II. iNTERNSHIP

 

INITIAL INTERVIEW

I received a grant for my graduate education. However, for every year I received expenses for tuition, books, and a monthly stipend, I was obligated to work for the state for one year. Since I received money for one year of master’s work and two years of doctoral studies, I had to work for the state for at least three years. They did this because there was a paucity of employees who were willing to work in state mental health facilities. That was because the pay was lower than what could be earned elsewhere and because patients in mental hospitals were difficult to treat. However, I could not have afforded graduate school on my own, as my parents had little money. To pay for my undergraduate education, I lived at home, commuted to school, and worked part-time during the school terms and full-time during the summers. Thus I was able to pay for my college education. I could have continued this regimen after graduation, but it wouldn’t have come close to paying the costs of graduate school. So I really didn’t mind the requirement to work for the state, as I thought it would give me good experience as well as relieving a potential financial burden.

Upon completion of my studies, I was to be assigned to one of the state mental hospitals. I could choose which. However, I was required to be interviewed by the hospital personnel, after I made my choice. I was interviewed by the Director of the Psychology Department and the Internship Director in a joint interview.

Now the amusing part to me, even at the time, was the fact that they acted like they had the final say in whom they would select, which they didn’t. They conducted a clinical “etiological” interview with me. It was a bit like a mental status exam: an exploration of my personality traits, which I didn’t mind, and an exploration of my personal history, focusing on my childhood and parents, which I thought was inappropriate. You could not conduct these types of exams today, but back then, there were no prohibitions against them. The directors kept making these interpretations, most of which I tried to correct, as I thought they were incorrect and non-applicable. As they continued to do this throughout the interview, I kept thinking that these would probably be my supervisors. If they were incorrect with me, how could they be good psychologists with mentally ill patients? It turned out that they were, so I don’t know what happened during their interview with me.

THE INTERNS

There were six psychology interns, five males and one female, all with state grants and obligated to work for the state. All of us chose this mental hospital for the same reason: it was the closest one to where we lived. The woman in our group was much older than the rest of us, and closer in age to our (and her) supervisors. As such she had little in common with us, tended to relate more to her supervisors, and spent more time with them than with us. While cordial, we all understood and commented on the difficulty she may have had relating to a generation that was old enough to be her children.

THE FACILITY

The hospital was a 5000-bed (you heard me right—five-thousand-bed) hospital. It consisted of multiple buildings across several city blocks and located within the outskirts of the city limits. Thus it was accessible by public transportation, and was surrounded by stable neighborhoods of mostly white residents, with nearby parks, recreational facilities, libraries, stores, and needed services. When it was built, there were few buildings surrounding the complex, but urban sprawl changed that.

The hospital had an administrative building, and three- and- four-story buildings housing acute, intermediate care, and chronic wards, separate child and psychiatric wards, and a separate building that contained the Alcohol Treatment Program. It had a self-contained employee cafeteria in the middle of the complex, several blocks from where I was working. That was okay in the summer months but a bit of an ordeal in the winter. The campus was quite large and spread out.

Later, a new facility was built across the street, and, as they decreased the census and closed some units, many were transferred to the new facility, including the ward where I was working. The new facility was interconnected by hallways, so one did need to go outside the building to reach another unit. It had a cafeteria, but patients were also allowed to eat there, and that meant that most employees stopped eating there. We either brought our own lunch to work or we went out somewhere to eat, as there were plenty of restaurants and fast food parlors to choose from. It also had a fine library, which I used to my advantage. But more about that later.

THE PSYCHOLOGY STAFF

The members of the Psychology Department consisted of the Chief of the Department, the Director of the Intern Training Department, staff psychologists who worked on the wards, and a program secretary. All were male, except the secretary and one female psychologist, both of whom were African-American. Most of the psychologists were psychoanalytic and psychodynamic in orientation. Generally they were in their 50s and 60s. The African-American female psychologist didn’t seem to relate to any of the staff. She attended our weekly staff meetings and never contributed any ideas or comments. The most I ever heard her say was “hello,” unless she was asked a direct question. I never got to know her, as she was not part of the training program. Even after I became a staff psychologist I had little interaction with her. Since there were few African-Americans working in the field of psychology—I only had one African-American male professor in graduate school—I can now understand how alienated and perhaps estranged she might have felt.

THE PHYSICIANS

When I first came to the hospital, it was staffed by unlicensed physicians. The rules have long since changed and now all medical personnel are required to be licensed, but in those days, there were few licensed doctors who were willing to work in state mental hospitals, mostly because they could earn a more lucrative living elsewhere.

These doctors were foreign-medical graduates who were unable to pass the state licensing board examinations. But they were allowed to work as physicians in the state mental hospital system. They had a scam going on, which the hospital superintendent—a physician—knew quite well, and actually condoned. These doctors would work overtime at the hospital. What were they doing? They were in small groups studying for the state licensing exam. This allowed them to accrue a great deal of comp time, which they then took, with full pay, to study for the exam. Even with this generous largess, most could not pass. If any one of them should happen to pass this exam, they immediately quit the hospital.

Now there were two adverse effects of this situation. First, I felt they knew little about mental illness. I felt psychologists were better prepared to deal with and treat psychiatric patients than these foreign graduates. Perhaps I may be self-serving, but many non-psychologists felt that way too

Now the second issue concerned their relationship with psychiatric aides. We often had many admissions at night, where a skeleton staff was assigned to this late shift. They needed a physician “on call” to come to the ward and order medications. Now what were these “on call physicians” doing? They were elsewhere on the grounds studying for the state exam. They didn’t like to be interrupted. And if any of the psychiatric aides complained, the next time the physicians were needed, it took them longer and longer to report to the unit. And the doctor could easily say they were busy attending to another patient. So the aides had to grin and bear it if they wanted to see the doctor there at all.

While I worked at the hospital, I worked with six physicians. On the intermediate care ward where I began my career, the physician was one of the few licensed physicians and psychiatrists at the hospital. He was in his late sixties and had a reputation as lazy and something of a sourpuss, but I liked him. He had never married, lived in a high-rise, did not cook and so went out for dinner every night, and routinely played serious poker. He spent the bulk of his time watching TV in his office and did not attend the community meetings between patients and staff, but did not interfere with the work of others, as long as we all understood that he was in charge.

He once told me that he decided one day to try psychotherapy with a patient. He said he thought he did a pretty good job with her, but it took too long and he didn’t have the patience to do it. So he was pleased that a psychologist was around, because he thought psychotherapy was valuable, but that was not something he wanted to do. That worked out fine for me.

There was a rumor that he was having an affair with the ward nurse, but I never questioned either one of them about it and kept my boundaries. Neither one of them ever made any suggestions that might have indicated the nature of their relationship.

The hospital eventually hired three other physicians to work on this ward. The first two were unlicensed foreign Hispanic physicians, one male and the other female. Neither stayed very long and I never knew why they left. They were hired to conduct physical exams and monitor the physical health of the patients, leaving the psychiatric care to the head of the ward. However, for some reason, both of them seemed to enjoy bringing up issues of sex when I was around. The female doctor would point out to me whenever one of the female patients was wearing some low-cut or sexually explicit garment. The male doctor would often act in a similar fashion and joke about the patients’ sexuality. One of the woman’s test results came back positive for a sexually transmitted disease. When the doctor reported the results to us in the morning staff meeting, he remarked “Well, at least she got sick having fun.” I thought that was unfunny, very crude—and typical of how he would react to his responsibilities on the ward.

The third physician was an octogenarian licensed primary-care physician who had his own issues with sexuality. He told me female patients would come in to see him for an exam just to have their breasts examined for cancer, because they enjoyed having their breasts manipulated. I questioned that motivation, but he was insistent about it, so I dropped the subject.

On the acute unit, where I was eventually named as the unit director, there was an unlicensed, foreign-trained physician who had been there for a few years. We had a few issues that was eventually worked out together and we formed a positive working relationship. However, he didn’t know much about psychiatry and was somewhat insensitive. As an example, after a patient had had a lobotomy, he brought me into his office along with the patient to show me the skull and how good the surgery was. I thought it was insensitive to do this in front of the patient, especially since the patient’s skull looked hideous. But he seemed to me a good doctor. He passed the licensing exam and quit to enter private practice.

His replacement was a foreign-born, foreign-trained unlicensed physician who had had a psychiatric residency elsewhere. At least he understood psychiatric disorders, but I was unsure about the quality of his physical care. He began having an affair with one of our social workers on the unit, eventually obtained his state license and relocated to Hawaii.

NURSES

Both the intermediate ward and the acute unit had one primary nurse. They worked closely with the doctor, oversaw the distribution of medication, provided clinical supervision of the psychiatric aides, and attended ward and team meetings. During my tenure, there were four different nurses assigned to the intermediate ward. The first one I met as an intern. She was helpful to me in explaining things around the ward. It was rumored she was having an affair with the ward psychiatrist, but I never explored that with her. She eventually retired.

The second was a lovely Irish American with a darling brogue. She had a gift of working with psychiatric patients and was very motherly towards everyone. As a middle-aged woman, she had a degree of maturity that complimented her nursing and interpersonal skills. Her husband became seriously ill with cancer and she had to quit. I missed her very much.

The third nurse was a single white female in her 30s, and kept trying to seduce the ward psychiatrist who was in his 60s. The only reason I know that was because he told me about it, and laughed about it. Later, it was rumored they went to Las Vegas together, though that was never confirmed. They were scheduled off on vacation at the same time frame.

The nurse I really became close with was the staff nurse on the acute care unit. The unit didn’t have one when I first became its director, but my boss assured me he would hire one for me as soon as possible, and he did. She was a gentle human being, very responsible and caring and had a way with people. She was warm and quite attractive, and many male staff from the hospital hit on her, even though she was married. She would laugh about it and tell me who was the next guy to make a move. We became quite close, often went out to lunch together, and she confided in me on several occasions. She would call me at night to discuss issues on the unit or with the staff. Sometimes she would ask me to pick her up and drive her to work, as it was not very much out of my way. We occasionally socialized together with our spouses as well. Invariably there were rumors that we were emotionally involved with each other. In a sense that was true, but not in a romantic sense. We both were quite professional about our relationship and maintained our boundaries.

At the suggestion of my immediate supervisor, this nurse and I began monthly meetings with the night shift. It was senseless to drive to my house, which was 30 miles from the hospital, and then turn around and go back. So she and I went out for dinner and then we went back to her house, which was closer to the hospital, until it was time to return there for our meeting that began at midnight. Sometimes her husband would be there, and sometimes he was out of town or working at his job. When I decided to leave the hospital and take another job, I knew it would be her that I would miss the most, and it was. She went on to a distinguished career, working at private psychiatric facilities, and receiving awards from the professional nursing associations for the quality of her work.

PSYCHIATRIC AIDES

The psychiatric aides were under the immediate supervision of the charge aide—that person in charge of the aides on that shift—but under the clinical supervision of our staff nurse. On the intermediate care ward, all of the aides were African American. On the acute care unit that I eventually took over as the director, they were primarily African-American females, though two were white males, one assigned to the morning and one to the afternoon shifts. I’m sure they hired males because the unit received acutely admitted patients, who occasionally had to be put into restraints. They distributed patient medication after it had been checked by the nurse, escorted patients to meals and other medical appointments within the hospital complex, intermingled with them during recreational programs, attended ward community meetings and team meetings (morning shift only), observed their behavior and documented their observations in the patient’s medical records.

The acute unit had two male psychiatric aides, both white, both who worked the afternoon shift, and occasionally the day shift. If an aide was not there then, if a patient needed to be placed in restraints, then the rest of us had to help out and do the job.

One of the male psychiatric aides told me he thought he had a learning disability or some kind of brain damage, and therefore was afraid to marry and pass along any problems to his children. He did have some problems understanding things, would get upset easily, and had to be taken aside and calmed down. He was tolerated because there were few male psychiatric aides working at the hospital and they were needed to restrain patients, especially during off hours.

The second aide, I was much closer with. He regularly reported to me, without being asked, what was going on with and between the other aides, during the shifts that I was not there. I don’t think there was ever any suspicion that this type of communication was occurring, because incidents continued to be reported to me. If they were aware of this source, I don’t think they would act in certain ways when he was present. I never told anyone about his reports and I was saddened when he quit to get married and live in an Amish community in Iowa.

PSYCHOLOGISTS

Clinical psychologists were assigned to almost all wards in the hospital, including the child ward and the adolescent ward. They were assigned to do individual and group therapy, often take charge and run the community meetings, attend team meetings, and supervise interns. The psychology interns, supervised by senior staff psychologists, primarily did psychological testing. None were assigned to the chronic care wards.

RECREATION THERAPISTS

Both the acute unit and intermediate care ward had a recreational therapist assigned to us. For patients on the intermediate ward, the therapist primarily had a rug loom and continually tried to teach the patients to use it, but most showed little interest.

The acute care unit had a male recreational therapist who was very active in engaging the patients. He had a recreation room to himself that was stored with a lot of useful material to engage the patients. He was assigned to the morning shift and attended community meetings and team meetings with the rest of us.

SOCIAL WORKERS

On the intermediate care ward, we had one social worker, whose job was to arrange for placement and discharge referrals. She attended team meetings and sat in our community meetings. She developed a romantic relationship with a vocational rehabilitation specialist who was hired for the ward, where they eventually married. They moved to California where she became a licensed family therapist, then relocated to Texas, and finally to Florida, where she resides with her husband. He became a clinical psychologist and developed a lucrative practice in pain management psychology. She became a full-time housewife and raised two children, who themselves became psychologists.

The social workers on the acute care unit had a similar role, acting primarily as case managers, dealing with discharge planning and contacting families to assist with this process. There were two men and one woman. She developed an affair with the unit psychiatrist. Meanwhile, her ex-husband would occasionally visit her during working hours, where they spent a fair amount of time behind closed doors. I eventually had to address her about this and it stopped.

VOCATIONAL REHABILITATION COUNSELORS

There were two of these specialists, both of whom were assigned to the intermediate care unit. I have already told you about the first one, two sections earlier. After he left, a married female was hired. She was a sweet lady who desperately wanted to get pregnant but was having trouble doing so. One day she reported to work and, very excitedly, announced she was pregnant. I was so happy for her and there was a visible change in her mood and attitude.

Then, a month or so later, she came to work and told us she was not pregnant. She had a large tumor, which caused a false reading, and she had to have surgery. We were all saddened. She had the surgery but never returned to work at our facility. And the hospital decided not to hire another vocational rehabilitation specialist.

PSYCHIATRIC RESIDENTS

One of the wards had a psychiatric resident assigned to it. They changed every six months and the psychologist assigned to the ward (who smoked a pipe continuously, reeked of tobacco, and had brown tobacco-strained teeth) consistently had two complaints about them: (1) He believed they didn’t know what they were doing, but they thought they did. (2) They kept changing the organization and structure of the ward and the ward activities. I was pleased that I didn’t have to go through that, as I was happy with our team and its structure. No one’s assignments interfered with anyone else’s assignment. We would have been considered a “traditional” psychiatric team.

THE MEDICATIONS

Today’s anti-psychotic medications are better able controlling psychotic symptoms than were the medications in use when I first entered the field. In fact, a recent study appearing in the American Journal of Psychiatry studied the effectiveness of six commonly used anti-psychotic medications ranging in price from the cheapest to the most expensive. Results showed they were all able to control psychotic symptoms. In other words, all did what they were designed to do. The authors concluded it was unnecessary to prescribe more expensive drugs since the cheaper drugs work just as well. There were, however, differences, in the side effects caused by these medications. Psychiatrists tell me they prescribe an individual drug for an individual patient more based on what side effects the patient is willing to tolerate.

When I first came to the hospital as an intern, and in the seven years that I remained there, the physicians essentially had the use of the following anti-psychotic medications: Thorazine, Mellaril, Haldol, Stelazine, Librium, and lithium (the last two used to manic depression, now called bipolar disorder). The first four drugs named above belong to a class of drugs called phenothiazines. The main side effect of these drugs was the development of extra-pyramidal effects (tremors, shaking). To counteract these effects, physicians prescribed another drug, usually Cogentin.

A major long-term side effect of these drugs is a condition called tardive (meaning slow or belated onset) dyskinesia. This is an involuntary speech disorder, often characterized by slurred speech and a “lazy” tongue (lip smacking, pursing, or puckering), other tongue movements, and/or involuntary limb or body movements. Grunting or difficulty in breathing may also occur. To prevent the development of this disorder, physicians now prescribe the lowest possible dose of drugs called neuroleptics. Also, a “drug holiday” may be prescribed, in which they discontinue the medication for a while, and then resume it when psychotic symptoms increase. I’m not sure if the physicians were aware of this maneuver during my years there, as I do not recall patients ever being taken off these drugs, and I saw plenty of tardive dyskinesia in patients, especially those housed on the chronic wards.

Side effects of medication continue to be a problem for physicians. Later in my career, I was named the chairperson of the mental health’s quality assurance committee at a VA Medical Center, where I was head of the drug abuse treatment program. One of our charges was to assess the effective use and dosing of a particular medication. (There were physicians on the committee besides mental health professionals.) Physician educational monthly programs, called “Grand Rounds,” were also available to non-physician mental health professionals Several Grand Round presentations were on various drugs. I noticed that one problem that seemed endemic to all these newer medications and one problem that permeated a concern with their use was the fact that most, if not all, tended to increase glucose levels in patients placed on these drugs. So our committee decided to assess whether our psychiatrists were adequately monitoring this potential side effect, because these drugs could precipitate diabetes in these patients.

Reviewing the prescribing practices of one of our doctors, we found little documentation of the requirement to ordering fasting blood sugars to assess glucose and A1c levels. The doctor explained to me that she had tried many times to get the patient to agree to such testing but he adamantly refused. She said it was hard enough to get the patient to keep on taking his anti-psychotic medication and that it was worth the risk of developing diabetes if she could control his psychosis. Thus, the committee concluded there was no neglect on the doctor’s part, but rather patient management that was as good as could be expected under the circumstances. It was unfortunate that such overviews were not in use when I worked at the state mental hospital.

This is an example of the problems physician have with patient non-compliance, which has been listed as the number one problem in medicine. Patients do not follow doctor’s orders and usually discontinue medication after they leave the hospital. While they are in the hospital, nurses can monitor and ensure that the patient is receiving the medicine the doctor ordered, but after they leave the hospital it is quite difficult for the family to ensure medication compliance.

For males, a common side effect of these drugs is the difficulty in establishing or maintaining an erection and problems ejaculating. So they simply stop taking the medicine. Other psychotic patients do not believe anything is wrong with them and hence they don’t need it. Acutely paranoid patients believe people are trying to poison them and so won’t take it.

How strong are these medications? For Thorazine and Mellaril, it was not unusual for patients to be placed on 200-300 mg daily. The nurse on our intermediate care ward decided to test the effects of these drugs. The minimum dose of Thorazine was 25mg. So she took one on her day off and told me it knocked her out and she slept all day. For our psychotic patients, 200 mg often produced little results.

These drugs are no longer in common use. The newer anti-psychotics have been termed “atypical” anti-psychotics. They derived that name because they were supposed to be prescribed after the other available medications were proven less effective. However, they have become the first line of treatment for psychosis, although the name “atypical,” now a misnomer, remains prevalent among prescribers.

THE LIBRARY

Our psychology department had a really good library of books that was available to us. Since the vast majority of staff was psychoanalytic/psychodynamic in orientation, the bulk of those books were, too. We were given sufficient opportunity and time to read those that interested us and even check them out and take them home. I availed myself of them quite frequently. On one particular occasion, one of these books came in really handy.

I had taken an “incomplete” in one of my testing courses (on the Rorschach Inkblot test), and had to arrange to take a make-up exam. I contacted the teacher and we set a date. We were allowed to bring in one book for this exam, which I knew was going to be the test responses of a person who took the Rorschach, and we were required to interpret it and reach a diagnosis citing the test evidence to reach our conclusion. There was one book in the library that dealt with differentiating schizophrenia from organic brain disorders based on Rorschach responses. It was written by Irving Weiner, Ph.D., ABPP, whom I later met at conferences, had dinners with and contributed articles for in some of his later books. My coursework only touched on this issue in a tangential way and I bet the instructor believed that students would bring their textbook with them to the exam. I didn’t need to do that, as I knew the various signs and indices, how they were formulated and their potential meaning, so I brought Irv’s book to the exam. The teacher inspected this book and said, “You can bring in any book to this exam, except this one,” and confiscated it.

Now why would he do that? There could be only two reasons: (1) he selected the case for the exam that was in that book, or (2) it provided the evidence that would be directly coordinated with the task of the exam. In either case, I therefore assumed that the diagnosis was either schizophrenia or organic brain disease. (I aced the exam.)

RESEARCH

There was minimal research at the hospital. When I returned from school, after taking a leave of absence to pursue my doctorate in clinical psychology, the chief of the psychology program assigned me, for the summer, to the psychology department with no official duties. In effect, he was granting me three months to work on my dissertation full-time by conducting my research with the patients at the hospital. I diligently pursued lining up patients to test every day—all day. One day, the chief approached me and said,

“Bob, you are the only person I know who is all ego.”

“Well,” I said, “if, by that, you mean I will not anything stand in the way of completing my dissertation, then I will accept your complement.”

Now, in order to conduct research at all institutions, a research protocol must be followed. Usually a committee at the designated institution must review and approve the proposal. This group is usually called an Institution Review Board. They ensure that the research is not dangerous to the patient, that the patient is fully informed of any potential risks or adverse effects, that the patient is informed, within limits, of the nature of the research, and that the patient is informed of the right to withdraw participation at any time during the experiment. These rights pertain more to medical research, but are also applicable to psychological research, even though there are few potential side effects or adverse effects from such participation. The patient must agree to and sign a Research Consent Form, of which they receive a copy.

During the time I was conducting my research, I had approval from the Institutional Review Board from my University, but our hospital did not then require such formalities. Patient consent was simply asking a patient if they were willing to participate. If they did, the testing began (before they could change their mind).

My dissertation, titled “Overinclusive Thinking and Performance Behavior of Chronic Schizophrenics Under Competition,” tested two theories of schizophrenic thought disorder. Kurt Goldstein argued that the main thought disorder of schizophrenics was their concrete thinking, which he defined as the inability to form concepts. Norman Cameron theorized that their thought disorder was characterized primarily by overinclusive thinking, which he defined as the inability to maintain conceptual boundaries so that environmental stimulation is fused with personal ideation. Both theories made different predictions when the patient was placed under conditions of cooperation or competition.

Every day I would scour the wards, asking patients if they would like to play a game, answer some questions, and earn a chance at a prize. I was testing two theories of schizophrenic thought disorder by assessing whether cooperation or competition increased the level of anxiety and thought disorders with chronic schizophrenics. Patients were asked to name as many words as possible in 60 seconds and given several trials to this. Patient were in either a cooperative or competitive situation, with the promise that whoever did better would receive a package of cigarettes. In actuality both patients (tested individually and in pairs) were given the cigarettes.

Cigarettes were highly valued by the patients and hence were an attractive inducement to elicit their cooperation. Today we would not use tobacco products as a reward, as we have become more aware of their bad effects on health, but in those days this was not well known.

I did have one unusual experience while testing one of the chronic patients. He was cooperative, but had the longest belt I have ever seen. Between trials, he would wrap this belt around his body. The belt went around his waist two or three times. Then he would pull it as tight as possible and grunt. He did this repeatedly between trials of the experiment. Later I was telling my supervisor about this behavior and he asked me if I ever asked the patient why he did this. I told that as long he was cooperating in my experiment, he could do anything he wanted, as it was difficult enough to get patients. To participate in research I have often wondered what this patient might have been like as an individual therapy patient. I would guess that this behavior was a kind of self-flagellation, but who knows? This patient was not assigned to the ward I was working on and I never really knew anything about him.

The other “unusual” experience I had with this study occurred when it came time to analyze the results. While in graduate school, I had to take a required course on advanced statistics. This was actually the third course in a sequence of courses, with the additional requirement of having to learn computer programming of the raw data. The professor had arranged computer time with the university computer and, at that point in time, all computerization was done with IBM punch cards. We were given the new cards and had to punch in the data.

We started slow, programming the calculation of a simple arithmetic mean. The professor gave us the raw data, and we had to go to the computer center, punch in the data, and then give the printout to him, demonstrating that we had mastered this module. Then we had to calculate the mean and standard deviation using a different data set, then the mean, standard deviation, and T test of significance, then a correlation coefficient analysis, then an analysis of variance, then an analysis of covariance, and so on. Each time we had to submit the printout (with the correct answer). I must admit that I was not very facile with these tasks. I probably set the record for number of error messages until I could get the correct answer. I would borrow another students program to ensure mine was correct. I would use his/her program with the data I received and it would work. When I submitted my program with the same data, I got error messages. So it was my programming that was at fault. I was spending more time with this course than all my other courses combined, and all of it was in the computer lab trying to find my keypunching errors.

One of the analyses we had to program was a two-by-two multifactorial analysis of variance. Now, this was the design that I had in mind for my dissertation, so I was very motivated to get it right. I saved the program punch cards, knowing that I would need them later. All I would have to do was to punch in different data, because the analysis should work. After I had collected all of my data, I punched in the new data, submitted to the computer center and anxiously awaited the findings. Oh no! Multiple error messages! I tried several more times, with the same results—error messages. I deleted all the data and inputted it again—with the same results. I went back to the raw data we had used for this module in the stat course, ran it through the computer, and it worked fine. So it was not the statistical program that was at fault—it was my keypunching of the data that was the source of the problem.

So all my ingenuity that assured me I would save a great deal of time by using the computer was for naught. I had to input this data by hand into the old Friden calculator. And believe you me, that took forever! And I had to do it twice, to make sure that I got the same results. The only fortunate thing for me was that the Psychology Department had a Friden calculator. I spent literally weeks inputting this data and running a myriad of analyses, which, if done by computer even in those days, would only have taken a few minutes.

After my experiment was finished, the director of the psychology staff asked me to present my research design and findings to the psychology staff. I felt this would be good preparation for my final oral examination, where I would have to do the same thing to my university professors, so I readily agreed.

Anyway, I had two colleagues ask me if I could help arrange patients for them to conduct research for their dissertation. One person was doing a body image study using the Rorschach inkblots and a body-distorting mirror. He allowed the staff to try this mirror, which was kind of neat. The entire effort was innocuous and probably of interest to our patients, so I arranged for several patients to be tested. Again, he had university approval for this research but he did not need hospital approval.

Another colleague I had first met while I was a student studying for my master’s degree in clinical psychology. Afterwards, I worked for a year at the state mental hospital, then took a leave of absence for two years to study for my doctorate. I returned each summer to work there full-time between semesters. I was working there full-time after graduation as a staff psychologist when this colleague called me and asked me if I would be willing to arrange for some of my patients to be tested as part of his dissertation. I willingly agreed, after learning what his experiment was all about.

As far as I can remember, these were the only two research experiments done while I worked there. This was a primary clinical setting and research was not a priority.

WEEK ONE

The first two weeks was general orientation. We visited and met with various department heads, clinical staff, and administrative staff. The one thing I remember most about that orientation was the obvious amazement and glee when they learned how long we would be working at the hospital. To a person, they responded with enthusiasm that we would be there from one to three years, at least, depending on the amount of financial assistance we received. It was quickly apparent to us that the hospital was quite understaffed and most of these people were seeking some relief from the workload. Accordingly, they tried to convince us to select their work environment as our first assignment.

PSYCHOLOGICAL TESTING

During my internship, we had a strong program in psychological testing. We had a range of supervisors on staff as well as a nationally recognized consultant who came weekly for several months, teaching us her methods of interpretation.

One of my first cases was a middle-aged, married white male with a Ph.D. in economics, who had taught at the University of Chicago. In those days this university did not have the reputation in economics that it has now, but teaching at this university was still was considered a prominent position in most fields. However, he had not attained tenure, and his career was floundering.

On the other hand his wife was also employed there, and though she “only had a master’s degree” in her field, she was nationally recognized in it. That bothered him quite a lot, though he would try to hide his feelings on this matter. His diagnosis at the time was manic-depressive psychosis, which today is called bipolar disorder.

Because of his own lack of academic success vis-à-vis his wife’s fame, he had strong feelings of inferiority, which he used the defense mechanism called “reaction formation” to mask. So much of his behavior consisted of propping up his fragile ego.

I might notice a class ring on his finger and ask about his schooling, and he would answer, but soon turn the conversation back by saying, “Did you know that I taught Economics at the University of Chicago?’

“Yes,” I would say, trying to feed that ego.

At another time I was giving him an IQ test. Such a test could be very threatening to a person who doesn’t think much of himself or of his abilities, and I think it was. So to compensate for these feelings, he tried to manifest just how smart he was.

I was giving him a vocabulary subtest from an adult IQ test, and asked him to give me the meaning of the word “tirade.” He responded with the accurate definition, but did so in a haughty and denigrating manner.

“A spate of words. S—P—A—T—E.”

He spelled the word spate, as if I didn’t know how to spell it myself. Of course by choosing the word spate in his definition, he also revealed his clinical cognition was characterized by a “spate of energy.”

NEUROPSYCHOLOGY

Neuropsychology is now a mainstay in health psychology. This branch of psychology assesses the relationship between the brain and behavior. Such assessment requires a thorough understanding of the brain, its anatomy, and its normal functioning, as well as the neural substrates of impairment. Later, when I was employed at the VA Medical Center, we had a full-time neuropsychologist, a full-time intern in neuropsychology, and the other interns could elect a rotation in neuropsychology.

At the VAMC, referrals came to the neuropsychologists from both the Departments of Neurology and Psychiatry. The training of the neuropsychology internship also included case presentations weekly in the lab. The chief of neurology had his neurology residents, interns, and neuropsychology intern in the lab. He would present the symptoms of the patient and ask this group to predict or describe the state of the brain that would accompany this disorder. He would then show them the patient’s brain if it had been autopsied or relevant brain test results to affirm or refute their predictions. Then he would show them the brain or brain test results of another patient and ask them to predict what symptoms or problems the patient would have, given the test findings. He did not discriminate. He had the same expectations whether or not you were a neurology resident, intern, medical student on neurological rotation, or neuropsychology intern. I report this to show how much this science had changed in the intervening years.

But during my internship, the field of neuropsychology was a nascent sub-specialty in psychology. There were two major tests extant, the Ward-Halstead Neuropsychology battery, and the Luria-Nebraska test of Neurological Functioning. The Ward-Halstead dominated this young field, but the Luria-Nebraska was becoming increasingly popular.

Our training director set up an all-day seminar at the University of Chicago on neuropsychological assessment and testing using the Ward-Halstead battery of tests. We also had the highly awaiting expectation of meeting Ward Halstead himself, who was on faculty there. Unfortunately he had had a stroke and, when he came to “talk with us,” he had esophageal speech and was barely understandable. I felt sorry for him.

Anyway, we were anxious to get some exposure to this training, even though I did not plan to do any such testing later in my career. I was assigned a case to conduct “routine” psychological testing (i.e., not neuropsychological testing) and asked one of the staff if he would supervise me on the case, which he did. I reported all test results to him and he had a Ward-Halstead training manual. He drew it out of his desk drawer and began to consult it. As I went over each test he went over the test manual and pinpointed the area of the brain with which the patient was suffering. He concluded that this particular patient had left-sided parietal brain damage.

I was very enthralled with the way this supervisor went about the business of supervising me and diagnosing the source of the problem. I touted his abilities with the other interns and urged them to ask him to supervise them on one of their cases. I asked him to supervise me on the next case, and again he pulled out his Ward-Halstead manual and went through the test signs and concluded that this patient had left-sided parietal brain damage.

I began to be a little suspicious, so I asked him to supervise me again on a third case. This time the patient had frontal lobe damage. You know the old saying: Fool me once, shame on you; fool me twice, shame on me. I consulted with my intern colleagues and they reported the same experience. It didn’t really matter what symptoms or problems any patient exhibited, the foregone conclusion was brain damage. I never asked him to supervise me again.

I understand that many believe that there must be brain damage associated with mental illness, yet that in and of itself is controversial. Some believe that while some mental disorders may be associated with brain malfunction (e.g., schizophrenia), others believe that stress can cause mental disruption. There is also an intermediate view, whereby stress triggers an underlying biological substrate disorder. These views continue to be argued to the present day.

For example, when the Diagnostic and Statistical Manual of Mental Disorders (DSM), the official diagnostic manual of psychiatrists, was revised, it contained two disorders that caused some contention among mental health professionals, especially those who did not espouse a biological explanation of these disorders.

The first was schizophrenoform disorder. To make a diagnosis of schizophrenia, the patient must manifest a cadre of listed symptoms (called criteria sets) for at least six months. If the patient had these symptoms, but has not had them for six months, then they are to be diagnosed with the schizophrenoform disorder diagnosis. The belief is that they will eventually reach the six-month diagnostic criterion, as if it is a biological determination. Those who believe in a biological causation of schizophrenia take this position.

The second instance was the introduction of a new personality disorder called schizotypal disorder. It was considered one of three more serious personality disorders (the other two being borderline and paranoid disorders). The diagnostic criteria sets were written as if this was the biological personality substrate that formed the “necessary” traits that put one at risk for developing schizophrenia.

CLINICAL INTERPRETATIONS

At the other extreme were those supervisors who took a strictly psychoanalytical viewpoint to understand and explain all behavior. Psychologists developed a group of tests called “projective” tests. The projective hypothesis asserts that all human expression emanates from our basic personality. Therefore, any behavior is potentially interpretable if we knew about that personality and its historical origins.

If this is true—and I believe that it is—then activities such as graphology (handwriting analysis) can reveal personality traits. The written hand comes from our own projection. And that is why such things as reading tea leaves, tarot cards, and astrology cannot be accurate because they do not come from our own behavior. If anything, what is more likely true is that the interpretations more accurately reflect the personality of the interpreter. That is the danger of interpreting projective tests. Does the interpretation reflect the projection of the psychologist or does it more accurately reflect the personality of the patient?

Although the Rorschach inkblot test has its share of critics, a substantial body of research suggests it can reveal important aspects of personality functioning. Again, the basis of such conclusions comes from the fact that what the person sees in the inkblot comes from their own perceptions. That is why graphology can be revealing, but there is little research to date that validates many of the interpretations, such indices as slanted text reveals an optimistic attitude.

The general public is well aware of the symbolic nature of many objects, whose interpretations have often been used in jest. Cigars or other elongated objects are reputed to be symbolic of male genitalia. Rounded objects, on the other hand, are taken as vaginal symbols. Sigmund Freud popularized such usages in a book where he analyzed such things as slips of the tongue, dream association, and other symbols. However, and here is where the tires hit the ground, so to speak, sometimes a cigar is only a cigar and when a woman about to be married dreams of an intruder breaking into her china cabinet and stealing her valuable possessions, it may not mean apprehension about losing her virginity (hymen attack?), but perhaps a fear of being robbed while living in a dangerous neighborhood replete with crime. And that is the problem in interpreting these symbols and dreams.

Projective tests do not have the kind of validity associated with them that other tests do, particularly those with more objective answers, such as tests based on questionnaires. However, the Rorschach does have a strong body of research that does validate some of its principles.

Figure drawings became popular because their production emanates from the person and because they are replete with symbolic interpretations. For example, the appearance of a sun in children’s drawings is taken as the presence of a warm parental figure in the person’s life, or a wish for one. However, while research validates some of these interpretations, most are based on “expert” opinion. I taught projective testing to graduate students and I would distinguish those interpretations whose “signs” have a degree of validity from those based on expert opinion without empirical substantiation. I have also published research on some of these basic signs. So I am well aware of the data on these tests.

But as an intern, I had to accept what my supervisor said a test means, unless I could prove or demonstrate otherwise. And most of my testing supervisors took an analytic interpretation of test signs, including figure drawings. Here is an example.

I tested a white male who was about 24 years old. I asked him to draw the basic things (e.g., a house, a tree, and people of both genders) required of the test. His drawing of a man was on an island, standing on a barren landscape in front of a gigantic, snow-capped mountain.

The supervisee offers an interpretation of the person’s test response and the supervisor comments on the interpretation, either concurring with it, challenging it to see if we could properly defend, or tell us what it “really” means. Concerning the above drawing, I said the patient feels lonely, isolated and emotionally barren. (There is no research that suggests any of that, but it seems to correspond with some aspects of his present circumstances.)

The supervisor asked me how I arrived at that interpretation. I cited my evidence. I interpreted the mountain as symbolic of how much he felt he had to climb to get over his problems. Here is what followed:

“This patient feels engulfed by a mother who abandoned him. He strongly desires to be nurtured, and yearns to be one with his mother, who did not love him in the way he unconsciously desired. So this patient has an unresolved oedipal complex.”

“Now how did you arrive at that conclusion?”

“Because that is not a snow-capped mountain. It is a gigantic breast with a nipple.”

Now he was serious, and that was an example of how he thought and interpreted figure drawings. One problem I have with such interpretations, other than the fact that they have not been empirically validated, is the fact that the basic interpretations all lead to the same conclusion: an unresolved oedipal complex. That was a very popular way of interpreting these tests, particularly among those who had been trained a few decades earlier. Another such case could have had direr consequences—for me, and for the patient.

Many years later, I decided to apply for Board Certification in the specialty of Clinical Psychology. For this examination, I had to complete an application documenting my qualifications and experiences, along with producing proof of such things as diplomas, internship, state license, and employment verification. After my qualifications were approved by the boards and they indicated I was eligible for examination, I had to produce a taped clinical diagnostic interview (fully transcribed), with diagnosis and treatment recommendations, copies of a full battery of psychological tests (e.g., objective and projective tests), and a tape of a psychotherapy session (also transcribed), with short- and long-term goals and a report on how my session addressed the short-term goals. Although I could have presented three different cases as an example of my proficiency on these areas, I only presented two, and the therapy case included the patient’s psychological test results.

I had to go to the campus of Indiana University Medical School in Indianapolis, where I was required to spend the entire day. In addition to reviewing my assessment materials with a panel of three board-certified psychologists, I had to interview a live patient that they provided, again giving my diagnosis and treatment recommendations. I then had to return home and write a formal report of this analysis, which was also part of the exam.

The patient, whose test results and therapy tape had been previously submitted, had a very problematic psychological history. However, the problem was all of her psychological test results were normal. Now how could this be, given her history, which should have resulted in far more psychopathology than evinced on testing? I thought the panel might help me understand this, so that is one of the reasons I selected this case for presentation. During my presentation, I made this basic point, and said that while I was not a big fan of the Rorschach, I did give it in the belief it would tap the psychopathology I believed should have been there. The tests indicated she was not trying to fake them.The Rorschach revealed a basic hysterical personality structure, as was in evidence on some of the other tests, but that is commonly seen in many women. So again she appeared normal on testing. I asked what the panel thought of this. Here is the response I got:

“There is psychopathology in the test.”

“Where?” I asked.”

“In the figure drawings.”

“Where in the figure drawings? Which one?”

“In the Draw-A-Tree test.”

“Could you point out where in the Draw-A-Tree you detect psychopathology?”

“One of the branches at the base of the tree is longer than the other branch that forms the trunk of the tree, and that reflects psychopathology.”

Now I thought, This person actually believes this! I taught projective tests, including figure drawing interpretation, and I was absolutely certain no such research validated that “sign.” I could have contested this, pointed out the lack of research evidence, and asked him to cite any evidence that would substantiate his conclusion. However, I didn’t want to become argumentative. And besides, I needed his vote and didn’t want to antagonize him. So I said,

“Well, I teach my students that if the presence of a sign in one test does not appear in other tests, then that sign is probably not applicable to that person.”

“Okay, but that represents psychopathology.”

And we moved on and I passed. But that is an example of how supervisors, at one time, viewed the interpretation of projective tests

Let me provide another problem with figure-drawing interpretation. Let’s assume that I have given figure drawings as part of a battery of tests to a patient and that I am testifying in court on the interpretation of these tests and their meaning as it relates to personality functioning.

Me: “This patient feels isolated, alone, without sufficient resources in her environment to help her cope with her problems.”

Defendant’s Attorney: “On what basis did you make those interpretations?”

Me: “On the basis of the fact that her drawing of the tree displayed a skinny tree, void of many branches, without vegetation and no signs of growth.”

Defendant’s Attorney: “When did you test my client? When did she draw the tree you describe?”

Me: “On February 6^th.”

Defendant’s Attorney: “Dr. Craig, do you have a window in your office, where you tested my client?”

Me: “Yes.”

Defendant’s Attorney: “Isn’t it possible that my client simply looked out the window, and copied a tree she saw outside on the lawn? There wouldn’t be any branches on it, nor vegetation, because it would have been wintertime.”

Now the answer would be that what is important is the fact that she drew the tree she drew, because it comes from her unconscious. But let’s further assume you are a member of the jury. Which argument sounds more plausible to you?

This unproven psychodynamic thinking didn’t apply to only testing. There was a book in the department library, written by a psychoanalyst, that details any disease and reports on the psychological conflicts that produced it. Today, this source is not reputable, but it was during my internship and for some years beyond as well.

LET’S PARTY

The Psychology Department held a Halloween party at the house of one of the staff members. My fiancé and I were scheduled to be married the following week and this would be my fiancé’s first experience meeting clinical psychologists, other than college psychology instructors. We are not very creative when it comes to costumes and we had been to a fraternity toga party (what frat bother hasn’t?) and thought that would be the easiest costume to prepare, since all that was needed was a sheet and some costume jewelry.

That turned out to be a mistake, because the psychology staff, throughout the evening, tried to embarrass us by making snide comments with sexual innuendo, such as “Do you plan to snuggle between the sheets tonight?” One of my supervisors dressed up as Jesus Christ, with a “crown of thorns” in his head, a wig with long hair, and a robe-like dress. As a Christian, I found that particularly offensive, but, wisely I think, I kept my mouth shut. The wife of one of my supervisors kept extolling the size of her husband’s penis. She said she planned to make a cast of this giant genital and place it out on the front lawn. Meanwhile he kept smiling and smirking and didn’t contradict her. Another psychologist tried to do the cha-cha while doing a handstand, broke his wrist, and had to be taken to the hospital, where it was put in a cast. He returned later that night, asking us to sign it.

That was the introduction to psychologists for my wife, who, for quite some time, was reluctant to go to any such parties until I assured her that the people I was then working with were more traditional than the ones she had met during my internship.

The next psychology party we went to as a couple was with some of the younger psychology staff members from the hospital as well as some psychologists we had gone to school with and who were working elsewhere. This was another Halloween party and one of the couples dressed up in one of the best costumes I have ever seen. He came as an artist, dressed in a paint-covered smock, beret, paint pallet, and artistic brush. His wife came as “the picture.” She was in a velvet gown, a wig of flowing black hair, with cosmetic makeup applied quite appropriately, with a picture frame mounted on her should as if she was the painting. And here is the kicker. The frame had an interior, battery-operated light that lit up just as you might light up the china cabinet to enhance the contents inside. We bobbed for apples (she had to take off the picture frame on her shoulders to participate in that event), played an anagram game consisting of words all related to the occasion, and generally had a good time. Now that was a party!

The interns also held a party. The female intern was invited but declined. Those of us who were married brought our wives. (I convinced my wife it would be okay to go). It was held at the suburban house of one of the interns and, as the saying goes, a good time was had by all. We tried to avoid talking about work and our supervisors, but I must admit we succumbed to the temptation.

The last party I will mention was held in the basement of the apartment building where our acute unit staff nurse lived with her husband. She said it would need some cleaning up, so, one evening after work, she and I went over there and cleaned up the basement. She said the toilet was broken and she didn’t want 40 people going two floors up to relieve themselves and I wasn’t about to call a plumber to fix their toilet. Fortunately, I was able to fix it myself, so the party was on.

All staff from our acute unit were invited along with their spouse or significant others. My wife refused to attend, so I went alone. This was a mixed racial crowd: the psychiatric aides were African American and the clinical staff was all white. One of the aides, who was very buxom even with her clothes on, showed up in an extremely low-cut dress, that put even bikinis to shame. She came alone and spent the evening flirting with everybody. Most of the staff was making snide comments about her dress and behavior and the following Monday I heard the charge aide reproaching her for dressing in that manner, telling her “you’re very big on top.” I think she knew that already. I was glad my wife didn’t go to that party, because I’m unsure she would ever gone to another psychology or mental health party again.

STAFF PSYCHOLOGIZING

The bulk of my supervisors were psychoanalytic in orientation, wore beards (emulating Freud?), and tried to carry themselves in an erudite manner, as if they had the answers to all troubles. I was talking to one of them one day, a person who I had thought was particularly reasonable, until the following conversation changed my mind:

“I can’t stay too long, I have a session with my analyst.”

“You’re in psychoanalysis?”

“Yes.”

“Not to get too personal, but why did you do that? You seem pretty okay to me.”

“Thanks but there are some issues I’m working on.”

“How has it been going?”

“Fine, but I got off to a rough start. For the first ten sessions—and I was going every day—the analyst said that I could only talk about my childhood. One day I was laying on the analyst couch talking about my past and I got a funny feeling. I looked over and the analyst was asleep. I didn’t know whether I should wake him up or just keep talking.”

“You woke him up, didn’t you?” (That’s what I would have done).

“Not immediately. I just kept talking, hoping he would wake up and I would not be embarrassed, but finally I stopped and woke him up. He got really angry and said that he never would have gone to sleep if I had been talking about something important.”

“You dropped him then, didn’t you?”

“No, he’s a really good analyst.”

Now I understood better why he needed analysis. That showed really poor judgment to in my mind.

HE DIDN’T LIKE TESTING

There was one person who interned with me who didn’t like testing and didn’t plan to do any of it after he graduated. However, he had to learn it, just like the rest of us. In group supervision formats, he rarely spoke up unless called upon and rarely offered any suggested interpretations. It was the same thing when our testing consultants gave us seminars on psychological testing. Worse yet was how he handled test interpretations in individual supervision. He would test the patient, and then go through the testing files that were stored in the department files, until he found a patient who had a similar if not an identical test score, go through the test report and lift the section that reported on the meaning of that test sign. To me, this was much more effort than trying to master the subject in the first place. And besides, there were mitigating factors that could alter the interpretation of any given test finding, so even lifting a paragraph or two of interpretations could easily be wrong.

However, it was probably more of a mental block than lack of ability. We had a seminar led by a nationally known figure in this particular test. She had been hired by the Internship Director to enhance our training in psychological testing. On several occasions during the seminar he offered what turned out to be very accurate interpretations and I was impressed with his level of skill here, especially since he spent most of the time telling us how hard testing was for him.

Towards the latter part of our internship supervisors somehow discovered that he was lifting data, and he had not been getting good reviews on his testing experience anyway. They made a deal with him that they would give him a passing grade on the testing part of the internship that pertained to psychological testing if he agreed to sign a letter of intent that stipulating that, after graduation he would not do any psychological testing.

He did sign the letter, which was essentially unenforceable. After graduation they had no control over his practices and once he attained his state license he could do whatever he wanted, as long as it was ethical. He went on to have a successful career in individual psychotherapy in private practice and never did do any psychological testing.

SEMINAR REFERRAL

We had an excellent seminar on interpreting the Thematic Appeception Test. This test requires the person to tell stories about pictures, which are then analyzed along certain dimensions. The seminar leader was a nationally recognized expert, who had written a seminar text on her method of interpretation, and who they had brought in just to teach us this method. I did very well using her approach and, as part of the learning process, we had to take this test ourselves, which she then analyzed for us in private consultation session. Following my private session with her, she asked me if I would be interested in working part-time analyzing test results for an executive consulting firm, for which she consulted. This required me only to analyze tests and then write reports to the consulting firm. I was pleased that she recommended for this opportunity and eagerly expressed my willingness.

She gave me the number and name of the person to contact, and they asked me to come for an interview. As part of their evaluation of me, they wanted me to analyze a set of tests for an executive they had already evaluated. I said I would be willing to do this as long as they paid me for my time. They agreed and arranged for me to come to their office on a Saturday. Except for the Thematic Apperception Test, I had not been exposed to any of the tests this firm had given this executive. However, they provided me with the test manual along with the test results, and I had been trained on how to evaluate objective tests, so it wasn’t that hard for me to do.

To my amazement, when I opened the test folder, there in front of the file was the actual report the firm’s psychologist had written. Thus I could have had the “answers” so to speak, if I had chosen to do that.

Now industrial psychologists have different ways of assessing clients. For example, if they take a client out to lunch and ask them to pass the salt, they observe whether he just passes the salt, passes both the salt and pepper, or asks whether you might want the pepper too. Then they make personality interpretations as to which one of these the person chooses. So I was unsure whether they were testing my honesty and integrity or whether the merely forgot to pull the test report from the file.

I decided to play it honestly. I really wanted them to judge my interpretive competency so I put the report aside and interpreted the tests and then wrote my report. After I had finished I then read the original report. Of course this report was more polished than mine, as the psychologist knew the tests better than I did. However, my report covered the gist of the main issues for this client. Then I wrote the following statement and attached it to my report:

“Upon opening the client file the official report was in the folder. I did not look at it until after I had completed my assessment because I wanted you to judge my interpretive skills.”

I thought this was both the honest and ethical thing to do. Besides, I didn’t want to get this job under false pretenses. So did I get this job? No, I did not. Because one week later, the owner of the firm was arrested and indicted for bribing officials in order to get city contracts. They gave him immunity from prosecution if he testified at trial against these officials, which he later did. Of course, his contracts with the city were terminated and he no longer needed any part-time workers. Several of his full-time employees also lost their job.

SAY HELLO TO THE PEOPLE, JUNIOR

Certainly behavior therapy has its place in our clinical armamentaria. It is specifically recommended in cases of simple phobias, but it has been tried in a number of different problems. One case I remember occurred on a field trip during my internship.

We went to a facility for the mentally retarded, about two hours from our hospital. This was a state institution that had a variety of programs and cases, from crib cases to the educable mentally handicapped. The crib cases were most enlightening and a good training experience. It is one thing to read about cases of pica (e.g., cognitive deterioration resulting from ingesting lead-based paint) and yet another to actually see such cases first-hand. We saw cases of people with hydrocephalic (abnormally large) or microcephalic (abnormally small) heads, all with various degrees of mental retardation. These were but a few examples of these textbook disorders that were available to us during this all-day excursion. Invariably, the following day, our intern group spent some time discussing the pros and cons of euthanasia, as these cases (i.e., people) would never improve and the severe cases would never leave that institution.

However, there was one case of a mentally retarded patient of which the staff psychologist was particularly proud. He was a 20-something black male who was mentally retarded and had had a severe case of head-banging. He would bang his head against the wall with such force that it occasionally would knock him out. They tried a variety of approaches, to no avail. Somehow they discovered that he liked to smoke cigars and the psychologist use this as a reinforcement to get him to stop banging his head. The psychologist explained to us the procedures he used to accomplish this feat and, no doubt, he had improved the functioning of this resident through behavior therapy.

He brought the resident into the room, where he stood before us, somewhat slumping in stance, but quite muscular. I could imagine the difficulty the staff had had with him when they were trying to get him to stop head-banging. The psychologist said a few words about the patient, who they called “Junior.” He asked him if he would like a cigar. The resident replied “yes,” whereupon the psychologist lit the cigar for him, gave it to him, whereupon the resident put it in his mouth and began puffing it without inhaling it.

Psychologist: “Say hello to the people, Junior.”

Resident: “Hello, to the people, junior!”

We didn’t know whether to laugh or not. I think we wanted to laugh but were afraid to do so, fearing the resident’s reaction, and I certainly didn’t want to offend the psychologist, who had put in much time getting him to perform the desired behavior. But I remembered thinking, Is this the effect of behavior therapy?

Any intervention may have both positive effects and negative effects. While medications produce their primary intended response, such as opiates’ control of pain, they also have side effects, such as potential opiate addiction. This was the case with Junior. He had taken behavior therapy to an autonomous realm (that was the bad) but was able to stop head-banging (that was the good).

ADOLESCENT WARD

Most of my work as an intern was on the adult wards. The hospital also had separate child and adolescent wards. The child ward was headed by an (unlicensed) physician but a senior staff psychologist headed the management and clinical activities of the ward. He seemed pretty normal to me, but unfortunately the child unit did not allow trainees there, for reasons I never understood nor explored. I really had no intentions of working with children anyway, so I didn’t want to waste my time.

I had no intentions of working with adolescents either, but I thought it would be a good experience, so I elected a six-week rotation on that ward. It was headed by an (unlicensed) physician who rarely seemed to be around. The ward had a staff psychologist there, who chaired the community meeting with the patients, but was deemed too young to supervise an intern. Another staff psychologist conducted group therapy with some of the adolescents on that ward and became my supervisor for the six weeks that I was on that ward, where I participated in the group therapy, interviewed the teens for diagnostic and behavior analysis training, and participated in team meetings and in the community group. Three experiences stand out.

First, and most meaningful, was a 15-year-old African-American female who had been admitted several weeks ago. My supervisor asked me to interview her for diagnosis. Her story was that she was out on the roof of a building when the police were called and she was coaxed off the roof and then taken to the hospital. The admitting papers said she was suicidal.

When I interviewed her (and I will tell you it was early in my training, as my first excuse), I could not find anything wrong with her. She denied any suicidal ideation. She said this was all a mistake and asked me to see if I could get her discharged. When I asked her why she was on the roof, she said it was hot in her mother’s apartment, it was not air-conditioned, and she put the mattress out on the roof, so she could get some air and go to sleep. I probed and probed her motivation and her story remained unchanged. Afterwards, I checked the medical record.

Now for training’s sake, sometimes we were able to consult the medical record prior to the interview, and sometimes we were not permitted to do so and had to glean as much information as we could from the interview, free from possible information bias. There are advantages and disadvantages to either method. Most of the time, it saves time to learn as much about the patient as possible, but having no information is good training, even though we rarely approach clinical interviews blindly.

Anyway, upon checking the medical record after the interview, I learned that the roof was on an angle of about 45 degrees. All along I had assumed it was a flat roof. It wasn’t. Now that in and of itself doesn’t prove she was suicidal, but it does suggest bad judgment, even if her story was true. That one training incident taught me to be as explicit and concrete as possible when interviewing patients concerning the details of a particular act. (I should have known this anyway. During my late adolescence, I came home one night, and my mother asked me if I had been drinking. I told her I only had one glass, which was true. But I never told her it was a quart glass.)

Second, my experience in group therapy taught me that when dealing with adolescents you have to make modifications in training and the work doesn’t often correspond to what is recommended in the textbooks. The one immediate disagreement I had with my supervisor was the fact that he always brought treats to the group. Usually it was glasses of pop, or candy bars or cookies. His point was that the adolescents wouldn’t come to the group if they didn’t have treats. My opinion was that it was bribing them to attend and they should be motivated to attend in order to get better. Now who was I to argue with someone with vast experience compared to my wealth of no experience? So my next learning experience on that unit was the loss of naiveté.

Third, one of the reasons that I disliked working with adolescents was the fact that they lie, and frequently. I couldn’t trust much of what they were telling me in interviews, and couldn’t believe much of what they were talking about in group therapy nor in the community meetings. One incident has stayed with me, but for the wrong reason.

The staff psychologist was dating the unit nurse. They were often seen together and it was no secret that they were involved, and the adolescent patients didn’t need many excuses to bandy about lies or allegations. In one of the community meetings, an adolescent patient claimed he had seen them kissing and making out. The staff psychologist denied this and convinced the staff that the patient was hallucinating. Later that day, when I discussed this with him, he admitted that the patient had been telling the truth. They were necking in the area reported by the patient. And he thought it was quite funny that he had convinced the patients otherwise. At that moment I lost all respect for him and gave him as little interaction as I could, given the parameters of the internship assignments.

The psychological testing of most adolescents is also a trial, more so when they are psychiatrically disturbed. Most adolescent patients think there is nothing wrong with them. They blame their problems on others—parents, teachers, police, and other authority figures. And they remain defensive, uncooperative, defiant, and problematic.

An example of this was a 15-year-old white male who refused to cooperate with testing. He said there was nothing wrong with him and he didn’t have to do it. Most of the time I would tell the patients the reason for testing, and how the results would be used to benefit them. Sometimes with adolescents I would say that while we do not expect to find anything seriously wrong, we do want to cover all our bases to make sure we don’t miss anything. I would use taking blood tests as an example, telling them the blood test acts as a screening test for the body and the tests I was about to give acted as screening tests for the mind. As a last resort, I would tell them their doctor had requested these tests.

With this particular patient, none of those ploys worked. So I agreed with him that we couldn’t force him to take these tests but we could force him to stay here until time was up, which would be in 1½ hours. I told him to just sit there. Meanwhile, I had work to do, and I pulled out some test material I had already collected on other patients and began analyzing it and writing up a draft of the report. I also scattered the Rorschach inkblot test cards in an array on the table, so they were clearly visible. I hoped that curiosity would get the better of him. It did.

He finally picked up one of the cards:

“What is this?”

“What does it look like to you?”

“It doesn’t look like anything.”

“Boy, you are really weird. Maybe there is something wrong with you. Everybody says it looks like something.”

“Well, it might look like a...”

This continued for several of the cards. This was a very atypical test administration. I did the same thing with a test that requires telling stories to pictures (the Thematic Apperception Test). Again, the administration was out of the desired sequence but at least we got some material to analyze. Later I would adapt this style of testing with other defiant or uncooperative adolescents.

So overall my experience in working on the adolescent ward proved beneficial, but in unexpected ways.

INDIVIDUAL PSYCHOTHERAPY

Our internship was strong in clinical interviewing and group therapy. It had an excellent resource library in the department, and we had very good training seminars. However, it seemed deficient in mentoring individual psychotherapy. In fact, we were prohibited from seeing patients individually, for reasons we could not understand. We were promised that in the second half of the internship we would get training on this modality, but most of us couldn’t wait. So we found ways to conduct individual psychotherapy on the sly and without our supervisors learning of it. In the second half of the internship they brought in a board-certified clinical psychologist to conduct a seminar on individual psychotherapy, and we were assigned individual patients to see. Meanwhile we continued to see those patients whom we had already began to see individually, and I don’t think the department ever learned that we had been doing this.

BOARD CERTIFICATION PREPARATION

While working as a staff clinical psychologist, I felt I had developed sufficient skills to pursue board certification in clinical psychology. The awarding of this certificate is peer recognition of a person’s clinical competence in the selected field. Board certification has long been a requirement for physicians and surgeons. Psychology had tried to emulate this in fields of specialization, but it never acquired the degree of necessity that it has attained for medical doctors. Still it is a desirable credential to have, and I had an opportunity to begin training for this certificate.

On staff were two board-certified clinical psychologists. One was an expert in group therapy and the other was an expert in family psychotherapy. I was doing both and gaining competence and confidence in both, but was uncertain in which I was stronger. So I asked them both if they would supervise me in those modalities and make the supervision as if it was an actual board exam. Both agreed, and I did this for about a year but continued to be ambivalent about pursuing it, since it did not mean any increase in income for me and applying for an going to the exam was costly at that point in my career. So I never pursued it until many years later.

Since I was treating a long-term private patient in individual psychotherapy in my part-time private practice, I thought this might be my last opportunity to pursue certification, so I applied. Along with verification of credentials (e.g., doctorate in clinical psychology, internship, state license, requisite years of practice, and endorsement from two board-certified psychologists), I had to submit

•  A tape of a clinical interview, along with transcription of the tape, with diagnosis and treatment recommendations.

•  A tape of a therapy session, along with transcription of the tape, with short- and long-term treatment goals and specification of how the interventions within the session advanced those treatment goals.

•  Complete psychological testing with the accompanying report along with client history and referral information.

After notification that I was “board eligible,” I had to go to Indiana University Medical School, where I had to interview a live client behind a two-way screen where I was being observed (with client permission) by three examiners. I had to arrive at a diagnosis and treatment recommendations. After returning home, I had to write a clinical report and send it to them for review. They then examined me on the tape of my clinical interview and psychotherapy session. Finally, they quizzed me on my knowledge of ethics and contemporary issues in the field.

As I am typing this, above me on the wall of my office hangs my board certification in clinical psychology awarded by the American Board of Professional Psychology (ABPP).

CONGRATULATIONS, DR. CRAIG

I had completed my dissertation and now only faced my final doctoral orals to attain my doctorate. My university had two significant hurdles to overcome on the way towards the degree-awarding ceremony. The first was comprehensive examinations. We had to take written exams on two successive Saturdays, covering ten areas of psychology. The morning exams were objective: multiple choice or true/false exams covering five areas. The afternoon session consisted of essay questions, two each for each of the five areas, and we could chose to omit writing an essay on one of the areas.

The second hurdle was dissertation proposal orals. Here you had to propose an experiment with design features, statistical analyses, the methodology to be used in the experiment, the reason this experiment would contribute to the literature in that area, and report on what your results were expected to be. This hurdle was everything. If you could get past this hurdle, then you merely had to do the experiment, conduct a literature review, which had already been done as part of the proposal orals, and then write up the results and then discuss them. The final orals were “nothing” because if you didn’t know the area by now and you couldn’t meaningfully discuss the experiment and its results, then you didn’t deserve to graduate. To most of us the final orals were a “mere formality.”

There was one other “minor” hurdle, which actually became a major hurdle for most other students. The university had a requirement that if you didn’t pass your proposal orals within one year of passing the comprehensive exams, you had to take these exams again. This was a great motivator for me, because I had studied six evenings a week for six months prior to these comprehensive exams and I was not about to take them again.

I was assigned a half-day intake assignment during the summer and I requested a morning shift. Most of the time, patients didn’t begin arriving until 10:00 AM, so I had roughly two hours every day with little to do. I went to the hospital library, took out journals that contained the literature I needed for my proposed experiment, read them, and took notes. By the end of summer, I had completed my literature review. For one of my courses we had to prepare a paper, and I wrote what became the literature section of my dissertation. That saved me a tremendous amount of time.

The following summer I conducted the experiment, and wrote several drafts of it before I was ready to submit it to me dissertation advisor, who pronounced it in good shape and advised me to work with the Graduate School Department to schedule my final orals. My advisor already had a copy of my dissertation. The university had a policy that one member of your dissertation committee had to be a faculty member from a Department outside of the Psychology Department. This was to ensure that things were on the up and up. As I recall, the outside reader was someone from the engineering department, so I made an appointment with him and dropped off my dissertation and gave him the date of the oral exam.

I received authorized absence from the hospital for this exam and told them that I would report back to work after this was completed. When I got to school that morning, only my advisor, the outside reader, and I were in attendance. The Graduate Department had forgotten to notify the other three members of the committee, and so they were absent. The Graduate School tried to contact them to see if they could come to the exam in a reasonable amount of time, but they had classes and could not attend. So the date of the exam had to be rescheduled for the following week.

While my advisor was understandably apologetic, I told her, “You better not give me any trouble next week, given what I was put through today.” She didn’t and the committee didn’t either. It was the outside reader who actually found a mistake in my dissertation. While I had properly interpreted one of the statistics, I had mistyped one of its numbers and the outside reader pointed out that what I was concluding didn’t jibe with the statistic I was using to make those conclusions. When he pointed out the reference, I immediately saw the problem and reported the accurate value.

Anyway, I reported to back to the hospital after this postponement, where the psychology staff had planned a surprise party for me. As I walked into the room, there was a large sign reading “Congratulations Dr. Craig.” Well, I told them to take down the sign and told them what had happened. It was very embarrassing.

This was the second time I had some trouble with “orals.” For my master’s thesis, I wanted to do the experiment that I actually did for my dissertation. As I began the literature review, I began to see that this was too complicated and would take too long for a master’s thesis and so I decided to do something that was quick and dirty. My advisor had a rat lab—he was really an experimental psychologist and was doing what might today be questioned.

Basically he was trying to develop animal models of suicide. So, for example, he had timed how long a rat could swim before it would drown from exhaustion. He contrived experiments that provided various levels of electric shocks to the animal. He reasoned that this would replicate the amount of stress in the life of a human, Then he would open the cage door. Before the cage was a garbage can filled with water. After continuing to shock the rat, he would open the cage door, allowing the rat to jump into the garbage can. It would swim around until it was exhausted and my advisor knew about how long it could last. Just before it went down for the third time, he would come and rescue and revive the animal. The next day he would begin shocking the rat and then open the cage. If the rat jumped again, he reasoned that, given its prior experience, jumping was equivalent to suicide.

Another abusive experiment involving “suicide in the rat” consisted of placing hungry rats on a hanging platform. Again, from preliminary work, he had determined that height at which the rat would be crushed to death if it jumped off the platform, instead of only breaking a leg or only being knocked out. In the actual experiment, he food-deprived the rat, placed it at a height where it would knock itself out if it jumped, and then put food below the platform. The rat would eventually jump off, knocking itself out. He would then come, revive the rat, food-deprive it again, place it again atop the platform and providing food below. If the rat jumped again, given its prior experience, he reasons that was, again, “suicide in the rat.”

I don’t know if he ever published any of these experiments, but that was what he was working on when I was a student there. The locals didn’t like having this rat lab in their neighborhood. He would ride his bike home, late in the evening, initially riding down the alley, in back of his lab, as it was the fastest route home a few blocks away. Someone placed many broken bottles of glass in a long column on each side of a small barrier they had constructed. They hoped that he wouldn’t see the barrier and hit it, falling over onto the broken glass. Thankfully, he saw the barrier in time and avoided it.

Anyway, I decided to do a magnitude of reward study, which he approved of and did the experiment over a month-long experiment. Subsequently, he published the paper with me as a co-author. That was my first professional publication, and I was very excited about it.

In any event, I was scheduled for my orals, which was essentially on my experiment. I was brought into the room, seated, and this was the first question asked of me by an experimental psychologist:

“Why didn’t you use [statistic] to test for the linear or quadratic equation?”

Now I thought to myself that he was joking. He must have known how nervous I am, and so he was surely trying to relax me. No, I thought again. I’ve never known him to joke and so I better play it straight.

“I’m sorry. I’m not familiar with that statistic.”

“Trend Analysis.”

Now once he said “trend analysis,” I understood want he meant and why he had asked me that question. He understood that statistic mathematically and asked me the question mathematically. I didn’t understand it that way, but understood what the statistic was trying to do, and when and how it should be used. I thought that was sufficient for my purposes.

Now the real answer to his question was that I used the statistic my advisor told me to use. However, I was not going to say that, since, at this level, I should be able to think for myself. So I offered my explanation, and hoped my advisor would speak up, which he did. That was the only possible contentious issue during the oral exam. Everything else went smoothly. The last question they asked was whether or not I planned to pursue my doctorate, to which I responded in the affirmative.

They asked me to wait outside and they would get back to me shortly. One hour later, they still had not exited the room. Meanwhile, I was outside with all sorts of fantasies about why they were taking so long and I began to fear they would not pass me, based on my fumbling math ability. Then the opened the door and were startled to see me there. THEY HAD FORGOTTEN ALL ABOUT ME. They had busied themselves on some department business and lost track of their original purpose of being there.

So “orals” were not my cup of tea.

END OF INTERNSHIP

Perhaps, by now, you might be wondering what happened to our six interns, as well as what my eventual career path was. The female intern got a good paying job working in a school system after her internship and that was the last I heard of her. Another intern left the field of psychology and went into business. I lost contact with him, too. The remaining four were hired as staff psychologisst, as we still had years to pay back for our education. This time the hospital had a choice, and didn’t have to retain us, but they did.

One of the newly hired psychologists eventually was selected to head the Alcoholic Treatment Unit. He became the first psychologist at our institution to be named head of a program. The hospital physicians tried to create a stir, because a physician did not head the program, but had to relent and rationalized that it was all right since it wasn’t a psychiatric ward and the building was away from the main body.

I vividly remember the day this psychologist was named the director of the Alcohol Treatment Program. The chief of the psychology department called us into the conference room for an emergency meeting, where he made the announcement. The staff were stunned, and here is where the chief began to lie. He told the staff that he was very happy a psychologist had been named as head of a program but he assured them that any of his psychologists could have been named as the head of that program. He also alleged that he tried to convince the hospital superintendent to select one of his more senior psychologists, but the superintendent wanted the newly named person to head the program.

Now, I thought, none of the senior staff would have been a good selection and the psychologist named to the position was a perfect selection. I couldn’t believe that the staff believed any of this nonsense. But they did, because they began to thank him for thinking of them and for standing up for them. This newly named psychologist eventually went into private practice, doing psychotherapy and made a good living at it.

Another of my intern colleagues remained working with the state hospital system and eventually became the superintendent of one of the state hospitals downstate. A third colleague remained with the state for a few more years, then left the facility where he developed a successful outpatient private practice.

As for me, I was hired as a staff psychologist and remained there for seven years. At the end of the internship, we were expecting a final evaluation from our intern director. We never got one. So I insisted that he give me an evaluation, even though I had now been hired and was working there for a few months. The conversation went like something this and this is what I remembered from it.

Director: “I’m sorry this took so long and that you had to wait so long for me to do this. It is something that is difficult for me to do and I really don’t like to do it.”

Me: “I’m sorry too, but it is part of your job.”

Director: “I know, it just makes me feel uncomfortable. Well, anyway, I think the most serious fault you have is that you don’t act like a psychologist.”

Me: “Oh. I thought that was one of my strengths.”

Even though they had hired four of us to work there as staff psychologists, he never did give the other three their evaluations and they never pressed him for it.

While I was an intern, I had a stipend that paid $400 per month. This was tax-free. When I was hired as a staff psychologist, I was paid $450 per month, but this was taxed, and so I was actually bringing home less money than when I was an intern. Now I was happy with my job at the hospital, but I needed more money. After several months, I answered an advertisement for a rehabilitation psychologist that paid $525 each month and, much to my surprise, I was called to come in for an interview.

The facility was noted for its rehabilitation following medical trauma. The personnel director (now called Human Relations) had set up an all-day session with a variety of people from different sections of the hospital. Everybody was very gracious and cordial. It felt like a nice place to work with nice people. At the end of the day, I again met with the personnel director:

Director: “Well, how did it go today?”

Me: “Fine. But I think there might be one problem. I noticed that everybody I met was Jewish. Before we go any farther, I want you to know that I am not Jewish. I am Catholic.”

Director: “Oh, we don’t care about that. The only person we won’t hire here is an Arab!”

I couldn’t believe she said that. I’m sure, with all the litigation that potentially surrounds hiring decisions nowadays, no one would say anything like that now.

Well, I didn’t get the job. And I don’t believe that my religion had anything to do with their final decision. I believe that I didn’t have the background, training, or experience and so I wasn’t a good fit for that facility. It was just as well, because I don’t think I would have been happy there. So I stayed on and can report the tidbits listed in the following chapters.