Re: Ask The Mineshaft: ethical shrinkage edition.

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Fundamentally, there are almost no situations where it's appropriate to convince somebody to convince suicide by swallowing their tongue, but if she ends up with Yoo or Addington as a client, she should at least consider it.


Posted by: Sifu Tweety | Link to this comment | 06-27-08 9:21 PM
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In a Daihatsu.


Posted by: apostropher | Link to this comment | 06-27-08 9:24 PM
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Convince-a-thonic, chronic, take a Daihaitsu to the Sonic and FUUUUUUCK.

Hey, Apo, tell me straight up, can I put a single coherent thought together tonight?

No, don't answer that; it'd be unethical.


Posted by: Sifu Tweety | Link to this comment | 06-27-08 9:26 PM
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It really bothers me that "socially responsible" is a rare enough trait among "human service professionals" that they need to start a network.


Posted by: rob helpy-chalk | Link to this comment | 06-27-08 9:26 PM
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Human service professionals? Like butlers? They don't have a socail networking tool? What was "Ask Jeeves?"


Posted by: TJ | Link to this comment | 06-27-08 9:30 PM
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I confess that I don't immediately see what environmental concerns have to do with private practice as a psychotherapist.


Posted by: parsimon | Link to this comment | 06-27-08 9:38 PM
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1. Post a chart of sliding-scale costs on the wall in the waiting room, and put it up on her website if she has one. Transparency in pricing is an important kind of ethics.

2. Decline to take cases for which she is experientially unprepared (due to class, language, culture, gender, sexual identity, life stage). This requires humility and a robust Rolodex of trusted colleagues to whom she can refer. [This is primary in my mind because I just met another well-meaning white Protestant 23-year-old girl-woman who is So!Committed! to being a bilingual marriage counselor for Hispanic couples.]

3. Think in advance about barter arrangements she will accept for "pro bono" cases. Nearly everyone has something to barter, and except in cases of extreme vulnerability most people seeing a therapist can afford a little time and energy out of their lives to give back. It's generally more respectful to do it that way too. The question is where she wants to draw the boundary. Will she accept home-grown vegetables, baked goods, hair braiding services, lawn-mowing help? Music lessons for her child, car repairs? Worth considering in advance to avoid awkwardness or ethical missteps.

4. Make friends with an MD or RN who is well-informed about how to apply for pharmaceutical companies' indigent drug programs. It's likely that some of her patients are or will be medically diagnosed, and her talk therapy will be more effective if they have a reliable and affordable source of meds. [See B's saga of trying to get her prescription filled, which I think she posted at her blog a few months back.]

Extra credit: I don't know about organizing principles, but task #1 should be to show up at the relevant professional associations' annual conferences and make a very, VERY large fuss about their abdication of ethics in the cases of medical professionals overseeing and enabling torture in Guantanamo and elsewhere.


Posted by: Witt | Link to this comment | 06-27-08 9:51 PM
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It probably wouldn't hurt for her to look up the local affiliate of Physicians for Social Responsibility, either. Not direct professional overlap, but would probably be useful for her if she hasn't already made contact.

Also, what rob said.


Posted by: Witt | Link to this comment | 06-27-08 9:56 PM
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Is this psychotherapist a psychiatrist or a clinical psychologist? The distinction is important for some of Witt's (excellent) advice.


Posted by: teofilo | Link to this comment | 06-27-08 9:56 PM
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Oh, and quite importantly: She should find some middle-class or UMC clients with good insurance and/or who will self-pay on time. You can get sucked down the black hole of non- or under-renumerative work (is that a word? it is now) so easily, and she has to be able to make a decent living and keep her own sanity on an even keel. Assuming she's not independently wealthy, she is actually a small-business owner, and it helps to think like one.


Posted by: Witt | Link to this comment | 06-27-08 10:00 PM
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Human service professionals? Like butlers?

No, Inhuman service professionals, like The Terminator.


Posted by: Gonerill | Link to this comment | 06-27-08 10:11 PM
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Goofus helps her clients resolve psychological issues that are preventing them from becoming early 21st century American consumero-normative sheep unwittingly working 24x7 to kill the earth.

Gallant exploits her patient's delusions to convince them that David Addington is the human form of a selenium-based organism from another galaxy sent here as an advance scout for an alien invasion, and that he must be stopped by means fair or foul.


Posted by: JP Stormcrow | Link to this comment | 06-27-08 10:18 PM
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12: I had a several pieces of pithy well-written practical advice all ready to go, but then I saw I was pwned yet again by Witt in 7 and 8.


Posted by: JP Stormcrow | Link to this comment | 06-27-08 10:21 PM
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This is primary in my mind because I just met another well-meaning white Protestant 23-year-old girl-woman who is So!Committed! to being a bilingual marriage counselor for Hispanic couples

Ouch.


Posted by: Gonerill | Link to this comment | 06-27-08 10:29 PM
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14: Indeed. No wonder there's so much burnout in social services.


Posted by: teofilo | Link to this comment | 06-27-08 10:36 PM
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They're letting Hispanic couples get married now? Is there no end to this assault on marriage?


Posted by: Stanley | Link to this comment | 06-27-08 10:39 PM
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Holy shit, Witt.

And here I was about to point out that someone is asking ethical advice from the Mineshaft: a bunch of ethics and analytical philosophers (who are utterly useless!), and other people who look to Apo or Ogged for life advice. You're doomed.

Except for Witt. She saves you when we're all shit-faced drunk.


Posted by: Po-Mo Polymath | Link to this comment | 06-28-08 3:04 AM
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1. Post a chart of sliding-scale costs on the wall in the waiting room, and put it up on her website if she has one. Transparency in pricing is an important kind of ethics.
and
Oh, and quite importantly: She should find some middle-class or UMC clients with good insurance and/or who will self-pay on time. You can get sucked down the black hole of non- or under-renumerative work (is that a word? it is now) so easily, and she has to be able to make a decent living and keep her own sanity on an even keel. Assuming she's not independently wealthy, she is actually a small-business owner, and it helps to think like one.

Very importantly. The rule as I heard it is that a normal practice is going to score 1/3 of the income of bill hours, due to insurances, people skipping out, etc. At a 100$ an hour billed, that's about 30 bucks an hour in reality, which is 1200 a week or 60k a year pretax. That's decent but not exactly wealthy. If there's a sliding scale involved (which is still going to get a 1/3 return), that per year figure shrinks pretty fast.

Not getting paid enough to live is bad, so really, the first thing to do is to make a living wage.

The thing I would would be to keep a timesheet of billed versus unbilled hours. That would be useful from a P&L perspective ('I've got all these clients, why am I broke?!') and from a scoial conscience perspective ('I did twenty hours of free work this week! Yay, me! Ok, I'm going to the beach.').

There are the issues with not being able to have it all that B has often hit on. There are also issues around the fact that the therapist is not only a Rent-a-Friend but a Dial-a-Mom (or Dad) and thus in loco parentis. Good moms model healthy behaviour for their children, and a therapist has to do the same for their clients so the clients can learn it for themselves. Playing Jesus on Calvary Hill is not an option; burnout will kick in and then the therapist is of no use to anybody.

If the sister in question is say, treating a BPD, and only getting paid for an hour of therapy a week, but has to spend twenty minutes a day doing email with the client because the client can't stand to be separated for longer than that lest they start carving themselves up again, I would count that under pro bono.

2. Decline to take cases for which she is experientially unprepared (due to class, language, culture, gender, sexual identity, life stage). This requires humility and a robust Rolodex of trusted colleagues to whom she can refer.

Humility is good! Jesus had an in with the supernatural, so one shouldn't expect or demand miracles from mere humans. Which goes back to modeling healthy behaviour.

Nearly everyone has something to barter, and except in cases of extreme vulnerability most people seeing a therapist can afford a little time and energy out of their lives to give back. It's generally more respectful to do it that way too.

Beyond that, if someone is hard up and cannot pay in folding green because they've got issues around work and money, accepting barter if it can be had is important. A five-year-old may be counterproductive in the kitchen but you still want them to try; that's how they learn to do things on their own. So mud pies are ok, even if nobody is going to eat them, because accepting that encourages them to keep trying, which is what you want. If they keep at it, sooner or later they'll make something edible, which is good for everybody.

If the lady in question really makes a go of it, she will have more opportunities to employ/satisfy her social conscience than she knows what to do with. The time to worry about social conscience is when she's treating nothing but wealthy neurotics who just want someone to babble at, and that is really unlikely to happen unless she really works at it, which a few people do.

max
['So first things first, horse before cart, &etc.']


Posted by: max | Link to this comment | 06-28-08 5:11 AM
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Wobegon has an amazing young new doctor who deals only with uninsured patients. She does everything cash-only, pay-when-you-can. Her customers seem to be self-employed (a lot of them here), Amish, or Mexican (she speaks Spanish).

One secret is that she came from a rich family and got out of college without debt. She's also willing to live in Wobegon. And third, I think that she's married to an HMO MD.

One option is to have a low, but not too low flat rate on a "pay if and when you can" basis, with no follow-up billing. My father did something like this as a country doctor. In psych practice, though, I suspect this would tend to draw people with certain kinds of disorders which cause them to be unbearable nuisances (the dread "borderlines").


Posted by: John Emerson | Link to this comment | 06-28-08 6:15 AM
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Any self-employed Mexican Amish?


Posted by: Sifu Tweety | Link to this comment | 06-28-08 6:19 AM
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Yes, but not around here. They're in Mexico.

There's a Japanese Hutterite group in Japan, made up of ethnic Japanese who have converted. They do not speak an archaic German dialect. Just Japanese. They are accepted by the other Hutterites, as I understand.


Posted by: John Emerson | Link to this comment | 06-28-08 6:31 AM
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See: Japanische Hutterer: Ein Besuch bei der Owa Gemeinde (Japanese Hutterites: A Visit to Owa Community) by Rev. Joshua Hofer

Available here.


Posted by: John Emerson | Link to this comment | 06-28-08 6:36 AM
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a bunch of ethics and analytical philosophers (who are utterly useless!)

You won't be saying that next time you're at the wheel of a runaway trolley!


Posted by: zadfrack | Link to this comment | 06-28-08 6:52 AM
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There are no Kantians in the trolley cars.


Posted by: John Emerson | Link to this comment | 06-28-08 7:02 AM
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Japanische Hutterer

For a moment I thought this had to do with Japanese haberdashers.

But I think that would require an umlaut.


Posted by: JRoth | Link to this comment | 06-28-08 8:02 AM
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Therapists take barter? Dude.


Posted by: Jackmormon | Link to this comment | 06-28-08 12:53 PM
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The rule as I heard it is that a normal practice is going to score 1/3 of the income of bill hours, due to insurances, people skipping out, committing suicide, etc.


Posted by: bitchphd | Link to this comment | 06-28-08 1:36 PM
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committing suicide

That's actually pretty rare, you know. Most completers are not in therapy (or bailed out some time previously).

Threatening to commit suicide is very popular.

max
['Really.']


Posted by: max | Link to this comment | 06-28-08 1:48 PM
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It was a *joke*, Max, you humorless crazy person.


Posted by: bitchphd | Link to this comment | 06-28-08 1:55 PM
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Ah, the slashing attacks of the aristocracy wound me to the quick! But I remeber when we lived in the gutter and ate nothing but rat on a stick and the people who had eaten too many rats would go crazy and vote for George Bush!

max
['Ze suicide is ze painless!']


Posted by: max | Link to this comment | 06-28-08 2:50 PM
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['Ze suicide is ze painless!']
i remember reading a book where everybody, all historical personalities like artists, writers, were jews and anti-semites and committed suicide
i remember thinking it's just like another form of transition to the 'other' spheres or dimensions, like in The little prince, and should maybe be considered not like untimely expiration, but like exactly timely one coz self-willed, conscious choice
though if to think it's all caused by depression and supplied the lack of dopamine they all could survive, but the question would be then survive until what, one's natural death? what's the difference and what's after, whether it would be the same spheres etc
also like where were therapists?
i mean good luck, the sister-psychotherapist, i think it's a very important job, counseling
this one belongs to the other thread, ogged's pre-last one, just found along browsing
maybe it was already linked there


Posted by: read | Link to this comment | 06-28-08 3:57 PM
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Hey read, did you see Mongol? Whatdya think?


Posted by: Wrongshore | Link to this comment | 06-28-08 4:17 PM
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19 is a good setup for a Northern-Exposure type TV series. Quirky! And heartwarming!


Posted by: PGD | Link to this comment | 06-28-08 4:29 PM
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no, i didn't, i never go to the movies here ;(
if it's in the netflix browsing list i'll watch it maybe
there were some negative reviews in our press, objecting to some as they say faulty description of our customs and to that that the movie draws Temujin as a slave escaping from some imprisonement as i understood, i don't know whether it's so
when he never was a slave and if even was held a captive early in his life, most probably by his own clan rivals, not by other Mongol tribe or Chinese, that's for sure


Posted by: read | Link to this comment | 06-28-08 4:29 PM
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A few thoughts:

Do not be a hack. Commit yourself doing the best possible work you can do, making honesty and integrity core values in your approach.

Spend years in your own therapy to know yourself and the complexity of the human psyche from the inside out. Understand that we are fallible and that we can and do lie to ourselves, which means that, as psychotherapists, we cannot afford to be lax about the kind of people we are or the things we represent to our clients.

Don't settle for the minimal credentials necessary to hang out a shingle. Seriously pursue an education and training of depth and breadth, developing an understanding of competing theoretical paradigms and approaches, the research on these approaches and the philosophical underpinnings of each approach. Remain committed to serious study with other serious students for as long as you work in the field. Know why, in depth, you've choosen the approach you've chosen. Know its strengths and its shortcomings. Failing this, you will be tempted to adopt shiny gimmicks of the sort touted on Oprah and the literature of pop quackery. It is socially irresponsible to substitute weekend pop seminars for years of rigorous clinical and academic training.

Neither psychotherapy nor your clients should be used to advance your personal causes. People come to you and pay you to address serious personal matters, not for political conversion and not to serve your needs for reassurance and affirmation. It is a privilege to assist people in their personal journeys and an abuse to make the work about you.


Posted by: Dr X | Link to this comment | 06-28-08 4:33 PM
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There's a Chinese source claiming that he had been a Chinese slave. Temujin's biography before 1202 is vague, and there's a 13 year discrepancy in the accounts of his age. Some think that the reason why he was able to outsmart the Chinese is that he spent some time in the Chinese military and learned their ways. He was very successful in persuading Chinese leaders to switch over to his side, though these Chinese leaders were often Khitans, (a sinified people related to the Mongols.) The rulers of N. China at that time weren't ethnic Chinese either, but Jurchens, a sinified Manchurian people.


Posted by: John Emerson | Link to this comment | 06-28-08 4:34 PM
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if there is a proven source
but we basically do not believe Chinese sources
historically and prefer to remain our barbaric ways
the other day, a week maybe after the earthquake, i read in the news that they found a 103-4 yo woman from under the debris
i was so moved and told to my Japanese coworker about that, how life is strange, thousands kids buried alive and the luckiest grandma to live past 100 yrs and survive the eathquake
his reaction was like, oh, probably she's 60-70 yo, you can never trust Chinese
i know it's irrational, even reproachful and all, but kinda like illustrative of the distrust, sorry


Posted by: read | Link to this comment | 06-28-08 4:51 PM
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If the sister in question is say, treating a BPDBPL, and only getting paid for an hour of therapy a week, but has to spend twenty minutes a day doing email with the client because the client can't stand to be separated for longer than that lest they start carving themselves up again, I would count that under pro bono.


Posted by: Minivet | Link to this comment | 06-28-08 5:10 PM
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I don't know how the system works in the UK, but is it possible to outsource some of the labour involved in doing pro-bono work by working under the aegis of some charity or other?

Someone I know used to work for a mental health charity, and a big part of their job was matching up people using the services of the charity with volunteers and other charity providers to ensure they got access to things they needed.; acting a bit like a social worker, but coordinating volunteer and charitable services as well as state provision.

The charity in this case dealt with all the admin costs and the work involved, leaving the volunteers and other charity providers just to do their part of the work without absorbing the admin overheads.


Posted by: nattarGcM ttaM | Link to this comment | 06-28-08 5:18 PM
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In the US, I mean.


Posted by: nattarGcM ttaM | Link to this comment | 06-28-08 5:18 PM
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In the movie, they show him imprisoned by the usurping Khan at the age of 11, then sold into Chinese slavery by Jamukha in adulthood. As a Chinese slave he's simply imprisoned on display.


Posted by: Wrongshore | Link to this comment | 06-28-08 5:21 PM
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What Wrongshore describes isn't in any of the sources. One Chinese source only briefly mentions that a Mongol told a Chinese that Temujin had been a Chinese slave. That may merely mean that he had been captured and enrolled in the Chinese army. The Mongoln Persian, and other Chinese sources don't say even that.


Posted by: John Emerson | Link to this comment | 06-28-08 5:31 PM
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39: This is the direction in which she's leaning: doing casework for a local AID's clinic. She's also in her mid-40s, not a callow youth, in other words. And she spent eighteen years working in a settlement house, so she's not fooling herself about changing the world. She just couldn't find good information on ethical practices that went beyond: don't fuck your patients. Oh, and she can't do the barter thing, though she thinks it's a great idea. Her professional organization has deemed barter unethical. Finally, she asked me to say thanks to you all. Well, to those of you who weren't assholes, which is to say, four or five of you.


Posted by: sis's brother | Link to this comment | 06-28-08 5:38 PM
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39: That's how a lot of pro-bono legal work happens -- some organization finds clients, and lawyers looking for pro bono work go through the organization, or collaborate with it, to get their work done.


Posted by: LizardBreath | Link to this comment | 06-28-08 5:39 PM
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43: You sent in a question here and expected not to get asshole responses? Dude.


Posted by: LizardBreath | Link to this comment | 06-28-08 5:40 PM
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That last part was a joke: she said thanks to all of you.


Posted by: sis's brother | Link to this comment | 06-28-08 5:42 PM
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44: No, she knew what she was in for. And she really does appreciate the suggestions. 43.last was just a joke. Sorry.


Posted by: sis's brother | Link to this comment | 06-28-08 5:44 PM
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Someone not clear on the Unfogged concept.

As long as I'm alive, Unfogged will teem with off-topic Mongols, Hutterites, and carp.


Posted by: John Emerson | Link to this comment | 06-28-08 5:44 PM
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I bet we could get the thread to 250 if we tried to figure out why "those of you who weren't assholes" fell flat.

Come on, people. Sabbath ain't shit if you don't think on what you do and have done.


Posted by: Wrongshore | Link to this comment | 06-28-08 5:58 PM
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I was just having a humorless™ moment. Sorry about that, sisbro.


Posted by: LizardBreath | Link to this comment | 06-28-08 7:49 PM
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don't fuck your patients

no, do fuck your patients! It might help! Just don't pull a disappearing act the next day. That would definitely be unethical.


Posted by: PGD | Link to this comment | 06-28-08 8:14 PM
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I bet we could get the thread to 250 if we tried to figure out why "those of you who weren't assholes" fell flat.

Because it's a humourless thread and the jokes weren't broad enough to be obvious. Oops.

i remember reading a book where everybody, all historical personalities like artists, writers, were jews and anti-semites and committed suicide

I remember browsing a book where every single famous person in the history of the world was gay.

i remember thinking it's just like another form of transition to the 'other' spheres or dimensions, like in The little prince, and should maybe be considered not like untimely expiration, but like exactly timely one coz self-willed, conscious choice

Well, it might be exactly timely, but I'm not sure it would always be proper. Or rather, usually be proper.

though if to think it's all caused by depression and supplied the lack of dopamine they all could survive, but the question would be then survive until what, one's natural death?

Presumably.

what's the difference and what's after, whether it would be the same spheres etc
also like where were therapists?

'Death is just another life transition.'
'Yeah, but a transition to what?'

Unfogged will teem with off-topic Mongols, Hutterites, and carp.

Mongols are off-topic?

max
['I knew there was something wrong with this blog.']


Posted by: max | Link to this comment | 06-29-08 5:32 AM
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I think that the problem with the assholes joke is that we didn't know the person who told it and didn't even know whether they were familiar with the local custom of calling each other assholes. We though maybe that Bro was an outsider who meant we were assholes in the bad sense.


Posted by: John Emerson | Link to this comment | 06-29-08 6:10 AM
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Mongols are off-topic?

No, there are on-topic Mongols and off-topic Mongols. It's more complicated than it looks at first glance. Someone is working of a graph theoretic approach.


Posted by: soup biscuit | Link to this comment | 06-29-08 8:31 AM
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Carp: always on topic. When you think otherwise, it may be because you don't understand the topic.


Posted by: NĂ¡pi | Link to this comment | 06-29-08 9:59 AM
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53: We though maybe that Bro was an outsider who meant we were assholes in the bad sense.

In other words, we thought he was right.


Posted by: JP Stormcrow | Link to this comment | 06-29-08 11:25 AM
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I don't see many assholic comments in this thread; mostly jokes.


Posted by: parsimon | Link to this comment | 06-29-08 11:37 AM
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