Most psychotherapies, probably due to tradition, tend to pay very little stock on the social dynamics around the individual who is receiving treatment, unless it is looking for, either an explanation for the symptomatology, or for an immediate vehicle to modify the present suffering. However, if we consider a patient as a part of a multidimensional, social and biological system, with local areas of complexity which often clash with each other in many surprising ways, we cannot limit to one layer alone. I usually see examples of unexpected conflicts in sometimes overlooked dimensions. The following is a simplified example.

Mr. P is a middle aged  male who presents complaining of “not being able to say the right things to people”. He also tends to worry too much and spend a lot of time “ruminating” about his conflicting relationships with close family members, especially his wife and children.

His past medical history is significant, with some major issues, however completely resolved. He does not seem to be physically strong, but, there is some inner energy beyond what would usually be expected. His gaze is direct and focused; he moves with speed and coordination for a man his age.

As opposed to many other patients looking for “someone to talk to”, he is not particularly verbose or circumstantial regarding his somewhat painful exchanges with his loved ones (he just describes them succintly, with precision). Anxiety is always in the background when he describes emotionally loaded segments of his life and also evident during our encounter, although mostly hidden below the surface.

His does not brag about it, but he has had access to high quality education, and has become (on his own) a financial expert.

Not surprisingly, the more success he had in the areas of engineering and finance, the more he focused he became on expanding his proficiency in those areas. As it usually happens, self esteem gradually gets to gravitate around these abilities, and interaction with other people becomes more and more centered on the corresponding areas. There is constant positive feedback from people around his proficiency as a financial whiz and a provider (for his family). This particular lifestyle has been typically analyzed from the perspective of ‘personality types’ and ‘object relations’. However, here I show that there is no need to resort to metaphysical constructs to conceptualize this.

When it comes to family interactions, there is need for open channels at many levels. All layers of communication should be equally available, and the constant nuances of both cognition and emotion* should be able to be expressed and perceived by all parties involved. This uninterrupted collective drift allows for sharing experiences and to relate to each other’s states of mind. Changes of state of each component of the system needs to be followed by the other members and, while this is taking place, all of them are internalizing (‘recording’) the trajectory (‘sequence’). Since the number of cognitive trajectories is finite, as is the length of each trajectory, then the group gets to accumulate its own particular ‘repertoire’ of trajectories which become their ‘culture’ (family culture or otherwise); that is what allows them to ‘bond’. That sort of multilayered interaction is what allows  us to consider another individual ‘a person’, and not just the bus driver, the teacher, the  mailman, etc. When the number of layers of communication is arbitrarily lowered, our perception of people as persons becomes degraded and they become just ‘the man in the toll booth’‘, ‘the waitress’, ‘the mailman’, and so forth. They become less and less human and more and more of a utilization object. In the most extreme case they become livestock (or, if you will, raw material for lye soap).

Admiration and kudos can become as addictive as any other experience. Receiving them can make someone crave for more. The object that triggers them may become the center of our life. J.L. Borges, during an interview close to the end of his life said, “there is only Literature”; Bobby Fischer, at the peak of his career as a world champion said, “Chess is life”. On the other hand, Nietzsche did not hide his contempt for a man that had gradually become “only an ear” (maybe his ex-friend Wagner?) and for the fact that the common folk did not only take this man for perfectly acceptable, but even for “a great man”. And it does not end here; there comes the fear (constant fear) of losing the treasured object (Literature, Chess, the Ear, etc); so, there are additional efforts to defend and preserve it. Hence Krishnamurti’s blunt statement, “a talent can become a man’s curse”.

Mr. P’s children (and probably other family members) got used to deal not with a man, but with (as he himself says) “a bank”. His feelings? They don’t matter, as long as he can sign his checks. Also, since “the bank” is always open, there is no need to develop their own financial skills.

Does it mean we should not uncover and cultivate our talents? Not exactly. We must develop them. We must use them constantly for altruistic purposes. And we must always remember that we do not own them (it is rather a lease).

Is there any hope for Mr. P? Yes. However, it will require some work to stop “being the bank”. He has depended on that role for too long; his self respect relies on it; without it, he is nothing. So, the task ahead is to shatter his uni-dimensional axiology and help him to rebuild a new one. The change required is deeper than what a casual look may suggest.

*  Emotion is an evolutionary sophistication “on top of the basic neural networks”, one may think, due to the fact that operationally it may be construed as a multiplication vector that is going to assign “weights” and “priorities” to the “basic computational processes”. All as a response to the problem of dealing with an unwieldy amount of information in order to improve the likelihood of survival. The funny thing is that emotion was present from the beginning (including the olfactory and the limbic system), and it was probably the appearance of further cognitive levels, with abstractions (or, as Maturana would say, ‘coordinations of coordinations of behavioral interactions’) void of direct emotional content being precisely the evolutionary novelty.

It does make sense from an evolutionary standpoint, since it increases the efficiency and speed of the system (which can certainly use some help whenever it attempts to solve real world problems using deterministic approaches, and inevitably chokes with immense numbers).

Considering this, along with the fact that the production of language acts like the vehicle for sequentially increasing levels of abstraction, the existence of homomorphism is a highly likely (although not necessary) consequence. In a clinical setting, likely beyond a reasonable limit (let’s say 0.9999) is good enough for me.

So, mapping different layers of homomorphism (as some sort of metacognition) is probably another important cognitive activity in itself. That is the realm of ‘free association’, dreams and all sorts of art. Maybe that is what the frontal lobe does frantically during those precious REM sleep minutes. Maybe survival depends on it. Establishing a strong connection between the physical world and this metacognitive world should be the most important goal for humankind as a species. Considering that living systems are operationally closed (and have no way to distinguish between the inside and the outside), studying organization in general is equivalent to studying ourselves. Let’s do that.

Among primates, and humans are no exception, to hold their power, the dominant individuals need to systematically oppress their orderlings. Since early awakening is a common feature in old age, a good use of this feature by the dominant males is to force others to wake up early too. That way what is basically a health problem becomes a virtue and also a mechanism of domination. They can force all their subordinates to be at work before dawn. That helps them look responsible, hard working and productive. It’s also a way to infuse a sense of defeat on the ones in the lower ranks.
So, here is the answer why so many institutions have a mandatory early schedule. Our leaders set an example of virtue and work ethics by showing up at work earlier than everyone and obviously forcing everybody else to do the same. Only recently some voices have been raised to question the early schedules in schools, for example. However, popular culture (which is usually shaped by the dominant groups) still maintains the traditional association between early rising and hard work, virtue and honesty.

Life goes on, sometimes at mind boggling speeds.
However, I cannot overlook the importance of this historical day.
Many believe that this change is going to have positive repercussions all over the world.
On a deeper sense, for some reason Barak Obama reminds me a little bit of all-time human rights hero Nelson Mandela.

The physician turnover in hospitals all over the nation is very high; I recently read that it was 20% per year; different sources may probably disagree on the exact figure, but they will surely agree that it is above what you would usually expect. That strongly denotes a problem in the industry. Although financial incentives for physicians are good motivators to accept job offers, there is need for more to keep the new employee. What forces clinicians to leave the institutions? I speculate that it is quality of life.

For example, physicians are usually considered “exempt employees”, meaning that they have a variable daily schedule and are not required to punch time cards. This is supposed to be a privilege. The concept looks progressive because of its apparent flexibility and may probably apply very nicely to workers like programmers, writers or artists; you may come to work and leave at different times without being micromanaged, as long as you complete your projects in time and fulfill your duties. The physician, however, despite being an exempt employee, is required to be in the hospital at a specific time, usually 7:30 or 8:00 in the morning; what is really variable is the finish time, which is usually well beyond that of other employees; personally, I seldom left the hospital before 6 PM and met colleagues who would never leave before 9 PM. That obviously means that the “exempt employee” status is a sleight of hand to avoid having to pay the physician overtime.

Working hours are just one aspect of many that make current hospital jobs unattractive in the long run. But I think it is the administrators’ job to do their homework and figure it out by themselves. I don’t think it is as much a matter of insight as it is a matter of decision; I believe they know that it would be a lot cheaper to improve the permanent doctors’ conditions (and hire more of them) instead of getting a continuous flow of Locum physicians; I also believe that they somehow sense what has to be done to improve efficiency, decrease their department overhead and increase the workers’ satisfaction; it is not rocket science. What actually stops them from carrying out the necessary changes is probably fear to angry the establishment, since such changes would entail treading into the terrifying land of the unconventional. In the meantime, I believe that the Locum companies are going to keep flourishing during the following years, providing care for the areas with no permanent physicians.