A Response to Harriet Hall on Psychosis and Civil Rights

Harriet Hall has an interesting piece about the right to refuse treatment for psychosis over at Science-Based Medicine. The premise of the article is essentially that the right to refuse treatment must be balanced with the potential danger to the public when someone with a sever psychosis is allowed to live in the community. I believe this is true, and I marvel at the modern mental health system where the word of a lawyer and a judge trumps the word of a psychologist or psychiatrist in deciding whether a person is dangerous, yet, as we saw in the Tarasoff case, the mental health practitioner is still responsible for contacting the family of a named potential victim if the legal side of an involuntary commitment hearing falls through.

So overall I agree with Dr. Hall in that, in some cases, it should be easier to commit someone long term, and we should build long-term treatment facilities. I do, however, have 3 points of contention that I would like to address with Dr. Hall’s post.

Number 1, Hall states that “anosognosia is part of their disease… If you can’t recognize that you are ill, why would you accept treatment for a condition you firmly believe you do not have?” In my experience, and I realize that anecdote is not the singular form of data, but this has been pretty across-the-board, most people with schizophrenia realize that they are ill, but the hallucinations and delusions that they experience are so real that they can’t help believe them. They don’t stop taking medications because they do not believe they are ill, they stop because medication is not perfect and paranoia can set in during brief relapses. Every person with schizophrenia that I have ever worked with has stated that they stopped taking their pills because they thought that the pills were poisoning them. This paranoid delusion also makes people with schizophrenias more resistant to therapy because they believe that the therapist is trying to harm them.

 I’m not saying that anosognosia  doesn’t play a role, but no client I have ever dealt with has stated that they believe they were not sick. However, most of my clients with schizophrenia have been older and in the system for a while. Perhaps it would be different for someone who is recently diagnosed.

Number 2, Hall at one point leads readers to believe that someone has to have committed a violent act before they can be involuntarily committed, stating “Society will do nothing to help you until he actually hurts someone.” Laws relating to involuntary commitment are different from state to state, and it really boils down to the will of the county mental health commissioner, but in my local system the law clearly states that the individual has to be “a danger to themselves or others.” That doesn’t mean that they have had to attempt a violent act, but they must be a viable threat. I’m not saying that it is easy to have someone committed, but it is not quite as hard as Hall states.

Number 3, Hall seems to forget that the ethos of deinstitutionalization was not just to shut down hospitals, but to put more emphasis on community-based treatment. It is possible to provide a high level of care for people with schizophrenia in a community-based setting. The Title XIX Medicaid Waiver program provides funding for in home care for three distinct groups of people, the MR/DD population, the elderly, and people with severe persistent mental illness. The problem is that most waiver funding goes into the MR/DD sector, with elder care and care for persistent mental illness splitting a very small pot. If we could increase funding for mental illness care, we could provide 24-hour staffing for individuals living with severe and persistent mental illnesses such as schizophrenia.

Of course, maybe one of the problems is one of categorization. We classify MR/DD disorders as Axis II disorders and schizophrenia as an Axis I disorder, despite the fact that both of these disorders appear, if current research is correct, to be fully caused by a person’s genetics and biology. However, the typical age of onset of schizophrenia, late teens to mid twenties in men, early twenties to early thirties in women, leads many to believe that schizophrenia has some sort of social/environmental cause. Mental retardation appears at birth. Schizophrenia takes a while.

Of course, as I type this, a group of doctors are meeting privately to decide the content of the DSM-V. Maybe this insulated group will change things. Then again, maybe not.

Annoying Habits of Therapists

I can’t believe I’ve never found PsychCentral before! This is a great site. There is a story on the front page that I thought I would touch on, The 12 Most Annoying Bad Habits of Therapists. I want to comment on a few of them.

1. Showing Up Late for an Appointment

This one should go without saying. I can’t believe that someone would have to tell you to be in time.

2. Eating In Front of a Client

Do people actually do this? I’m only a case manager, and the place that I work has a water tower and coffee that are free to the clients and staff, so we do a lot of drinking in the office, but eating? During a session?? That’s just crazy.

3. Excessive Yawning or Sleeping During a Session

Yawning sometimes can’t be helped. It’s all well and good to say you should get a good night’s sleep, but when you work a job that has on-call hours, it isn’t always possible. Of course, explaining this to a client would be good.

6. Distracted by Phone, E-mail, or a Pet

I know someone who works in the field who will answer her cell phone at any time, with a client or in a meeting with the boss. I know some of her co-workers would like to jam that phone someplace very uncomfortable, too. It’s annoying for everyone, clients and co-workers alike. If your wife is pregnant, and she’s in the third trimester, it’s okay to check the cell phone to see if it’s her number otherwise, don’t.

And pets? Do these people even think about allergies?

5. Inappropriate Disclosures

7. Expressing Racial, Sexual, Music, Lifestyle, or Religious Preferences.

These are really the same thing. I learned early on to not let clients too far into my life, but I have seen this happen before.

I like the music thing here. I could see myself getting into an argument with a client about the greatness of Pearl Jam, or, for you old guys, the Rolling Stones vs. The Beatles.

9. Hugging or Physical Contact

I’m not a hugger. And it really tells you something about the state of mind of some people that you have to explicitly state that having sex with your client is inappropriate. There’s an old saying where we work; every rule exist because someone screwed up in the past.

11. Clock Watching

12. Excessive Note Taking

Ah, the two things I’m probably going to be most guilty of. If you don’t keep track of the time, you end up with a Number 1 with your next client. I have cut back on the note taking, though.

I have a friend who works as a counselor, and he has a good way of doing things. He lets the client stay for a whole hour instead of 50 minutes if thy want to help recap the session for the note. I like that.

You should read the whole list. It’s rather good.

Fluoxetine in the treatment of depression with comorbid substance abuse disorders

Twenty to 30% of adolescents diagnosed with Major Depressive Disorder are also diagnosed with at least 1 comorbid substance abuse disorder. Moreover, reported drug use has been found to be a predictor of suicide attempts in adolescents, with a positive relationship being found between the number of drugs abused and the likelihood of a suicide attempt.

Fluoxetine (you may know it better as Prozac) is the only antidepressant that the FDA approves for use with children and adolescents, and fluoxetine has been found to be effective in reducing depression and comorbid substance abuse disorders in adults. Findling et al., publishing in the Open-Access Child and Adolescent Psychiatry and Mental Health, decided to study the effects of fluoxetine in adolescents with depression and comorbid substance abuse disorders.

The study originally included 18 patients in a fluoxetine experimental group and 16 adolescents in a random, double-blinded control group. Of the subjects, 26 reported that the depression started before the substance abuse and 6 reported simultaneous depression and substance abuse. Urine screens were used to assess drug use throughout the experiment.

At the end of the study, 12 subjects remained in the fluoxetine group and 13 remained in the placebo control. Both groups had reduced symptoms, but the placebo group had a greater mean reduction in symptoms. Fifty percent of the participants in each group met the criteria for remission. (There is a great graph in the article showing the difference in scores between the two groups, but I’m working off an old computer and can’t get a really good screengrab.)

This study gives us some good data, but it is important to keep in mind the small sample size and low statistical power of the study. I like that the authors didn’t let this study become part of the file drawer problem. It is just as important to see that a psychological or medical intervention is not effective as it is to see that something is effective.

Findling, R., Pagano, M., McNamara, N., Stansbrey, R., Faber, J., Lingler, J., Demeter, C., Bedoya, D., & Reed, M. (2009). The short-term safety and efficacy of fluoxetine in depressed adolescents with alcohol and cannabis use disorders: a pilot randomized placebo-controlled trial.

UPDATE: I just read in one of John’s posts on PsychCentral that the FDA just approved Lexapro for use in children, despite some misgivings. So fluoxetine is not the only SSRI approved for children. Check out John’s post for details about the controversy.

 Child and Adolescent Psychiatry and Mental Health, 3 (1) DOI: 10.1186/1753-2000-3-11

Traumatic Brain Injury

Following the death of Natasha Richardson from a head injury, MSNBC is running a bit of information about Traumatic Brain Injury that they pulled from the CDC. It’s some good info for anyone who is interested in brain trauma.

Really, Mr. President? Really?

First it was Dick Morris saying “retarded” on The O’Reilly Factor, now it’s the freakin’ president! Obama was on Leno the other night and said something to the effect of I bowl like someone in the Special Olympics. Really, Mr. President? You bowl that well?

President Obama had the decency to call Tim Shriver at Special Olympics and apologize before the show even aired, but still… It leaves a bad taste in my mouth.

C’mon, can we please get rid of those parts of our vocabulary that are offensive to people with intellectual disabilities? Do we have to use retarded when we mean stupid, or make a reference to the Special Olympics when we want to say we’re bad at a certain sport? What if I said “I did as well on my science test as an inner-city black kid?” That wouldn’t be cool! Not cool at all!

So stop it! Stop! Think before you speak, for Pete’s sake.

And don’t think Sarah Palin is on my good side because she has spoken out about the same issue. She is the political equivalent of one of those D-list actors you always see on VH1, she’ll do anything to get press. Where was she on the Dick Morris thing? Nowhere, that’s where. Nobody cares what you think. Go back to Alaska and try to explain how we rode around on the backs of dinosaurs.

CBT for Eating Disorders

I’ve stated before that I am firmly in the cognitive-behavioral therapy (CBT) camp. I read in a paper assigned for my last class that people do not choose theoretical orientation die to efficacy. I disagree. I initially started reading books by Aaron Beck and Albert Ellis because CBT has a wealth of research behind it, and I found that it just seemed to make logical sense.

In a randomized controlled study by Fairburn et al. published in the American Journal of Psychiatry, researchers studied the use of a specific form of CBT designed to treat eating disorders. There are two forms of the therapy, CBT-Ef, which is a focused form that highlights issues directly related to eating disorders such as body image, extreme dieting, binging, and purging, and CBT-Eb, a broad form which also touches on other psychopathology, such as depression, low self-esteem, mood intolerance, and interpersonal difficulties.

When the results were tallied, researchers looked at complex psychopathology and simple psychopathology. Subjects in the complex psychopathology group tended to be assessed as having more mood intolerance, interpersonal difficulties, and self-esteem issues. The results are kind of interesting:

As you can see from the graph, CBT-Ef works best with simple psychopathology, but does not work nearly as well with complex psychopathology. The CBT-Eb group shows similar results with both simple and complex psychopathology.

It looks like the focused approach is not really necessary, but can give better results when used with clients with less complex psychopathology. The broad approach seems to be preferable, but less effective.

This study shows us the importance of clinical judgment. Clinicians need to be able to assess the complexity of their clients’ psychopathology in order to find the right emphasis for therapy. In these two therapies, the first four weeks are the same regardless of whether a clinician is using the focused or broad approach, giving clinicians plenty of time to assess their clients’ needs.

Fairburn, C., Cooper, Z., Doll, H., O’Connor, M., Bohn, K., Hawker, D., Wales, J., & Palmer, R. (2009). Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two-Site Trial With 60-Week Follow-Up American Journal of Psychiatry, 166 (3), 311-319 DOI: 10.1176/appi.ajp.2008.08040608

How do you treat the duck?

I’m reading Science and Pseudoscience in Clinical Psychology and in a chapter about recovered memories, I found this:

In 1997, Nadean Cool won a $2.4 million malpractice settlement against her therapistin which she alleged that he used a variety of techniques and suggestive procedures to convince her that she had suffered horiffic abuse and harbored more than 130 personalities including demons, angels, children, and a duck.

The emphasis is, of course, mine.

If anyone out there knows how to provide psychotherapy to a duck, please let me know. If breadcrumbs are involved I want to be prepared.

Of course, the other issue is that you could never tell with any validity if the woman was a witch.

John C. McGinley kicks ass!

Ever since I saw my first episode of Scrubs it has been one of my favorite shows. I knew John C. McGinley, the actor who plays Dr. Perry Cox and is well known for his roles in Platoon and Office Space, has a son with Down Syndrome and is very active in trying to raise awareness for people with mental retardation and developmental delays. Of course, that is very cool.

I got my start working in behavioral health working with the MR/DD population as part of a program called Title XIX/Medicaid Waiver. The Waiver program, as we called it, provides an alternative to hospitalization and institutionalization by providing funding for home care workers, nurses, case managers, and psychologists to provide services for people with MR/DD diagnoses. Waiver has a number of sub-programs, such as day-habilitation (or DayHab, providing assistance to individuals in the community, which includes providing transportation, helping people shop and pay bills, etc.), residential habilitation (ResHab, providing assistance in the home with chores, personal care, cooking, etc.) and respite services, which provide parents and other unpaid caretakers with a break so that they can take care of themselves.

This is a really good program. It is also the hardest and, in some cases, least rewarding work you can do in behavioral health. Improvement comes slowly, so you can never expect to see any drastic changes from day to day or week to week, and it is physically and mentally exhausting. But I would trust a great waiver worker over just about anyone else to do the right thing when needed. This is incredible front-line training for future behavioral health workers, and I would recommend it for anyone interested in a career in the field. To put is simply, if you can work waiver, you can do anything.

But enough nostalgia. John C. McGinley was on the Bonnie Hunt Show last month and he spoke about his son and about Special Olympics, and he touched on a controversy. Apparently Dick Morris was on The O’Reilly Factor and used “the R-word,” or retard, in an interview, and a bunch of kids at the Special Olympics sent O’Reilly a letter asking for an apology. Apparently, O’Reilly did apologize, which is cool. Here’s the clip:

And here’s the clip of O’Reilly apologizing:

What does it mean, though, when he says “Dick Morris is speaking off the cuff?” Why couldn’t he just apologize? What exactly does “off the cuff” mean? Is he saying that Morris didn’t prepare a statement? That it is okay to use “retarded” as a pejorative as long as you don’t do it on national television? I mean, it’s cool that the guy apologized, but why does he have to try to backhand the apology by trying to explain away the remark? Would saying that he is speaking off the cuff and apologizing be appropriate if he had said nigger instead of retarded? Actually, the producers and O’Reilly himself would have stopped him at the time if he had dropped a racial slur, but it takes three days to apologize about using retarded as a euphemism for dumb and slandering millions of people with intellectual disabilities, people who have to work harder to do the same things we do and still end up doing as well as the average American.

Anyway, enough with the rant. John C. McGinley, I salute you!

Taking a closer look at child sexual abuse

Each year, approximately 150,000-200,000 children are sexually abused, 70-80% of those cases involve a family member or a friend of the family that the child knows, including older children. It’s an appalling proposition to anyone who wants to work in the treatment of mental disorders. The people that we are supposed to trust, the “in group,” is more likely to do damage than any stranger. Even the most well-balanced counselors and therapists I know get floored by stories of child sexual abuse.

The Journal of Mental Health Counseling published an article by Frazier et al. covering some very good information regarding recovery from CSA. Here are some of the key facts regarding recovery:

• Primary symptoms of CSA include avoidance behaviors (including caregiver phobias), developmental delays, diminished responsiveness to the outside world, lack of interest in a previously-enjoyed activity, and feelings of detachment or estrangement.
• Survivors of CSA may lose developmental achievements. They may start bedwetting behavior, or they may become unable to feed themselves.
• When an abused child views their preabuse life as high-quality, they are more likely to have a positive self-view after the abuse.
• Survivors who believe that others do not view them as responsible for the abuse often feel empowered, leading to a more positive adjustment.
• Abused children who receive emotional support from a non-offending adult are less symptomatic.

Note that the emphasis of this article is on children. Adults who survived CSA are more likely to show symptoms of depression and anxiety, but children respond well to treatment. Frazier et al. recommends using an ecosystem approach in working with child survivors of CSA, and calls for counselors to be aware of transgenerational trauma, or situations in which a child keys into an adult’s behavior surrounding the adult’s experience with sexual abuse. Children are quick to pick up cues from parents. If we can assist these children as early as possible, we may be able to break that cycle.

Of course, CSA is not without its controversies. The biggest of which is probably the diagnosis of Dissociative Identity Disorder.

I’ve been reading bits and pieces of Science and Pseudoscience in Clinical Psychology, and last night I finished a chapter on DID (Lilienfeld & Lynn, 2003). It does a great job of highlighting the controversy surrounding DID.

Briefly, DID is a disorder in which a client presents with two or more distinct “personality states” that alternate in their control over the individual. It is one of the dissociative disorders, disorders which present with disturbances with memory, identity, or perception of the external world. The common belief regarding DID is that the development of separate personalities is caused by child sexual abuse. (note: this is a more recent development. The two famous early cases, those presented in The Three Faces of Eve and Sibyl contain no mention of CSA). The belief is that the child develops the second personality as a way of protecting the primary personality from facing the fact that they are being abused.

The other camp, the place where I hang my hat, claims that DID is the result of therapist cueing. Lilienfeld & Lynn point to a few facts: that a huge number of DID cases come from only a handful of therapists, the flexibility of memory as demonstrated by Elizabeth Loftus, the fact that a majority of the cases of DID begin treatment for other problems and do not report the expression of different personalities until later.

Lilienfeld and Lynn are quick to point out that they are not denying that DID patients experience these symptoms. The question is whether the symptoms are a natural reaction to trauma.

This leads me to a story. In an earlier job, I was treating a female with DID who claimed that her parents performed ritual sexual and satanic abuse. I was an undergraduate student at the time, and I happened to read one of Loftus’ memory studies around that time, and read the FBI statements that there had never been any documented cases of ritual satanic abuse in the US. I was confused, so I went to my boss. He was (and still is) a great counselor and he said “it probably isn’t true, but it is true to her.” This, or course, is a take on the old adage with schizophrenia, never challenge the delusion. Of course, it does beg the question, how do you treat someone who bases their life on events that did not occur?

(Original Photo by D Sharon Pruitt)

Frazier, K.N., West-Olatunji, C.A., St Juste, S., Goodman, R.D. (2009). Transgenerational Trauma and Child Sexual Abuse: Reconceptualizing Cases Involving Young Survivors of CSA Journal of Mental Health Counseling, 31 (1), 22-33

Sunday Sessions

I feel like crap. I’ve got some sort of upper-respiratory thing (I thought those would go away when I quit smoking!) and my head feels like it’s swimming. I’m getting cold chills. Basically, it feels like a fever, except the thermometer doesn’t read over 98.5. I don’t care what it says. I would have an argument with it, but at this point I’m afraid it would win.

So, here’s a couple of quickies for Sunday (and to prove how messed up I am, it’s technically Monday).

Is Genius Inherited? Time asks this question. The answer is “yes and no,” and, while I appreciate coverage of anything psychologically-related in the national press, I have to ask… Really? Haven’t we pretty much settled this one by now?

Anatomy of Thought Neurophilosophy has some beautiful engravings of the human brain.

I Love This Website

Polite Dissent. It’s medical reviews of comic books and House. It’s a geek’s best friend.

Treatment-Emergent Mania Correlates in Bipolar Depression

Treatment-emergent mania, or TEM, is the onset of bipolar mania in patients who are taking antidepressant drugs. TEM can have a large negative impact in the treatment of bipolar disorder, and so it is important to understand this phenomenon.

In a study published in February’s Journal of American Psychiatry, Mark A. Frye and colleagues looked at 176 adult outpatients taking antidepressants for treatment of bipolar disorder. 85 patients responded successfully to the antidepressants, while 45 did not responded and 46 responded with TEM. The researchers were looking for correlates that could be used to predict TEM.

People with bipolar disorder are prescribed antidepressants because depressive symptoms are three times more likely to appear than manic symptoms during symptomatic periods. Somewhere between 40-50% of patients with bipolar disorder are currently on antidepressants.

According to the study, TEM correlates with minimal manic symptoms at baseline coexisting with full syndromal bipolar depression.

Researchers also used the Young Mania Rating Scale at baseline and found that TEM is associated with increased motor activity, speech, and language thought disorder. The researchers call for a careful examination for these specific symptoms before starting antidepressant treatment. Frye and colleagues note that because most mood stabilizers do not work on depressive symptoms, patients need to work with their health care provider to find suitable alternatives.

I have seen this effect in clients in short-term inpatient settings. Clients find it very disturbing to be in a treatment setting and suddenly develop manic symptoms. It also goes to the heart of a few clinical controversies relating to medical treatment. Medications will often work for a period of time, followed by a period of relapse.

Some claim that this means that drugs are not effective as psychotherapy, or make arguments that psychiatric medications are useless money-makers for drug companies. I’m not the world’s biggest cheerleader for drug companies, but the evidence has been there in front of us for years. A combination of psychotherapy and medication works better than either therapy or medication alone. (If you don’t believe me, see articles here, here, and here).  But that doesn’t mean that each treatment is equally effective for each presentation of the same disease.

M. A. Frye, G. Helleman, S. L. McElroy, L. L. Altshuler, D. O. Black, P. E. Keck, W. A. Nolen, R. Kupka, G. S. Leverich, H. Grunze, J. Mintz, R. M. Post, T. Suppes (2009). Correlates of Treatment-Emergent Mania Associated With Antidepressant Treatment in Bipolar Depression American Journal of Psychiatry, 166 (2), 164-172 DOI: 10.1176/appi.ajp.2008.08030322

Washington DC mental health privatization sparks controversy

In Washington DC, public officials are attempting to privatize the provision of mental health care by transferring patients to private clinics and closing public clinics. This has sparked some controversy in the area.

According to The Washington Post, the city plans to close their six clinics and enter contracts with 30 private clinics by 2010. The city argues that this will save money, which will allow them to provide services for more people.

Critics are arguing that the public clinics provide a higher level of care than private clinics, who are worried about profit and the bottom line. They argue that doctors make less in private clinics and have a larger client load, prompting many doctors to leave.

Apparently DC was court ordered to provide mental health care through clinics after a 2001 court order which restricted confining patients to hospitals. The city says that it was never meant to be a perminant plan, and they are behind their orignial schedule to privatize the system.

Ken Duckworth, the medical director for the National Alliance on Mental Health, thinks this is a bad idea, asking “If the government doesn’t take care of the most severely ill people, who will?” It’s an interesting question that everyone in and around the field has been asking since the days of deinstitutionalization.  The real question is to what extent should the government be involved in the provision of healthcare versus paying for health care.

In West Virginia we have two hospitals that are owned and operated by the state. local services are provided through private non-profits throughout the state. Prestera serves Charleston and Huntington, United in Clarksburg, Eastridge in the Eastern Panhandle, and Westbrook in Parkersburg. So I’m kind of unfamilliar with the concept of public health care. I don know that private groups can do a good job with public money, so I’m not nearly as alarmed by this as some of the critics are. And if this frees up money to provide services for more poeple, I definately see it as a positive.

Predicting Behavior: Depression in adolescent girls

It is sometimes essential that we be able to correlate behaviors that may relate to mental illness. Research points to early intervention as being an important predictor of recovery. If we can correlate one set of mental health symptoms with something that occurs early in life, and if that correlation holds true, we can better predict who will need mental health care and get services to them in a timely manner.

A recent study in the Journal of Early Adolescence points to a correlation between antisocial behavior in young girls and depression in adolescents. This is based on a University of Washington study starting with first and second graders and following them for 7 years.

Antisocial behavior is most commonly seen as a problem in boys, but this study found that antisocial behavior and anxiety were predictors of depression in early adolescence. The researchers note that more girls than boys suffer from adolescent depression.

This all leads me to question: are the minds of children and adolescents well-formed enough to apply an adult disorder to their mind. This is a serious question, I’m not doing one of those rhetorical questions to try to show that psychiatry is misguided, etc. If we were to diagnose depression in a 10-year-old girl, just as an example, on what criteria do we base this decision? Is the DSM adequate, considering the mental abilities and emotional state of a teenager?

Masculinity and the Gay Male

Masculinity takes a beating fairly often in both the media and in a lot of research. George Carlin once referred to “the continued pussification of the American male,” and Dennis Leary spends a good portion of No Cure for Cancer talking about the changing tide of American manhood and the lack of the tough-guy John Wayne figure in modern male culture. Of course, gender identity is not static. These days being a man is less about working with your hands and more about working out at the gym, less about aggressive fighting and more about aggressive trading. Basically, as men have gone from cigarettes to luffas, masculinity has been redefined for the 21^st century. Essentially, metrosexuality is nothing more than a hyperreal acceptance of certain aspects of traditional masculinity, but it also becoming the paradigm.

A study from Psychology of Men and Masculinity attempts to determine what gay men associate with masculinity and how they feel masculinity affects their self-image. Data was collected nationwide and answers were grouped based on similarity of responses.

The results were in some ways surprising to me. In two of the questions, one asking how self image is positively affected by traditional ideas of masculinity, the other asking how traditional masculinity positively affects gay men’s relationships, the most popular answer was “There are no positive effects” (24% and 30%, respectively), but a plethora of responses were available when discussing how masculinity negatively affects self image and relationships.

I would have presumed the opposite. There are a number of gay men among my clientele at work, and most of them balance masculinity and femininity very well. In fact, the feminine gay man is rate at my office (maybe 3-5%), and that says a lot. I work with people with HIV/AIDS, and about half of my population is gay.

Common statements about the negatives of masculinity include “By being gay, you’re not a ‘real man,'” “It restricts ones expression of emotion,” “fear of appearing feminine,” and “it restricts open expression and communication.” Positive statements include talk about the expansion of the concept of masculinity. This is one positive that I can see.

My father is a truck driver. He doesn’t use moisturizer. He doesn’t work out. He quit smoking recently when he was diagnosed with lung cancer, but before that he consistently smelled like a bar. Like you would imagine bikers would smell.  Dad’s concept of masculinity is based on John Wayne and Steppenwolf, Clint Eastwood and Zeppelin, the Hells Angels and D-Day.

My concept of masculinity comes from my father, but also from actors, musicians, and public figures that have hit the scene since the early 80s. Bill Gates is considered nerd chic, and things that were acceptable when my father was growing up are no longer acceptable now. For instance, when my father was growing up the concept of being gay was completely antithetical to masculinity. Now it is becoming mainstream.

One problem with the article: I wish the gay men used in the study would have been asked to self-identify as masculine, feminine, or neither. That would give us a better sense of who is saying what in the responses. Do we have masculine gay men who are having trouble with their masculinity, or are we seeing feminine gay men answer questions about masculinity?

Francisco J. Sánchez, Stefanie T. Greenberg, William Ming Liu, Eric Vilain (2009). Reported effects of masculine ideals on gay men. Psychology of Men & Masculinity, 10 (1), 73-87 DOI: 10.1037/a0013513

How good is this advice?

I love newspapers and news magazines. They are absolutely obsessed with positive psychology. Everything is about making yourself better, faster, stronger, etc. And they always put this stuff in a section called “Living” or “Life.” This brings to mind growth. No one wants to hear the bad stuff,that you will probably die alone, that you’ll never get that promotion. I wonder what kind of person reads this stuff every day.

Today, I’m taking a look at an article from The Huffington Post, How to Attract your Life Partner. I want to know, is this stuff real, or is is simply leftovers from Cosmo?

It starts out simple enough. If you want the right partner, here are a few things that you can do to work on yourself to “enhance your ability to attract someone who is really complimentary to you.”

1. What did you learn? Look at your last relationship and what went wrong. What were their complaints about you? As much as you don’t like what they were, you need to look at why they had them and, without dismissing it, find out if there was any truth in it. Usually there will be something in their opinion, at least to some extent. That will give you a good indication where you need to make steps to evolve.

This is pretty good advice, and I’m all for self improvement. Although I wouldn’t go calling the person up. “Hello, yeah, could you tell me the top five things about me that disgisted you?” Also remember that you are very likely to dismiss everything your ex says and your ex is likely to exaggerate every miniscule thing about you in the heat of the moment.

2. Dispelling the Unknown. Are you in any way uncomfortable around the opposite sex? Now this can be more prevalent if you didn’t grow up with a sibling or parent of the opposite sex, or you did, but you didn’t get on well with them. If this were the case, then you would do well to learn as much as you can about how the opposite sex is different and how the other half tick. Maybe that means developing friendships, reading books, going to therapy. If you are a woman, read men’s magazines, if you are a man, read women’s. Anything that will help you gain more information and dispel any enigmatic qualities that you think they might hold. The more knowledge you have, the better.

This is kind of silly. Women’s magazines suck. They’re all about picking up men, and they’re mostly wrong (unless it involves sex, or food, if sex is not available due to some unforseen circumstance like religious affiliation or rationing.) In psychology we study sex differences; it’s not going to get us laid. (“I have a better sense of direction but you have a better sense of location that is genetically hard-wired into our brains. Lets fuck!”) The key is to talk to the guy (or girl) like he is a human being. And if you have a question, ask. I still ask my wife questions.

3. A good match. Write down the best qualities of your father, if you are a woman and the best qualities of your mother, if you are a man. That will really give you a good indication the kind of man or woman that would be suitable for you.

They say that men marry women like their mothers and women marry men like their fathers. In reality, I would say that there are certain featured that both sexes look for and that people who maintain successful relationships seem to have. You think you married a man like your father because a good proportion of the traits you are looking for are actually very attractive to the population as a whole. David Buss writes very well on human mate choice.

4. Your internal partner. What does your internal male side think of your internal female side? Imagine you are writing down what he thinks of her and write whatever comes to your mind. Maybe he thinks she is fearful, insecure or a bit aggressive. Then when you have finished, write what your internal female side thinks of your internal male side. Maybe she thinks he’s a bully, weak or thoughtless. Whatever comes to mind, write it down. Your long-term goal is that they come to really love and respect each other. Remember, whatever happens externally has to happen internally first and your goal is to feel really whole inside to help magnetize you towards a partner that is really good for you.

I hate this stuff. You do not have a “male side” and a “female side.” You are either a male or female, and you will present interests and characteristics that are associated with male and female socialization. Just because I enjoyed Fried Green Tomatoes doesn’t mean I have some female side. In fact, the whole idea behind this is scary. These people want to believe that gender role socialization is so biologically ingrained that any expression of opposite-sex socialization means that their opposite sex part of the brain has taken over. This is actually offensive.

5. What do you want? List the qualities that are important to you in a partner. Don’t make them super human, as that person doesn’t exist and being unrealistic will stop you from drawing them in. So write down the top five qualities you would like and leave the rest to fate. Do you want them to be warm, loyal, honest, giving with a good sense of humor? Chose your own, but do be specific.

As i said before, those top five qualities will probably be the same as everyone else’s. Just look at the qualities mentioned: warm, loyal, honest, giving, good sens of humor. No one says “I want a cold, cheating, dishonest thief who nevr laughs at my jokes and thinks Andrew Dice Clay is funny.”

So, after this trashing, here’s some real advice.

1) Evaluate yourself- What are your strengths and weaknesses. More importantly, what do you love and hate about yourself. If you hate some quality of yourself, it will show, and it will look like self-loathing. Your potential mate will be turned off either by the same quality you hate, or your hatred of said quality. Work on yourself first.

2) Be assertive and flexible- Don’t be one of those dayes who always says “I don’t know, where do you want to eat? What would you like to watch?” No one wants to make all of the decisions all of the time. Your partner will be unhappy and you will be unhappy because you’re not getting what you want. Stand up for the things that you really want, throw away the stuff that you really don’t care about (“red or blue sweater, make a decision now!”), and be flexible for all of the stuff in between. If you’re assertive and your partner can’t handle that, the relationship was doomed anyway.

3) Be honest- Ask questions. Tell about yourself. Don’t treat the situation like a romantic one. Think of it as finding a new friend. Introduce yourself the same way you would to a friend, and allow the relationship to grow from there.