COVID-19 and McFadden Mental Health

Information is being updated by the minute about Coronavirus. I am hoping for the best, but also taking reasonable precautions to serve both my patients and the public.

As of 4/25/20, I intend to be in the office as usual (Tuesday through Friday). If you feel traveling, and are not experiencing symptoms (fever, cough, or trouble breathing) you are welcome to come into the office. If you are having symptoms, or are concerned about exposure, let me know. We can do a phone call or virtual video meeting if you are in Pennsylvania or New Jersey at the time of our scheduled meeting.

In my office, the meetings are one-on-one - the lowest risk for any exposure. The office is large enough to allow appropriate social distancing. The Philadelphia Building has taken significant measures to keep surfaces clean and to provide hand sanitizer on each floor. I have a sink in my office if you want to wash your hands. I have been vacuuming and disinfecting surfaces in the office on Tuesday afternoon, Wednesday in the late evening, Thursday afternoon and Friday afternoon. The office is the cleanest it has ever been 😊

Until at least 5/8/20, I will be suspending any charges for late cancellations. I understand that this situation is evolving, and that you may need to make a last-minute decision. If you decide to not attend a meeting, please communicate with me. We could switch to a phone meeting at the scheduled time if appropriate, or iron out a new time in the near future.

Here are two links of interest, the CDC Guide to COVID-19 and the Philadelphia DPH Guide:

Let’s stay optimistic, take reasonable precautions…and smile. Viruses hate smiles.

More Sights of The City of Philadelphia

Here are some visions of Philadelphia local to my office. Philadelphia has beauty all around - it is a city that rewards the person who “stops to smell the roses.”

Sun Breaking Through Over the Delaware River

Zagar's Magic Garden

Zesoner - Philly Manga

William Penn from Broad and Chestnut

Walking into Philly on the Ben Franklin Bridge

The Interpersonal Limits of Problem Solving

“Would you please just listen and stop trying to solve my problems?!”

It is a request that comes up so frequently in relationships that we all can relate to it. Your partner is telling a story - maybe from their workday, maybe about a frustrating interaction with a family member, maybe about a health issue they are managing. You slip into “Problem Solving” mode without even realizing you have done so. “What I would do….” or “Why don’t you….” or “My advice is…” or “You need to….” and you are off to the races. The finishline? A problem neatly solved and placed in the “SUCCESS” outbox.

Why does this happen so often?

Some people are highly effective problem solvers. Some people earn their living by identifying and assassinating problems. For these people, it is easy to slip into this mode in their personal lives. Or, maybe the better way to put it is that it is hard for these people to shift OUT of problem solving mode when they get home. Hard to look for interpersonal opportunities other than problem-solving. Because they are valued for their problem solving in all other facets of their interpersonal life.

Also, problem solving is often a form of distancing yourself from your partners experience. By choosing a different path, you expose yourself to distressing emotions. For all of us, it is instinctual to try to avoid painful experience. Unfortunately, this leads to many missed opportunities for deeper interpersonal experiences.

What’s the big deal? Wouldn’t we all like less problems and more solutions?

Well, sure. But this puts the cart before the horse. It presumes valuing of “Destination” over “Journey.” It presumes the story is a problem to begin with, and that the supposed problem is obvious in one telling. So much of our communication is whitewashed today. By the media, by politicians, by institutions… and by us. Do we want to communicate a long-winded story about the ups and downs of our vacation? No. But we are happy to post a picture, and a glossy, twenty-five or fifty word summary.

The moral of the story is: we need to think about other options in conversation with our loved ones. Here is a brief list:

Reflecting - succinctly share the thoughts and feelings of your partner Expressing - reply with what you are hearing, interpreting, and feeling Inviting - imagine there is more to the story, and ask them to keep telling it. Crucial Conversations (Switzler, Grenny and McMillan) has great discourse on inviting others to tell their story. Their technique starts with facts, and moves to observing what emotions they create Commiserating - you share deeply of yourself and your individual experience, without making it about you Reacting - be human! You don’t always have to hold your breath and be thoughtful. You are allowed to react to intense stories. If this is an issue, pause to process it with your partner. After all, it is a more ‘reflexive’ part of expressing. It should AT TIMES help to deepen the discussion. Observing - perhaps there is data in the story that YOU can see, but you suspect is HIDDEN from your partner. Perhaps it is a pattern in the data, or a connection to other stories. Observing is an infomatics approach, where data becomes information that becomes knowledge. Processing - allowing a space for both your partner and you to digest the story Strategizing - sure, this is getting close to problem solving. But this is a broader discussion. Where is the story going? Are their goals? What are they? What are the paths forward? This has a very different feeling than problem solving. Problem solving is the surgeon going in with the scalple. Strategizing is the consultant trying to understand more about the situation and the goals in a broader fashion.

Local Visions of Philadelphia

Here are some visions of Philadelphia local to my office. Philadelphia has beauty all around - it is a city that rewards the person who “stops to smell the roses.”

2029 The Next Year of the Rooster

A Bolt of Lightning

First and Only Flurries of 2019

Italian Market

PMA to City Hall

Formulation as a Basis for Planning Psychotherapy Treatment by Mardi J Horowitz, MD

The cover photo of Dr. Mardi J Horowitz’s 2019 second edition of Formulation as a Basis for Planning Psychotherapy Treatment is certainly appropriate. Dr. Horowitz presents a clear road ahead to understanding the value of a formulation, and how he develops it for clinical use.

Formulation as a Basis for Planning Psychotherapy Treatment

Dr. Horowitz begins with macro-analytic formulation methods, and their utility in “continuous reduction of ambiguity in understanding complex interactions and enduring patterns of mind, brain, body, culture, community, and current stressors. The book reviews eleven parts of formulation methods that are almost universal. It presents a starting place for developing a formulation, considers the phases of treatment, and then gets down to the brass tacks of the book - the Configurational Analysis.

The book takes the reader through the five elements of the Configurational Analysis: Phenomena, States of Mind, Topics and Obstacles, Self and Relationships, and Integration and Therapy Technique planning. Each of these is broken down into clear elements with both technical guidance and clinical examples to build the readers foundation of knowledge, and confidence in applying the techniques.

“Formulation as a Basis…” is extraordinary. It is of use to the beginner, who is just starting to appreciate the importance of a formulation and how to build one. It is of use to the seasoned practitioner, who wants to sharpen or expand their formulation approach.

Two added notes. First, I presented lectures to medical students and residents using this book as source material. Dr. Horowitz was kind enough to allow me to distribute one of his many helpful tables to the class, which facilitated the learning process for the young physicians. Second, Dr. Horowitz has another book (“A Course In Happiness”) which presents the process of using the formulation from a patient-based point of view. The two books are a wonderful matched pair for the clinician who wants to better understand how their clients could be using the Configurational Analysis.

Highly recommended.

Psychodynamic Approaches to Behavioral Change by Fredric N. Busch, MD

Analytically oriented (or psychodynamic) psychotherapy is a type of talk therapy. As a treatment, psychodynamic therapy focuses on the identification of factors that lead to problem behaviors and get in the way of change. Direct work on behavioral change, however, was traditionally seen as distupting neutrality and abstinence, two of the foundations of psychodynamic technique. Dr. Busch’s book, Psychodynamic Approaches to Behavioral Change (APA Publishing, 2019), details ways in which psychodynamic therapy is uniquely positioned to help people change their behavior. Dr. Busch demonstrates that many patients require more than insight - one of the main “therapeutic engines” of psychoanalysis. Dr. Busch’s book details the underpinnings of why analytically oriented therapist historically avoided “suggestion” to promote behavioral change. He recognizes that there are risks of attempting to address behavioral change (for instance, adverse impact on the therapeutic relationship, having only the patient’s perspective, and countertransference factors). However, Dr. Busch discusses how psychodynamic psychotherapy is uniquely positioned to address these risks. He elucidates elements of the psychodynamic formulation (development, trauma, self and other representations, conflicts, defenses, personality difficulties, deficits in mentalization skills) that the dynamic psychotherapist can create to assist the patient.

Psychodynamic Approaches to Behavioral Change

Dr. Busch reviews techniques (free association, clarification and confrontation, interpretation, development of mentalization skills, working through, and use of countertransference) that can help promote behavioral change. He builds and describes a framework for targeting behavioral change that includes making use of homework. Dynamic therapy can more effectively identify contributors to problem behaviors, for instances through the use of inference. Dr. Busch show how the process of identifying alternative behaviors can be integrated into therapy (which is a significant departure from traditional psychodynamic therapy). The technical portion of the books ends with 1. how to help patients sustain behavioral change and 2. how to help patients deal with the responses of others. The final two chapters illuminate specific situations that a therapist will experience when targeting behavioral change in dynamic therapy. The penultimate chapter focuses on specific, frequently encountered behavioral problems. The final chapter reviews recommendations for addressing behavioral problems related to adverse developmental experiences and trauma.

The book is impressive. It transitions from being a technical guide, to demonstrating examples, to advice on specific problems and a specific patient population.

I have taught two lectures to medical students and psychiatry residents based on the material from this book and I received positive feedback about the content. One resident told me, between the first and second lecture, that they had already successfully used one of the techniques in the book! In my private practice, the book has been a welcome addition to the collaborative work I do with my patients.

Highly recommended for both cognitive behaviorally (CBT) and analytically oriented therapists.

Youth Soccer Mercy Rule

This essay is meant to inform youth coaches regarding their handling of unbalanced games. It especially encourages coaches to reflect on the meaning of “mercy,” to become familiar with what their organization’s rules are, and to prepare to implement appropriate mercy adjustments at the appropriate time.

Sports are a wonderful way to bring people together, facilitate activity, and compete. Sports teach many lessons about teamwork, the value of practice and preparation, the need to listen to our bodies, and overcoming adversity. Sports is also an important tool to teach sportsmanship – the fair and generous treatment of others. Sportsmanship is especially valuable in youth sports. Balancing the tension between the (intense and aggressive) desire to win, and the (sensitive and reflective) state of being a good sport can establish early mastery of dialectical forces – forces that appear to be in opposition, but actually complement each other.

While there are infinite ways to encourage “being a good sport,” many youth sports leagues have created “mercy rules” to codify sportsmanship. A Google search of “mercy rules youth soccer” turns up more than 4,800,000 results.

Mercy, according to Merriam-Webster, has two definitions and one “figure of speech” that are relevant for this essay.

  1. compassion or forbearance shown especially… to one subject to (another’s) power
  2. compassionate treatment of those in distress
  3. “at the mercy of” - wholly in the power of, with no way to protect oneself against

The first definition suggests the party in power exercise restraint. This applies to when there is a significant skill, or size, or athleticism different between two teams. The second definition suggests a sympathetic awareness of those in distress, coupled with a desire to decrease the distress. This applies to any situation in which one team is demonstrating discomfort with a lopsided score. The figure of speech is a colloquialism that suggests one party is completely without defense, without agency. This applies only in the most extreme of situations - when one team has become totally overwhelmed and cannot adequately function within the rules of the game.

A review of the first 100 results about “mercy rule youth soccer” demonstrates two types of pages. The first are ‘Mercy Rule’ guidelines from various youth sports associations. The second are opinion pieces about these rules generally, or experiential pieces on how specific situations were handled.

The guideline pieces fall into two categories. The first category is quite concrete. They designate a score differential that triggers the rule, an amount of time into the game when it is applied, and specifics on when in the action the rule takes effect. For instance, it can be the moment the 10th goal is scored in a shutout. Or at the end of a quarter, once the first half is complete, if there is a 6-goal differential. The second category is more abstract. While specific triggers are suggested for enactment of the ‘Mercy Rule,’ how exactly the rule is applied is left up to the coaches and referees. In this category, coaches are encouraged to confer with each other as soon as they “have the sense” that the game is heading in an unbalanced direction. Options include adding players to the field or encouraging players to play positions (or use skills) that would be an ‘extra’ challenge for them.

The opinion pieces have impressive range. Ideas about overprotecting children and the downfall of society are on one extreme. Ideas about firing coaches if they do not have complete control over their 6-year-old players are on the other. My favorite article referred to a team “gaming” the mercy rule – scoring on their own goal, triggering a Mercy Rule that forced the winning team to officially lose.

Some themes from these articles that are valuable:

  1. Children can learn from adversity.
  2. Coaches do not have complete control over their players’ attitudes and behavior.
  3. Lopsided games are teaching moments.
  4. It is unfair to take talented players out of the game for succeeding – especially if their parents have paid a fee and players are promised equal playing time.
  5. At most youth ages, coaches will need to be vocal in enforcing rules.
  6. Most winning coaches are not sadistic…but a few are. Most losing coaches will cooperate with ideas to balance the game…but some will not.
  7. Involving referees in the application of the less concrete rules is beneficial, perhaps necessary.

I have coached over 30 seasons of recreation soccer and have “been on both sides” of lopsided games. I’ve seen it handled well and handled poorly. I’ve seen it, purposefully and beneficially, NOT handled.

My thoughts:

  1. If there is a significant differential in size, or age, or athleticism that is apparent during pre-game warm ups, the coaches need to immediately have a discussion. This is the most critical situation, as it is the one with greatest risk for injury.
  2. As soon as one team is consistently demonstrating a significant advantage over the other team, the coaches should chat. The discussion starts with: Are both teams still having fun? Is the losing team in distress? I coached a 16-5 game during which the losing team was having a great time. I coached a 6-1 game during which the losing team was utterly miserable. If a “losing” coach knows their players (and their players’ parents) are fine, they do NOT need to enact any in-game changes. This decision should be reevaluated in ongoing fashion, including accepting feedback from the opposing coach and the referees. After the game, if the losing coach chose to make no adjustments, they need to “take the heat” if there are any complaints about the score. However, the “winning” coach and referees SHOULD enact some in-game changes.
  3. Lists of in-game adjustments both coaches can make are simple, easy and readily available. Examples for the winning team include 3 passes required before a shot, or use of non-dominant foot. An example for the losing team is placing an extra player(s) on the field. Cherry Hill FC has a short list of recommendations in their “Mercy Rule” statement. To me, these are the third most effective mercy adjustments.
  4. Coaches need a couple extra pinnies in their teams’ jersey color. This opens up the possibility of exchanging players with the other team as a competitive balancing measure. To me, this is second most effective mercy adjustment.
  5. Conferencing with the referees, and having them take an active role, is critical. Calling stricter rules (handballs or offsides, for example) on the winning team helps. Giving more – or all – throw-ins to the losing team also helps. Decreasing the time of the game is a loss for all parties, but especially helpful if it seems there is an increased risk for injury or excessive rough play. To me, these are the most effective mercy adjustments. Referees must be trained by their organizations in the application of these concepts.

Here is a list of some of the sites I looked at (not exhaustive)

Have Mercy - How Coaches Can Manage A Mismatch

The Tricky Challenge of Managing Routs

How To Manage A One Sided Game

Cherry Hill FC Mercy Rule

Why The Mercy Rule Should Be Eliminated In Youth Sports

Best Of Alice In Chains

25 years ago, Alice In Chains released their third EP, Jar Of Flies. It is an acoustic album that features the band’s incredible range. Blues, soul, country, instrumental, grunge and alternative rock could all be used to describe the EP’s music.

I have loved AIC since the first track of Facelift (“We Die Young”) acoustically and metaphorically hit my eardrums. As a student at Rutgers College, I eagerly awaited new releases, and felt a thrill whenever I found a “bootleg” recording to acquire.

Recently, I challenged myself to earnestly listen to the band’s 3 newest albums. In previous attempts to listen to this material, I was holding myself back. Holding back out of an unprocessed grief after the death of the band’s lead singer, Layne Staley, in 2002, and the band’s bassist, Mike Starr, in 2011.

The band persevered, thankfully. As I read about the anniversary of Jar Of Flies, I was able to find a new sense of gratitude for AIC’s survival. Jerry Cantrell, the band’s guitarist and co-lead vocalist, has spoken and written about grief and loss and survival. Alice In Chains has an on-going story to tell, and a sound that has evolved into something both familiar and new.

The music, and my newfound appreciation for the band, inspired me to create a “Best Of” playlist on Spotify. I selected tracks from 8 albums - 6 LP’s and 2 EP’s spanning 1990 to 2018. The tracks are in chronological release order for three voyages through the albums. I hear a story of pain, despair and addiction. I also hear a story of relationships, loss and survival, insight, wit and newfound purpose.

I end with 8 tracks I felt could not be denied inclusion on this playlist. “River of Deceit” is from the ‘superband’ Mad Season, and demanded incorporation for Layne’s honesty and haunting vulnerability. “Nutshell” has a second version added from AIC’s Unplugged concert to acknowledge my muse for rediscovering the band.

When I worked the closing shift at the Rutgers Recreation Center, I would signal the late-night gym-goers that they needed to wrap up by blasting “Would?” on the facility’s AV system.

I hope you enjoy! Here is the link to the playlist.

New Frontiers in Holiday Sanity

Every year, I hear both causal and clinical queries regarding how to stay sane during the holidays. In fact, a Google search of “sane holiday” turns up 357,000 results. By the 40th page of results, the posts become a bit recursive and seem to largely cover the same ground. Here is some quick, sound advice:

• Simple Mindfulness: breathe and be in the moment

• Keeping Perspective: there is much suffering in the world; love is the greatest gift

• Be Realistic: set limits and stick to a schedule

Yes, with just a little bit of effort, you can achieve holiday sanity. The tried-and-true ideas bulleted above will work, but the “new school” ideas are a great way to spice up your eggnog. If you are looking for some new strategies, here is some new ground to break during this upcoming holiday season.

  1. Celebrate a different tradition with someone. Maybe you’ll go to Midnight Mass with a family that routinely attends. Maybe you’ll listen to prayers while lighting the Menorah with friends. Maybe you’ll eat a bowl of Udon before listening to the 108 chimes of Omisoka. Whatever you choose, just do something different. As the millennials sat, YOLO (you only live once)!

  2. Celebrate with exercise. Diet? Heck no! Eat, drink, and be merry this season, but do not take a vacation from exercise. Find time in the days before and after the holidays to exert yourself in a way that your body can handle. Swim some laps, ride your bike, go for a jog, do some yoga, get to the gym – you will be surprised how many comrades will ask to join you in a post-meal walk. Afterwards, feel good about saying “yes” to a cappuccino and a cannoli.

  3. Celebrate with a game. If you have not checked out the board gaming scene in the last 10 years, you are in for a fun surprise. Party and family games have received a major facelift, so there’s no need to be stuck in playing classic games like Monopoly or Yahtzee. Here are some great family games to try (in increasing order of difficulty): Love Letter, Catch the Moon, King of Tokyo, or Pandemic. And check out party games like Codenames, Time’s Up, Telesrations and Dixit.

Managing The Stress of 'Back To School'

Parents of children ages 4-14 report a variety of stresses about the “back to school” process. While each parents individual story is unique, I have observed some common themes in families that learn to do it successfully.

First, it is important to recognize that this is a time of transition for everyone in the family. Certain routines that worked over the summer will need to be adjusted or redeveloped. Old, successful routines from last year need to be remembered. I worked with a father who annually “forgot” how helpful it is to make lunches for everyone in the evening (right before dinner, before leftovers are put away), rather than in the morning. “Every year around Halloween, it would dawn on me…I had this figured out last year!” So, take a moment. Recognize that change is hard. Look at what works for your family, and reflect on what worked last year.

Second, parents are at their best when they adjust their perspective visa-a-vis their children. “It’s like they’re constantly changing the game. As soon as you catch up, they sprint ahead”, one mother told me. When you are with your children everyday it is easy to forget the magic of development and maturity. Back-to-school time is an excellent opportunity to take a moment and read up on your children’s current stages of development. Many great resources exist, including the [simple and easy to read “Yardsticks: Children in the Classroom ages 4-14” info sheets] (

Finally, managing your children’s needs and anxieties is an effective way to succeed and be happy in a time of transition. Again, each child is unique, but two themes seem universal. First is the separation from the home environment. “It doesn’t feel like home, like my family” was how one child described the difficulty of going back to school. Second, is the challenge of more difficult academic work. “Why does is always get harder?” one child asked me, woefully. Help your children to see the best in their teachers and (re)connect with their classmates. And nothing replaces spending time with your kids. Sit with them when they do their homework. Both your presence and your knowledge will build their confidence early in the year. And as Ben Franklin said, “Well begun is half done.”