Don’t Ask Me What I Do, Instead Ask Me Who I Am

Don't Ask Me What I Do, Instead Ask Me Who I AmI carry a few different business cards in my purse. Because I never know what conversation I will have with a stranger at any given time.

A month ago I fetched cream for my coffee at a café in South Bend, Indiana. Naturally my family didn’t know a soul in the joint. However, by the time I returned to my table, I knew some incredibly intimate (not to mention interesting) details about the daughter of the man next to me who was reaching for a napkin: his daughter is bipolar; she was anorexic as a teenage ballerina; and she’s on some of the same meds as I am.

I ended up giving him a business card with everything but my email scratched out.

I didn’t want to have the conversation of what I do for living.

It doesn’t have anything to do with who I am.

And that’s why I get so annoyed that we have to start all of our conversations with that question.

As a country, we are obsessed with our jobs: An understatement. Our professions are central to our self-identities and our industries define who we are. We don’t even know how to vacation. It doesn’t matter that United States workers receive far fewer vacation days than other workers in other industrialized countries because American employees fail to take the time off that they have accrued. Our European friends shake their heads at that one.

I remember how refreshing it was to ask a French couple “what they did” (I plead guilty) at a swim meet for our kids.

“We are skiers,” they said emphatically. No equivocation. No insecurity. No approval-seeking.

That was who they are and were proud of being, and told me a hell of a lot more about them than had they rattled off their resumes starting with their last places of employment: “I’m an accountant with Ernst & Young.” “I’m a consultant with Booz Allen Hamilton.” “I’m a program manager with Northrup Grumman.” Snore. Snore like Gramma.

My conundrum is that I wear a few different hats at the present moment, so I, in fact, don’t really know what I am. I know what my ministry or innate purpose in life is — to provide hope to those who struggle intensely with depression and other mood disorders — but it’s not related to what I do for a living as a government contractor. One pays with blessings, the other is generous with benefits. And, unfortunately in this country, most benefits are tied to your job, so while following your dream is all good and noble, you might get screwed if your appendix bursts like mine did a year ago and you need some quick medical attention. Passion, at times, has to take a back seat to medical care and other life necessities.

Upon meeting someone new, part of me hopes I will never hear the dreaded four words (what-do-you-do) because then I wouldn’t have to assess how I am going to respond — with my pragmatic communications-consultant role, or with the idealistic wanting-to-save-the-world profile.

At the least, it would be nice to delay the work conversation toward the second-half of the conversation, after the other top three questions: Where are you from? Why are you here? (conference, cocktail hour, reunion, fundraiser, Chuck E Cheese), How many kids do you have and what are their ages and when were they potty trained?

For this reason, I’ve always loved writer Oriah Mountain Dreamer’s poem, The Invitation, that went viral 15 years ago and was later published in a book. May we all share this vision one day.

It doesn’t interest me what you do for a living. I want to know what you ache for, and if you dare to dream of meeting your heart’s longing. It doesn’t interest me how old you are. I want to know if you will risk looking like a fool for love, for your dream, for the adventure of being alive.

It doesn’t interest me what planets are squaring your moon. I want to know if you have touched the center of your own sorrow, if you have been opened by life’s betrayals or have become shriveled and closed from fear of further pain! I want to know if you can sit with pain, mine or your own, without moving to hide it or fade it, or fix it.

I want to know if you can be with joy, mine or your own, if you can dance with wildness and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be careful, to be realistic, to remember the limitations of being human.

It doesn’t interest me if the story you are telling me is true. I want to know if you can disappoint another to be true to yourself; if you can bear the accusation of betrayal and not betray your own soul; if you can be faithless and therefore trustworthy.

I want to know if you can see beauty even when it’s not pretty, every day, and if you can source your own life from its presence. I want to know if you can live with failure, yours and mine, and still stand on the edge of the lake and shout to the silver of the full moon, “Yes!”

It doesn’t interest me to know where you live or how much money you have. I want to know if you can get up, after the night of grief and despair, weary and bruised to the bone, and do what needs to be done to feed the children. It doesn’t interest me who you know or how you came to be here. I want to know if you will stand in the center of the fire with me and not shrink back.

It doesn’t interest me where or what or with whom you have studied. I want to know what sustains you, from the inside, when all else falls away. I want to know if you can be alone with yourself and if you truly like the company you keep in the empty moments.

Kaiser Permanente’s eCare for Moods Racks up Another ‘Win’

Kaiser Permanente's eCare for Moods Racks up Another 'Win'In the last decade, Kaiser Permanente launched a web-based service known as eCare for Moods, meant to help support patients within their health care system with bipolar disorder. Over the years, there’s been some research to support the use of this online tool to help improve patient outcomes.

In the November 2012 issue of Psychiatric Services, another study was published demonstrating the effectiveness of this free online tool for Kaiser Permanente customers. The study, by Hunkeler et al. (2012), found that depressed patients who had access to and used the eCare system had better outcomes — reduced depression and better overall health.

But although the research team clearly believes this is a “win” for eCare for Moods, after examining their data, I’m not so sure. If it’s a win, it’s more of a statistical win than a win for reducing a patient’s depression symptoms.

First, let’s get out of the way the fact that more than half of the study authors (out of 12) are affiliated with Kaiser, the publishers of the eCare system (parts of which Kaiser has also applied for patents, suggesting a potential revenue motive underlying some of this1 ). Obviously, when you work for an organization and are researching that organization’s tool for effectiveness — and possible later license or such — there might be some… ahem… incentives for a positive finding.

The study was designed to measure depression symptomology of participants who were divided into two groups. One group would have access to Kaiser’s proprietary eCare for Moods online web-based support and messaging system, in addition to their usual mental health care. The other would have just the usual mental health care provided by Kaiser. This design helps ensure that the primary difference between the two groups is the eCare for Moods program.

The program itself is comprised of a secure, password-protected website that provides personalized self-monitoring tools, secure messaging with the patient’s eCare manager — a trained psychiatric nurse — 8 depression psychoeducational modules, an appointment calendar, and a monitored discussion group (which you could only access after completing all 8 modules). eCare was only offered during the first year of the study. The second year of the study was just ongoing assessment of how the two groups were still doing, to see if the effects of eCare — if any — wore off over time.

How participants were doing was measured in telephone interviews after the initial interview was conducted in-person. The interviews included a number of different health surveys and questions designed to measure progress.

Which brings me to the second nitpick — why didn’t the study authors use a standardized and recognized measure for depression symptoms? Instead, these 12 researchers decided to make up their own, with no rationale for doing so (and no psychometrics provided on their made-up depression scale):

All interviews included an assessment of depressive symptoms experienced over the previous two weeks with questions adapted from the SCID. This provided a psychiatric status rating of the severity of current depression on a 6-point scale derived from the research diagnostic criteria2

Worse, the interviewers then had the subjects recreate a week-by-week blow of their mood for the previous 6 months. By memory. Could most people accurately recall how they were feeling three weeks ago — much less 3 months ago?

So the researchers were reliant on accurate memory recall to fill in the blanks every 6 months. It’s not clear why they didn’t simply have participants keep paper-and-pencil journal logs or use some other more frequent data recording method if they wanted weekly data tallies.3

Weird.

Depression Scores Decrease — for Everyone

The third problem is that the average depression score at the baseline of the study was 3.88 (eCare group) or 3.65 (usual care group). According to the researchers, depression is scored as: “3, moderate impairment; 4, marked impairment but below DSM-IV criteria for [a depression] episode.” In other words, the average of the participants was somewhere below the threshold to actually diagnose anything but the mildest of depression.

But if you think that’s bad, wait — it gets worse.

After a full year of treatment, the eCare group still averages a 3.00 — moderate impairment (technically, still depressed). They’ve dropped nearly a full point on the scale, but that’s it. According to the criteria, they’re still pretty much as depressed as they were when they started (as a group). The usual care group after one year looks pretty darned similar — a 3.10. While they’ve only dropped a half point (since the group wasn’t as severely depressed as the eCare group), their improvement is less impressive. But again, as a group, still depressed.

At the end of 2 years, no statistically significant change occurred in the eCare group — now it’s at a 2.95 average score. Same with the usual care group — now at a 3.11.4

Now, unfortunately, the clinical trials record doesn’t note what specific primary outcome measure they had planned to use. So we can’t know if they decided to change the primary outcome measure because it was even less impressive than what we’re seeing here.5

That’s okay — the researchers had another way to make these results look more impressive than they are. They also measured the “presence of depression” (as though depression was like an off/on switch). Any score less than 3 on the PSR means depression isn’t “present” any longer. Score 3 or higher and you’ve still got depression.

If this sounds arbitrary, that’s because it is. It is one of the ways researchers today get around the fact that a treatment isn’t really as effective as they hoped it would be. (Of course, the eCare group came out on top in this measure.)

Summary

The upshot? Here’s a study demonstrating the statistical effectiveness of a treatment intervention supplement — eCare for Moods — that likely had very little real world benefit for the patients who were using it. One of the areas that stand out in the data with a difference between the two groups — learning new coping skills — could be attributed to the psychoeducational modules the program offered.

These modules, of course, could be offered to the general public today and help potentially thousands learn new coping skills.

The eCare system itself has problems with keeping its audience. While 90 percent of patients logged into the system during the first 6 months, that dropped to under 50 percent in the next 6 months. Only 4.6 (on average) of the 8 educational modules were completed by participants — less than half of participants completed the full 8 (a problem common among virtually all online psychoeducational interactive learning modules).

While I appreciate that eCare for Moods can be a helpful supplement to people with mood disorders — such as depression or bipolar disorder — I feel like this research team may have overreached in extolling the benefits of the program. I’m not so sure that weekly depression severity was significantly different from the usual care group, given the data presented in this article alone.

 

References

Hunkeler, E.M. et al. (2012). A web-delivered care management and patient self-management program for recurrent depression: A randomized trial. Psychiatric Services, 63, 1063-1071.

 

Footnotes:

  1. Yes, even non-profits can have a revenue, if not profit, motive.
  2. Criteria, I should note, that were first proposed back in 1978 — long before the DSM-III-R made the scene. The researchers list no rationale for using this depression scoring method — as opposed to one of the well-researched and regularly-used depression measures. The researchers also fail to acknowledge this as a limitation in the article.
  3. The researchers make no note of this methodology concern in their limitations discussion. Ideally, the study would be designed to incorporate data directly from patients themselves, without retrospective memory coming into play, or the potential bias of the interviewer.
  4. p = 0.047 in a time-by-treatment repeated-measures design
  5. This study took a really long time — more so than usual — to make it into publication. This study was begun in 2002 (and was supposed to include bipolar patients too) with data collected primarily in 2003 and 2004. Its results were first presented at a conference in 2009, and it finally appeared in a journal in late 2012. Draw your own conclusions.