I was thinking of one of the Johnson County judicial mental health referees I often worked with years ago. L. Jay Stein died in 2014. I looked up his obituary the other day and was a little surprised to find I had written a remembrance for him. I’d forgotten it.
“I will always remember my first encounters with Judge Stein. I was a first-year resident in psychiatry at The University of Iowa Hospitals & Clinics. He often presided at mental health commitment hearings at which I was often the nervous trainee providing “expert testimony” as the treating physician. Jay taught me and countless other psychiatry residents about the importance of procedure. His knowledge was prodigious. But it was his compassion, his fairness, and his inimitable sense of humor I will always treasure.”
Judge Stein’s vocabulary was impressive. Even his recorded telephone automatic replies sounded amusingly erudite. Occasionally, when I had a question about legal procedures in mental health I would call him but get his answering machine. These out of office replies were entertaining and sounded very much like the way he did during commitment hearings. I can’t remember all of it, but it began with something like, “Once again, your request has been denied…” It made me think of what I might hear at a parole hearing—not mine of course.
We saw the 1959 movie “The Tingler” starring Vincent Price on the Svengoolie show last Saturday. Price plays a prison pathologist, Dr. Warren Chapin, who’s trying to scientifically study a parasitic creature called the tingler (tingles up and down your spine means you’re scared right out of your mind!).
It sits on your spine and feeds on fear by clamping down on it, eventually breaking it unless you scream. Then it’ll just let go. However, if you’re mute, scared speechless, or it grabs you by the throat—you’re done. So, the tingler lives on fear, although if you express fear vocally by screaming, you escape it.
OK, so I’m going to spoil the opening scene, which shows a prisoner being dragged to the electric chair, screaming all the way until the executioner throws the switch. When Dr. Chapin does an autopsy, he finds the prisoner’s spine is cracked. He says it wasn’t caused by the electrocution, but by the tingler.
Huh? But the prisoner screamed bloody murder (murder was why he got the death penalty by the way) hardly stopping to take a breath. Shouldn’t that have weakened or killed the tingler? You can find examples of inconsistencies like this in any cheesy movie, but where’s the fun in that?
One web article says the tingler creature was modeled after the velvet worm, which looks pretty creepy. In reality, the velvet worm is harmless to humans, but is a predator of many invertebrates. Just keep telling yourself, “I’m a vertebrate.”
You can watch the full movie on the Internet Archive. The most interesting part of it for me was the use of what was called “acid,” (meaning the hallucinogen LSD) by Dr. Chapin. He wanted to experience and record the actual experience of being scared by the tingler, just to see what it’s like apparently. He mainlines himself with a fairly stiff dose of LSD although I can’t remember how much.
Incidentally, an article in JAMA notes, “Doses of 20μg/kg of body weight are known to have been taken without a lethal outcome.” (Materson BJ, Barrett-Connor E. LSD “Mainlining”: A New Hazard to Health. JAMA. 1967;200(12):1126–1127. doi:10.1001/jama.1967.03120250160025). I don’t know how much Dr. Chapin weighs.
This was about the same time as a lot of people in the U.S. were experimenting with the hallucinogen in various ways, including mainlining it. There are web references to psychiatrists using LSD recreationally (this was when it was legal). Bad trips were and still are common, although there is a growing body of clinical studies that involve using the psychedelics as adjuncts in psychotherapy. It’s not for everybody, although tinglers might have a different opinion.
Anyway, Dr. Chapin has a bad trip, gets really scared of hallucinations and screams. Web articles say that killed his tingler, but I didn’t see it flop out of his mouth.
There you have it. Another really cheesy and fun Svengoolie movie. I’m a vertebrate.
I just found a blog post I wrote about assessing decisional capacity. It’s over 13 years old and you can tell I was a little frustrated when I wrote it. It was back in the days when consulting psychiatrists were called psychosomatic medicine specialists. Here’s to another blast from the past.
Blog from 2011: Thoughts on Assessment of Medical Decision-Making Capacity
Listen very carefully to what I’m about to say. A patient’s ability to make decisions about her medical or surgical treatment does not depend on knowing her surgeon’s name.
Let me put it differently. Simply because you can recall your surgeon’s name doesn’t mean you have the decisional capacity to give or not give informed consent to have surgery.
If that’s too obvious to most of you, then maybe I can stop worrying that it isn’t to so many doctors, who sometimes misunderstand or are simply unaware of the basic principles of assessing decisional capacity regarding medical treatment. Believe it or not, some physicians actually believe the above is part of an adequate decisional capacity assessment.
Psychosomaticists are frequently called to assess decisional capacity to participate in the informed consent discussions that are such an important part of the doctor-patient relationship today. Many non-psychiatric doctors simply don’t feel confident that they can do it themselves. And when they try, their description of the process often indicates an alarming deficit in their medical school education about this basic skill.
In order to give informed consent, you need to have enough information from your doctor, be able to voluntarily make a decision without undue pressure from others (including your doctors), and be competent to decide. Exceptions to obtaining informed consent include but are not limited to “incompetence” (the inability to decide) and medical emergencies.
In a nutshell, the basic elements of assessing decisional capacity are:
Any physician can do it; a psychiatric consultation is not obligatory though it may be helpful in difficult cases in which delirium or other mental illness may be substantially interfering with decision-making.
The patient’s ability to understand her medical condition and the risks and benefits of the main and alternative medical interventions proposed as treatment.
The patient’s appreciation of the nature of her medical condition and the potential consequences of the treatment options or no treatment in the context of her values and wishes.
The patient’s ability to reason through her choices regarding treatment.
The patient’s ability to express a choice.
Notice that nowhere in the above list is recall of the surgeon’s name even mentioned. Remembering your surgeon’s name may be flattering but it’s not essential to the assessment of decisional capacity.
There are several reasons to assess decisional capacity including but not limited to an abrupt change in the patient’s mental status. This is commonly caused by delirium, which by definition is an abrupt change in affect, cognition, and behavior that fluctuates and is by definition related to medical causes.
Any physician can conduct a decisional capacity evaluation, yet a psychiatric evaluation is frequently requested. The reason for that may arise from the assumption that the Psychosomaticist is a sort of “informed consent technician”[1]:
“Efficiency model” scenario
Incompetence is presumed.
Psychiatric consultant is expected to remove legal barriers expeditiously to obtain a surrogate decision maker.
“Pseudoconsultation” scenario
Consultation requestor lacks the patience, interest, or time to do an assessment.
“Persuasion” scenario
Psychiatric consultant is expected to persuade the patient to reverse his refusal of needed treatment.
“Protection” scenario
Psychiatric consultant is expected to provide documentation to protect against potential litigation.
“Punishment” scenario
Stigma associated with psychiatric evaluation is used unconsciously to punish treatment refusal behavior.
In all fairness, psychiatrists are sometimes just as guilty of this buck-passing; for example, when we request a cardiology consultation to “medically clear” a patient for electroconvulsive therapy to treat life-threatening depression.
In an ideal world, a decisional capacity evaluation would be requested in and accepted in “the true spirit of dialogue as the result of a genuine evaluation of the patient’s mental state as a whole”[1].
We don’t live in an ideal world. So when a doctor is truly stuck and needs help with decisional capacity evaluations, she can confidently call a practical Psychosomaticist in the true spirit of collaboration as a result of the genuine appreciation of the importance of the patient’s medical and psychiatric care as a whole.
1. Zaubler, T.S., M. Viederman, and J.J. Fins, Ethical, legal, and psychiatric issues in capacity, competency, and informed consent: an annotated bibliography. Gen Hosp Psychiatry, 1996. 18(3): p. 155-72.
May is Mental Health Month! Have I said that already? Anyway, this is yet another one of my Dirty Dozen lectures. It’s on Psychodynamic Psychotherapy.
It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size. If you see weblinks, right click the links to open them in a new tab.
This slideshow could not be started. Try refreshing the page or viewing it in another browser.
Dirty Dozen on Psychodynamic Psychotherapy by Jim Amos, MD
Psychodynamic Therapy Core Beliefs
-We feel and behave as we do for specific reasons.
-We’re often unaware of why we feel and behave in certain ways.
-Past experiences, often outside our awareness, determine how we feel about ourselves and our world.
-The need to master psychological pain is compelling and accounts for why many of us behave consistently and predictably in often self-defeating ways.
Psychodynamic Therapy Core Beliefs, cont.
-The power of the therapeutic relationship is built on the physician’s ability to provide a safe environment for examining emotions and psychological problems in a nonjudgmental, empathic way, i.e., rapport.
-The past experiences of both patient and therapist play a role in determining the power and valence (positive or negative) of the therapeutic relationship.
-Successful treatment must integrate both affective and cognitive components of patient’s self-awareness and includes supportive as well as interpretive interventions.
Essential Assumptions
-Maladaptive relationship patterns are learned in the past.
-Such maladaptive patterns are maintained in the present.
-Dysfunctional relationship patterns are reenacted in vivo in the therapy.
-The therapeutic relationship has dyadic quality.
-The therapeutic focus is on the chief problematic relationship pattern.
Behavior Is Not Haphazard
-Therapists ask “Why is the patient expressing this topic now?”
-Process communication (complementary to content)
-Listen for understanding
-Patients communicate on multiple levels and often indirectly
-Jokes, revelations at end of session, metaphors, sudden shifts in topic
Behavior Is Not Haphazard, cont.
-Resistance: Paradoxical phenomenon of ambivalence that all pts have about treatment
-Tends to provoke subtle, covert, and sometimes overt oppositional behavior that prevents deeper understanding of problems
-Protects pt against threatening feelings and fantasies
-A form of defense mechanism-a way of relating to internal and external worlds in an attempt to avoid unpleasant and strong feelings. There are both adaptive and maladaptive defense mechanisms
Defense Mechanisms
-Defenses (or resistance, which amounts to the same thing) are one of the three different means by which people cope with threats, the other two being social supports and cognitive coping strategies.
-Defenses are coping processes. They are unconscious distortions of inner and outer reality for protecting the ego from disorganizing anxiety and depression. They may seem odd. They may also mature over time.
-Confronting people with their defenses can be unwise. Recognizing them in order to make sense of otherwise inexplicable behavior and to make rough predictions about response to therapy is helpful.
Defense Mechanism Examples
-Denial: refusal to appreciate information about oneself or others
-Projection: attribution of conflicted thoughts or feelings to another or to a group of people
-Identification: patterning of oneself after another
The Past is Present
-Implicit memory and the need to avoid unpleasant, disruptive feelings
-May explain why some traumatic experiences are not accessible
-Transference & countertransference: responding to someone in the present as if that person were an important figure from the past.
-Used for corrective experiences and encouraging more adaptive behavior as pt becomes of aware of this phenomenon
Self-Defeating Behavior
-Making the same mistake repeatedly, e.g., marrying abusive, alcoholic partners
-Might understand this as attempts to master enduring conflict or trauma in order to finally resolve the painful experience
-Remembering can replace reliving-challenge of psychodynamic therapists is to foster this
Essential Operations of Psychodynamic Psychotherapy
-Accepting: Therapist affirms the pt’s past and present subjective experience.
-Understanding: Therapist appreciates both the conscious and unconscious contributions to the pt’s emotional problems.
-Explaining: Therapist expresses, through interpretations, his or her understanding to the pt.
References
-Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004
-Focus: The Journal of Lifelong Learning in Psychiatry. Psychotherapy. Ed. Jerald Kay, MD. Spring 2006. Vol. IV, No.2.
Back in 2018, one of my emergency room staff physicians asked me to do a Pecha Kucha on what a consultation-liaison psychiatrist does. If you know what a pecha kucha is, you can understand why it was challenging for me to put it together and present it.
Although you may have seen the video I made of the pecha kucha 5 years ago on this blog, I think it’s OK to present it here again.
Briefly, PechaKucha is Japanese for “chitchat.” It’s a presentation format using 20 slides displayed for 20 seconds each. It took a while to rehearse to get it right.
I think it’s also worth emphasizing because most of the ideas in it are still relevant to consultation-liaison psychiatry. See what you think.
Hey, because May is Mental Health Month, this is another one of my Dirty Dozen lectures. It’s on Interpersonal Psychotherapy.
It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size. If you see weblinks, right click the links to open them in a new tab.
This slideshow could not be started. Try refreshing the page or viewing it in another browser.
Dirty Dozen on Interpersonal Psychotherapyby Jim Amos, MD
Definition of IPT
–Time-limited, dynamically informed therapy.
–Goals are to relieve symptoms and improve interpersonal functioning and social support.
–Focuses specifically on interpersonal relationships to bring about change.
Applications for IPT
–Major Depression
–Postpartum and peripartum Depression
–Dysthymia
Essential Characteristics of IPT
–Focuses specifically on interpersonal relationships as a point of intervention.
–Time-limited when used as an acute treatment (12-16 sessions).
–Interventions used do not directly address the transference relationship.
Premises of IPT
–Interpersonal distress closely associated with psychological symptoms.
–Helping people improve communications in relationships or change their expectations about those relationships relieves symptoms.
–Helping people build or improve social support network improves ability to cope with crises that precipitated distress.
IPT Contrasted with CBT & Psychoanalytic Approaches
–CBT focus is on cognitions.
–Psychoanalytic focus is on understanding contributions of early life experiences.
–IPT focus is on improving interpersonal communications in the present.
Theoretical Framework of IPT
–Attachment Theory
–People are driven instinctively to form attachments to get and give care.
–Hallmark of good mental health is ability to form flexible attachments.
Theoretical Framework of IPT cont.
–Communication Theory
–Securely attached persons able to communicate needs effectively.
–Insecurely attached persons communicate in an indirect, ambivalent way that may elicit neutrality or hostility.
Problem Areas of Focus for IPT; Conducting IPT
–Grief
–Interpersonal Disputes
–Role Transitions
–More important than technique is the focus on extratherapeutic interpersonal relationships and fostering of productive therapeutic alliance.
Conducting IPT
–Opening Phase: diagnose, frame the treatment, relieve symptoms.
–Middle Phase: develop strategies for problem areas: identify situations which elicit feelings, validate feelings, explore and role play options, summarize sessions.
–Conclusion and Maintenance Phases: reinforce independence.
Conducting IPT cont.
–Communication Analysis and Interpersonal Incidents (accurately describe in detail).
–Use of both content and process affect (what happened outside and inside).
–Observe transference but don’t comment on or interpret it.
IPT References and Links
–Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004
–Stuart, S. (2012). “Interpersonal psychotherapy for postpartum depression.” Clin Psychol Psychother 19(2): 134-140.
In keeping with May being Mental Health Month, here’s another slide set on psychotherapy. This one is on the basics of Cognitive Behavioral Therapy. Once again, it’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.
This slideshow could not be started. Try refreshing the page or viewing it in another browser.
Dirty Dozen on Cognitive Behavioral Therapy by Jim Amos MD
Origins of CBT
–Psychoanalytic theory dominant in 1960s
–A. Beck, the creator of CBT, was trained as a psychoanalyst
–Conducted experiments in late 1950s and early 1960s intended to support psychoanalytic constructs-found the opposite to be true
CBT Definitions & Assumptions
–Focused therapy based on model that psychological disorders involve dysfunctional or unhelpful thinking
–We often feel what we think and behave accordingly
–Assumes that modifying dysfunctional thinking improves or resolves symptoms
–Modifying dysfunctional beliefs that underlie dysfunctional thinking produces more sustainable change
Overview
–Pragmatic, action-oriented treatment approach
–Initially developed for depression and anxiety
–Empirically validated brief psychotherapy shown effective in over 350 outcome studies
–Effective in treatment of many medical and psychiatric conditions
Examples of Automatic Thoughts
–I should be doing better in life
–I’ve let him/her down
–I can’t handle it
–I feel like giving up
–Something bad is sure to happen
–I’ll never be able to get this done
Examples of Maladaptive Schemas
–I must be perfect to be accepted
–I’m a fake
–I’m unlovable
–I must always be in control
–Other people will take advantage of me I’m stupid
Key Behavioral Concepts
–Depressive behavior can be modified with behavioral techniques
–Exposure therapy and related methods can be effective interventions for anxiety disorders
–Behavioral interventions can be useful for helping patients improve coping, social, and problem-solving skills
Principles of CBT
–Overall goal is to help achieve remission of disorder by solving problems and relieving symptoms.
–Achieved through collaborative empiricism
–Approach which teaches patients to view reality more clearly by examining their distorted cognitions
–Correcting faulty ideas leads to improvement in mood and function
–CBT is educative in nature; it teaches patients to be their own therapists. CBT is goal oriented.
CBT Methods
–Socratic questioning
–Stimulate curiosity to engage in learning, less didacticIdentifying cognitive errors
–Thought change record
–Guided discovery-series of inductive questions to reveal unhelpful thought patterns
–Examining the evidence
–Generating rational alternatives
–Role play and rehearsal
Behavioral Methods Used in CBT
–Activity and pleasant event scheduling
–Graded task assignments
–Exposure and response prevention
–Relaxation training
–Breathing training
–Coping cards;example: suicide safety plans
References
–Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
–Garland, A., R. Fox, et al. (2002). “Overcoming reduced activity and avoidance: a Five Areas approach.” Advances in Psychiatric Treatment 8(6): 453-462.
–Temple, S., PhD, and S. Stuart, MD (2010). Psychotherapy for the hospitalized medically ill patient. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 242-248.
References cont.
–Whitfield, G. and C. Williams (2003). “The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings.” Advances in Psychiatric Treatment 9(1): 21-30.
–Williams, C. and A. Garland (2002). “A cognitive–behavioural therapy assessment model for use in everyday clinical practice.” Advances in Psychiatric Treatment 8(3): 172-179.
–Williams, C. and A. Garland (2002). “Identifying and challenging unhelpful thinking.” Advances in Psychiatric Treatment 8(5): 377-386.
In observance of May being Mental Health Month, this is one of my Dirty Dozen lectures. It’s on the elements that are shared among some of the important psychotherapy methods.
It’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.
This slideshow could not be started. Try refreshing the page or viewing it in another browser.
Dirty Dozen on Common Elements of Psychotherapy by Jim Amos, MD
What is Psychotherapy?
-Change facilitation
-Self awareness development
-Doesn’t necessarily have to occur in formal therapy encounters
-Can happen between patients and a wide range of professionals
Patient Variables and Relationship Factors
-Ability to relate, psychological mindedness
-Therapeutic alliance
-Readiness to change
-Respect, listening for understanding
Placebo, Hope, and Expectancy Effects
-Power of providing a “treatment experience”
-An emotionally charged relationship in which therapy instills hope for change
-A particular set of procedures that enhance belief in the therapist’s competency
-A therapeutic explanation of the problems that fits the patient’s belief system
Motivational Interviewing
-Intended to raise patient’s awareness of ambivalence between opposing thoughts and behaviors
-Accepts the “yes, but” responses without confrontation
-Emphasizes validation, reflection, reframing
-Source: Miller, W. R. and S. Rollnick (1991). Motivational interviewing : preparing people to change addictive behavior. New York, Guilford Press.
Motivational Interviewing cont. Stages of Readiness to Change
-Precontemplation
-Contemplation
-Preparation
-Action
-Maintenance
-Termination
Cognitive Behavioral Therapy (CBT)
-Foci of treatment are internally based cognitions and challenging, unhelpful or harmful thoughts and behaviors.
-Time limited
Interpersonal Therapy (IPT)
-Focus on interpersonal communications with others
-Focus on helping improve communication and social support in the present
-Time limited
Psychodynamic Psychotherapy
-Focus of treatment is on understanding contributions of early life experiences to psychological functioning and unhelpful or harmful behaviors
-Can be lengthy or open-ended
Essential Operations of Psychodynamic Psychotherapy
-Accepting: Therapist affirms the patient’s past and present subjective experience
-Understanding: Therapist appreciates both the conscious and unconscious contributions to the patient’s emotional problems
-Explaining: Therapist expresses, through interpretations, his or her understanding to the patient
Integrating Therapies
-Skillfully staged combinations of approaches may be more successful than one used alone
-Cognitive behavioral or interpersonal approaches first for more immediate symptom relief
-Psychodynamic approaches first for increasing self-awareness and exploring the need for change
References
-Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
-Miller, W. R. and S. Rollnick (1991). Motivational interviewing : preparing people to change addictive behavior. New York, Guilford Press.
I want to gas; I mean talk about copyright as it relates to consultation psychiatry or telling dad jokes. By the way, those aren’t the same.
I used to teach medical students and residents how to do certain quick bedside cognitive tests for delirium and dementia. Over the years the instructions about how to administer them (and the restrictions over using them at all) have changed slightly. The major point to make is that they have been copyrighted, which usually means you have to pay to play.
One of them, the Mini Cog, despite being copyrighted, does not require you to pay for the privilege of using it. The video below shows part of it. I didn’t do a comedy bit about the short term recall of 3 objects. The video also flickers when I show the delirium order set; just pause it to stop the flickering.
There used to be a cognitive assessment called the Sweet 16, which started off being non-copyrighted, but then became copyrighted. At first the Sweet 16 mysteriously just disappeared from the internet. You can now download it from the internet, but it’s clearly marked as copyrighted.
The reason the Sweet 16 became unavailable is because a company called Psychological Assessments Resource (PAR) acquired the copyright and then started enforcing it. I found out about this when I could not obtain the PAR version of a cognitive assessment very similar to the Sweet 16 called the Mini Mental State Exam (MMSE) unless I forked over at least $100.
I then started teaching trainees how to use the Montreal Cognitive Assessment (MoCA) because it was free to use without any strings attached. Then it also was copyrighted although you can use it under certain conditions.
Moving right along to telling dad jokes, I found out that dad jokes (and indeed, any joke) can be copyrighted, at least in theory. In fact, it’s hard to enforce the copyright on jokes, even when you can prove originality. Here’s an example of a dad joke I think I made up:
What do you get when you cross marijuana with a Mexican jumping bean? A grasshopper.
Note: this joke may become more important now that the DEA, according to news agencies, plans to reclassify marijuana from Schedule I to III in the near future.
Sena thought it was funny (the joke, not the DEA), which probably means it’s not, technically, a dad joke. That’s according to the authority about dad jokes, Dad-joke University of Humour, (DUH). I’m far from a joke teller at all, as Sena (and anyone else who knows me) would assert. On the other hand, I did graduate from DUH and have a diploma to prove it. You can now give me money.
Furthermore, I also investigated whether something called anti-jokes can be copyrighted. According to the internet, the answer seems to be no. Here’s my attempt of the anti-joke:
Knock, knock.
Who’s there?
The doorbell salesman.
See what I did there? In case you didn’t know, experts say that Knock-Knock jokes are among the hardest to copyright for reasons I suggest you look up later. If you also frame the Knock-Knock joke as an anti-joke (stay with me here), the literalness and mundanity of the so-called punch line makes it virtually impossible to copyright. And, like the dad joke, it’s usually not funny—although there can be exceptions.
Just for the sake of incompleteness, I’ll mention the concept of copyleft, which is not the same as open-source. Although this is usually applicable to computer software, you could broaden it to include dad jokes—I think. Copyleft could mean you can use or modify a dad joke (or anti-joke), spread it freely at parties and whatnot as long as it’s bound by some condition. This includes paying me (no personal checks, please).
What pet do inventors have a love-hate relationship with? A copycat.
Go Retire Psychiatrist 