May 8th, 2013
 In my last post, I outlined the fundamental problem facing advocates of nonviolence: Despite nearly universal conceptual agreement with this goal, human psychology conspires to make peace elusive and strife apparently unavoidable. Our emotions trump our rationality, biasing assessments of real-world evidence and leading to post-hoc justification of whatever our “gut” feels. Unfortunately, and rightly or wrongly, our gut feels scared or mistreated much of the time. Violence is often the result, whether construed as self-defense or justified retribution. This occurs with individuals, groups, and nations, and behaviorally ranges from brief verbal expressions of contempt to weapons of mass destruction and genocide.
Gut reactions cannot be overcome by rational argument alone. ”Fight or flight” responses to threat, and urges to inflict retribution or punishment, start at the emotional level. Since it is unrealistic to hope for a world without emotional triggers — without perceived threats that “demand” violent self-defense, or injustice that “demands” violent retribution — those who advocate nonviolence must accept the reality of emotional provocation. Another reality is that even those who endorse a nonviolent philosophy are saddled with the same emotional reactivity as everyone else. Given these constraints, how can nonviolence be promoted an emotional level?
Safety
It has often been said that our physiologic response to stress serves us well in situations for which it was originally designed, e.g., an attack by a wild animal, but that it is misplaced in our modern world of “attacks” by time deadlines, career pressures, and miscommunication by loved ones. Autonomic stress responses — increased pulse and blood pressure, outpouring of stress hormones, faster reaction time — may save our lives in dire situations, but only hurt and exhaust us when activated chronically and without purpose. Many effective ways of managing unhealthy stress do so by enhancing feelings of safety and relaxation, emotions that are incompatible with the stress response.
In many respects, violence is similar. With rare exceptions, it is a reaction to a perceived threat. It may be said that violence serves us in situations “for which it was originally designed”: self-defense against a warring enemy or a criminal intent on killing us. Yet it only hurts and exhausts us individually and as a species when activated chronically. Enhancing feelings of safety and relaxation helps us be less violent and more peaceful; conversely, a heightened sense of danger and tension promotes violence. While dangerous threats exist in the real world, they trigger violence emotionally, not rationally. Being cut off in traffic may constitute a real physical threat, but our urge to respond with verbal or physical violence arises from a complex stew of imagined contempt by the other, anonymity in our vehicle, an assessment of the likelihood of further escalation, how much we feel they “deserve” it, and similar factors. Emotional safety is complex and not easily assured. Yet it is a necessary element in our closest relationships, in our work, in our communities, and on the world stage. When it is lacking, violence often results.
Humanization of the Other
This is perhaps better stated in the negative: It takes dehumanization to commit violence. From schoolyard putdowns to racial epithets to “the enemy” in wartime, our thoughts and language serve to make emotionally driven violence acceptable. It is hard to treat another person as expendable or deserving to suffer while imagining his or her grieving parents or children — so we take pains not to. Seeing each other as cherished, capable of suffering, and harboring a unique view of the world — in a word, human — is another necessary element for promoting nonviolence. Without it, people are means to an end, not ends in themselves.
Role Models
Depicted with the prior post was Mahatma Gandhi, the first to apply nonviolent principles to politics on a large scale. Gandhi’s nonviolent philosophy, which he termed satyagraha, would likely have had little influence without his personal actions and role-modeling that led to political change in India and elsewhere. Gandhi modeled nonviolence working. Role models such as Gandhi, Martin Luther King, Jr., and Jesus of Nazareth show others a peaceful path by modeling not only behavior, but also emotion: the courage to act according to ideals, without succumbing to fear that might otherwise justify violence.
A similar role model is depicted with this post. Morihei Ueshiba (often called O Sensei, or Great Teacher) founded the Japanese martial art of aikido. Based on earlier violent styles, aikido aims to neutralize violent attack while leaving the attacker unharmed. Aikido’s core principle of harmonizing one’s physical and spiritual energy with the attacker’s would be little more than esoteric philosophy if not for its practical application. As Gandhi did in politics, Ueshiba modeled nonviolence working, in this case against literal physical attack, and in a manner that can be learned and practiced by others.
Early Learning
Patterns of emotional reactivity are established in early childhood. While a propensity to violence may be inborn, nonviolent alternatives can be introduced quite early as well. A society dedicated to nonviolence would teach this in preschool, introducing more sophisticated and challenging scenarios in grade school and beyond. Such a curriculum would not pretend that the world is a peaceful place. Maintaining a nonviolent stance in a world that seems to demand the opposite is a lifelong challenge. All the more reason to start confronting this challenge as soon as possible, ideally before personality is codified and harder to influence.
Practice
It’s one thing to aspire to an ideal, quite another to behave accordingly. There is no substitute for practice, “walking the walk” as well as “talking the talk.” Emotion may trump rationality, but intentional action (and well-chosen cognitions) can shape emotion. Practicing peaceful conflict resolution may occur in daily life, of course. But in addition, dedicated training or exercises may be necessary elements. For example, disciplined participation in nonviolent political action, or in aikido training, may instill peaceful “reflexes” in a way that merely hearing or reading about these practices cannot.
In this post I outlined ways of promoting nonviolence, taking into account emotional and worldly realities. This list is very general and far from exhaustive, and is offered in the spirit of collaboration and discussion. Instead of dividing ourselves by tactics — more guns laws or fewer? death penalty or not? — common ground seems a better place to start. Most of us seek peace, yet most of us share emotions that feed violence. This makes a peaceful world an elusive yet worthy goal we can work toward together.
April 25th, 2013
 Prompted by the Sandy Hook shootings and Boston Marathon bombings, a bumper crop of articles about our violent society has sprouted in recent weeks. I was particularly drawn to this opinion piece in the New York Times. Author Todd May, a Clemson University professor of Humanities, articulates well the crucial underpinning of a nonviolent world view: “the recognition of others as fellow human beings, even when they are our adversaries.” Drawing on the philosophy of Immanuel Kant, who said that the core of morality lay in treating others not simply as means but also as ends in themselves, May argues that the key to a nonviolent society is “to see our fellow human beings as precisely that: fellows. They need not be friends, but they must be counted as worthy of our respect, bearers of dignity in their own right.”
May is surely correct about this. A morality based in respect for others, and in recognition of our duties and obligations to others, underlies most of the defensible arguments favoring nonviolence. (The major alternative, a utilitarian morality based on outcomes and consequences, will forever argue that the ends justify the means, even if the means are violent.) The Golden Rule ”do unto others…” and biblical admonitions to “love thy neighbor as thyself” are based on this type of reasoning, called Kantian or deontological.
At the philosophical level, then, the challenge is to convince ourselves and each other that deontological respect for our fellow human beings is itself a concept worthy of respect. To put it mildly, this is not so easy. Everyone from Confucius to Jesus to Gandhi has tried. Yet “peace on earth, goodwill to men” still sounds like a pipe dream, lovely words that have no bearing on real life. Even the many of us who claim to accept this precept often act otherwise. Why does this perspective, favored by virtually all world religions — as well as secular humanists — and argued most compellingly by our greatest thinkers, nonetheless fail to gain traction? The answer to this central question of human existence: psychology.
Sadly, we humans don’t always behave sensibly. Our feelings often precede and even dictate our thoughts. This was first brought home to me when, as a college student witnessing a political protest, I suddenly realized that the emotional fervor expressed by both sides had very little to do with thinking the issue through. Indeed, it seemed people who understood the subject the least had the strongest feelings about it, pro or con. Moreover, it appeared that people become emotionally invested first, and only later bolster their positions with post-hoc reasoning. Around the same time, I helped with a well-known psychology experiment on confirmation bias, our human tendency to grant greater weight to evidence that supports what we already believe. In the experiment, subjects who already had strong opinions pro or con about the death penalty reviewed exactly balanced “evidence” — I should know, I fabricated it — and reached opposite conclusions. That is, both sides felt more justified in their prior belief by weighing more heavily that portion of the evidence that agreed with their existing position. Those already in favor of the death penalty became more in favor, those already opposed became more opposed. Both the political rally and this experiment figured centrally in my decision to pursue a mental health career. Here was proof that people simply aren’t rational — and that’s fascinating.
While fascinating, this reality bodes poorly for reasoned arguments aimed to influence others. As a society we argue endlessly over social issues: the role of government, whether private gun ownership increases or decreases one’s safety, the legitimacy of gay marriage, how we should treat undocumented immigrants. Selected (i.e., biased) facts, statistics, and images are lobbed back and forth. Those who already agree with a particular bias applaud; those who are opposed become annoyed and counter with facts, statistics, and images of their own. For the most part, everyone feels vindicated by their confirmation bias. Very few minds are changed.
Nonviolence is an especially poignant case. Nearly everyone claims to be on the side of discouraging and decreasing violence, yet there is vehement disagreement over how to achieve this. Moral directives to “do unto others” or “love thy neighbor” are dismissed as naive. Here in the real world it’s “peace through strength,” “the best defense is a strong offense,” and “a pacifist is someone who hasn’t been mugged yet.” Violence is treated emotionally as axiomatic, a given, with post-hoc justification that “they deserve it” or “they started it,” or that committing violence now prevents more later. It is a necessary evil, an entrenched part of the human condition.
In part two, I will pick up from here. Given that moral reasoning alone rarely changes anything or anybody in the real world, what can? Is there a meaningful way to promote nonviolence?
March 24th, 2013
 The annual meeting of the American Psychiatric Association (APA) is in San Francisco this May. I’ve attended twice before as I recall, both times when it was here. I enjoyed it, and even felt it was worth the $1000 we non-members pay to get in, although in my opinion it’s not worth doubling that for airfare and lodging to attend in another city. The presentations were generally of high quality, and so plentiful that I always found something worthwhile to attend. Up to 50 CME (continuing medical education) hours are available over five days, enough to maintain a California medical license for two years. This year, in addition to the other presentations, the new DSM-5 will be unveiled and discussed, so we can anticipate hearing a lot that is new and essential for clinical practice. Bill Clinton will give the keynote speech.
Yet it’s a hard decision for me to attend this meeting. The APA and its annual meeting reflect aspects of psychiatry that concern me. In 2006 the drug industry accounted for about 30 percent of APA’s $62.5 million in financing, half through drug advertisements in its journals and meeting exhibits, and the other half sponsoring fellowships, conferences, and industry symposia at the annual meeting. Every year the annual meeting features a huge exhibit hall of lavish booths courtesy of the pharmaceutical industry. In past years I watched my fellow psychiatrists line up for branded coffee mugs and similar swag; although voluntary restrictions by the Pharmaceutical Research and Manufacturers of America (PhRMA) in recent years have curtailed this, the APA itself welcomes such giveaways according to this year’s information sheet for exhibitors. This year there are industry sponsored “Product Theater” presentations most days around lunchtime (six sessions total, up to 250 attendees per session), and “Therapeutic Update” meetings at dinnertime (three two-hour sessions) — pure marketing vehicles that are not approved for CME, that lack any pretense of scientific balance or neutrality, and that come with a nice free meal to tickle the limbic systems of the recipients. In fact, there’s a surprisingly wide range of promotional and marketing opportunities at the meeting (pdf here) that the APA sells to industry. We participants may sign up for the scientific presentations and collegiality, but the APA invites us for the millions of dollars we bring in.
Of course, individual attendees aren’t forced to take a seat at a “Therapeutic Update” and may never set foot in the exhibit hall. So what’s the problem? Can’t attendees enjoy an educational experience free of commercial influence? Unfortunately, with APA selling everything from sponsored wi-fi, to plasma-screen billboard space, to branded do-not-disturb signs at the hotel, the industry flavor will be hard to miss. Registrants are warned that our names, titles, mailing addresses, and email addresses will be “shared” (i.e., sold) to meeting exhibitors. Perhaps there’s an unpublicized opt-out I’m not aware of.
Whatever one thinks of this blizzard of advertising to a highly selected, captive audience of over 10,000 psychiatrists, it hardly needs to be said that the practice of psychotherapy will have no deep-pocketed sponsorship; healthy nutrition, exercise, lifestyle balance, and introspection will enjoy no “Product Theater” or “Therapeutic Update.” If this year’s meeting resembles those I attended in the past, many presenters will mention the importance of psychosocial factors in mental health, and, if one seeks them out, there will be talks by some of the luminaries in trauma research and psychological treatments. But this will be in the context of blaring signs promoting the newest antidepressant, mood stabilizer, and anti-psychotic — which nowadays may all be the same product — and a zeitgeist of DSM diagnoses leading to pharmaceutical remedies.
Speaking of DSM, the unveiling of DSM-5 ought to be interesting. DSM diagnosis is an integral part of most mental health (not just psychiatric) practice, as treatment authorization and reimbursement by health plans often hinge on the DSM disorder for which the patient “meets criteria.” Both the process of creating the new DSM-5 and its conclusions have come under repeated attack from a range of reputable critics, including the chair of the DSM-IV Task Force Dr. Allen Frances, Division 32 of the American Psychological Association (the “other” APA), the British Psychological Society, the American Counseling Association, and others. One common criticism is that diagnostic categories are being loosened (or widened), such that more patents will meet criteria for a mental disorder, and in turn more psychiatric medications will be prescribed. Dr. Frances charges that the APA treats publication of DSM-5 as a “cash cow,” citing the hefty cost ($199 hardcover, $149 paperback) of this instant and inevitable best-seller. My own feelings about the DSM are mixed, and I’m curious to see how the newest edition turned out, particularly the section on personality disorders.
Despite my concern about undue commercial influence, misplaced priorities, and its controversial diagnostic manual, I plan to go to the APA meeting this year. There’s too much of value to me in all those presentations. But when I pass the anti-psychiatry protesters at the entrance, I know I will wish for some way to declare myself neither anti-psychiatry nor, despite appearances, in full agreement with the spectacle within.
February 15th, 2013
 There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about. The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one’s history. In essence, the patient’s conscious agenda for coming to therapy has been exhausted. I tell trainees this often happens around session #7 — truly it’s more variable than that — when the patient has voiced all his or her prepared topics, said everything already known or consciously felt about the issues, and offered all the background he or she believes is relevant. The patient may then appeal to the therapist for guidance, not in any profound sense, but simply to suggest something to talk about, so they don’t sit there in awkward silence.
A dynamic therapist typically turns this back on the hapless patient: ”Say anything that comes to mind.” This challenge can bring therapy to a grinding halt — or trigger the start of genuine exploration. For it is only when the patient speaks unrehearsed and without self-censorship, in the moment, that the two can observe the here-and-now workings of the patient’s mind. It has been mere preamble up to this point, groundwork at best and chit-chat at worst, not the real work of dynamic psychotherapy. Speaking “without a script” allows topics to arise that are impolite, uncomfortable, and awkward, ideas the patient previously thought but chose not to say, feelings that had been brushed aside up to that point. Some patients unfortunately cannot speak without a script; it is too scary and they are too defensive. Dynamic therapy ends at that point, although emotional support and cognitive techniques may still prove very helpful. But for those with the courage to look at themselves, their own defenses, resistance, and unconscious motivation, it’s time to dive in and explore the unknown.
In a similar vein, patients at any stage of treatment sometimes arrive to a session with nothing to discuss that day. They exude an uncharacteristic blandness or boredom, as if to signal: “Nothing to see here, just move along.” With a mildly apologetic tone they claim to have no burning issues, nothing especially vexing or troubling. In fact, maybe it’s time to talk about wrapping up treatment…
If this presentation stands in contrast to the patient’s usual enthusiasm, I take it as a very good sign. Something emotionally important is going on, and the patient’s Unconscious is trying desperately to throw us off the trail. In the language of dynamic therapy, this is resistance: unconscious effort to avoid painful or troubling material in therapy. Some patients employ this sort of resistance constantly, and for this reason are either very challenging to treat, or they “vote with their feet” and leave treatment early in the process. But when a new resistance stands in clear contrast to the patient’s typical openness, it is easier for the therapist to recognize it, easier to point it out to the patient (who is more open to hearing about it), and easier to identify dynamics that may underlie it.
In my experience, these unusually boring or bland openings lead, more often than not, to the best sessions. Because the patient is not consciously avoiding a troubling issue, and because I rarely know at first what motivates the patient’s avoidance that day, it becomes a shared exploration where new discoveries and insights come to light. For reasons I can’t quite explain, the factors motivating such resistance are not deeply buried or inaccessible. They usually become apparent to both of us well within the 50-minute hour. ”Making the unconscious conscious” (in Freud’s famous words) leads the patient to new and unexpected insights — usually a delightful experience for us both — and also to clearing of the leaden resistance, which is no longer needed to keep the material out of consciousness. Rather than heralding the end of the treatment, awkward silence at the start of an hour, like the awkwardness near the start of many a dynamic psychotherapy, points the way to important thoughts and feelings. It turns out there is a lot to talk about.
January 14th, 2013
 A patient of mine recently observed that the increasing use of the the term “psychopath” in popular media is really a disguised way of criticizing selfishness. Dressing up selfishness as an odd and frightening clinical disorder — slapping a diagnostic label on it — makes for catchy news copy, and grants pundits emotional distance between themselves and those monsters who look just like us, but who lack the empathy and remorse that make us human.
I immediately thought of how narcissism had its heyday in popular culture very recently as well, and to similar ends. Narcissists and psychopaths care only about themselves, and have no qualms about hurting and sacrificing others when it suits their purposes. These are dangerous people lurking among us; all the more reason to publish lightweight magazine and newspaper pieces on how to spot them in the wild.
Both labels sound like psychiatric diagnoses, but actually they’re not. According to Heinz Kohut and other theorists, narcissism is a quality everyone has to a greater or lesser degree. It normally develops in infancy: the sense all babies have that the world revolves around them. However, we gradually learn that we are not the center of the world, and that other people, including our primary caregivers, have their own goals and perspectives separate from our own. Infantile narcissism is thus tempered by the reality of healthy relationships, although its vestiges are present in our self-pride, and perhaps in our proven tendency to overestimate our own efficacy and performance. Pathological narcissism in this view is infantile normality carried abnormally into adulthood. It only becomes a psychiatric diagnosis when the condition fulfills certain observable criteria and impairs social and/or occupational functioning. Likewise, psychopathy is a personality trait, not a diagnosis. Renowned psychopathy researcher Robert Hare notes that “psychopathy is dimensional (i.e., more or less), not categorical (i.e., either or).” DSM-IV doesn’t include a diagnosis called “psychopathy” or “sociopathy.” Instead, there is antisocial personality disorder, which overlaps with psychopathy but is not the same thing.
These terms, psychopath and narcissist, are loosely applied personality labels when popularized in the media. What do they add over simply calling someone callous or selfish? First, they offer an explanation — a pseudo-explanation really — of frightening and/or mystifying behavior. Our feeling of powerlessness is eased by the label, as though now that the threat is identified, we may be able to do something about it. Second, such labels imply that misbehavior is a function of one’s character, a categorical determination. Yet categorical psychiatric diagnosis, especially of personality, is controversial in general. Moreover, we often overestimate personality factors and underestimate situational ones (the “fundamental attribution error“) in explaining the behavior of others. Using a label like psychopath or narcissist to describe another person (whom we’ve only heard about in the news, and haven’t formally evaluated) reaches for a premature conclusion about the cause of that person’s behavior. In a way, we are falsely reassured.
Third, the label adds power to our verbal disapproval. We have a long history of abusing psychiatric labels in the service of putting others down. Consider “idiot,” “moron,” and “imbecile,” all originally coined as official categories describing low IQ. Or “cretin,” which originally referred to physical and mental disability due to congenital thyroid deficiency. Or the casual use of “crazy” and its synonyms. Some patient advocates argue further that any diagnostic label used as a noun is demeaning, i.e., calling someone a schizophrenic, a neurotic, a borderline, etc. Instead, it is more respectful to refer to a person (or patient) who has schizophrenia, or a narcissistic personality. But that’s exactly the point of the popular use of terms like psychopath and narcissist: To show disrespect and disdain, to disapprove. And to underscore the difference between ourselves and the person with the label.
Our earliest social categories are “good guys” and “bad guys,” defining one against the other. From “cops and robbers,” to team sports, to bipartisan politics, to our allies and foes on the world stage, we divide self and other at every level, calling the former good and the latter bad. Callousness and selfishness are in all of us to some degree, and it hurts to admit it; it damages our self-image. Instead, we psychologically defend against this realization in ourselves by projecting these traits onto others using a broad brush and pejorative terms. While some people truly are unusually callous or selfish, the popular use of scientific-sounding labels serves our own psychological needs by identifying “bad guys” and making us feel better about ourselves.
December 30th, 2012
 A person is drunk or angry or momentarily distraught. Or all three. He or she takes an overdose or cuts a wrist, then reconsiders — or never intended to die in the first place — and either calls 911 or tells someone else who calls 911. The police come and transport the person to a psychiatric emergency service where a three-day legal hold is placed. Despite expressing regret for the suicide attempt, the person is admitted for observation and safekeeping.
I sometimes question the clinical utility of short-term psychiatric hospitalization for regretted suicide attempts. Not that it’s always wrong, of course, but sometimes it seems to result from sloppy thinking. The usual rationale is that it’s better to be on the safe side. I.e., if the person’s recent words or actions cast doubt on his or her wish to be alive, it’s better not to take chances. This has merit in cases where there’s some honest doubt: Since our statistical success in predicting dangerousness to others and to oneself is quite limited, “false positives” are the price we pay (well, they pay) to keep the “true positives” safe.
But another reason seems even more pervasive though less often stated: Hospitalization is a predictable and presumably undesired consequence of expressing suicidal feelings. At one level, legal holds and involuntary hospitalization “train” patients not to express suicidal feelings, lest they spend three or more days in an expensive inpatient unit with its attendant shame, stigma, and many inconvenient rules and expectations. It may also serve a related function of taking the patient seriously. Big consequences follow big actions, real or contemplated, and in this way discourage the patient from “upping the ante” with a more serious suicide attempt.
The other side of the coin is that legal holds and hospitalization make us feel better. We’re taking action, not just sitting there. Clinical management is clear-cut for a change. We have an interesting little story with heroic overtones to tell our colleagues. The treatment plan is easy to justify to third-party payors, unlike more subtle interpersonal interventions. (A few days ago I was on the phone with a managed care reviewer who demanded a “5-axis diagnosis” and behavioral treatment plan for my dynamic psychotherapy patient. A more pointless exercise I cannot imagine, except that my patient won’t receive insurance reimbursement without it. This level of skeptical scrutiny rarely arises in hospitalizing the suicidal, even though the cost to the payor is far greater and the benefits sometimes less apparent.) We’re hardly ever faulted for choosing to hospitalize.
Of course, this propensity to “hospitalize first and ask questions later” can backfire. I recall several times in my residency when homeless veterans came to the VA emergency room with bags packed, seeking psychiatric admission. Their claims of suicidal feelings — or even command hallucinations to commit suicide — were hard to argue with, even though it seemed obvious that the real goal was room and board, not psychiatric care. Their complaints quickly disappeared once admission was assured. At the time I noted that civil commitment laws exist to protect the unwilling and undeserving from being hospitalized; none address those who strive to be hospitalized without a valid reason.
A great many suicide attempts and gestures are communicative in nature. Far from being unambivalent decisions to die, they are cries for help, expressions of rage, tests of whether anyone really cares. Our responses as mental health professionals are communicative too. Hospitalization can say, “I’m not playing your game of manipulative suicide threats — I’m calling your bluff.” It can say, “I hear you, and I take your suicide threat very seriously. It’s my job to keep you safe.” It can say, “I blindly follow the rules. You say suicide, I call 911.” Conversely, choosing not to hospitalize can say, “I’m not playing into your drama of getting me to overreact,” or “I’m not taking you seriously, not hearing your pain,” or “I defy the conventions of my profession, you cannot count on me to hospitalize you.”
It’s important to pay attention to the message in one’s clinical actions, and also to realize that one’s message can be communicated in different ways. Hospitalization is not the only way to convey serious concern, even if at times it may be the only way to assure physical safety. If calling the police is an angry reaction to the patient’s misbehavior, it should be re-thought. Nor should it be an unthinking, reflexive response. The converse is true as well: If inaction is an expression of angry avoidance, denial of the severity of the patient’s risk, or a reflexive expression of the practitioner’s bold, iconoclastic nature, that too should be re-thought.
Failure to consider the risks and benefits (pros and cons) of hospitalization on a case-by-case basis would be evidence of sloppy thinking in psychiatric practice. While it may be less common than other forms of sloppy thinking I’ve posted about, it still happens disappointingly often. I also wanted to post about it to give readers a place to comment and ask questions about legal holds, as there is ongoing interest and concern on this topic.
Photo courtesy of Petr Kratochvil.
November 26th, 2012
 I just read a mildly disturbing article in the New York Times called “What Brand Is Your Therapist?” The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master’s degree in clinical psychology. Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients. The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand.
Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services. Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell. In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better. Such services may be “fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance.” Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy. Sharing personal details makes one more approachable and “human,” at the cost of complicating and possibly precluding transference work. Active use of social media such as Facebook and Twitter can attract potential clients and publicize one’s “brand,” but may also blur relationship boundaries essential for effective psychotherapy. Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of “selling” of various services, few of which are recognizable as psychotherapy.
Of course, I am writing this on my psychiatry blog, which is linked to my own practice website. I too have grappled with similar trade-offs. I launched my website over five years ago, and started the blog about a year later. Several months ago I heeded marketing advice I found online: I re-wrote my website in the first-person and added photographs. I expanded the sections on my hospital committee work and past research. I included more practical information about my practice.
Like Gottlieb, I had mixed feelings about doing this. On the one hand, helping potential patients make more informed choices sounds innocuous enough. I want suffering people to be able to find me and to know what I can help with. I want the process of engaging in psychotherapy to be as transparent as possible. I explain what I do, and even list my fees on my website (most of my peers don’t).
On the other hand, I’m concerned that branding and marketing commodifies a personal healing relationship. It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one’s indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision. It conflates psychotherapy with counseling and coaching, all of which are useful but different things. Mainly it risks dumbing down psychotherapy. Psychotherapy is often complex if done carefully, and in my opinion it can’t be conducted as well over the phone, by email, while sitting by the pool with Skype running on one’s laptop, or in a guaranteed four-session package.
I haven’t availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name. If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist. Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off. That makes good sense, and encourages me to take another look at my own website — I may turn it down a little. What do you think?
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