.”

One teammate thought that Robinson, the sole black on the field, was the loneliest man he had ever seen. Red Barber, the Dodger’s radio announcer, said that Robinson was the only man he had ever seen who could actually play better when he was angry.

The death threats flooded in—the people who wrote that they would be carrying a rifle into the ball park to kill him. Opponents tried to spike him, pitchers threw at his head and body. Even his Southern teammates received hate-mail for allowing themselves to take the field with a “n____r.”

But Robinson’s teammates stood up to Ben Chapman and the Phillies. Fellow Alabaman Eddie Stanky called Chapman a coward. Meanwhile the St. Louis Cardinals baseball team plotted a May strike against Robinson and the Dodgers. Ford Frick, the National Baseball League President, quashed the strike and faced down the Cardinals:

If you do this you will be suspended from the League. You will find that the friends you think you have in the press box will not support you, that you will be outcasts. I do not care if half the league strikes. Those who do it will encounter strict retribution. They will be suspended, and I don’t care if it wrecks the National League for five years. This is the United States of America, and one citizen has as much right to play as another.

The National League will go down the line with Robinson whatever the consequence. You will find that if you go through with your intention that you will have been guilty of madness.

—

As I said earlier, we have been here before, in this dark place in America that seems to surface especially in difficult economic times or in times of change, of which we have both just now. America is changing today, just as it was changing in 1947, and that metamorphosis brings out the worst in some of us. But the courage of people like Jackie Robinson, and the decisive confrontation of unfairness by people like Ford Frick, are heartening.

At the 1948 Democratic National Convention, Senator Hubert H. Humphrey made an impassioned speech in advocacy of a strong civil rights plank that failed to become a part of the Democratic Party’s platform in that year’s election. His words are worth remembering, as he recalled the founding of the nation in 1776:

To those who say, ‘we are rushing this issue of civil rights,’ I say we are 172 years late. To those who say, ‘this issue of civil rights is an infringement on states rights,’ I say that the time has arrived for the Democratic party to get out of the shadow of state’s rights and walk forthrightly into the bright sunshine of human rights.

—

Eventually most of Robinson’s skeptical teammates and competitors came to think differently and act differently than they had, at least to the point of accepting that blacks had as much right to play the “Great American Pastime” as they did. Still, the animosity did not end immediately.

As noted by Stuart Miller in the April 25, 2010 New York Times, Robinson continued to be the target of pitched balls in those days before batting helmets. In his first eights seasons he was lower than third in HBP (Hit By Pitches) only once. Moreover, the handful of blacks then in the National League—people like Monte Irvin, Sam Jethroe, George Crowe, Billy Bruton, Ernie Banks, and Hank Thompson—were similarly treated. In the American League, Larry Doby, Luke Easter, and Minnie Minoso found it no different.

Time passed, the hard-line bigots left the game, and others who were more open and less shocked and offended by integration took over the field of play. When Ernie Banks joined the Chicago Cubs in 1953, management saw to it that he join the club at the same time as (and roomed with) Gene Baker, so as to avoid the issue of having one black man and one white man live together.

It took 10 years from the time of Robinson’s debut for the Philadelphia Phillies to allow a black man into a Major League uniform, with the Detroit Tigers behind them. The last to integrate was the Boston Red Sox squad in mid-1959.

Along the way America changed too, for the better. And one must believe that the voices of the fulminating, frustrated few on the political landscape today will eventually be replaced by those who are less self-righteous and more in control of their emotions.

As a therapist it is impossible to do my work without believing that people can change.

It doesn’t always happen, of course.

But it happens more than enough to keep pitching.

March 17, 2010

What It Means To Be a Man: Reflections on the Ides of March

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We hear the expression frequently—“Be a man!” Usually when we are small and usually directed to males. In the context of an admonishment, it typically means to “be tough,” show little emotion, be stoic, have courage, avoid whining.

But, when you are a little older and more thoughtful you might come up with a different definition. The German word “Mensch” (“man” or “human being”) provides us with a starting point.

You will recall that Friedrich Nietsche gave us the idea of an “Übermensch” or “superman.” Not someone who “leaps tall buildings in a single bound,” but a superior creature to whom a new set of life rules applies. Indeed, the Übermensch creates a set of values, discarding those that belong to a world that he rejects and a god that he thinks to be dead.

Goethe, the great German poet, scientist, and philosopher of an earlier time, had something quite different to say about man in his poem The Divine:

Let man be noble,
merciful and good;
For that alone
Distinguishes him
From all the living
Beings we know…

In Yiddish, a language that has German roots, to be a “mensch” means to be decent, forthright, strong, honorable, and dependable. Someone to be leaned on and counted on. A person of principle, with both a good heart and a good head. A fellow to be reckoned with; a companionable individual of integrity, unafraid of self-assertion.

But there is a different version of “being a man” in the popular culture. In my mind, it is associated with the likes of Clint Eastwood and John Wayne, as portrayed in the numerous “Western” movie roles they took on; on the political front, George W. Bush probably is a rough equivalent.

This “man’s man” is a tough, intimidating, austere, cocky, unrepentant, decisive, and unflinching he-man who never complains or cries out in pain. A guy like this doesn’t look back. He is the opposite of the “Alan Alda,” version of what it means to be a man, which emphasizes a kind, empathic, more sensitive side of human possibility.

The popular vision of a man is someone who is more into solving problems than dealing with feelings, someone who is “logical,” someone more in touch with his head than his heart. When a woman opens herself to him with an injury, he is prone to offering a solution or trying to “fix” things rather than patiently listening and holding her hand.

This rock-solid, heroic figure is the strong-silent type, uncomfortable with public (and sometimes event private) emotion, and a person of few words; certainly not one given to eloquent speech. He is much more inclined toward action than talk. The “John Wayne” version of a man is well described in the closing lines of Shelley’s Prometheus Unbound:

To suffer woes which Hope thinks infinite;
To forgive wrongs darker than death or night;
To defy Power, which seems omnipotent;
To love, and bear; to hope till Hope creates
From its own wreck the thing it contemplates;
Neither to change, nor falter, nor repent;
This, like thy glory, Titan, is to be
Good, great and joyous, beautiful and free;
This is alone Life, Joy, Empire, and Victory.

In any discussion of manhood, one must also inevitably give a nod to “manhood” as it is understood in every day speech; that is, male sexuality. It takes a few forms.

One is simply the ability to be commanding and sexually appealing, to be an experienced and confident lover. Another is the capacity to perform sexually. The problem that follows from this, of course, has to do with the pressure to perform, the anticipated evaluation of that performance, and sometimes the failure to perform.

In old age, both the capacity and interest in such activity have been known to fall away, leaving it to the man and any companion or spouse to determine whether manhood should still be subject to judgment about anything to do with sex. Medicine is perhaps making such considerations irrelevant with the easy availability of Viagra, Cialis, and the like.

On the other hand, a failure of potency, that is, the ability to perform sexually coupled with an inability to foster children, remains a problem in the minds of most such men and one that still lacks a scientific work-around other than adoption or artificial insemination of the man’s wife by someone else, a solution that most males find decidedly abhorrent.

Finally, if you’d like a more Shakespearean commentary on the subject of being a man,  you must read Julius Caesar. Those of you who know the play are aware that Caesar is not the main character, even if he is the title character.

Rather, the story is about Brutus, Caesar’s friend and admirer, who is persuaded to believe that Caesar has become a tyrant and will visit evils upon the Roman people. Others among the conspirators have their own axes to grind against Caesar and seek personal gain by his overthrow. But Brutus agrees to the plot despite the fact that it is against his nature, only because he concludes that the assassination of Caesar is in the best interests of his fellow countrymen, in order to free the Republic from Caesar’s control.

As so often occurs in classical tragedy, the conflict between one’s public obligations and private loyalties is the undoing of the hero, in this case Brutus. And so, the famous murder happens in the Roman Senate on March 15th, 44 BC, 2054 years ago this week, after Caesar ignores the warning “Beware the Ides of March!” There is a fantastic movie rendition of the play starring James Mason as Brutus and a young Marlon Brandon as Marc Anthony, Caesar’s ally.

After Caesar’s death, Anthony is targeted for death by Brutus’s fellow conspirators, but Brutus stops them, allowing Anthony to speak to the people and eulogize the fallen Caesar, only to rally the Romans against the conspirators and ultimately, to defeat them in the ensuing civil war. It is Brutus’s essential humanity, decency, and sense of fairness (all qualities that contribute to “being a man”) that call him to let Anthony speak.

You will recall the words “Friends, Romans, countrymen, lend me your ears…,” so persuasively rendered by Brando in the aforementioned film, that stir the Roman crowd against the conspirators. Had Brutus been less honorable, he would have avoided the risk that Anthony’s words might incite the rabble against them and perhaps even agreed with his co-conspirators to kill Anthony. And, as portrayed by Shakespeare, it is the decision to allow Marc Anthony to live, not the murder of Caesar, that is the proximate cause of Brutus’s downfall.

The play ends with Brutus dead, and Anthony reflecting on who Brutus was and why he was worthy. And, it is Anthony’s words that provide us with a final comment on what Shakespeare has already told us in the play about what it means to be a man.

Please note that the word “gentle,” as used by Shakespeare, means something approximating “true, cultured, and affable:”

This was the noblest Roman of them all:

All the conspirators save only he

Did that they did in envy of great Caesar;

He only, in a general honest thought

And common good to all, made one of them.

His life was gentle, and the elements

So mix’d in him that Nature might stand up

And say to all the world ‘This was a man!’

—

The bust of Julius Caesar above is to be found in the Musée Arles Antique. The image was created by Mcleclat and sourced from Wikimedia Commons.

February 20, 2010

Teenagers, Chicago Parking Meters, and Left Fielders

http://upload.wikimedia.org/wikipedia/commons/thumb/6/68/Alfonso_Soriano.jpg/500px-Alfonso_Soriano.jpg

The “Windy City” — the “City of Big Shoulders” — has a way of making some big mistakes.

Recently, they’ve come in the form of some fiscal short-sightedness affecting both baseball and government. Just over four years ago, the Chicago Cubs signed Alfonso Soriano to an eight year contract, all for the measly sum of $136 million dollars. Alfonso was 31 before he ever played for the team. They will “own” his contract (although the words “owe” and “ouch” come to mind) for three more seasons beyond this one.

After only the first three, he demonstrated that his sunny personality, million dollar smile, and ability to hit home runs when no one is on base don’t make up for declining offensive production and an attitude toward playing left field that suggests, according to Baseball Prospectus 2010, that Soriano believes the outfield wall at Wrigley is actually covered with poison ivy.

Not to be outdone, the local city fathers decided to lease every last parking meter in the city for a term of 75 years to an independent company that agreed to pay 1.15 billion in up-front dollars for the privilege. They doubtless wished to out-do the Cubs in boondoggles, since it is reported that the money is already spent. It has also been said that the city could have negotiated a better deal, and certainly one that didn’t so offend the parking populace by the inflation of parking fees to multiples of their previous size.

In both instances, there is more to come — more parking fee increases and further productivity decline from the Cubs left-fielder. And, long before the end of either contracted term, we will be saddled, metaphorically speaking, with the back-end of an animal that didn’t even look too great from the front-end.

When I think about this sort of short-sightedness in clinical terms, the behavior of teenagers inevitably comes to mind. Teenagers are stereotyped for taking risks, acting on impulse, and using poor judgment. Some of them tend to allow tomorrow to take care of itself, not fully grasping that tomorrow will indeed arrive soon enough and claim payment for the errors of today.

Now, I’m not talking about all teenagers, but rather those prone to vices like smoking, drinking and drugging to excess, blowing off academics, etc. And, it is not as if adults are free from this “live for today” approach, even adults not employed in management by the City of Chicago and the Cubs.

In a just world, all such folks would pay for their indiscretions somewhere down the line.

But, of course, the world isn’t just. And sometimes this works out quite well for the impulsive and heedless joy-seekers in our midst.

I recall one woman who ate and smoked and drank and had unprotected sex as if there would be no tomorrow. When I reminded her that tomorrow would likely come, she assured me that she would be dead by then, and so it didn’t matter. Even as she entered middle-age, she ignored the pain in her joints and her diabetes, continuing to indulge herself well beyond the bounds of medical advice and good sense. This lady believed in the motto uttered by John Derek in the old Humphrey Bogart film, Knock On Any Door:  “Live fast, die young, and leave a good-looking corpse.”

I doubted the wisdom of this, but she turned out to be right, dying of a cancer unrelated to her excesses in her late-40s. I guess if you know with certainty that your time is relatively short, then indulgence might become the preferred path, although it can also create a self-fulfilling prophecy.

Of course, most of us don’t know the appointed day of our departure with the prescience that characterized my acquaintance. Many decisions depend upon just such an estimate of the future: whether to go to college, how much to save for retirement, the care and feeding of your body, the need to exercise, and so forth. In a way, we all are gamblers, those of us who imbibe and those who abstain, those who are profligate and those who save for a rainy day.

We place our bets on what “feels” right now, how we expect to feel in the future, and how long that future might last, if there is one.

Let’s just hope that our bets are wiser than those practiced by the City of Chicago and the Cubs.

—

The photo above taken by Scott Ableman at RFK Stadium on May 5, 2006 is of Alfonso Soriano in his days as a Washington National. It was sourced from Wikimedia Commons.

January 24, 2010

Can You Sleep At Night? Being Ashamed and Feeling Guilty

There is an important distinction between being ashamed and feeling guilty. Both are connected to wrong doing, errors, mistakes, or failures. Both involve emotions. Feeling guilty, however, unlike being ashamed, doesn’t require an audience.

A person typically feels guilty almost automatically when he believes that he has done wrong. It matters not whether anyone else knows or finds out. Often, it doesn’t even matter that others might forgive the transgression. Thus, a sense of guilt is an internal state connected directly to an act thought to be wrong.

Shame, on the other hand, requires an audience, or at least, others’ knowledge of the inappropriate behavior or failure, even if they did not directly witness it.

By these definitions it is possible to feel guilty without being ashamed. One need only believe that one has done wrong. But someone who has been shamed (in other words, found out and condemned) might only come to feel bad if his behavior is widely known.

You might think that this always happens, but it doesn’t. Take the recently removed Governor of Illinois, Rod Blogojevich, who has yet to admit any guilt and who certainly doesn’t act ashamed; indeed, who appears quite shameless. Shamelessness is never a compliment, but rather a statement about someone who has no “shadow,” no sense of ever doing anything inappropriate.

To cite a couple of other examples, one a therapist and one a minister, neither felt guilty even after having their iniquity publicly exposed. In both cases the misbehavior was of a sexual nature that involved infidelity, as well as a violation of the code of ethics of their professions.

In the former case, the therapist had sex with ex-patients; in the latter example, the clergyman had sex with parishioners. Both were married (not to each other) at the time of these acts. The public exposure of their actions and ensuing humiliation mortified each of them and, indeed, each one contemplated suicide. But neither really believed what had happened was terribly wrong, and rationalized the transgressions in defense of his own self-image. In both cases the rationale involved holding the sexual partners largely responsible for the romantic encounters.

The connection between shame and suicidal depression is interesting and can be found even in the epics of Greek mythology. When Achilles died in battle, the Greeks held a vote to decide who among them should be awarded the splendid armor of Achilles, which had been fashioned by the god Hephaistos. Ajax (Aias) the Greater, the best warrior after Achilles, lost this competition to the cleverest of the Greeks, Odysseus, who had designed the Trojan Horse strategy that won the war. In his humiliation, Ajax went mad and eventually killed himself. Such is the devastating effect of a “loss of face.”

It should be said that the therapist and the minister I have referred to were quite narcissistic people who saw themselves through a very forgiving lens. Both terminated contact with old friends following their public embarrassment, in order to avoid facing them. In a sense, the self-love and lack of a well-developed conscience of the two people in question set the stage for their wrong doing — they believed that they were without moral flaws and therefore that anything they thought to do would automatically be a morally acceptable behavior.

Beware of those who say that they can sleep easily at night and use this standard as their primary method of judging or evaluating their own behavior. I doubt that the worst of the totalitarian rulers and despots of history would have failed this test of moral correctness, despite the murder, unhappiness, and genocide they created.

In the USA, on the political front, we have seen lots of people who don’t admit wrong, who rationalize what they do, and who serve themselves while claiming to be acting “on behalf of the American People.” I’m sure some of them come to believe their own story, their own rationale — shameless, as I said before; indeed, almost a kind of self-delusion.

In my experience, people who come to psychotherapy because they feel ashamed (but not particularly guilty) don’t usually take responsibility for their actions in the course of treatment. Rather, if the process follows the typical course, they will recover from the injury to their ego and be able to go on with life, still guarded against significant self-awareness. Moral self-reflection doesn’t seem to come easily or naturally to them.

By contrast, individuals who experience guilt that causes them to enter counseling often can learn to forgive themselves and recover from the depression that usually accompanies their guilt. For them, however, the risk is in taking too much responsibility and being too severe in their self-judgment, exactly the opposite of the person who is only ashamed.

It is useful to be capable of feeling guilt, to admit wrong doing, and to feel ashamed; that is, if one is to lead a moral life. On the other hand, it might be argued that those who are shameless and who rarely feel guilt probably have more fun in life and are less troubled — the mirror reflects their image back to them in the way that they want to see it, and not in the way it actually looks. They live in a state of ethical blindness. Whether that permits a satisfying life is another story.

You be the judge.

—

The above image is Shame by Libertinus Yomango, sourced from Wikimedia Commons.

November 11, 2009

An Inside Story on (Mental) Health Insurance Reform

There is much misinformation and misunderstanding about the workings of the health care system. Here are a few observations on how things work from the perspective of someone who is a practicing clinical psychologist with experience both inside and outside of hospitals:

1. The Doctor/Patient Relationship. In the days before managed care, doctors and patients really did make decisions without too much interference from insurance companies and the government. While insurance companies set some limits on what they would pay out (maximum benefits for mental health services were usually expressed in dollar amounts) and would pay no more than what they deemed “reasonable and customary” fees for each “service,” they did not typically require that practitioners obtain “pre-certification” (pre-authorization) of those same services. So, if you and your therapist thought you needed the treatment that he was offering, the insurance company let you obtain that care and supported it by paying in accord with the insurance contract that you held directly with them, or, more likely, held through your employer.

Managed care caused several changes. First, it required “pre-certification” for many forms of treatment, thus explaining the “managed” nature of the care. That meant that the practitioner (or a member of his staff) had to fill-out forms that explained the nature of your condition, provide a treatment plan, and justify the type of treatment that he hoped to provide.  Depending on the insurance company, sometimes pre-certification required a phone call with the insurance company’s “gate-keeper” to discuss the information just mentioned. And, depending on the length of treatment or changes in the patient’s condition, this process would be repeated so long as you were in the care of the therapist in question.

It is important to understand that the relationship between the doctor and the insurance company was (and is), at least to some degree, antagonistic. If the therapist is unfettered by the restraint of the managed care arm of the insurance company, he stands to get paid by them for as much treatment as he prescribes and the patient consents to receive. On the other hand, to the extent that the insurance company can limit or say “no” to the doctor’s plan, the company gets to keep more of the money paid to them in insurance premiums. Both sides will maintain that they only work in the patient’s best interests, but it should be easy to see the slippery slope that both parties are on, a slope called “financial self-interest.”

Another change was the establishment of panels of “providers.” The “docs” knew they were in trouble when they began being called providers, a business-type of term, rather than doctors (which would include anyone with a Ph.D. or an M.D. or a D.O or a D.D.S) or therapists or social workers. Some providers agreed to accept discounted fees (saving the insurance companies and patients some money) in return for having patients steered in their direction. Usually, the insurance companies would then give patients encouragement to use practitioners on their list of such “preferred providers,” and better insurance coverage when they consulted those individuals, rather than doctors who were “out-of–network.”

HMOs (Health Maintenance Organizations) worked a bit differently. The care was usually even more strictly managed. There were fewer doctors and hospitals from which to choose, and typically smaller co-payments (the amount the patient paid out-of-pocket to the healer). Even more services were managed and required a referral from the patient’s “primary care physician.” Depending on the nature of the contract between the doctor and the HMO, he or his medical practice might lose money to the extent that he authorized too many referrals and too much treatment. This was clearly another step in the conflict between getting treatment and the ability of the insurance company (and sometimes the docs) to make money.

At present, there are relatively few insurance policies (very, very expensive ones) that don’t attempt to limit your choice of doctors or hospitals, or manage your care in some fashion. So, when you hear some politicians say that they don’t want the government to interfere with the doctor/patient relationship, be aware that your insurance company almost certainly already does that.

Negotiated Fees for Services. I’m always amused when the press, insurance companies or politicians refer to the “fact” of doctors and insurance companies “negotiating” fees for the healer’s services. Understand that doctors have virtually no leverage in these situations. If they wish to participate in “preferred provider” panels in the hope of obtaining more patients, they are typically given a fee schedule as part of the contract that they are offered. Large institutions may have some leverage (hospitals or very, very large practices), but solo practitioners and small practices, which make up most of the providers you would routinely consult, are pretty much told to “take it or leave it” in terms of the contractual conditions and the fee schedule by which they will be compensated. Again, if politicians tell you that they are defending the rights of doctors to negotiate such fees, I’m not exactly sure who they have in mind. Most of the psychologists, psychiatrists, and social workers I know must choose either to take what the insurance company or PPO (Preferred Provider Organization) offers, or to be “out-of-network.” As an out-of-network professional, you can set your own fees, but don’t benefit from the PPO or insurance company’s efforts to send you patients.

Parenthetically, it should be noted that few if any of the healing professionals I know got into this work for the purpose of making tons of money. Indeed, most of us didn’t think much about the business-side of our work when we chose to pursue our vocation. As you doubtless have already concluded, the business-end can’t be ignored easily.

Covered Services and Pre-Existing Conditions. Insurance companies aren’t all alike. Some have larger provider panels, some cover more services, etc. Depending on your policy, psychological testing, neuropsychological testing, individual psychotherapy, family psychotherapy, alcohol/drug treatment, and marital therapy, might or might not be covered. Indeed, some insurance policies do not cover mental health services at all.

Pre-existing conditions are those from which you suffered prior to the start-date of your insurance contract. If your insurance company excludes pre-existing conditions, it usually does so in one of two ways. It can have a waiting period (perhaps one year) before it will cover you for treatment of that condition. On the other hand, some contracts require that you have not been treated for the condition for a specified period (again, perhaps one year) before they will pay for treatment; this is based on the assumption that if you have not had treatment in that time, any future therapy will probably not be for precisely the same condition.

You should be aware that when you submit an insurance claim, or ask your doctor to do so, you have now been marked down in a sort of “permanent record” kept by the insurance industry. Whenever you apply for insurance on an individual basis, you are routinely asked to sign a waiver that allows the insurance company in question to consult your life history of insurance claims and your past medical records. If they find something that is not to their liking (meaning that it causes them to believe that you are a bad risk), they may deny you coverage either for the particular condition in question or simply refuse to issue you an insurance policy. This can apply not only to health insurance (the topic I’ve been talking about until now), but also disability and life insurance. As a consequence, some people (if they are able) prefer to pay for certain types of health care out of their own pocket, rather than creating a record of illness that might be used against them by insurance companies at a later time.

Needless to say, one of the most consumer-friendly features in the health care legislation just passed by the House of Representatives is the prohibition of pre-existing condition exclusions. The Republican alternative does not have such a provision.

The Efficiency of the Private Sector. My office manager could give you an ear-full about the difficulties that she has in getting insurance companies to do what they are contracted to do; that is, pay bills promptly and correctly. The number of “lost” claims that require resubmission, delayed payments, and incorrectly paid claims give the lie to the notion, at least among the mental health professionals who I know, that the private sector is to  be preferred in this arena to the performance of Medicare. Of course, some companies actually are quite efficient, while others are frank disasters.

Mandatory Insurance and the Idea of a National Health Insurance or “The Public Option.” In order to get a sense of how a mandatory health insurance program might work, it is useful to look at how a similar approach has fared for automobile insurance. Virtually every state in the union requires that drivers have auto insurance. There are reportedly a number of problems that have occurred with this. First, stipulating that there is a requirement doesn’t necessarily get people to buy car insurance–you need an enforcement mechanism to make certain that they follow the law. I’ve heard stories of people who didn’t have insurance and were brought to court after an accident without being required to pay the expected penalty, but instead were ordered to buy a policy and return to court with it. Doubtless, having done this, those folks might then cancel the policy, especially if they couldn’t really afford it. The expense of creating a data base and monitoring all drivers to determine whether they have current auto insurance is costly and perhaps inefficient, since most people who can afford it will probably buy it on their own without threatened penalties. Some states have chosen to attempt to single out “high risk” drivers for particular scrutiny and oversight, presumably at reduced costs.

Almost certainly, some of the same complications would be present in any national health insurance program. Without going into all the arguments for and against, it should at least be noted that we already have a form of national health insurance. Its called Medicare, and the people who have it apparently like it quite well; but it does cost a fortune and creates an enormous weight on the generations who will have to continue to pay for it.

Thus, the moral and practical dilemma: providing coverage for people who need it (before Medicare, for example, it wasn’t unusual for the elderly to live in poverty, having been wiped out by medical bills) vs. the cost of such a program in dependency and dollars.

I hope that I’ve offered at least a little bit of useful information.  Here is hoping that you will, if needed, learn more and weigh-in with your Congressman or Senator; decisions with far-reaching consequences are being made right now.

November 6, 2009

On the Fort Hood Tragedy

What happened at Fort Hood? Why would a psychiatrist, a physician trained in the treatment of “mental and nervous” disorders, go on a rampage against his own comrades? I suspect we will be reading about the following in the days ahead:

1. Did Major Nidal Malik Hasan, the accused murderer, have proper supervision of his work and his own fitness for duty? Did he suffer from a psychiatric disorder of his own and was he being treated? News accounts suggest that he was terrified in anticipation of an expected deployment to Iraq or Afghanistan.

2. To what extent did he feel marginalized within the Armed Services? He is said to be a man born in the USA, the son of immigrant parents. It is also reported that he had become increasingly devoted to his Muslim faith and might have experienced some harassment from other soldiers because of his religion.

3. Was the Major marginalized in other ways? He is described as a 39-year-old bachelor who had been looking unsuccessfully for a mate.

4. Major Hasan is believed to have treated numerous veterans suffering from PTSD (Post Traumatic Stress Disorder) returning from the Middle East. Is it possible that he suffered a form of vicarious trauma from hearing the disturbing, if not tragic stories of these young people?

5. To what degree have the Armed Services been able to reform an organizational culture that discourages soldiers from showing emotional vulnerability and seeking treatment before they become dysfunctional? It is one thing for the returning wounded veterans to get psychiatric services; it is another for them to believe, early on, that their anxiety, worry, and depression will not be seen as a weakness by their comrades, make it harder to perform their duties in war-time, and cause them to be ridiculed? Did Major Hasan, who apparently had not experienced combat himself, believe that his own inner-turmoil was acceptable and would have received support from his superiors?

6. Did Dr. Hasan have a history of having received treatment prior to his entrance into the military? If Dr. Hasan did seek treatment at any time, what was the result? Is their any routine assessment of the psychological status of both the soldiers and those who are given the task of treating them? Does the military realize that the nature of their work puts virtually all personnel at psychological risk?

7. What security procedures exist in military installations such as Fort Hood?

8. Is the military sensitive to cultural conflicts that are experienced by its uniformed personnel?

Most of us assume that mental health professionals have their own personal lives well under control. Unfortunately, such is not always the case. For more on this subject, please read my recent blog: “When Helping Hurts: Therapists Who Need Therapy.”