There's an article in The New York Times which discusses therapy with very wealthy clients. The thrust of the piece is on the difficulties these clients face, as well as specific challenges for the therapists who are treating them. What struck me as fascinating, however, was the fact that one of the treatment providers in the article charges $600 per session. Yes you read that correctly: two $300 bills. Or you could give him $10,000 and get $9400 in change. I have never heard of such a rate for therapy and my take on this is that his clients are simply foolish for paying it.

In New York City and many parts of the United States there is a discrepancy in cost for therapy in a private practice based on the discipline of the provider. From what I've seen Social Workers tend to charge less than Psychologists, who usually get somewhere between $125 and $225 per session. A Psychiatrist friend of mine charges about $275 and stated that's mainly because she can prescribe and manage any necessary medications. There's probably some elitism involved in that as well but that's not important right now. I've heard of some Psychiatrists charging upwards of $400 per session and recently as much as $500 but this new benchmark of $600 blows me away, especially given that there's no mention of medication management involved.

Here's the rub: I've discussed the perils of choosing a therapist based on degree or years of experience. People constantly make that mistake: he went to so and so school or has been in practice 30 years, so even though he's pricey he must be the best. Unless I've missed some new research on this topic there isn't substantial evidence to support the "you get what you pay for" philosophy. My postdoctoral training was at an Ivy League hospital. While outstanding in its own way, it wasn't really any better than the tiny community mental health center in Smalltown, Ohio where I trained as a graduate student. The human condition is so complex and constantly evolving and no one person or institution has all the answers. Therapy will never be an exact science and therefore there will never be the perfect textbook or teacher or school that will create the Ultimate Therapist who puts his hand on your head and cures you of any and every ill.

What is this shrink saying for 45 minutes that could possibly be worth $600? "Your mother is the sole cause of your neurosis. You have both my ethical and legal permission to kill her." I suppose that might be worth a lot. Is he reciting words of wisdom off of some diamond-studded scroll from the mountain tops with bolts of lightning crashing down to punctuate how profound his statements are? Does he hold the secrets to world peace and immortality? Does he offer a Happy Ending to the clients who are into that stuff?

I suspect that he's charging this rate simply because he can. His wealthy clients will believe that he's worth it because he's so expensive. They'll tell their other rich friends that's he's "the best." And if they can afford it good for them. But the reality is that Altoids don't taste any better if you pay $59 per tin.

If anyone has $600 laying around, let me know and I'll contact this guy about doing a 45-minute interview for the site. I've been cranky for the past few days so maybe he can fix that as well while he's here.

Recently a Psychologist came in to my office for treatment. He was a late 40's gentleman who had been diagnosed with Bipolar Disorder. While medicine is generally a first-line approach, treatment is often augmented with Cognitive-Behavioral therapy to help decrease impulsivity and irritability as well as helping clients to manage mood swings.

For me working with colleagues is generally a positive experience. We share a common bond because we've been through the same years of training and share a similar mindset about people and their problems. Clients who are shrinks themselves know the lingo; they know the format. It usually flows well. Many theorists believe that psychotherapy has an inherent power differential that isn't always comfortable: I am the expert, you are not. I am healthy, you are sick. My life is exactly the way I want it to be, yours is not. If you've read more than two words of this site you know that thought process is skewed, but many people enter a therapeutic relationship with this dynamic intact. I make every attempt to minimize this power differential by making therapy a collaborative relationship where we each share thoughts and ideas. Doing this with colleagues is often quite easy.

Conversely, the potential problem for me with a "pro to pro" relationship is a certain, self-induced pressure. Does she know more about therapy than I do? What if I make a mistake? Will she call me out on it? Is his practice more successful than mine? His Armani suit is much nicer than my Banana Republic khakis and Gap button-down polo shirt. I'll bet he makes more money. He's wearing a ring too...why is he married and I'm old and alone??

Another difficulty is the inherent strangeness that often comes with two shrinks interacting. Because mental health people tend to be highly analytical, bizarre moments of circular logic can develop:

Dr. Rob: So you can see, then, how this type of thinking is leading to your negative mood?

Dr. Non-Rob: Hmm...interesting. That's not how I would have handled it though.

Dr. Rob: How would you have handled it?

Dr. Non-Rob: I'd probably have asked about the origins of this type of thinking. Did it come from my mother?

Dr. Rob: Did it?

Dr. Non-Rob: Did it what?

Dr. Rob: Come from your mother?

Dr. Non-Rob: I don't know. I think if you had asked me earlier my answer might have been more spontaneous and emotional.

Dr. Rob: Would you like me to ask you that now?

Dr. Non-Rob: I'm not sure. Do you think that's the best course of action?

Dr. Rob: No, otherwise I would have asked you that to begin with.

And so on.

The Psychologist with Bipolar Disorder and I used the first appointment to design a possible treatment plan. When the time was up I asked him if he would like to return for another appointment. "Oh yes, absolutely," he said. "I just need to check my schedule so can I call you?"

"Of course. Here is your receipt. Will you be paying by check for this session?"

"Oh...could I just pay you next time?"

This isn't unheard of as some clients assume that I will bill them at a later date. However, most Psychologists know that the most common approach is to "pay as you go." I looked at him a bit suspiciously.

"I suppose so. As a general rule I prefer if clients pay for their sessions as they occur because I'm a solo practitioner and don't have an elaborate billing system. But I probably didn't explain that over the phone, so it's fine."

"Great. I'll be in touch to set up something."

A week went by and I didn't hear from the Psychologist. After about ten days I called him to find out if he was still interested in working together. If he wasn't then I'd close his chart. I left a message on his voicemail.

After another week I called again. Voicemail. A few days later I mailed him a bill. No response. Another phone call followed, but this one had more edge. "Dr. ___________, please return my call as soon as possible to resolve your bill for the therapeutic services that were delivered." Those are pretty intimidating words so I assumed that I would hear from him immediately.

No return call. The proper clinical term for this is "being screwed over."

More harassing phone calls, collection agencies, small claims court. All of these are options that practitioners take to obtain payment for services rendered. I haven't decided if I will pursue any of these or simply let it go. Regardless of the outcome, however, I feel betrayed. Other shrinks are supposed to know what it's like. They are supposed to know how hard it can be to build a practice, to have to deal with clients who are demanding or unappreciative or complain about fees or refuse to pay you if they don't like something you say. They're supposed to know that you're not rich simply because your name starts with "Dr." And they're definitely not supposed to take advantage of you. Apparently, though, some do. And that's just wrong.

Below is a video of a psychiatric patient dying on the floor of a New York City hospital. Over the course of many hours she ignored by two security guards, but what isn't shown here is that she is also kicked by a nurse (apparently to detect if the patient was alive) and neglected by a physician.

The mentally ill are often talked-down to and generally are treated as second-class citizens. During my graduate training I had some experience in psychiatric wards and the patients were often ignored or infantilized by the medical staff. This phenomenon was empirically demonstrated in 1973 by D. L. Rosenhan, whose study had people pretending to be patients in a psychiatric hospital. They approached staff members with questions like "Could you tell me when I will be eligible for grounds privileges?" or "When will my case be presented at Grand Rounds?" 71% of the time the psychiatrists (these are doctors, mind you) simply looked away and walked past. Only 4% of the time did they stop to talk to the people.

35-year-old studies are often not valid to highlight current psychological principles. After watching this video, however, the results seem more relevant than ever. If people want to make the argument that patients can be very demanding and need boundaries and limits, that's all well and good. However, the fact remains that this woman died at the very hospital where she was being treated, and multiple members of the staff watched it and did nothing.

To say that this disgusts me is an understatement. I bash shrinks all the time for being neurotic and weird and elitist and all sorts of other negative shit. I didn't know I should consider some of them to be soulless as well.

It's no secret that many staff workers at psychiatric hospitals are both overworked and underpaid, which often is an underlying cause of poor interpersonal contact and the delivery of therapeutic services. But what occurred in this video is simply inexcusable. And so the staff is fired according to news report. That's it? Does this "doctor" get to keep his license? If so I hope he ends up treating the very people who decided that he can continue to practice medicine.

I don't see a silver lining in this, save for the fact that perhaps people will give some more thought to the idea that the mentally ill are just as significant as the rest of us. But if this is what it takes to make people think, then I'm embarrassed to be part of the mental health community.

For as long as I can remember I have wanted to make people laugh. As a young boy I asked my mother "what's the key to having a good sense of humor?"

"Being able to have a laugh at yourself," she said. "Without being able to poke fun at yourself you'll never have a great sense of humor. You're also a tremendous disappointment to your father and I so please leave me alone."

She was right about that. The sense of humor part that is. And as a pseudo-young, Caucasian male it's important to have a lighthearted view of myself and my fellow white people.

To that end we have with us today Christian Lander, author of the popular website StuffWhitePeopleLike.com and soon-to-be best-selling book. Mr. Lander joins us to discuss the subtle yet complex intricacies of the psychology of being a white person.

Your new book is an investigative guide into the Caucasian being. Can you give us a glimpse into the 'Psychology of Whiteness' that you describe in your work?

It's hard to provide a glimpse using only words. I think the best way to do it is to watch an Obama rally and really observe the people. Failing that, a trip to a Farmer's Market or San Francisco will do more to delve into the psychology of white people than my words ever could.

I'm often told that I'm "pretty fly for a white guy." I believe this is a compliment and thus it pleases me but what exactly does it mean?

Though some would say it means that white people can only achieve a basic level of 'fly,' it actually is a person telling you that they enjoy Offspring. It could be your key into future friendships or relationships with that white person.

I know white people who are constantly liking things. Just the other day my good friend Dr. Allison said to me, "I'd like you to please go away. You're annoying." Do white people ever stop or is this just an endless cycle of pathological liking? In fact is there anything white people don't like?

White people do not like non-organic food, low property values, sending their children to public schools, and many more things. White people also like to use the word 'like' because love is too strong a word, and "like" reminds them of middle school relationships.

It's no secret that white people love etiquette. Let's suppose that a white person, after a long day of shopping at IKEA, visits a local Starbucks. But rather than simply order a Vente Latte the white person also wants Altoids. Because those are strategically placed next to the Celine Dion CD's the white person naturally buys one to hear her mellifluous, Canadian voice. The total is $20.14. Having just come from the Chase ATM, however, the white person only has $20 bills. Is it acceptable to pay the sum with two of these bills or does the white person have an obligation to buy a copy of Tuesdays with Morrie to bring the total to a more reasonable $35.60?

Ha! Trick question! As I point out in the book, white people do not carry cash! This would be easily put on their Amazon Visa and they would collect essential reward points. Also, advanced level white people would never buy anything by Mitch Albom.

One of the things I, a white person, truly like is wine. However I prefer red wine as opposed to white. Is there some strange psychological irony at play here or am I reading too much into it?

Many white people associate white wine with white trash, while they associate red wine with France and Italy (two very desirable things!).

So true, France and Italy are pretty great. Now we all know that white people love music and are probably the most knowledgeable about the subject. The question I pose to you is who is the rockingest of all the hard-core rockers out there: Dave Matthews or John Mayer?

This is tough because both artists are so beloved by "the wrong kind" of white people. The truthful answer is that the best, hardest rocking band is the one that I have heard of but you haven't.

Most of us are aware of the acute oppression that the white person has suffered over the centuries. When will the day come that a white individual can simply enjoy his ascot, brunch or Gap Gift Card without fear of reprisal?

The problem is that the reprisal and hatred come from within. So white people will only escape their oppression when there are no more white people.

As a white person I enjoy a good roasting of my peeps. Why do you suppose people are able to make fun of their own race, color or creed without being labeled "racist?" And is there a message that white supremacists should take from your lampooning of white people?

I suppose you can go after your own race since you've earned credibility by being born into it. As for white supremacists, I suppose they could learn how to infiltrate the white society that they hate so much and then I guess destroy it from the inside. Although, in my experience with white supremacists (limited), they have not been particularly crafty.

Christian, thanks for joining me today to embrace our whiteness. This is great stuff. I'd like to take you out for a ride now in my brand new Volkswagon Jetta as a show of gratitude.

Part 1 Part 2 Part 3

My time in this group was preset from the day I walked through the agency's door. September to May. And when May came, I didn't like the idea of leaving. After such an unusual and intense training experience the thought of going back to doing research on projective tests wasn't overly appealing. With the group it felt like I was doing real work but more importantly, I knew that I would miss a lot of the women there.

Shrinks who say they love or even like all their clients are either delusional or lying. Not everyone who comes into therapy is likable and often their psychological problems can make them very difficult to deal with. Other times people are just disagreeable and make no mistake that the reverse is true as well: no shrink is going to be a perfect fit for every client and certain clients will actively dislike their therapists. That being said I was fortunate in this particular situation because I did like many of the women there and the feeling appeared to be mutual.

Even though our support group wasn't a formal therapy setting, many of the women improved to the point that they didn't need the group anymore (assuming their significant others were no longer in treatment). Others reported that they would stay in the group for as long as it existed, that they always took something new from what the members had to say. I believe that some of the women saw themselves as role models for new members and relished the opportunity to serve as a sponsor of sorts for new participants.

For the last group I had a small speech planned: review what we learned together, tell them how proud I am of them, never stop growing, rah rah rah! I've never successfully delivered a pre-determined speech and I knew this would be no exception so I scrapped it before group and decided to let the final session flow organically.

My supervisor had some charts and notes for me to sign before I left the agency for the last time so I took care of all that before group began. I arrived a few minutes late to find the women already there talking up a storm.

"He did what? That's horrible."

"He should be lynched for that."

"String him up by his balls!"

"Hi ladies," I said. "I think I'm missing an interesting conversation here."

"Jill's husband was late for their anniversary dinner. Being late...is something we don't tolerate around here," Anne winked.

"Ah, my supervisor warned me about negative reactions toward me. This is because I'm a man?"

"Yep. You're all the same," Jill said.

"Fortunately not everyone is like our men," Anne said with a small frown.

"No, not everyone is like that," I said. "You all have a very unique situation."

We talked about this notion of 'being different.' Some women challenged the idea, stating that plenty of people have family members who are murderers, thieves, rapists, or even a combination of those things. "No one has a perfect family," one woman asserted. "People are messed up, they do messed up things. Sometimes really messed up things. Do you know how many thousands upon thousands of people are in prison? Well those people have families. That's us."

Others held fast to the idea that the lives of the women in this group weren't like anyone else's. "I don't know anyone who is married to a Pedophile," said Ann. "I know these people exist but when I picture them they're just hypothetical figures, blank faces on generic bodies. So it's only here that I feel I'm with my own kind."

"That's why I'm here and I'll probably never leave. Because we're different." Jill said. "However, this one," she said pointing at me, "is leaving us," and smiled.

I couldn't help but think there wasn't at least some resentment behind that.

"Yes, as we had discussed, today is the day." I said. "I'd like to ask each of you how you feel about this."

"And are you going to share as well?" one woman asked.

"Absolutely."

Jill spoke. "I have mixed feelings about this. Our last two group leaders were women so this is a new experience for me." She paused and looked down into her lap. "I'm happy for you in some ways. You've taken another step toward getting your Ph.D. You probably learned a lot between working with us and our partners. And you were helpful and I'm grateful for that."

"Thank you," I said.

"But part of me is very jealous. You get to leave here and when you do your life is your own. We have to stay the 'significant others of the sex offenders' and you don't have to carry that burden. I resent that and I feel that you're abandoning us."

We had spent a small number of sessions talking about how the women might feel about me leaving. This is always good clinical practice but not always easy to implement, especially in groups. The members have crises and problems to attend to and not everyone is comfortable sharing thoughts about their group leader. So this was our first foray into deep feelings about...termination.

"Do other people feel this way?" I asked.

One woman nodded and then Ann spoke. "I feel abandoned but I don't resent you or feel jealous. I'll just miss you."

"I wouldn't blame anyone for feeling resentful or abandoned," I said. "This is how the system works and unfortunately people come and go through this revolving door that is our lives." Revolving door that is our lives? Christ, you are walking cliché.

"I want you to know," I continued, "that I will miss this group terribly. You've all been through a lot and those of you sitting here decided to fight back against your problems. Even if that meant leaving your spouse you didn't bail and hide under a rock. You sat here, week after week, and worked through the feelings. I'd like to think I was a part of that process. I didn't always agree with your decisions but to say I respect you for your work is an understatement."

"Well we respect you too, soon-to-be Dr. Rob" said Ann. "And I'll bet you'll make a lady very happy someday with all of the knowledge about sex you learned from our discussions."

At the end of the session the ladies gave me a card. It had just a tree on the front. Inside it had all of their signatures scattered about and, in the middle, it said:

Stay Warm
Stay Safe
And for God's Sake Stay Legal!

They all laughed and smiled as I read the card aloud and I gave a perfunctory smile. Even though the women knew I was not flawless, Freud might have said that, in addition to using humor to protect against psychological pain, the last line was a warning to not shatter the positive image they had of me. This isn't unheard of in therapy where clients will give admonishments and pieces of advice that underneath the surface are really saying "Please don't change, don't become something bad. I need you to stay exactly who you are!"

And just like that it was over. Some women gave me a hug good-bye, others simply waved as they walked out. The next week a new intern would be in my spot, doing my job and forming a relationship with the women. My women. I was jealous that someone else was going to be helping them going forward.

That was my first experience with the "loss" involved in a therapeutic relationship, at least of one that had some significant time behind it. Even today this part of the job doesn't get much easier. The best therapy relationships are the ones that are hard to let go of, even when you're ecstatic for the person who has made the gains they sought out.

I left the agency that night and met up with my fellow students, many of whom had finished their internships as well. We were that much closer to graduation. One year to go. We drank beer and wine and partied to start the summer off right. I even got the phone number of a woman I had my eye on at the bar. But for a few weeks after the group ended I had a nagging feeling that I can only describe as grief. All of us grew as people because of our experiences together but I still lost them and they lost me. I eventually got past that feeling and moved on to other groups and other therapy relationships - the woman who gave me her number never returned my call, but let's not get into that right now - but the women were never forgotten.

Dr. Rob,

My best friend is a therapist and I talk to her about my problems with men. She often has helpful things to say but sometimes she'll say I have "deep-seated" issues regarding my father and the men I choose to be with. She thinks that I should seek professional help. She says that because she and I are friends she doesn't want to do therapy on me. But she's not really acting as my therapist, is she?

Jill

I have a fair number of friends who ask me for advice or to just sit and listen to them so I can relate to your friend's ideas. One of my friends created a list of "100 Reasons why I Hate my Mother" and asked me for feedback on it. Some of them were quite valid (e.g., She disowned me when I married a Jewish man); others not so much (e.g., She wears Crocs). But I digress. The issue is when, if ever, do shrinks cross the line from acting as a good friend to that of doing therapy? This is a really tough call without a clear answer.

The standard rule is you cannot engage in a formal therapeutic relationship with friends, family members, past or future sexual partners and pretty much anyone you know personally. The question then is what does formal mean? If a friend comes to the office, spends 45 minutes discussing and working on a psychological problem, then pays for the session -- that would qualify as formal. But does calling a friend and asking for advice on men, while this friend happens to be a mental health professional, qualify as a formal relationship? Probably not but the lines start to get blurred. Part of the problem is that therapy is, in the most basic sense, just a conversation. As I've mentioned before it's very difficult to completely turn-off your therapy mind when talking about problems. If you know something that might be helpful, do you withhold it simply because you're a therapist?

As an example of a blurred boundary between helping a friend and acting as a shrink, consider Dr. Pete's Social Phobia. His music therapy had not been helping so Dr. John decided to stage his own intervention and convinced Pete to let him help out. John arranged to do Exposure Therapy which is probably a better choice for Social Phobia anyway. This is a behavioral therapy approach that is predicated on the notion that if one can be in the presence of an aversive stimulus (in Pete's case, people) for enough time and talk through the anxiety-producing thoughts, the anxiety will subside. In other words Pete's anxiety is a false alarm: he meets people and his mind and body assume that he is in a threatening situation. So dragging Pete to a loud bar with lots of people, while extremely anxiety-provoking, can ironically be therapeutic if Pete can just sit there long enough to let his anxiety ebb and flow and ultimately dissipate. The thinking is that the false alarm will learn to correct itself when the person's mind and body realize that there isn't any inherent danger being in the presence of others. Most of the time this treatment takes more than one session but occasionally very positive results can be seen quickly.

Many people would help a friend overcome an anxious situation, quite possibly by spending time with him in bars and trying to talk down his anxiety. Does the fact Dr. John is a shrink make this intervention inappropriate? I would say no (although Pete could have easily gone to see an expert in Social Phobia for this) but others might argue otherwise, stating that because John and Pete are friends, John's objectivity is compromised. As a side-note on the efficacy of John's work, he started drinking pretty heavily upon arriving at the bar and began hitting on every woman there. Nine single-malt scotches later John was virtually passed out on his barstool and Pete was still a nervous wreck from having no one to talk through his thoughts and feelings. So much for objectivity.

Maybe your friend has a valid reason for suggesting you see a therapist. I don't like to throw around the term "deep-seated" too freely but if this is recurring problem maybe you could benefit from a professional voice that isn't emotionally connected to you and is worried about your friendship being compromised. Or just stop dating altogether and be done with it. While shrinks are a strange bunch they do usually have a good intuition when someone needs more than just a friend's ear. Except maybe Dr. John because he's always drunk.

So what have we learned today:

1) As usual I have no definitive answers to the questions that come in. And I wonder why no one listens to me when I have something important to say.

2) Don't overtax your friends who happen to be shrinks.

3) Stay away from Crocs if you want your kids to like you.

You'll never find a site with gems of wisdom like that. It simply doesn't exist.

To read Part 1 click here, to read part two click here.

The group met in a large conference room at the mental health center. It was empty save for the large table that could have easily sat 25 people. Because we had less than one third of that we scattered around the table, maybe to make the group seem larger which would magically mean that even more people struggled from the same troubles. I always got to the room first and sat at the head of the table to establish my faux-authority as the group leader. Most of the ladies would come in one at a time, except for a few veteran members who had become friends and arrived together. Most women always had at least a perfunctory smile and no visible distress. Some came in with cups of coffee, others with bottled water and one woman even brought in cupcakes for the group. Sometimes I thought we were about to begin book club rather than talk about sex offending. In retrospect I think the women arrived still holding on to the façade they showed to the outside world: strong, put together, functional. Some women maintained that stance throughout their time in group. "I want to be in control and I'm going to fake it 'til I make it."

Lengthy introductions were not required at each meeting. Instead people just went around the room and gave their first name as a reminder to the other members. Even though my self-loathing anxiety had dissipated I generally managed to flub even the simplest of introductions. "I'm Roberr. I mean Robert. Just Rob is fine. I'm the leader. Or facilitator. Whichever you prefer. Let's go with facilitator."

When a new member came to group each person gave a more detailed account of who she was and why she was here but only if she so chose. The new member was then asked to say hello and share whatever information she would like.

"My name is Ann. I'm...not sure why I even need to be here. My husband is...well he did bad things to our neighbor's daughter. He spent some time in jail and now he's home and getting...help here. She became teary-eyed. "I just can't believe this has happened. My husband is a convicted sex offender. Just saying that makes me sick to my stomach. I feel horrible for the girl he did this too and I'm so embarrassed. I don't even know what to say to her family."

She cried for a few moments and a group member reached for a tissue to give to her. "NO!" shouted a woman named Jill, a seasoned member of the group.

"What? Why not?"

"You're interrupting the healing process," she said.

Jill was right. Crying can be a form of processing, a way to make sense of everything that is happening. Most people become uncomfortable watching someone cry and will try to comfort the person in distress. By doing so they also control their own discomfort. However it is important to let this process take its course in this setting.

Ann sniffled and said, "No no, it's okay. I'm alright. This is just...hard. So hard."

"It is hard," Jill said. "We understand that here."

Many groups have their own leader outside of the facilitator. Someone tends to assume the Alpha role. When not self-serving or narcissistic it can be a good thing because this person can serve as a hybrid of a therapist and client, where words of wisdom come from someone who has truly experienced what the group is going through. Jill was that person and, while sometimes a bit rough, brought her own therapeutic element to the room.

After new members introduced themselves I reviewed the goals of the group.

"Our job here is to support each other as you work through a very difficult situation. Only you know how you feel about everything that has happened to you but hopefully the people here can use their experiences to help you make good choices and feel better about everything that has occurred. In this room no emotions are inappropriate. I hope that you will feel comfortable to share anything that is bothering you with fear of embarrassment or shame. The members of this group ideally care for each other and it's our mission to help everyone get to a better place."

Ann raised her hand.

"Yes?"

"That was well said. Did you memorize that?"

Yes. "I review my notes periodically."

"I'll bet you have that on an index card in your pocket, Rob" Jill said with a smile.

This was also true and I went over it a half-dozen times in the bathroom prior to each start time. The ladies laughed and it was clear early on that many of them appreciated a lighter feel when dealing with heavy topics.

In the early weeks I found myself not saying much. New members needed to be comforted by more senior members as they opened up. "It will get easier," "we will help you," "you're strong and you'll be okay." Although not always helpful these words tended to stick and help the new women get acclimated and trust the group's cohesiveness. In fact there were times I hardly spoke at all as the women would launch into conversations about holding one's head high in the community or how to talk to their children about what their father had done. While all of this was going on I found myself sitting with a thought that no one had spoken: Why did these women stay in their relationships?

"Ladies, I need to ask you something to help me understand you better. Given what's happened to you, your family and your relationship why do you decide to stay with your partner. Why not just leave?"

The question came out more as a judgment than I had wanted because I wasn't necessarily thinking that every woman in the group should leave. I actually had no idea what anyone should do in this spot which was a part of my initial anxiety about taking part in this project. Fortunately no one seemed offended by it. I suppose it was because they were used to defending their choice. Jill spoke.

"Rob, let me ask you something first. What do you think about what they've done?"

I had thought about this question many times since I was told I would be a part of the treatment team. Treatment. That meant that this was an illness, didn't it? The research on the effectiveness of 'treatment' wasn't very promising though. Recidivism rates are high. Many don't improve at all. Did that mean that their behavior was simply a conscious choice?

"I've wondered about this since I learned we'd be working together; I don't know if my answer will surprise you."

"At this point I'm getting used to surprises," Ann said.

The ladies laughed. "It's like...your husbands or loved ones have done some horrible things. They have hurt other people, possibly beyond repair. In that sense I'm really disgusted."

I waited to see or hear any reaction but the women just looked at me and waited for me to continue.

"But I also know that your husbands have a lot of psychological problems: depression, low self-esteem, anxiety, substance abuse. Whether these things are a result of what your husbands did or a cause of it I don't know. But I don't think it's a coincidence that they co-exist. Maybe if they hadn't ever engaged in deviant sexual behavior then they wouldn't have developed this obsession with it that they talk about, like the way a cocaine addict doesn't become addicted if he doesn't try it. But that's neither here nor there because they all did it and now need treatment."

Ann pushed me a bit on this. "So what are you saying? They're ill?"

"Yes. I think they suffer from a real disorder, an illness."

There were a few suspicious glances, a few nods of agreement and one stare into space as if deep in thought.

"You answered your own question then," Jill said. "That's why I stay. My husband is a sick man and I'm going to stand by him."

"Well I don't agree with that at all," another woman spoke out. "He didn't have to become a Peeping Tom. He chose that. He made his bed and now he has to lay in it. I'm only here to be with other people who cope with this. When our kids are eighteen he's out."

"I don't know what to think," Ann said. "I flip-flop. Sometimes I think he's mentally ill and other times I believe he's simply a monster. I was hoping this group would help me to figure out what I really know and want."

"So Rob, since you're an active member of the group now, why don't you share with us what you would do if you were in our spot?" Jill asked.

Over time it became apparent that the women wanted to hear my personal opinions on many topics. Whether it was for my 'expertise' or simply for a man's take on this problem they clearly wanted to draw me in to the discussion. Not knowing a lot about the protocol of support groups I wasn't sure how I felt about this dynamic. And with my supervisor on an "extended vacation" that really seemed more like a sabbatical I was left on my own to figure it out. Did I really have all that much to offer other than honesty?

"I don't think I would stay with someone who did this," I admitted. "I don't judge anyone for their choices in this group and as I said I do believe it is an illness, but I'm pretty sure I couldn't handle the betrayal."

"So you'd leave someone who became Schizophrenic?," Jill said in a way that seemed less challenging than as a way to more fully develop the discussion. "That's an illness as well."

"It is and I would like to think that I wouldn't leave a person who developed Schizophrenia. But of course I can't say for sure because that hasn't happened to me at this point in my life." Not much at all has happened to me at this age which is why I'm completely naïve to the world and sound like an idiot when I try to talk about anything important. "But the nature of the illnesses is different. One involves hallucinations and the other involves sexual activity with another person. I don't see them as fair comparison points."

"I agree," said Ann. "If my husband were Schizophrenic I don't think I'd feel this anger toward him. And if Pedophilia is an illness then okay. Fine, I get that. But that doesn't change the fact that he broke our marital vows. That part doesn't change even if it's due to 'illness,' which is why I struggle with what to do going forward."

Jill spoke. "That's why you're here. I've made a choice to stay and work it out. This woman has chosen to leave when the time is right for her. Other women just leave and don't look back. We'll help you figure that out. Even Rob here seems like he could contribute to helping you with this problem and he probably hasn't even started shaving yet."

As the weeks went on with me at the helm the group started to develop a positive routine. We tried our best to answer very difficult questions: Why did their husbands do this? How could they have risked losing everything: their family, their jobs, their freedom? What does it mean that they are 'sick'? And what about the victims? How would their lives be altered?

The women would give advice to each other. They continued to ask for my opinions. They never hated on me for being a man as my supervisor had suggested they might. We talked about how the women could handle themselves in the community. We discussed coping with the gamut of emotions that come with this new life that they now needed to deal with. We even talked about their sex lives. Sometimes people in the group would cry, sometimes they would get angry, and other times they would make jokes. Often at my expense:

"My husband and I try to be sexual but after all that's happened I can't relax and of course can't have an orgasm. I'm not sure how to talk to him about this. Rob, your girlfriends probably complain all the time about not having orgasms with you. How do you handle the criticism?"

One woman brought it a small bag of sex toys for the women to examine just in case they wanted to "go it alone for awhile," according to the woman. "Let's see if Rob knows what each of these wonderful pieces of technology do!"

After a few months the group membership reached a plateau. While new women had come in to the group a small number of others decided that they were leaving their partners and didn't want the group's support any longer. This position was never challenged and members were always told that the door was always open if they changed their minds about needing help.

With a set number of eight people we continued to work on living this new life that the women didn't ask for. Week after week the support everyone gave to each other was powerful. The women changed because of it. You could see them grow as people. They became empowered. They processed what had happened to them through talk and reflection. Sometimes the women would bring in letters that they had written to their husbands. The women would read them aloud and talk about the feelings of anger, betrayal, embarrassment and sometimes empathy they felt toward the partner's illness. They would read, cry, yell and usually they said they felt better because of it. Not only because of the catharsis but also because they were not judged for any of their thoughts or feelings. Sometimes the women gave the letters to their husbands, other times the simply wanted to express what they felt in a safe forum.

Sometimes the women wrote letters to the victims, apologizing for their husbands actions and saying that if they had known, if they had only known that something like that could happen they would have stopped it. The group members focused on reducing guilt about being powerless to stop such actions by being empathic and pushing each other to be kind to themselves. Again, no judgments.

What ultimately developed was a grieving process: the loss of the life they once had and what they thought their lives would be going forward. When the women embraced that things had changed, that their husbands were not the people they once thought, that life was different but certainly not over, the women changed as well.

When springtime came I was ready to complete my internship and would be leaving the group soon. That meant saying good-bye to the women I had spent each week with for almost a full year. I thought a lot about how difficult it could be on them to see me go. And then it dawned on me that this was the end of the relationship for me as well which meant addressing my own feelings about them.

To be continued...

Dr. Rob,

I work in a high security psychiatric hospital and was told that while highly unlikely the patients could become aggressive at times. I'm new to the field (I have a Bachelor's Degree in Psychology) and I wouldn't say I'm afraid but at least concerned. Have you ever been involved in any episodes of violence? How did you handle it?

My massive 165 pound girth prevents most people from attempting to mess with me. And violence in mental health settings is not a common occurrence, at least not to the sensationalized degree you might see on television, so keep that in mind. But that doesn't mean it isn't a good idea to take basic precautions. Some of the most common are to always sit closer to the door than a patient, never put your hands on a patient without prior warning and do not wear items that can be used as weapons against you, such as hoop earrings or necklaces that can be pulled on. Using common sense and respecting your surroundings can greatly lower your risk of trouble.

I have limited experience in the setting that you describe so I can't speak in detail about that type of work. That being said I have had a few tense moments with my clients over the years. In graduate school I worked in a residential treatment facility for teenagers with behavioral problems. These adolescents struggled with substance abuse, school truancy, were victims/perpetrators of physical abuse, had poor intellectual abilities and had little to no parental involvement in their lives. This was in addition to psychological problems such as depression and anxiety. These kids had been removed from their homes or the streets and placed in the facility for both treatment and schooling.

My job was to perform psychological testing on the residents to help develop psychological treatment plans. In addition to completing standard I.Q. tests and screening measures for ADHD, part of the testing battery required each teen to complete a very lengthy true/false test. The test would ask questions about psychological symptoms, personal interests and coping styles to help understand a client's personality and any mental difficulties.

Because the test was hundreds of questions in length the teenagers understandably got frustrated filling in oval after oval on one of those stupid Scantron sheets. And because many of the students had lower I.Q.'s they had trouble understanding many of the items. One student, I'll call him Sam, was just under 18 when he completed the testing. He was tall, at least 6'3'', and well over 240 pounds. If he and I comprised a Mental Health Football Team he was clearly the linebacker and I was the kicker. Possibly the waterboy.

To Sam's credit he worked very hard on everything he was asked. Normally the entire testing process took about three hours, conducted over three visits. Now on our fourth visit and sixth hour of work together he was getting frustrated. The testing room was hot, small and overcrowded with a big person (him) and a little person (me). At one point he came to a question that I to this day have trouble comprehending. It was one of those triple or quadruple negative statements that canceled out each other making it a positive. Or maybe still negative. I'm not sure. To paraphrase:

True or False: I do not enjoy not thinking about past mistakes or failures that will sometimes or often not bother me.

Sam read the question silently. Then aloud. Then silently again while mouthing the words. The pencil, which looked more like a toothpick in his hand, began to suffocate from the gradual squeezing he began to apply to it.

"True or false. I do not..." and he closed his eyes. Squeezed the pencil. He softly hit the desk with a fist. The pounded with both hands.

"I don't...get it!"

Having a client get angry was never a big deal for me as I viewed it as simply another human emotion that will ebb and flow with time. However when the pencil cracked and a second set of fists slammed down on the table a series of questions started to run through my mind:

This isn't therapy but should I let him work through the emotions? Should I tell him to just take a break from the test for awhile? If I do will that skew the results? I'm sitting closer to the door than he is; should I just run away from this place forever and go to dental school? Maybe I should I explain the question to him; hell do I even know what the question is asking?

"I DON'T UNDERSTAND!" he yelled and his now red eyes stared at me.

Using my street language that always went over well with the young ones I decided to try to relax him. "Hey man, it's all good. It's cool. This isn't such a big deal, let's just chill for a bit, kick it, and we'll come back to it."

Sam wasn't about to be consoled. He stood up, furious. In the corner of the small room was a statue of the Virgin Mary (the treatment center was Catholic-based facility), about five feet high. He walked over to it, stared it down and picked it up over his head. The room we were in couldn't have been more than eight by eight so if he slammed it down the consequences were limited:

1) Have the statue break apart all over the floor with the shrapnel flying all over the room, puncturing our vital organs, killing us both.
2) Smash me over the head with it, killing just me.

Watching him hold the statue up high I really started to get anxious. Then it crossed my mind that I should take a more authoritative approach. I stood up, tried to look as tall as my near six foot stature would allow, and pointed my finger at him.

"Sam! You put that down right now!"

I don't know if he saw my finger shaking from fear but he paused, stared at me for a moment and actually lowered the statue to the ground. I couldn't believe it worked. Sam then ran out the door, slamming it behind him.

I took a few moments to collect myself and thought about the people who would have missed me if I had died. Mom, dad...mom some more. I then went down the hall toward Sam's classroom only to find Sam leaning against the wall in the hallway.

"Sam? You okay?"

"I don't understand. I hate that I don't understand," he said, no longer yelling.

"I know, man. You have trouble with these things. But in all fairness to you it's a really confusing question. It's complicated."

"Will you help me?"

"Well I can't tell you exactly what the question means. In fact I'm not even sure myself what it's asking. But how about we do this: let's skip that question and go on to the rest of the test. You're almost done. When you're finished we can go back to that one and try again. If it still doesn't make sense to you then we'll just skip it."

"I can skip questions?"

"I think you can leave five blank so you're okay. But I'd like you to try again."

"Okay."

"And Sam? When push came to shove that was a good job in controlling your anger. Thank you for not killing me with that statue."

Sam smiled. "You're welcome man."

Sam ultimately decided to leave the question blank but completed everything else on the test. That was more than many of the other kids did so I was happy for him. And when all of his test results came back they showed he was actually smarter than originally estimated with stronger coping skills. Like knowing when to not break a statue. My guess is that Sam probably doesn't have the easiest life but he may have made something of himself with the right guidance.

I'm not entirely sure what the moral of this story is but it probably has something to do with not keeping religious artifacts in your testing room. And try to keep your finger from shaking when you confront a large teenager. And of course know your double negatives. Good grammar is obviously a key to mental health.

I recently received a phone call from a local hospital.

"Dr. Dobrenski, this is Dr. Straka," she said in a heavy accent that sounded Eastern European. "I'm a Psychiatrist at ___________ Hospital and I'm wondering if you'd be interested in sitting down to discuss an opening we have in our department."

Psychiatrists are fairly strange folk so the idea of sitting down with one didn't sound overly appealing, especially since I'm not actively looking for more work.

"What type of opening?" I asked just in case it paid four million dollars per week. Plus benefits.

"We just need someone to come in a few days each week to see some of our patients for therapy. I only have time to do the meds and there's no one else in the department who is available. You should know up front that you'd have to do your own billing and scheduling and that there is no group supervision unfortunately. It's just not in the budget. You know how it is."

"Yes yes, that's a shame," I said and a big smile grew across my face. You don't need to be an entrepreneur to appreciate this type of opportunity. Complete autonomy. No one like Dr. Allison chasing me around to talk about some obscure article on "Psychoanalysis for Cats" that no one will ever read. No Dr. Gail to get on my case about placing a period after each "A" and "M" on my morning clients' progress notes. No Dr. Pete to make me listen to Hall and Oates and discuss its ramifications on his music therapy practice. And of course no rent increase from Dr. Steve. I could just go in, see the patients, help them as best as possible and go home.

"Can we sit down tomorrow?" I asked.

The next morning I was in my jeans and blazer (as you know I don't wear suits). In typical physician fashion Dr. Straka was twenty minutes late. When she arrived she quickly introduced herself and whisked me away to a small room with a desk, two chairs and a lamp. She sat down and pulled out a form with my name and a list of the hospital's patients on it.

"If you don't mind me asking, how did you find me?" I asked. Through ShrinkTalk.Net I'm sure. It was just a matter of time before my words reached the greater psychiatric community!

"You submitted your resume to us about a year ago. We didn't need someone then but I held onto your paperwork just in case."

I had no recollection of doing this and marked it as a sign of early-onset Dementia.

Dr. Straka, while cordial on the phone, proved to be a very unusual woman. She scratched her face a lot. She touched the top of her head as if adjusting an invisible hat. She didn't even really seem very interested in my background or my qualifications. I suppose she just wanted someone with a degree to take some of the pressure off of her.

"You seem good enough. Let's get you over to nursing to discuss paperwork."

The head of the nursing department was a large, brusque woman whose English was difficult to understand. She was introduced to me as 'Mrs. Ma'am.'

"Hello Ms. Mrs. Ma'am" I said.

"No! I Mrs. Ma'am," she yelled. "You call me that!"

"I'm sorry, Ma'am. I mean Mrs. Ma'am."

Mrs. Ma'am nodded suspiciously and immediately launched into an argument with Dr. Straka about where my referral forms should be placed for her signature: on the right side of the desk or the left. It was Mrs. Ma'am's contention that the forms should be on her right side where she could easily reach them with her writing hand. Dr. Straka countered that the left side of the desk was closer to the door and therefore more quickly reached upon entering Mrs. Ma'am's office.

"No!" Mrs. Ma'am shouted. "On my right!"

"Mrs. Ma'am," Dr. Straka said, not so quietly herself as she scratched her face, "you have to understand that..."

At that point Dr. Straka noticed some vanilla wafer cookies on the desk. She picked up two of them, popped them into her mouth, and began to ramble incoherently, possibly more on how the left side of the desk was indeed the preferable side for my referral forms.

"It's important for you," chomp chomp, "to realize," chomp chomp, guhhhhhh....

Dr. Straka began to choke on the vanilla cookies to the point that her face started to change from a light tan to purple. Mrs. Ma'am put her hands up to her own throat indicating to me that Dr. Straka was choking which seemed obvious based on the wheezing and flailing of the doctor's arms.

Mrs. Ma'am came over to Dr. Straka and, rather than performing the Heimlich maneuver that I imagine most nurses would do, punched her in the back three times with a closed fist. On the third hit against Dr. Straka's hollow frame the cookies dislodged, allowing Dr. Straka to breathe fully if not very labored, and she nodded her head vigorously as if in agreement with Mrs. Ma'am's treatment approach.

"You want water?" Mrs. Ma'am asked.

"Ye..yes please."

Dr. Straka drank the water in one large gulp, sat the cup down, and recommenced her argument. "The left side of the desk is clearly where the referral forms should go," she said. At that point she picked up another vanilla cookie, tossed it into her mouth and, clearly having learned her lesson to cut her cookie intake by one-half, rattled off something that sounded like a valid reason for put the forms where she would like.

"Fine fine," Mrs. Ma'am said. "But only on a trial basis." Pointing to me she concluded "See how well we compromise here?"

"Ah yes," Dr. Straka said, clearly satisfied to be right. And alive. "Welcome aboard!" she said.

Ideally I'll be starting this new position soon. Dr. Straka probably mentioned my start date during lunch but I couldn't make out most of what she said. Apparently some shrinks are not only neurotic but gustatorially challenged as well. It's a small price to pay for complete autonomy.

To read Part 1, click here.

When people report success with group work they usually speak of what is known as 'Universality.' Clients will often say "It felt good to know that I'm not the only one with this problem," "I felt very accepted by the other members," or "It helps to be able to talk things through with people who understand, people who are struggling with this as well." The therapist or group leader's main responsibility is to facilitate group cohesiveness and disclosure to bring about the Universality phenomenon.

One important attribute for a group leader to help maximize success is known as 'credibility,' of which I had none. My age (25), gender (male), marital status (single), prior number of groups conducted (zero) and practical experience working with sexual offenders (none) essentially made me the worst possible person for this endeavor.

The morning of the first group I decided to play up my strengths rather than focus on my weaknesses. Like Stuart Smalley I engaged in an affirmation that quickly turned sour:

You, Rob Dobrenski, are...a nice person. You are fairly tall and...take very good care of your teeth. You're a good listener. You know the basics of human behavior and what makes people tick. Someday you might be very good at sex offender work because you've been reading about it incessantly over the past few weeks. In fact you probably have a thousand more great qualities but your low I.Q. is preventing you from thinking of any of them. What the hell is wrong with you?? Shit! I'll never be successful. Why did my parents have to get divorced? It was probably my fault because I'm so ugly. Only a blind dog would ever love me. Possibly a starving cat.

When I finished crying I thought about the first part of my mantra. I am a good listener. At least when I'm working. And I know about behavior and the dynamics of human interaction. If I could bring that to the table I might be okay and the group could thrive. That confidence lasted about an hour and I went back to being a shaky mess.

This particular group was conducted in an open format, meaning that there was no specific beginning or end. It ran weekly with members joining as their significant others were being treated as well as leaving if the offender completed or was removed from treatment. My supervisor told me that some women never left the group because they benefited from it so much and saw it as an important ritual in coping with their somewhat unusual situation. On my first night some of the women were there for the first time but others were seasoned veterans.

No one in the group was required to reveal the specific nature of their significant other's offense but could if they so chose. Because I was simultaneously running the treatment group for the offenders as well (that's another story for another day) I had that information at my disposal. Usually having 10-15 members this first group had only six people. Four of the women were the spouses of pedophiles, one the wife of a voyeur and one woman's husband was a rapist.

The idea of even introducing myself to the group terrified me to the point that I spilled coffee on my khakis due to the shakes. They'll never respect me as a professional. I'm going to be laughed out of the room. I'm poor and I can't afford dry cleaning for these pants. I went with the most generic opening possible.

"Hello, ladies. My name is Rob Dobrenski. I'm going to be leading this group for the next several months. I'm a doctoral student and I'm also working with your spouses or significant others. Maybe we could go around the room and you could introduce yourself to me and anyone who is new to the group. Then we can talk about how we'd like to use our time together."

"I'm sorry," a woman said. "But do you mind telling us how old you are?"

Yes. I do. "I'm 25 years old."

"And do you have experience in this field?" another asked.

"Not really, no. This is a training experience for me."

"I don't even know why I need to be here," said a third woman, clearly at her first session. "But if I am stuck here I'd like to make it worthwhile. How can someone like you be of help?"

I went on to tell them about how good a listener I was, my understanding of group dynamics and my burgeoning knowledge of this particular area of psychology. Some of them looked a bit suspicious as I talked about Universality and how we could all contribute to make the group a successful one. After I was done I paused, waiting for one of them to take out a large rifle and shoot me with it, ending my miserable existence.

"Okay then," a woman said. "This isn't a job interview and I personally would like to make my time here productive. So let's get on with it and see if you can help this group. If not we'll just fire you."

And just like that she began to talk about herself and why she was there. The other women followed suit. And at that moment a reality set in: the women weren't too concerned about me, my schooling, my expertise or the stains on my pants. They were justifiably wrapped up in the chaos of their own lives. They just wanted me to lead the group to the best of my abilities. I was so hyper-focused on what they thought of me, all of which was horrible in my own head. It was like Reverse Narcissism or something one might see in Social Phobia. "They are all looking at me. I'm being judged. They will see I'm weak." Once I got out of that mindset, once my mind shifted with an almost audible 'click,' once I realized that I could stop the negative, albeit self-serving, thoughts I was able to focus on the task at hand. I still had little to no clue what I was doing but at least I could concentrate on learning and helping, which was what I was sent to do there in the first place.

To be continued...

I have a small number of regrets about not going to medical school: prestige, money, being able to call myself a "doctor" without people laughing at me, that cool silver circle to wear on your head, the extensive golf-playing, and getting to yell "clear!!!" in the operating room before hitting the defibrillator. These are things I could have enjoyed but were just not meant to be. I can accept that.

What I truly crave however is that ability to help a sufferer outside of the office in an emergency situation. Much like the doctor who performs the impromptu tracheotomy on a man in the street using only a # 2 pencil and an alcohol wipe, I too would relish performing a psychological service to one truly in need: a sociopathic killer holding a damsel in distress on the George Washington Bridge who is talked down from his maniacal plan by the soothing and sagacious words of Dr. Rob. This of course would be followed by the cheers of a gathering crowd who hoist me onto its shoulders and whisk me away to the nearest ale house. That would be nice.

I had decided that such heroism would never occur and that I would have a simpler career with quality therapy delivered in healthy doses to those who seek out my services. Strangely it was after I came to that conclusion that my professional life got just a bit more interesting.

I had left Dr. Pete's apartment after a peer supervision session where the focus had annoyingly shifted from discussing important cases and therapy styles to Dr. Jane and Dr. Allison debating who was better looking: Freud or Rorschach (yes, Rorschach was a real man). I should have just followed MILF-loving colleague Dr. John's modus operandi and not attended at all ("Supervision is for pussies. Real shrinks don't need help.") but was at least smart enough to bail before they started talking about which male clients they would like to sleep with. Getting into the elevator on the 35th floor I came face to face with a middle-aged woman who was teary-eyed and panting.

"Are...are you alright?" I asked. I always hate when people ask that question when the person is clearly not alright but nothing immediately came to mind. I'm a sharp thinker that way.

She wheezed in and out. "I...think I'm...having a panic...attack."

"Are you sure? Have you had these before?" When people present with symptoms of Panic Disorder it's important to ensure that they are not suffering from a more serious problem such as a heart condition.

"Yes" she said, breathing basically into my face. "I get...them a...lot."

True panic attacks can be psychologically debilitating. Although there are a lot of erroneous beliefs surrounding panic (e.g., I might pass out, I'm going to lose my mind, I'm having a heart attack) the sheer terror that patients report during panic make it a crippling condition.

"I usually...take Xanax," she said. "But I left...them at...home."

"Can I help you with this? I'm a Psychologist."

"Pl...please."

When people are having episodes of panic their breathing becomes labored. They don't take in enough oxygen. Their heart rate speeds up causing more labored breathing and thus beginning a vicious cycle that can lead to beliefs about a heart attack or fainting.

I extended my arm out and up and beginning wiggling my fingers. "Look at my hand and try to focus on my fingers." Distraction can be a useful way for clients to get through the initial stages of panic. She looked up at it, still breathing heavily, slightly bent over from the fatigue of inefficient breathing.

"Everything is going to be fine," I reassured her. "You're just breathing poorly right now. "I'm going to put my hand on your belly. Is that alright?"

Therapist Rule: Rarely is it necessary to physically touch a client (or elevator partner). If you plan to do so ask beforehand so there are no misunderstandings.

She nodded her approval.

"Okay, keep looking at my fingers. Breathe in through your nose and slowly start to push your belly out. Picture your stomach pushing my hand off of it while breathing slowly through your nose. Keep your eyes on my fingers." This is diaphragmatic breathing and, while ideally done laying down, it can be successfully completed in any position with enough practice. Fortunately this woman seemed naturally talented and was successful right away.

She seemed to be a little calmer after about 10 seconds of this which was timed well with our arrival at the lobby of the building. "I think I...might pass out," she said. "I'm so tired now."

"You won't faint because your blood pressure is probably through the roof right now and that needs to drop for you to pass out but I don't doubt you're exhausted." I led her to a seat in the lobby. "How about you continue to breathe like I showed you and I'll get you some water?"

I went over to the doorman of the building, Samuel, according to his name tag. Pointing to the woman he asked, like any caring New Yorker would do, "What the fuck is wrong with that one?"

"She had a panic attack. Could you please get me some water?"

He rolled his eyes in annoyance, clearly pissed that I was taking him away from the Gossip section of the New York Post and walked off. He came back with a cone-shaped cup of water. "There's no loitering here so hurry the hell up and get out of the lobby."

Dick.

Formal panic attacks rarely last more than a few minutes and by the time I got back to the woman she seemed pretty much recovered. She drank the water, thanking me between sips. I told her that she would probably have felt better fairly soon without my help but that treatment is available beyond simply medicating yourself. She was excited to hear that and I gave her Dr. Pete's phone number for a consultation.

I left the building and felt fantastic. The psychological equivalent of a Sidewalk Appendectomy! At that point I was ready to help anyone I could find and began looking around for a distressed person to counsel. Then I remembered that I live in New York City and everyone here is distressed pretty much all the time. I guess I won't be out of work soon.

We've learned before about the importance of verbally confronting clients when psychological barriers are impeding their progress. Unfortunately there are times when you can talk a problem to death with no results. When that happens a client needs to do something to see change. A classic example of this is a common phobia: no matter how much you talk about your fear of flying, until you get on the plane and sit there and feel the anxiety until it subsides not much is going to happen.

This is known as Exposure Therapy and is based on the idea that anxiety is often a physiological reaction to a perceived danger. Through multiple plane rides (called "trials" in the shrink world) the body and mind starts to recognize that inherent danger is not present and the anxiety subsides. When a client can take that final step and begin exposure trials outside the therapy room life often becomes much better because Exposure Therapy has a great track record for treating fears and aversions. When he can't take that step his therapist has to at least consider the possibility of taking it for him.

Consider my work with Bryan, a young graduate student who was working with me on a variety of dating issues for some time. Bryan put a lot of effort into therapy and we had a very strong working relationship. Most recently Bryan had been grappling with initiating phone contact with women. He could speak with them in person, get their phone numbers and even make tentative plans to go out with them but when the time came to make the call to solidify those plans, he would freeze.

Bryan and I talked about this ad nauseum over many weeks using every therapeutic technique in the book.

"C'mon Bryan, what's going through your mind right now. I can practically see the wheels spinning in your head. Talk to me."

"I don't understand it. The odds of her saying yes are so high. I can't get a grip on what I'm telling myself that's making me lock up. Dammit!"

"Are you thinking that she might say no?"

"No. I'm actually thinking how great it will feel to get this call over with no matter what she says. I just want to get over this last damn step."

"Close your eyes. What do you see when you picture making the call?"

"I see us having a great conversation that ends with a plan for dinner. Possibly seafood."

"Great," I said. "I love seafood. Go home, pick up the phone and call."

"I want to but I know that once I leave here I'll say 'screw it' and be back here complaining about the same shit next week."

"How about this: call her here, in the office, right now. I'll go outside so you can have some privacy."

"I don't know. That's so...high school."

"Maybe so but you're not getting it done outside of this office."

"No, I'll just wait and do it later."

"Bryan, who are we kidding? You just said that won't happen. Even though you've told me that this date is a slam dunk you've got something blocking you. Instead of us analyzing that obstacle until we're both tired and miserable just call her. It's going to be fine. Would I ever lead you astray?"

"I think I'll just wait..."

"Bryan, give me your Goddamn phone!"

"What?"

"You heard me. Give it to me."

He reached into his pocket and cautiously handed it over.

"The number please."

He told it to me.

"It's ringing. Here. You're going to be fine. She'll say yes and you'll the next thing you know you'll be at your local eatery hoping they name a fish sandwich after me."

He took the phone, eyes wide, moved it slowly to his ear. Beads of sweat immediately appeared on his forehead. With his voice initially cracking he got out his name and a reminder on how they met. I stepped outside to give him a little space and when I no longer heard his muted voice and could make-out the snap of his cell phone closing I opened the door. Ah yes, another successful therapy session as a young man finds true love! Rob, why you aren't on every magazines' Best Doctors List is beyond me. In fact you should start your own dating site: DrRobsHotLoveHouse.com.

"So Romeo, how did it go?"

"She said no" he said staring blankly at the wall.

Shit!

"She said no?"

"Right."

"But...you said that this was probably a no-brainer."

"Yeah I thought so. Apparently she was really drunk when she gave me her number and doesn't have much recollection of me."

Therapist Rule: If you believe you've made a clinical error address it head-on.

"I'm sorry about that Bryan. Maybe pushing you like that wasn't the best idea. Are you angry with me?"

"No not at all. I think I'm still coming down from the anxiety of the phone call."

"To be honest if you had made that call on your own and this had happened I would have said that while we knew there were no guarantees that she would say yes, you did what you thought was a positive action. And in fact it was positive because you took a crucial step in getting over your fear. I don't know if that's what you want to hear right now given that I basically forced you into calling her."

"I guess that's all still true, right?" Bryan asked, cracking a smile as the adrenaline began to subside.

"So, um...since we're on a roll are there any other women you'd like to call during this session?"

Shockingly Bryan was interested in making another call. Exposure Therapy usually requires more than one attempt before the fear is extinguished. Unfortunately the second woman also rejected him, leaving me to wonder where the hell he was getting the idea that all these women were into him. "Is Bryan a Narcissist?" I wondered. "Probably not, just a little too cocksure, so to speak." We called it a day after that and he spent most of the week making calls to women with varying degrees of success.

The good news however was that Bryan ultimately overcame the phone aversion through Exposure Therapy. Many clinicians might question that choice of treatment claiming that he wasn't ready and I risked traumatizing him. This is a somewhat fair point although I knew Bryan well and assumed he could handle it. And the reality is that Exposure Therapy rarely goes wrong if the client is motivated and knows that taking that step is in his best interests. It's also hard to argue with results in this case. Unless I had beaten him with a cane or something until he called that woman. That probably would have worked as well I suppose. Oh well, maybe next time.

As more time passes between graduation and the present I realize how good school was to me. When it came to training opportunities I usually happened to be in the right place at the right time. Whether that was due to luck, solid professors or even by dint of the Psychology Gods smiling upon my naïve, albeit incredibly good-looking face I got to see and experience a lot in a relatively short period of time. In fact by the time I had my degree in hand there were few clinical populations or diagnoses that I hadn't worked with firsthand. Compare that with my "real doctor" colleagues who had obtained their M.D.'s yet hadn't even seen a spear through a patient's head or a gall bladder on their office floor. How lame is that?

When it comes to the human condition you don't learn all that much from textbooks. You learn by doing. You get into the room with the person and you interact. While you try to remember what the books and the professors said and you memorize the jargon, the real learning is by trial and error. Sometimes the training opportunities present themselves before a you have had any book knowledge whatsoever. For me this occurred when I facilitated a support group for the spouses/significant others of sexual offenders, a group comprised entirely of women.

"Support groups" generally differ from "therapy groups" in the sense that they often don't have a specific outline for each session, the members of the group tend to have varying levels of participation and attendance, and that their purpose is exactly what it sounds like: to simply provide support to the members who are dealing with a particular issue. Sometimes they are facilitated by non-professionals. Therapy groups, by contrast, are theoretically designed to treat a particular psychological problem. They are run by professionals and usually have an overarching objective or goal for the participants.

The Significant Others of Sexual Offenders Group was unique in the sense that enrollment in the group was required. If you wanted your partner to be treated for his sexual offending, you needed to be a part of the group. If you were not there during the regular meeting times, your man was kicked out of treatment, plain and simple. This requirement was based on certain theoretical principles:

1) Sexual offenders suffer from a psychological disorder that can, in some cases, be treated via a comprehensive program.

2) The process of becoming an offender involves experiencing various psychological problems such as low self-esteem, depression, anxiety, and substance abuse. The process includes certain behavioral problems in addition to the offending, especially lying to both oneself and others.

3) Without complete disclosure of the offender's thoughts, feelings, actions, and history of his psychological growth, both sexually and non-sexually, rehabilitation is not possible. This disclosure needed to be done in the presence of the treatment team, other offenders in the treatment group, and the offender's significant other.

4) Without an adequate support system to help the offender deal with the purging of the innumerable lies and egregious actions, rehabilitation is not possible.

5) Unless the significant other was involved in the offending itself the complete understanding of offending behaviors and their consequences are simply overwhelming and cannot be tolerated on one's own. Support is required for the significant others to deal with numerous emotions that come with sex offender treatment, so that the significant other can be a useful resource for the treatment. This benefits both the offender and the community who is considered at risk for future violation.

The philosophy behind these principles is that finding out that your significant other is a sex offender is incredibly difficult to deal with and it is unlikely that either of you will successfully cope with it alone. If you can't keep it together, there's no way your partner will, which puts the community at risk due to the increased likelihood of recidivism on his part.

The group took place at a local community mental health center where I was completing a one-year externship program. Some externships allowed you to pick and choose what type of work you do throughout the year. This one didn't and my leadership of the group was mandatory. The supervisor for my work was a psychologically strong, confident and intimidating woman who pulled no punches and gave it to me straight. She believed that every student should take on novel and challenging populations because a good Psychologist has "experienced the world."

"Like it or not, Rob, sex offending is a part of real life. Don't hide from the world, experience it."

At our first meeting together my supervisor broke down the possible dynamics involved in the support group. "Very few women are pleased, especially at the onset, to be 'going to fucking therapy' every week for a disorder that they do not have. Many of the women - and much of society in general - do not even see the offenders as "ill," at least not in the way one might view someone with Schizophrenia. They are incorrect but that is their belief. A male group leader, in this case you, will likely receive very strong transference reactions from the women who will see the facilitator- again, you - as an easy target for the gamut of negative feelings toward men that they understandably are experiencing. In other words prepare yourself to be a punching bag for a lot of rage."

"I really don't think I'm qualified..."

Dismissing me with a brief wave of her hand she continued. "You have to strike a balance between empathizing with their feelings of anger, betrayal, and embarrassment they have with a confident knowledge of the nature of sexual offending and its underpinnings as an illness that impacts not only the offender and victim but also the community at large. Can you do that?"

"Actually I'm pretty sure I can not do that. I'm not even sure what you are talking about."

"Hold old are you Rob?"

"I'll be twenty-six very soon."

"How soon?"

"Ten months."

"And how much experience do you have with sexual offenders?"

"About as long as this conversation."

"Alright then. You look like you're about 8 and have virtually nothing to offer in terms of life experience or knowledge to these women who are victims in their own right. As your supervisor I will guide you along as best as I can but I don't have the time to watch you moment to moment like they do at the university clinic. You're going to need to do a lot of this on your own."

I'm sure I looked panic-stricken and in need of deep breathing exercises or wine or scotch or an illicit substance so she took my hand and her firm, clinical and almost cyborg-type voice softened somewhat. "Rob, you'll do this and will someday thank me for my tough love. Remember, no matter how many books on support groups or Frotteurism you read, you need the growing pains of practicing as a professional."

"What's Frotteurism?"

"It usually involves sexually touching and rubbing against nonconsensual partners."

"Who does that??"

"Some of your clients' husbands so get comfortable with it. I will tell you this again and again until it sticks: don't hide from what's different and scary."

I left that meeting confused and nervous with a lot of questions and hardly any answers. I hadn't chosen to run the group and didn't see what an amazing challenge and growth opportunity it was. All I envisioned at the time were angry women who would see me as a possible enemy because of my gender.

I didn't know what to think about them. I'm sure many of them had children and didn't want to break up their families. Others were probably scared to be alone. Some probably truly loved their husbands and wanted to help them. In all likelihood most of the women were a combination of all of those types and didn't know what the hell to do about this issue. That I could completely understand and I suddenly felt sorry for them for being in such a horrible place. If I can just remember this feeling I'll be in a better position to help them.

Unfortunately the feeling didn't last and anxiety returned. I had the responsibility of helping a group of people with a problem I knew nothing about and who in all likelihood didn't even want to be there. On my own. With my 8 year-old face. Maybe I would get lucky and they would simply pity me for being a neophyte. Doubtful. On the night before the first group my final thought before falling asleep was "Set the bar low. If they don't castrate you consider the first session a success."

I'm back at __________ Hospital having completed my credentialing process and I'm amped to be doling out the mental health. I'm like one of those gunslingers who swings open the doors at the saloon ready to blow people away. Except instead of a Derringer or a Smith & Wesson I have a 'You too can Have High Self-Esteem' handout on one hip and a Positive Thoughts Worksheet on the other. That's how I roll.

Even though I work in the Department of Surgery I sometimes go by Outpatient Psychiatry to be among my own kind. Today outside the main door was a male administrator, late 40's, well-dressed and groomed. He was speaking to a man who was in all likelihood a patient at the hospital. The man was about 60 and overweight, had a few nervous twitches and was speaking in a soft voice. He was unshaven and his clothes were tattered. I have a guess that he might suffer from Schizophrenia. I've seen him before in a worse way, responding anxiously to voices and people that no one else could hear or see. Today however he seemed much healthier and functional.

"I! Hope! You! Have! A! Good! Day! Today!" the administrator yelled. Was the man hard of hearing? I suppose it was possible as some people seem to think that deaf people can hear them if they just scream loud enough.

"Me too," said the patient.

"Yes! You know what?! You're a good person, don't you know that?!" the administrator shouted again.

"Thanks."

The patient was clearly able to hear him so the yelling clearly wasn't necessary. I couldn't quite put my finger on what was driving my mood, but I was getting really annoyed at the way the administrator was speaking. Then it hit me that it wasn't simply the volume, it was patronizing tone that he was using, the way one might speak to an infant. "Such a good man you are, so polite, and you take your medicine just like the nice doctor man told you too!" I'm surprised he didn't pat him on the head and give him one of those oversized rainbow lollypops just for taking his Haldol.

Dr. Rob Soapbox Moment:

This is bullshit. Not that anyone listens to me but if by chance someone actually does pay attention to this: do not talk down, condescendingly or patronizingly to the mentally ill. Why people do this is not entirely clear to me. I'm not sure if it's because we are afraid of people with mental illness or think they're stupid or that we are skeptical of anyone who is different but the reality is that it is insulting and disrespectful. In graduate school a patient in the psychiatric ward told me, "The staff here talk to me like I'm in pre-school. I'm still an adult even if I'm fucked in the head." It's a fair point.

We seem to use this same patronizing tone with the elderly and the homeless. The only people who should be spoken to like children are children (and even that is open to debate). I was going to give the administrator a verbal smackdown and tell his ignorant ass to get it together and start speaking like a normal person but he jumped into his Douche Mobile (some obnoxiously yellow Hummer) and drove away. Probably out of fear of my wrath. I hope it costs him $400 to fill up that gas tank.

I'm off the soapbox for now but I'm still pissed off. Fortunately I have my anger management workbook on hand so I should be better off come my next post. Stay on my good side until then.

I got a frantic phone call from Dr. Gail this week.

"Rob," she said, clearly anxiety-stricken. "I don't want to alarm you, but one of the clinicians here at the practice has been getting threatening voicemails from one of our clients. We just had a meeting to discuss our recourse."

I'm rarely at Gail's office these days so I'm never invited to the meetings. At the last one I attended Dr. Allison and Dr. Mike got into a fight over how to spell 'Zyprexa,' (an antipsychotic drug) and both initially refused to even look it up because each was so convinced of his/her position. Eleven minutes later, dictionary.com proved them both wrong. It was neither 'Zipprecksa,' nor 'Xyprekksa.'

"What did the client say?" I asked.

"I don't want you to get upset, but she said, get this: I'll see you in hell!"

You might remember that I had received some highly vague threats as well as a more direct one so I'm not a stranger to a client's potential for a strong reaction to his mental health provider.

"And what exactly is the problem?" I said.

"Rob! This is a direct threat and a crime!"

"How is it a threat? You're probably not going to hell anytime soon and even if you are she just said she'll see you there. What's the big deal?"

"Can't you read between the lines? This is aggression, a violent impulse! Don't you see? You're so naïve!"

Yes I see. In fact I'm having a violent impulse right now.

"So what are you doing to subdue this obviously homicidal maniac?"

"Well she's called and left the same message five times in two days so I'm going to hire a lawyer to handle it from here."

In defense of Gail the psychological/psychiatric community has been more vigilant recently following the horrific murder Dr. Kathryn Faughy. However there is a difference between being reasonably self-protective and paranoid. In fact this paranoia is essentially glorified narcissism: Gail sees herself as the focus of her clients' world, some infallible and exalted Pope of mental health which she cloaks as a fear of being attacked.

"Gail, clients (and shrinks) say things in anger all the time. I know it's been over the course of two days but could she be just acting out? She's not describing any intent to do anything harmful to anyone. Do you even know why she's angry?"

"We raised her fee."

"Why don't you just call her and tell her to stop the antics or else she won't be able to attend sessions anymore?"

"Attend sessions??? Are you crazy? She is no longer welcome here! I will be following formal protocol for a threatening client and providing her with referrals. Through my counsel of course."

"So the woman gets pissed off for having a fee hike, leaves a couple of silly messages and therefore you're cutting off her services? Aren't her actions a sign that she might need more help instead of less?"

"You know Rob, you can be very smug and condescending when you disagree with your peers."

Unfortunately this is true. I'm working on it but sometimes it's hard.

"I was just trying to warn you," Gail said, "so that you could take protective measures when you come to the office."

"Protective measures. Should I buy a bullet proof vest due to the imminent danger that we are all in? Obviously this woman is consumed with us all."

"God you're so difficult. Just forget it!" Click.

In keeping with the paranoia/narcissism theme of the day I then got a call from Dr. Jane.

"Rob, I just read your review of that chauvinism book. Do you realize you put your email in it?"

"Right."

"Your email is online! Anyone can contact you now. That's so scary."

"Anyone could have contacted me before. There's a direct link on my site to reach me."

"Man I wouldn't want my readers or clients or whomever contacting me."

"Jane it's really not that big of a deal."

"Yes it is! Like, I have this one guy in my practice who asked me out on a date. He's obsessed with me. I had to reject him, of course, but I was so afraid of what he might say."

"So what happened?"

"He said he understood, that he wasn't entirely clear about the therapist-client relationship rules and that he hopes it doesn't impact our work."

"Wow he sounds like a complete stalker. I hope you have your mace next time."

"After reading your post I've been picturing my clients emailing me incessantly. It's freaking me out."

"I'm sure your clients have better things to do than email you throughout their day."

"I need to figure out what to do."

"How about you get over yourself?"

"Just shut up! I need a Xanax now. This is too much." Click.

To all my colleagues who have written in saying how wrong I am about shrinks having "issues": I apologize. You are clearly right and I'm wrong. We are much more normal than the rest of the world.