ISO Therapy Advice

[jducoeur]

Okay -- it has been driven home that my lingering depression of the past eight months still hasn't really let go, and that it would be wise to deal with it properly.

I'm starting to look into this seriously, but I'm something of a babe in the woods in this regard: I know nothing of the ins and outs of counseling, therapy or what-have-you aside from the broadest strokes, and it appears to be a complicated topic. I know that some of my friends have been down this road (or variants thereof), and I'm looking to tap a little of that collective experience. I asked about this vaguely some months back; now it's time to get a little more concrete.

So here's are a few relevant questions: what are the questions I should be asking as I look for a therapist and get this started? Are there particularly good starting points? What are the things I should be looking for or avoiding? What has or hasn't worked for you? Do you have any specific people you would recommend or avoid? I'm going to be doing my own research as well, but I am definitely naive to the topic at this point, and would like to know if there are pitfalls I should be watching for.

(The objective, if it's relevant, is broad. In the short term, to help work past the depression and get me back on an even keel. In the longer term, to develop some appropriate coping strategies to keep this from happening again. I'm introspective enough to have a pretty good idea of what is going on in my head, and even to a large degree why, but that doesn't seem to be enough for me to address it properly myself.)

If anyone has advice, but isn't comfortable talking about it publically, feel free to drop me email -- my LJ address should work fine. Thanks in advance for any pointers here...

Comments

[tpau]

i would suggest asking your PCP for a recomendation, and go talk to the person recomended. Be prepaired that you might not like this person. ask for another recomendation. whoeveryou start ut talkingto, tell them taht you are not sure hwo to pick out such a person, they shoudl be able to help.

[jducoeur]

Makes sense, especially since I do trust my PCP as a fairly sensible lady, with a relatively holistic view of things. Thanks...

[antoniseb.livejournal.com]

Here's a few things that I've picked up.
1. Medication can be a good short-term solution (3 to 6 months).
n.b. not all anti-depressants will work for you. The first few weeks might really suck eggs.
2. Getting lots of exercise can also be a good solution longer term.
n.b. when I was on the medication, I didn't feel like getting the exercise
3. getting enough sleep is very important.
4. eating right (less sugar), and getting to your old trim weight really helps (drinking lots of water helps).
5. At some point in your 40s you can still have as many orgasms as you could when you were younger, but they impact you more. Too many can give you an empty-soul feeling that goes away in a day or two.
6. Continuing to do intellectually stimulating things with your friends helps a lot
7. Preparing to sell a house is depressing. Once you sell it, you will rapidly start to feel better. Even knowing this is a factor helps.
8. I went to a therapist, and got very little improvement. She later sent me to a psychiatrist who could perscribe anti-depressants. I think a therapist might work if you had a specific problem like communicating with your wife, or co-workers in some way, but they aren't good at solving a broad pointless depression.

[ladyariadne.livejournal.com]

Explain number five please... I have NEVEr heard of this.. Usually they tell the guy to go get MROE sex... not less...

[antoniseb.livejournal.com]

Not much to explain, but easy to demonstrate. For starters, be a guy in your forties, and try having three orgasms a day for a few days. You can do it, but after a small number of days, your mental outlook will cloud over. Continued sex will postpone resumption of clarity and cheerfulness.

I imagine that this is not something that a lot of people talk about for a LOT of reasons. Personally, I'm disinclined to let on that there's any limit to how much sex I can have short of how long it takes my body to get ready to do it again. If some of the orgasms are from masturbation, I'm even less likely to talk about it (when I was on Welbutrin, I REALLY wanted to have sex VERY often, which is how I first observed this phenomenon).

While we're on the subject of similar things that men don't talk about much, it is also the case that sometimes I don't have to have an orgasm per se to get to this point. Sometimes my body will dump seminal fluid into my bladder (I don't know how), and when I urinate, some cloudy blobs come out AND I feel drained in the same way as though I'd had sex recently. This probably happens a few times a year, but it seems to count towards number 5 above.

That being said, if you are used to having sex four to ten times a month, and it gets cut back to maybe once a month, or maybe not, having more sex will probably cheer you up without this consequence.

[umbran.livejournal.com]

I imagine that this is not something that a lot of people talk about for a LOT of reasons.

What do you mean not talk about it? Can you think of a culture that doesn't have some form of the myth that there's power in there and you lose it if you don't control yourself?

[ladyariadne.livejournal.com]

I guess I know too many guys in their forties that if they DONT get sex or jack off several times a day get cranky. Ive never heard or seen this before.

[ladyariadne.livejournal.com]

Okay, after questioning many many men, most over forty, goggling a lot, and other lines of reserach I have found NOTHING to back this up. Can you actually point me to some evidence such as a scientific survey or something.

IN fact everything I have found points to the fact that you have been misled. This cloudy memeory was made up by some anti sex advocates (including MR kellogg) and have been debunked by people such as Sir Alfred Kinsey.

IN fact there is research into the fact hat frequent ejaculations help promote a healthy prostate, and the fact that sex actualy HLEPS depression because of the release of endorphins. (One of the reasons metal patieints did slef sex a lot because that was their one happy place...)


I found absolutely NOTHING to support this. Maybe this is something that happens to you (as other guys suggested you might have some kind of underlying physical problem such as an infection concenting that spunk in the urine as there is no connection between the two other then that one little pathway...), but there is nothing that shows this is a worldwide epidemic to men. Can you please point me to something. I would love to read mroe about this, but I also feel that this could be quite misleading to MArk if it is disproved rmalbing of a urban myth...

[antoniseb.livejournal.com]

Perhaps it IS just me. Who knows? I cannot point to a study that shows it, but I can attest to the fact that this happens to me (and is no illusion masked by other phenomena). It is not "disproved rmalbing of a urban myth", as I've never heard of it as an urban myth. I doubt that it is the result of some infection, but it may be that I have a peculiar reaction to whatever the body does after orgasm, just as different people react differently to various anti-depressants and other mood altering and psycho-active chemicals. Take it as an isolated data point if you like.

I elaborated a point, at your request. This was from a list of things that I said worked for me at fighting depression. If you don't want the depressed men in your life to try it and see if it works for them, then by all means, be an advocate for orgasms. Please do not try to paint me as a quack, or diseased individual with a sick agenda.

[jducoeur]

Hmm. Useful insights; thanks. The exercise and sleep suggestions are ones that don't surprise me at all; I need to figure out how to jigger my schedule to get more exercise back into it.

Preparing to sell a house is depressing.

Actually, in my case I don't think it's directly depressing, although it is *intimidating*. I've spent so many years desperately wanting a new place that the prospect is downright refreshing -- it's just getting there that's hard...

[rufinia.livejournal.com]

Advice that I don't think *you* will really need, but know other people who have issues with: I know of a few epople who have been reluctant/refused to mention the SCA to their therapists, because "they wouldn't understand and think I just play make believe." In the cases where this has been an issue, the SCA has been a significant part of their lives. Like I said, I don't see this as an issue for you, but I strongly suspect you're going to have to explain.

I also see tpau's suggestion as very sound.

[jducoeur]

Heh. No, not an issue for me. The advantage of being a computer geek is that I never developed the common work-related shyness about how strange my hobbies are...

[kfitzwarin.livejournal.com]

I think that's a lot of it - finding someone you're comfortable with. Also, if it's at all an issue, find out what your health insurance will cover. Some insurance wants you to see someone at the doctorate (MD/PhD) level first, as an "evaluation" and then you can see someone else if that's your preference. Most insurance plans will cover some number of visits at decreasing levels of coverage over time (like 20 visits fully covered and then 20 at 80% then 40 at 50% or something). If you have a PPO-style plan (or any "network" plan) find out what the differences are for in/out network.

You might want to think about whether you'd be more comfortable with a male or female person.

Then go in and see someone and see how you feel about them. Ask them about their methods, what sorts of techniques they use, what sorts of issues they specialize in, etc. At least that's my tuppence.

[jducoeur]

Insurance: good point. I'll need to figure out what the rules are.

You might want to think about whether you'd be more comfortable with a male or female person.

That one's easy -- I find it *much* easier to talk to women than men, at least on emotional matters. Beyond that, it's a more open question...

[chaiya.livejournal.com]

Insurance was also my first thought. If you're willing to have it on your medical record, insurance makes therapy downright cheap in some cases. We have limitless access to therapy for the copay of $15 per session.

There are many approaches to therapy. As many as there are therapists, probably. Knowing yourself the way you do, Justin, you probably want to find someone whose opinions about Meyers-Briggs you can respect, and also someone who can add to the conversation, maybe show you a different theory or a supplemental one or something. You also might want to think about what style therapist you're looking for -- do you want a collaborator, someone to core dump on, someone to ask you questions that make you think, someone to run the session for you and tell you what they think, some combination of the above ...?

There are also things about yourself that you want to sound out potential therapists on. For example, a friend of mine wants to start seeing a therapist about his gender issues, and that's the primary question he's asking every potential therapist. In your case, you probably want to sound someone out about being an extroverted introvert, the way that being Justin has affected you as Mark, and how they deal with depression in clients.

Finding the right therapist can be challenging, but worthwhile. It took me three years of seeing the wrong therapists to figure out what I did want. Now I'm seeing someone who doesn't talk down to me, but asks thought-provoking questions and occasionally points out my prejudices with good humor. It's great. :)

[jducoeur]

In general, I rarely hit "flaming bastard". My nadir is generally a fairly deep mopiness. Really, the biggest part of the problem is that I haven't been really *happy* is a pretty long time; after a while, that just wears one down...

[jducoeur]

Actually, this isn't the "broad pointless depression" type; at least, I don't think it is. I've pretty well identified what I believe are the key elements of the depression (and sometimes painfully verified those theories empirically). What I don't have is the coping techniques to work past these particular emotional quirks.

[pamelina.livejournal.com]

However, if you're experiencing what Anton said: a broad pointless depression, then you're dealing with something that a therapist might not be able to assist with. I believe that my sweetie's depression is physiologically based -- the best therapist in the world would not help.

You're falling into a common fallacy, CV. While you're right that most therapy/therapists don't make any difference in the brain physiology of depression, Cognitive Therapy has been empirically shown to be as effective a treatment for depression as anti-depressant drugs, (and often much longer lasting). The idea that brain physiology is not effected by thoughts/cognition is no longer accepted. See: how cat-scans show feelings/thoughts affecting the brain (http://www.mcmanweb.com/article-12.htm).

[goldsquare.livejournal.com]

This is not, in my opinion, a conversation I want to join on a public list. But if you think my experiences would be helpful, call me. Or catch me at the event this weekend.

Brain debugging

[dlevey.livejournal.com]

OK, first the disclaimers:
I am not a doctor, nor do I play one on TV. My work in college (what work I did, over 11 years...) was in psychology, focusing on affective mood disorders (such as depression) and creativity. I've had some small experience working with congregants on difficult situations - though these are mostly event-based. So take what I say with whatever size grain of salt you feel is appropriate.

Your PCP should be able to help you navigate through the maze of insurance, especially if you're not comfortable discussing this with your benefits manager (or whoever is filling that role at your company). You can get initial recommendations from her, but this may not be the person you need. From my perspective, the most (but not only) important thing is that you feel comfortable with this person. They can be the cleverest person in the world, but if you don't feel comfortable creating a partnership of sorts, they will have little to go on and you'll be less likely to take their suggestions seriously.

I'd also ask as to their approach. Most of the ones I've met will say they're "eclectic", but there are indeed some that will "own" a specific school of thought on, well, thought. If you have strong feelings about one or more approaches to the mind, this is where you can weed people out or move toward them. Consider other medicine for a moment: if you think accupuncture is hogwash you're less likely to want to go to an accupuncturist.

A chemical imbalance can cause depression. Depression can cause a chemical imbalance. Which one is the chicken, and which the egg? From the last I studied this, the thinking was that indescriminant medication can mask the symptoms of the latter while looking like it was the former. I would suggest therapy to see if there is perhaps some cause that can be treated without the pills. But if those pills are the answer, take them! And remember to refill the prescriptions! One friend would, when her pills ran out, lose initiative and not bother to call the pharmacy. And before the pills ran out, she felt fine and so wouldn't bother. In the end, her husband made a deal with the pharmacy that they would call him three days before the prescription was due to run out, and he would renew it for her.

As to what sort of things to start with, that will depend upon the therapist. They'll have their own approach.

A reasonable working definition of psychological depression is hopelessness/helplessness. That is, you see your situation as undesirable, with no hope of change - and you feel unable to change it under your own power. For me personally, I find that actually accomplishing something - making something, completing a project, reaching a milestone, etc. - can help remind me that there *are* things under my control, that I'm not trapped in my life. There are certain situations where I know I'll be reminded of my impact on others, and how what I do helps them. This helps remind me of my own self-worth. But again, that's me.

I would also second others' recommendations. Exercise has been shown to help with depression, as is maintaining general health. That does indeed mean sleep, eating right, etc. All those things the annoying commercials on TV say we should be doing. I can't speak directly to the advice about too many orgasms, but that makes sense. Orgasm releases certain chemicals into the bloodstream, and it would make sense that an overdose (or constant dose) of what is supposed to be an occasional thing could seriously affect mood (leading you to reduce that behaviour...). Oh, and by the way, when preparing for orgasm the prostate builds up seminal fluid. If no orgasm, that gets dumped into the urinary tract or reabsorbed.

[continued...]

Re: Brain debugging

[dlevey.livejournal.com]

[to continue...]
As to selling a house, watch out for a depressive spike AFTER the house is sold. A common cause of depression can be the completion of a very large and stressful task, or the aftereffects of a long-awaited event. Spending many hours and much energy on a task, and that suddenly no longer in the picture, can make for some emptyness. My personal opinion: embrace it, revel in it, wave to it as it sails off over the horizon and then go back inside and make breakfast. But, as they say, YMMV.

As the joke goes, the lightbulb has to want to change. By recognising this as a problem, you've made what might be the most important step in solving it.

Re: Brain debugging

[jducoeur]

All useful insights; thanks.

I'm not particularly wedding to any specific school, or averse to one -- at this point, I don't really know the landscape well enough to have an informed opinion. I suspect that'll come with time.

The chicken vs. the egg -- hard to say clearly, although I'm fairly sure that this *started* due to specific stressors, plus a few particular mental habits that sent me down a spiral. I'm pretty sure that my brain chemistry is a tad out of whack *now*, simply based on my emotional state, but I don't think that was the original root cause.

As for accomplishing something -- yeah, that fits my observations. Part of the problem is likely that I let myself get so buried under huge projects that I haven't had much room for little accomplishments. (And a few particular projects tanked, which didn't help.) It's worth thinking about turning that around...

Re: Brain debugging

[dlevey.livejournal.com]

I'm not particularly wedding to any specific school, or averse to one -- at this point, I don't really know the landscape well enough to have an informed opinion. I suspect that'll come with time.

I would second what Pamelina mentioned - my personal preference tends to lean toward cognitive therapy ("it's all in your head") and away from, for example, behavioural ("there's nothing in your head"). For me, it tends to provide a mechanism for examining the factors involved and working on strategies for combatting/coping/redirecting them. From what you mentioned you may do well to look there, at least first.

The chicken vs. the egg -- hard to say clearly, although I'm fairly sure that this *started* due to specific stressors, plus a few particular mental habits that sent me down a spiral. I'm pretty sure that my brain chemistry is a tad out of whack *now*, simply based on my emotional state, but I don't think that was the original root cause.

Looks like the stressors may be causing the depression, perhaps with some predisposition, but a real doctor will be able to help you determine this for sure. Were this my situation, I'd not look for medication first.

As for accomplishing something -- yeah, that fits my observations. Part of the problem is likely that I let myself get so buried under huge projects that I haven't had much room for little accomplishments. (And a few particular projects tanked, which didn't help.) It's worth thinking about turning that around...

Yeah, a project that gets yanked from under you, especially if you've invested significant effort, can give you that feeling of loss. Repeatedly happening can compound that. As for losses - depression is absolutely NORMAL, in the short-term. It comes, it goes, and it happens to everyone (with the possible exception who just don't care and those who heavily and perpetually so self-medicate that they'd never notice). As the time winds on, though, it's often useful to get external help. Hey, you'd call a contractor to replace your roof, wouldn't you? Or a doctor to check out your allergies?

I've made conscious decisions to grab onto little victories. It gives me something to celebrate, even as other stuff comes crashing down around me (for example, having to bury one of my friends, as just happened yesterday). Even spending 15 minutes a day doing something I *know* I will accomplish, or contribute positively to, creates a big difference in my overall outlook. Another example: in a discussion recently, the topic was a particular method and philosophy of learning a specific topic. Assuming that the desired outcome was indeed the in-depth knowledge of the subject, one person said that this method was horrible because it produced people who didn't know the subject matter, and generally produced ignorance. I was thinking of it as an inefficient way to produce the desired outcome, instead. The orientation was toward the positive, even when the outcome wasn't really positive. (Sorry so cryptic, the subject itself isn't really germane).

[lakshmi-amman.livejournal.com]

Some of this may be repeats - my apologies for not reading all the way through the comments:

So here's are a few relevant questions: what are the questions I should be asking as I look for a therapist and get this started?

The big question, right off - is a vocabulary question, which defines what you really want in terms of capabilties, training, approach, etc. About.com did a pretty great page:

http://psychology.about.com/library/weekly/aaprofessions.htm

The lesser trained people will usually bump a patient up the chain, they should be capable of knowing when they are over their heads. But as with most medicine - if you KNOW that the low-level isn't gonna do diddly, then agitate and move up the chain, and don't waste the time in fruitless meetings.



Are there particularly good starting points?

Usually the first appointment is an "interview" for both of you. The counselor is asking themselves "can I help this person?" and "how do I help this person", and you should be asking yourself these questions:
- can I talk to this person? Not just cocktail party talk, but the nitty gritty, icky, yucky stuff. The interior monologue, the stuff you may even feel ashamed of.
- does this person seem nice? More than a regular doctor, you have to feel that this person isn't gonna imply that you are dumb, ugly, or in some other way defincient. And it's not just "well of course not, they are a professional". It's got to be something from the gut.
- can this person assimilate my worldview? whatever you feel it is that defines who you are. For example - I won't waste my time with a therapist who isn't alternative lifestyle friendly, and they don't have to love the SCA, but they have to think that it's a healthy thing to do, because I have no intention of quitting. :)



What are the things I should be looking for or avoiding?

It's as personal as having a close co-worker relationship - things that irritate you will still irritate you, and it may be more so, as this is delicate territory. For example - lateness, flakiness, overly-preciseness, verbal ticks - all that stuff that makes one person nicer to be around than another. Be sure that the person you are working with suits you. Since you are the customer, and health coverage for mental health is usually not 100%, make sure you are paying someone you really like.

What has or hasn't worked for you?

Me? I like straight-up therapy. A nice, clean, elegant office with a comfy chair and some nice tissues. Regular, preschedule appointments (not walk in). A nice, professional but warm therapist with a loose sense of time - ie, 5-10 minutes of fluid scheduling is good, 20 minutes is not. Nothing wacky - I don't need to find my spirit animal, I'm not disconnected from my inner child, I don't need haromonic attunement - I just want to talk it out and figure out to handle life better, and I want to do with someone not in my social world, so I can say whatever I want without hurting feelings.

Do you have any specific people you would recommend or avoid?

Absolutely - Ronna Tapper Goldman in Needham - mail me offline, I'll send her number. She handles Blue Cross, and Tufts, I think, and not much else. Her business skills are a little soft, her therapy skills are very strong. She's very open minded, and an honestly caring person. I no longer see her, but I did for about 2 years.

The objective

It sounds like your objective is every therapist's dream. They usually want nothing more than an honest commitment to change - and someone who already realizes that the goal is to learn to cope better is a godsend. Having an open mind to therapy is the most productive thing you can bring to the table.

I personally think it's a pretty great tool. I have yet to have a therapist I didn't like, although I don't like walk-in venues. With my schedule, "walk-in" just doesn't work. I need the commitment of a regular appointment.

[lakshmi-amman.livejournal.com]

D'oh! Ronna's in Newton, not Needham! I am in Needham. D'oh.

Blame it on the novicaine. :)

[jducoeur]

Very much the kind of specific advice I was looking for; thanks much.

Ronna Tapper Goldman in Needham - mail me offline, I'll send her number.

Actually, if I'm remembering correctly, she's already come up in separate conversation, so I have her number. She's clearly made a very good impression on the people who have worked with her, and that's a major plus...

[pamelina.livejournal.com]

I have experienced several situational depressions based around losing a lover, and I am coming to realize that I'm feeling a broad-based mild depression. I concur with people who've recommended exercise (it makes a mighty difference in serotonin levels, for one thing), and keeping up with making progress on your list of things to do. I highly recommend Cognitive Therapy for depression. Cognitive Therapy has been shown very effective at long term relief of depression, with the same or better effectiveness as anti-depressant medications, and its effectiveness has been studied empirically (not as common in psychology as you would expect, sadly.) I believe it saved me when my marriage broke up. Also, since you are a reader and a thinker, you are in an excellent position to benefit from this technique, which may enable you to cope competently without using drugs.

Here are some links to start reading: Depression and bi-polar (http://www.mcmanweb.com/article-12.htm), Cognitive Therapy (http://www.psychologyinfo.com/depression/cognitive.htm), Help that Works (http://www.centerforconsciousliving.com/nf_rebt.html). If you are willing to try a book, which is how I helped myself, I highly recommend Dr. David Burn's Feeling Good (http://www.amazon.com/exec/obidos/tg/detail/-/0380810336/104-4286089-9122366?v=glance) and Feeling Good Handbook.

Anti-depressant medications have various degrees of side effects, including some which must be carefully ended by weaning off, (Zoloft) and may affect your libido among other things. They are fast and often effective, and I don't mean to negate their obvious helpfulness, especially for short terms, or combined with cognitive therapy, and among people who aren't good candidates for cognitive therapy. But if you can feel better without taking them, you're clearly better off.

Mini rant, here:
Finding a good therapist has been a big problem for me. Several things must happen for talk therapy to be helpful: first, you and your therapist must like and respect each other for their advice to be very helpful, (especially with a client like you or me who is self aware and insightful). Second, your therapist must have an excellent intuitive grasp of you, because she's necessarily geting an incomplete, if not distorted, view of your life and problems by only listening to you. Plus, by the time you've given her a good idea of what your life is truly like (in expensive 50minute chunks), you've run out of money. I think therapists should follow new clients around for a day in order to see how they really interact in their life, as opposed to trying to filter through their second-hand retelling of it.
Rant off.

Now, I'm going to take my own advice, and take another look into Feeling Good.

[jducoeur]

Very useful information as I figure out the landscape; thanks much. I have a mild bias against drugs (because I know I have a tendency to develop moderate psychological dependencies), so I prefer a non-medicinal approach for anything except *maybe* the extremely short term...

[pamelina.livejournal.com]

You're welcome. It could very well be that "The Feeling Good Handbook" might be all you need to fix yourself...

[hfcougar.livejournal.com]

I don't have time to address this properly right now, but I'll talk to you when I get home.

[cvirtue.livejournal.com]

Although the fellow I was speaking of in my comments doesn't mind being talked about, he's concerned about the longevity of things in a public forum, so I've deleted my comments. Anyone who wants to follow up on them is welcome to email me, though.

As for cognitive therapy, I recall one article that mentioned that yes, it could work, but now that it's nearly the only thing proved to work a lot of practioners have been calling what they're doing "cognitive therapy" without delivering 100% of their billed time on cognitive therapy. Watered it down, basically. So it's important to know what you're buying, as in any other transaction.

I had a short interaction with a therapist years ago who was very Rogerian, and I'm really glad that I didn't have to pay for it, because the money would have been better spent on a mirror or a journal.

[siderea]

Actually, the two best documented as effective methods are Cognitive-Behavioral and, ironically enough, Rogerian.

It has been much pointed out that the positive scientific gloss on CB therapy may have far more to do with the format of CB therapy than with its comparative merits; CB lends itself to study in that it focuses on very specific problems. Looked at from one perspective, it is almost wholly unconcerned with diagnosis. It is a form of treatment, not really an approach to figuring out why you're unwell. That makes it very handy for studies; it's like a drug and you can run the study like a drug trial.

For schools of therapy which are not just forms of treatment, but methodologies for problem solving[*], the drug-trial form of study doesn't necessarily work so well.

[* The most dramatic of which is, IMO, Family Therapy, which, while rich in technique, reminds me intellectually of doing tech support.]

[siderea]

Sorry I'm late to the party. I'm too tired to deal with this now, but I'll try to get back to it. Maybe tomorrow. Nudge me if I flake out and you really wanted my input.

Points of departure:

1) Depression
2) Different Flavors of Head Shrinkers, or, Intro to Alphabet Soup and Did You Want Prozac With That?
3) How to retain a Head Shrinker
4) A Field Guide To Psychotherapeutic Schools of Practice
5) Managed Mental Health Care: Tantalus or Sysiphus? Or, Ethical, Effective, Affordable: Pick Two.

[jducoeur]

I am *definitely* interested in your input -- I respect your thinking, and you've studied the topic more than most anyone else I know. Of the lot, I'd say that (3) and (4) are probably the ones that are most immediately useful to me that I know the least about, but all sound interesting.

Anyway, if you find the time, I'd love to hear your thoughts. (Although, given the potential length, you might want to post them in your own journal, where there are no comment-length limits.)