This OP is a review of George Simon Jr.’s Character Disturbance: The Phenomenon of Our Age (Little Rock: Parkhurst Brothers, 2011).

Simon’s thesis

Simon wants to warn lay readers about, and advise therapists on how to treat, what he calls “character disturbance.” In its more severe stages, character disturbance leads to “character disorders,” among which we can see varying degrees of personality styles that in their more extreme form might include what we know as pathological narcissism, “borderline” behavior, and sociopathy and psychopathy. We can identify character disturbances by choices people make, unfettered or insufficiently fettered, by the feelings of guilt and shame that afflict the rest of us.

Simon contrasts disturbed characters with “neurotics.” These are susceptible to “the conflict that rages between primal urges and qualms of conscience.” (That quotation comes from a blog post Simon has written. But he says basically the same thing, if less quotably, on page 13 of his book.) The average layperson and most therapists too often treat disturbed characters as neurotics acting from neurosis-like motivations. It’s more useful, however, to consider that disturbed characters simply do what they do to get what they want as soon as they can and with the least amount of work possible. We should hold them responsible for their actions, and therapists should use Cognitive Behavioral Therapy (with a focus on the “behavioral”) to give them the tools to change.

Character disturbance is the “phenomenon of our age” because our present-day society and culture encourage people to value their self-esteem over their self-respect. People with character disturbance already have a high self-esteem. They just don’t have the self-respect necessary to feel shame at what their actions show them to be.

The myth of our disturbed age

The book’s subtitle (“the phenomenon of our age”), preface, epilogue, and incidental remarks throughout all point to two questionable assumptions. The first is that character disturbance and character disorders are on the rise. The second is that the manner in which our current culture promotes and condones those ways of acting is unprecedented or somehow unique. Both assumptions imply that our current “near epidemic” [p. 14] is new and dangerous and threatens to undermine “the very foundations of our free society.” [p. 19].

I defer in part and dissent in part. I defer to Simon’s claims about his profession (he’s a former therapist, now writer). He says that therapists in the US are generally trained in the “classical” model of neurosis, with nary a regard for treating character disturbance as a thing in itself. This classical model does a poor job of treating individuals with character disturbance so that in recent decades, therapists whose clients have character disturbances do not treat them effectively. If Simon is wrong on these points, that’s something someone with more knowledge than I about the mental health professions and clinical practice can pursue.

I dissent, though, that we can know with Simon’s confidence that character disturbance is more prevalent now than before and that “self-esteem culture” is somehow unique in the way it encourages character disturbance. Maybe self-esteem culture from ca. 1970 onward condones and encourages character disturbance, but other cultural trends from different eras could plausibly have done the same. I offer as one example white supremacy and the “lynch law” it inspired in the era of Jim Crow. You can probably think of other examples.

I dissent also because it probably doesn’t matter. Whether character disturbance is more prevalent, less prevalent, or about as prevalent as before, it is still a problem that needs to be addressed. If it is indeed a “near epidemic,” then I guess we need to take more assertive measures, rethink our notions of crime and punishment, or go beyond the “political correctness…and the tendency to put personal beliefs and interests ahead of the general welfare”–all of which “impair our ability to conduct an honest discourse and debate.” (p. 252).

But any “honest discourse” has to consider the limitations of what we know. One of Simon’s key points of evidence–our rising prison population–could have other causes in addition to increased incidence of character disturbance. One might argue that the rising prison population represents society taking a firmer stand against character disturbance and disturbed characters are now facing their comeuppance. I don’t endorse that argument, but it’s consistent with Simon’s evidence and yet also runs against the point he wishes to draw from that evidence.

Continuums and sharp distinctions

Simon posits a “continuum” between neurosis and character disturbance [p. 29]. Someone is neurotic to the extent that they don’t have a character disturbance. Someone has a character disturbance to the extent that they are not neurotic.

Simon also notes the promise of a third way out of the continuum and toward what he calls “self-actualization altruism.” Those who approach this altruism “freely and completely commit themselves to advancing the greater good. They are not neurotic because they have no driving desire to avoid guilt or shame for doing otherwise. Also, they’re not out for personal glory or to be revered by society.” [p. 29, italics in original] He doesn’t dwell on that point. In fact, he’s skeptical that there is a third way out and suggests that for practical purposes his continuum makes more sense.

But even so, I’d like to see more discussion about the continuum than Simon offers. Too quickly he jumps from discussing the continuum to distinguishing between neurotics and people with character disturbance. He does not discuss the positions on the continuum where many (most?) of us likely fall. Maybe the turn toward “self-actualization altruism” happens never or only rarely. But is there then, as an alternative, an optimal place on the continuum for us to be?

Such a discussion is probably beyond the scope of the book. Perhaps Simon needs to draw sharp distinctions because 1) his audience includes laypersons like me as well as experts like him; 2) his goal is to warn us about character disturbances and advise us on how to deal with them; and 3) you can cover only so much in any book and still have it be readable.

So…you know it when you see it?

Let’s grant that for sake of readability Simon must make sharp distinctions between the character-disturbed and the rest of us, but how do we know who the character-disturbed or character-disordered are? He gives some clues, especially in Chapter 6, “Habitual Behavior Patterns Fostering and Perpetuating Character Disturbance.” Most of these patterns boil down to denying or deflecting responsibility for harmful actions.

But in a broader sense, how do we know, especially in the “edge” cases where someone is character “disturbed” but not badly enough to be character “disordered”? How do we–especially the laypersons who seem to be part of Simon’s target audience–discern whether someone is character disturbed as opposed to being neurotically disturbed?

Maybe if someone acts like a character disturbed person, we should treat them as such for our own self-protection and let the mental health professionals sort out the underlying causes. It’s probably on balance good to learn how to call out responsibility deflection whether or not the deflector is a disturbed character or merely an anguished neurotic. In some cases, it’s probably better to simply disengage regardless of where the deflector falls on the continuum.

Maybe we shouldn’t seek to “know.” Maybe judgment is for the Lord, and discernment is for a competent and licensed mental health professional. But that doesn’t sit well with me, either. One purpose of Simon’s work is to warn laypersons like me about these people. And while provisionally speaking I can learn a lot about how to respond to responsibility avoidance, part of how I respond depends on my general assessment of their character. If someone resorts to the trick of changing the subject when I bring up a problem it matters a lot to me whether that’s a one-off or part of a pattern of behavior.

Maybe the trick, then, is to find patterns. But there are patterns and then patterns on the patterns. Maybe I’ve just been lucky, but even the people I’ve known who I consider “character disordered” sometimes defy their own patterns.

The problem of suffering and compassion

My concern about knowing or discerning plays into another concern. If we actually have–and can say with confidence we have–an according to Hoyle disordered person before us, what role ought our compassion toward that person play?

Simon seems to say that the first compassionate thing to do would be to empower and help the victims. The second compassionate thing would be to help disturbed/disordered characters learn how to act differently. Cognitive Behavioral Therapy (with an emphasis on the “Behavioral”) can help–provided the disturbed/disordered character accepts responsibility for his or her actions and actually is willing to do what is necessary to change.

What about before the magic moment(s) when the disturbed/disordered person realizes they need to change? I think Simon would say the best we can do is call them on their tactics and make them take responsibility for what they do. In those cases, “compassion” is beside the point.

But I’m left to wonder, do disturbed/disordered characters “suffer”? Simon seems to say no, at least not as “neurotics” do. Or if disturbed characters do suffer, it’s only to the degree that they’re also neurotic (remember the continuum above). Disturbed/disordered characters are basically out to get what they want. Simon might concede that getting everything one wishes betokens a deeper and underlying, unhappiness or suffering. But I think he would suggest that we should focus on the behaviors and bracket the other types of questions as not useful.

Parting thoughts

Neurotics come off pretty good in Simon’s book. To the extent that he’s targeting a lay audience, he’s primarily targeting neurotics–and perhaps also the “self-actualizing altruists”– and not the disturbed characters qua disturbed characters. Neurotics make bad choices. But the key to helping them is work through the underlying issues, whatever those may be, in addition to introducing them to better coping behaviors.

Disturbed characters are different from you and me, especially if their disturbance is extreme enough to mark them as “disordered.” There’s hope for them, to be sure. At one point (I can’t find the page number), he suggests that even those we’d call seriously psychopathic might ultimately attain something like redemption or rehabilitation. But he seems to want our takeaway to be that they are the bad guys (and gals). And we, who presumably fall somewhere on the “optimal” range of the “neurotic”/”disordered” continuum, are the good people just trying to survive. That bothers me, even if he’s right. Especially if he’s right.

There’s something missing. Periodically, Simon hints that he too was once been a disturbed character, too. He refers (without specific examples) to other times of his life before he saw the light and started to change his behavior. He doesn’t go into detail. And he probably shouldn’t because that’s not the book he’s to be writing. However, if he ever chooses to write that book, I’ll be sure to read it.

Category: Hospital

My efforts to quit vaping came to the do-or-die phase at a pretty bad time. Basically, right when Clancy was resigning. That was leaving me in a pretty bad place because it was high-stress and I had no coping mechanism. It wasn’t through sheer grit that I didn’t turn to vaping, but rather where I was in the Welbutrin cycle. Long story short, I could vape all I wanted, but my nicotine receptors were scrambled and it wouldn’t do any good. I still vaped, but the whole puffing-to-no-effect was causing its own anxiety. So I basically had to make the decision whether to stop taking the Welbutrin or stop vaping. I just couldn’t keep doing both.

I decided to stop vaping. The first thing I did was order a Nintendo Wii U. Back before I smoked, playing basketball outside was the way that I found my zen and organized my thoughts. Due to the peculiarities of the house, I couldn’t set up a hoop here. Nor was there space for my backup plan, a pool table. But I had been circling the Wii for a while because it has some indoor activity stuff that could serve the same purpose.

Until I started taking it again, I’d forgotten one of the primary effects of Welburtin is that it reduces the need for sleep. I need about six hours a night usually and Welbutrin makes it so that I have trouble even getting that much. It’s an effect that subsides with time, but it takes a while. In this case, it leaves me with ever-more time to be awake and not vaping. At a time when I desperately want time to pass to that I can get over the hump, there are suddenly more hours in the day.

It was, it turned out, remarkably successful. Instead of vaping, I’d play one of the games from the Sports Resort package. I ended up doing a lot of it, in fact. So much so that with each progressive day, my muscles were more and more tired. Not in a bad way, though! I could just feel it. On the fourth day, the Wii Fit package arrived. For those who don’t know, the Wii Fit is the exercise program. It’s more physically intensive than sports.

I got the fit to help distract me from the vaping. Which it did. Just not at all in the way that I had imagined.

I had been playing Wii Fit for about 90 minutes when I jerked my back something fierce. It wasn’t too bad at first, but it kept getting worse. And worse. And worse.

When your back hurts, your body generally compensates by using other muscles. Which is all very well and good… unless all of your other muscles are three days into utter exhaustion. Then your legs and arms simply don’t have the energy to compensate. It then throws more burden to the back, which then spasms. And round and round it goes.

The second day was pure agony. I cannot remember the last time I felt so much pain. Clancy could not remember ever seeing me in that much pain. I was in a place where I was slouched on the sofa and I literally could not move enough to either sit up on it or lay down on it. Clancy tried to move my legs for me and that was even worse. And with each spasm, the muscles would tighten more, which lead to more spasms and more muscle tightening in a really vicious cycle.

Among the few things that helped was showering. So once I was able to get up and move around – which did happen eventually – I went into the shower. Clancy literally had to help me get dressed afterwards.

Now, the Himmelreich-Truman household is actually a drug den. Clancy gets medications for various things and she fills them whether she has to use them or not. The same is true of me. The Welbutrin I’d been taken was prescribed in 2010. So when something like this happens, we have options. This was especially true since the medicine cabinet was thrown at her when she busted her kneecap. She asked if I wanted to take some muscle relaxers. I asked if they were addictive and she replied that they weren’t but that she never took them because they made her feel loopy and dull.

I said that I wanted all of the muscle relaxers in the universe.

I came close to actually taking the Vicodin, which is addictive. I was in that much pain. It didn’t quite reach that point. Things did gradually start getting better, slowly. It was two steps forward and one step back. I put myself and my daughter at risk trying to drive her to preschool when my back was not in good enough shape that I could sit freely in the car seat (I basically used one of my two arms to prop me up). That was a step back. But showering twice a day and taking the drugs would represent a couple steps forward.

It’s been almost a week now since that happened. The nice Wii that I bought has barely seen any use as new games that I ordered before the injury started arriving. The biggest lag has really been that I have nowhere to distribute the weight, too. My arms are better, but my legs are still really sore. My back is almost better, though the legs keep pushing weight in that direction. The biggest bullet dodged was that throughout this entire thing, I never needed to use the can for serious business. That felt like a ticking timebomb about to go off because pushing excrement through requires pushing some of the same muscles that were spasming. Somehow – probably related to the diet – I went four days or so without needing to go.

I eventually had to stop taking the Welbutrin because I wanted to keep waking hours to as much of a minimum as I could. And vaping wasn’t really on my mind. Which turned out to be a real upshot because the big thing that I was trying not to do was really kept out of a mind that was crowded with physical pain and preoccupation.It has really only started to hit me the last couple of days that I have been well enough to go back to it (but not wanting to). At this point, it’s a longer trip to go back and restart the habit than it is to plow forward.

One last side effect of all of this is that it has forced Lain into greater independence. As a matter of routine, I carry her to the car and from the car into the church for preschool. But since I couldn’t, I forced her to walk. She, in turn, has taken to asserting her independence more and more. When Clancy busted her kneecap, Lain was really quite scared of her. She’s a little bit older now, though, and seems to have adapted to my malady well. She was even fetching my cane while I was needing it.

As things presently stand, my back is in pretty good shape but my legs are as sore as they’ve been in a long time.

So, none of this has gone as I had planned, but it does seem to have gotten me over the hump. It has even helped with the diet as going to the kitchen and getting something to eat was suddenly an ordeal. My calorie intake dropped from 1800 to 1500 or so and I was in too much pain to be hungry.

There is no grand lesson here, other than that if you have an MD wife telling you to take it easy with the active video games, you should probably listen to her.

Unless you’re desperate to kick a habit.

Category: Home

‘Charging Bull’ sculptor says ‘Fearless Girl’ distorts his art. He’s fighting back. – The Washington Post

The project is about “girl power,” she said, a message to corporate boards on Wall Street with a dearth of women members “that we are here, that we are heard, that we are permanent.”

They also drew inspiration from Di Modica’s surprise installment, albeit with a permit, and dropped her off in the middle of the night. The girl quickly became an online sensation, earning praise from Chelsea Clinton and actress Jessica Chastain and drawing its own swarm of women and girls who felt inspired.

The plaque at the feet of “Fearless Girl” reads: “Know the power of women in leadership. SHE makes a difference.”

This overt reference to State Street’s SHE Index could contribute to Di Modica insistence that “Fearless Girl” is nothing more than marketing trickery orchestrated by the firm’s New York advertising partner, McCann.

“That is not a symbol!” the 76-year-old Sicilian immigrant told the New York Post and Market Watch in March.

New York City’s relationship with its bread and butter industry is really quite fascinating. It’s analogous in some ways to mining towns’ relationship with the mining industries that often don’t treat them well.

Of course, Wall Street does actually treat New York reasonably well, all things considered. Certainly better than Anaconda ever treated Montana, or Shell treats Louisiana. And in both places, when the chips are down, they know who butters their bread.

It was a really fascinating thing after Deepwater Horizon, when folks everywhere seemed to be saying that we must halt offshore drilling. Everywhere except Louisiana, which had paid the heftiest price for the disaster. To this day they have not forgiven BP. But still, drill baby drill.

They need it. The joy of being as relatively privileged as New York City is that they don’t. They can be wealthy and sanctimoniously resentful of its source.

Category: Newsroom

The inflection point occurred a couple months ago.

First, just a bit of background. My wife works at two hospitals, Stone County Hospital and Mills County Medical Center. She was hired primarily to work at Mills, but because there were three people doing a job that could (theoretically) be done by two, that meant that she had some hours to make up working at Stone. Also, when I refer to “hours” that’s not “hours worked” but rather “coverage hours” which means hours that the service is taking in patients. So if she is working 16 hours for patients that come in within a 12 hour span, she gets 12 hours. Also, she is expected to take phone consultation call on the evenings of the days that she works, so if she’s working 12 hours, she also has another 12 of phone consultation (or 14 if the shift is 10).

One of the three doctors at Mills County Medical Center resigned, which left Clancy and one colleague having to do the entire job. This is possible, but it also leaves no room for somebody getting sick or going on vacation. The problem for Clancy was that in addition to her duties at Mills, they were still giving her hours at Stone. This was in addition to the above-mentioned phone consultation and one night a week of full call (where she is expected to go in). So Clancy asked the person responsible for scheduling if she really needed to be working those hours at Stone.

In response, she got a really terse, somewhat condescending letter from a higher up outlining what he thought the hours were. She was expected to work 144 hours per four-week period (that’s 36 hours a week, the remaining four being sick/vacation/holiday), and she had 12 shifts of 8 hours at Mills and so needed to work three shifts of 12 hours at Stone to make 144. He went on to explain about how people who want their job have to work a minimum number of hours yadda yadda.

The problem was that his math was wrong. The shifts at Mills were 10 hours instead of 8 and there were 14 of them instead of 12. And on top of that, they were giving her four days at Stone rather than three. The result was 140 hours at Mills, plus another 48 at Stone, for a total of 188 hours that wasn’t including phone consultation or on-call. The latter of which being a particular sticking point because most doctors don’t have to do it because they can’t deliver babies. They did a whole thing of “Do you really want to be the kind of employee who is sitting there counting hours?” but at the end of the day her argument was pretty bulletproof.

So they stopped scheduling her at Stone. However, to “make up for it” they expanded the coverage hours at Mills from 10 to 12. That meant that she was back at 168 hours, plus phone consultation plus obstetrical call with no vacation, sick time, or holidays. Clancy agreed to it because she mostly just wanted to (a) stop working at Stone and (b) stop having 10 day work stretches.

Unfortunately, it simply proved to be too much for her. She got several consecutive weeks of above-average patient loads. On top of all that, her employer worked out something with another service that Clancy and her colleague would start taking some of their patients, too. Clancy has never been the fastest worker, and she just got overwhelmed with it. Last month we racked up $850 a month in hotel expenses because she would work until she was too tired to drive. Attempts on her part to streamline her efficiency were thwarted by the constant level of reaction that she was in. Being away from her daughter and living in hotels ate away at her, and she was still getting yelled at by her superiors for not having her paperwork done in a timely manner.

So this week, she submitted her resignation. Her contract is up for renewal in June and she will stay on until then. We’re not sure what comes after this. We probably won’t be relocating for a new job immediately. She will likely do some temp work to keep us afloat and work on trying to become more efficient at her next job, to work smarter instead of so long and so hard. And beyond that, to take the time to find the right job, instead of doing what we’ve been doing, which is kind of falling into the jobs she’s taken.

It is unlikely we will be staying in the area for more than a year or two. I’m going to miss some of the conveniences of living so close to the city, and I’m really going to miss this house. But fortunately we won’t have to uproot in the immediate future.

Category: Office

One of my New Years resolutions was tending to my health. Most particularly the vaping, the weight, and soft drink consumption. These are all interrelated. The vaping is not a health problem in itself (I believe), but it coincides with my soft drink consumption because I do them both together, and with weight insofar as vaping provides relief to overeating. This post is about the weight thing.

I had tried to vaguely “eat less” and eat more of the high-fiber cereal in the morning, but it really wasn’t working. What I decided instead was simply to start counting calories and see where I stood. I never got an accurate measure, however, due to the Hawthorn Effect. Once I knew it was being counted, I modified my behavior almost immediately. According to the calculator I basically need to stay under 2500 calories a day, but every day but one (out of ten or so) I’ve come in under 2000. Despite the fact that my rules explicitly state I can eat whatever I want.

What I’ve learned most immediately is when I was mindlessly eating. Like I’d get a piece of cheese of Lain and then I’d get one for myself since I was right there. I also managed to, without much effort, figure out where I could scale back when preparing a sandwich for example. I also found out which foods are good at filling me up without taking up much in the way of calories. That last one could backfire because eggs are one of the good filler foods, but progress is progress.

What I find most noteworthy about this is how consistent I’ve been. In all but a couple of days, I’ve eaten between 1800 and 1900 calories. That’s a pretty range, made more interesting by the fact that I had no target in that range. To the extent that I had a goal, it was going to be 2500. Now I am for below 2000 – but no rules – and I not getting all the way up to 1990 or anything. My body apparently needs 1800-1900 to function and to stave off hunger.

It actually makes me wonder if my pre-monitoring calculations were similarly reliable. If I was eating between 2800-3000 calories, somewhat reliably, day-after-day.

Category: Kitchen

Dr. X, a friend of Hitcoffee, has warned against what some mental health professionals call the Dark Triad. This triad is, to quote Dr. X, a “personality organization that comprises three psychological traits: psychopathy, narcissism and Machiavellianism.” People with that personality organization are dangerous. They are a problem that needs to be dealt with, especially if they are a coworker or in a position of responsibility.

What do we do with such people? In the comment thread to that post, Dr. X suggests that we fire them. To me, the obligation to fire implies that we shouldn’t hire in the first place. If the dark triadic person is not independently wealthy and yet can’t or shouldn’t be hired, how should he or she fend for themselves? Perhaps once properly identified–either through that person’s actions or through some sort of deep analysis–then we ought to consider civil commitment, or prison if justified. Or you can do the Philip K. Dick option: hunt down the androids and eliminate them. I reject that “solution” as does Dr. X and most (all?) others I”ve heard speak on it. But the terms of the discussion are consistent with certain conclusions.

Absent in the discussion on that thread and in the material Dr. X cites (or at least in the quoted portions of that material…I didn’t read the linked-to articles), is a discussion of whether this personality organization is just how or what someone is, or if it has a (personal) history. If people develop into that organization or develop out of it. Not to call this an illness–it’s not clear to me that the language of “personality organization” is a language about illness–but…is there a cure? Or are people just like that?

I’m obviously uncomfortable with the idea. Maybe it’s naivete or wishful thinking. If such people exist, then they exist whether I like it or not. If almost by definition such people don’t seek to change or improve or grow, then they don’t. Sometimes survival and defense of the common good are important. My wish that such people who would imperil either don’t exist doesn’t mean that they don’t.

These discussions remind me of the “mark of Cain” from Genesis. I thought it would be cool to incorporate an allusion to that story when talking about such people. But then I actually read the story, probably for the first time since I was a child. The story starts out as I remember. Cain kills Abel out of jealousy or envy or whatever. The Lord punishes him: “When you till the ground, it shall no longer yield its strength to you. A fugitive and a vagabond you shall be on the earth

But it doesn’t end there. Cain complains that it “will happen that anyone who finds me will kill me.” To that the Lord commands that “whoever kills Cain, vengeance shall be taken on him sevenfold.” And he sets a “mark” on Cain to warn people not to harm him.

I’m no expert in Biblical interpretations, and I imagine that that passage has been interpreted and reinterpreted through the ages. There’s also a point of unclarity. The referent “him” on whom vengeance is to be meted sevenfold strikes me as amphibolous, at least in the version I’m quoting: I assume the vengeance is to be meted against the one who would harm Cain, but perhaps Cain is the recipient of the vengeance?

Still, the “mark” of Cain seems on my uninformed reading to be the opposite of what I had thought. It strikes me as a mark of mercy, or perhaps mercy tempered by a warning. People are not expressly forbidden to be wary of him or to stop him from further crimes, but they are forbidden to harm him.

Again, there may be other ways to interpret that story, and one might legitimately question whether that story ought to be a guide to anything. But that story exists and I can’t shake it, just like I can’t shake the possibility that dark triadic persons exist.

Rabbi Michael Lerner warns against psychoanalyzing/diagnosing Mr. Trump (or any political leader, for that matter), especially when such psychoanalysis is intended as a tool for opposition. He points out that it’s questionable to diagnose people without working with them for a long time in a therapeutic setting. Rather, he says, one should focus on actions instead of on the internal demons of one’s opponent. (Mr. Lerner lists other reasons as well. Read the whole thing.)

I’m inclined to agree. I get very uneasy when I read of a psychotherapist or other mental health professional diagnose a politician with a disorder.

Occam’s Razor can do some good here. If Mr. Trump is unstable, erratic, or unpredictable, his actions by themselves speak to how much we can trust him or how competent he is. Whether the diagnosis is right or wrong, we don’t need it.

Or mostly we don’t. Mr. Lerner’s warning is an “editorial note” to another piece, “Trump as Narcissist,” by Michael Brenner, also found at the above link.* Brenner makes several arguments that stand or fall on their own. But his key point is that Mr. Trump is a narcissist and we cannot expect the demands and incentives of the presidency to tame his narcissism.

That argument is marginally informed by whether Mr. Trump really and truly suffers from narcissism. If he does, there’s less hope that he’ll mature and grow into the presidency. If he doesn’t, there’s slightly more hope. And if a 25th amendment solution is at all in the offing, then maybe psychological unfitness is a way to invoke that process. (At the same time, I’m not sure we really want to invoke that process, and I am especially wary of admitting to that end testimony from mental health professionals who have not even met with Mr. Trump personally.) So…maybe diagnoses of the sort Mr. Brenner offers do some good after all.

But the argument that Mr. Trump will grow into the presidency doesn’t rely only on the proposition that he’ll become a better person. It also relies on the claim that our system of checks and balances might actually work and that the federal bureaucracy will do what bureaucracies do and somehow condition what Mr. Trump can accomplish. We may of course doubt whether any of this will happen or if it does, whether we’ll welcome what the country would look like afterward. (For example, I’m glad that Michael Flynn has quit the National Security Agency, but I also share Noah Millman’s concerns about the intelligence leaks that seem to have prompted his ouster.)

And for the record, I don’t believe there’s something epistemologically magical about the “months, or sometimes years” of working with a client that Mr. Lerner says is necessary to determine if a person suffers from a disorder. I acknowledge that the the diagnoser probably has to always base his or her decision on incomplete information. So maybe it’s not entirely fair for me to claim the public diagnoses lack sufficient information.

That acknowledgement, however, doesn’t change my mind that such health professionals are acting unprofessionally and to a certain extent dangerously in their public diagnoses. They’re contributing to a discourse in which mental illness is seen as something shameful or to be feared. To my mind they’re weaponizing techniques that originally were meant to help or at least understand people.

Such is not their intention, and it’s not everything that they’re doing. Some mental disorders and perhaps even “personality organizations” ought to disqualify a person from certain positions of responsibility, among them the presidency. When an apt case presents itself, then maybe these mental health professionals are doing a service in highlighting it. And as even Mr. Lerner notes, there is something to be said for noting certain “styles” of politics and cultural expression. He cites Christopher Lasch’s study of the American “culture of narcissism, and I could cite Richard Hofstadter’s essay on the “paranoid style” of American politics.

Maybe there’s no “pure” approach. Maybe some harm has to be done for a greater good. I will probably not convince these mental health professionals otherwise. But I urge them to at least acknowledge and more forthrightly address the dangers of what they’re doing.

*If you read Tikkun Olam a lot, you’ll find that Mr. Lerner often attaches editorial comments to essays he publishes but disagrees with.

Category: Hospital, Statehouse

For Linky Friday, I had an item about the c-section rate and whether it may promote evolution towards big heads. In the comments, Kristin Devine linked to this article, about c-section rates:

Experts say that even total C-section rates—which include cesareans for all births, not just the low-risk ones we focused on—should rarely be high. “Once cesarean rates get well above the 20s and into the 30s, there’s probably a lot of non-medically indicated cesareans being done,” says Aaron B. Caughey, M.D., chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine in Portland and a lead author of the new ACOG/SMFM recommendations. “That’s not good medicine,” he says.

When asked to explain their high C-section rates, hospitals offered several responses.

Mark Rabson, corporate director of public affairs at Jersey City Medical Center, described how his hospital, which serves “a diverse metropolitan area with many socio-economic issues,” was working to lower C-section rates by, for example, reviewing the care of all providers whose cesarean rates are above 30 percent and offering them assistance in how they manage patients during labor. In addition, he says the hospital is now using midwives, healthcare professionals trained to avoid intervening in childbirth unless medically necessary, and people fluent in multiple languages to educate patients about cesareans.

Patricia Villa, a spokeswoman for Hialeah Hospital, told us “while there are many factors that impact a woman’s decision to have a cesarean section, we are focused on driving improvement in this area.” She also noted that the hospital had been recognized by the March of Dimes for it’s efforts to prevent elective early deliveries before 39 weeks.

Most people know that hospitals and obstetricians have incentives towards c-sections, but it’s hard to fully appreciate just how many incentives there are unless you see it at work (or, like me, hear regular testimony). The fact that the hospitals get more money is only a part of the equation. The time physicians get back isn’t just for playing golf. When Clancy was in Arapaho, she was regularly faced with one of two options. She could hover over a mother all night, extracting all sorts of costly resources from the hospital along the way. She would be staying there, not seeing her daughter or her husband and not getting much goodsleep. She wouldn’t be generating any other revenue while there because she has to be on stand-by. If she delivered the baby before 6am, she would then finish her paperwork, get maybe an hour of rest, and spend the next day seeing clinic patients. If it is after 6am, then she gets the morning off. Which allows her to get some sleep, but forces patients to reschedule and means less revenue for the hospital/clinic. Alternately, she could reach for the scalpel at 8pm be done with everything before 9, come home, get rest, see all of her patients the next day. And, if she cares, make more money for the hospital and possibly herself (through bonus structures) or at least have better efficiency numbers when it came time for the performance review.

My wife is the type of person to hold the line. I’m frankly not sure that I wouldn’t find some sort of way to rationalize interventions.

But while people know about that aspect of it, and probably know that a lot of women pressure their obstetricians for c-sections, that’s really only a part of the equation. The other part involves decisions that the OB makes well prior to the c-section decision. Intervention begets intervention. If a woman gets an appointment for induced labor, a future c-section becomes more likely. If she gets an epidural, a c-section becomes more likely. If labor is sped along through other interventions, c-sections become more likely. Why? Well, as best as I can figure, the more that a hospital intervenes, the less control the body has over the process. So even if two physicians have the exact same philosophy towards c-sections specifically, their philosophy on earlier interventions may lead to different c-section rates. And a woman’s chances of getting a c-section may depend not just on the obstetrician or the hospital, but the specific anesthesiologist on duty and how aggressive their philosophy is.

In the map on Kristin’s article, you notice that a lot of rural states have lower c-section rates. That’s at least part of why. Clancy’s employer in Arapaho didn’t even offer epidurals. The less resources, the less earlier intervention. The less earlier intervention, the less likely a c-section is to become necessary in the first place. My wife’s c-section rate isn’t just low because she views it as the Option of Last Resort, but because she’s not an interventionist generally (in obstetrics and elsewhere).

So it’s not just a question of whether a c-section is medically necessary, but also whether it becomes medically necessary along the way. Both of these things are going to depend on a lot of things like obstetrician philosophy, hospital policy, resources, other personnel, and (as important as anything else) patient philosophy. Whether they want an epidural has a cultural context, and that’s going to vary from place to place. Whether a woman will be the only person she knows that had a c-section, or whether she’s been told that’s the way to go. Whether she lives in a place where people read Mother Jones, or Newsweek.

Right now we live in a culture where, in addition to all sorts of other incentives, c-sections are normal and giving birth on hands and knees or underwater is considered weird and unnatural. Because intervention begets intervention (both psychologically and medically), and our health care system is an interventionist one from top to bottom, I am skeptical that we’re going to see change any time soon.

Category: Hospital


Last week I posted an Linkage Over There about a superbowl Audi ad:

Well, if you’ve been reading along, I think you’ve figured out what the real message of this Audi advertisement is, but just in case you’ve been napping I will spell it out for you: Money and breeding always beat poor white trash. Those other kids in the race, from the overweight boys to the hick who actually had an American flag helmet to the stripper-glitter girl? They never had a chance. They’re losers and they always will be, just like their loser parents. Audi is the choice of the winners in today’s economy, the smooth talkers who say all the right things in all the right meetings and are promoted up the chain because they are tall (yes, that makes a difference) and handsome without being overly masculine or threatening-looking.

At the end of this race, it’s left to the Morlocks to clean the place up and pack the derby cars into their trashy pickup trucks, while the beautiful people stride off into the California sun, the natural and carefree winners of life’s lottery. Audi is explicitly suggesting that choosing their product will identify you as one of the chosen few. I find it personally offensive. As an owner of one of the first 2009-model-year Audi S5s to set tire on American soil, yet also as an ugly, ill-favored child who endured a scrappy Midwestern upbringing, I find it much easier to identify with the angry-faced fat kids in their home-built specials or the boy with the Captain America helmet.

While some dismissed this characterization, I thought it was rather spot-on. If this were a Chevy or a Nissan ad, I might think that some of the characterizations are happenstance, but this is an Audi ad. That means class is not incidental, but rather core, to the product. So we can likely assume anything involving class in the ad is likely intentional. And in this case, it did so in a rather politically skewed direction.

This ad was clearly conceived when it looked like Hillary Clinton was going to be the first female president. And in the run-up to the ad, Audi did a publicity blitz about its commitment to gender equality (hehe, hehe). It was aimed squarely at a particular segment of its clientele. But before we get too much into that, let’s talk about wine and cheese. For a few months, my Twitter feed contained this ad:

There is some really intense social and class signaling going on in that ad. I mean, let’s count the ways: Name-checking the most exclusive university in the country, science!, whiteboard with code, Apple computer, elegant geek girl. It really has it all and it just screams New White Collar through and through. Which, if they’re selling a cultural service like wine, is a pretty good pitch! They know their likely audience. Being close to that audience myself, I actually think it’s pretty well done. Maybe a bit overkill, but I only have one foot in that pond.

Now, the Audi ad goes for a slightly different set. Older and wealthier. More likely for their to be a family involved. As the article says, the protagonist isn’t the girl so much as the dad. The dad with the girl to be proud of. The dad who is on the Right Side of History. The dad who doesn’t need an Audi to be good, but is good and Audi is good and let’s get together. The characterization of The Other is probably a necessary component to that because goodness needs something to be compared to. Something a little grubby and unclean. The ad, as a whole, makes its pitch by equating vanity for virtue. It’s not toxic to conservatives, but to the extent that it appeals to conservative it’s going to be the squishes, the #NeverTrump sort, and those whose sensibilities align with left at least in terms of cultural cues.

Now, lest anybody think I am wanting to pick on one side, it’s not hard to come up with an idea of something similar aimed at conservatives would look like. Even if we’re looking an ad seeking to confuse vanity and virtue – or is it vulgarity and virtue – for the well-to-do right. We don’t even need to leave the auto market. Or the luxury auto market. Or the Superbowl.

A visceral yell. A combination of individualism and group (patriotic so it’s okay) achievement. My accomplishments are mine, your accomplishments are ours. It speaks to some less savory impulses in the same way the Audi ad does. Get this because you’ve earned it. Hard work! While the Audi focuses on a degree of innate you-are-evolved goodness, this one focuses on work and achievement. Which sounds good, if you kind of glide past the part where his achievements are his and others’ achievements are ours. But go America! This struck a positive chord with the people it was meant to, and a negative chord for others.

But just as you know the dad in the Audi ad didn’t vote for Trump, you’re pretty sure this guy did. This guy is, more or less, what I think of when I pass by the house of the guy that had the Trump flag in his yard. Really nice house. Obviously, the person was well off. Given that they put a flag in their yard, along with a Gadsden, suggests that he probably supported Trump throughout. That house has (surprise surprise) a full-size pickup in the driveway. Which is kind of on the opposite end of the spectrum as the electric car this guy is pitching.

Which is actually sort of the point. If the Audi ad is telling a well-to-do liberal that it’s okay to have a car that only rich people can afford because you’re good, this ad was telling future Trumpers that it’s okay to have an electric car because it indicates hard work and you work hard because you’re an American.

Category: Market


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